TUBERCULOSIS OF JOINTS, WITH THREE

CASES OF EXCISION*

WITH E. W. LEE, M.D.

THE discussion of the subject of exsections of the knee-joint which follows is abridged from a clinical lecture delivered in Cook County Hospital, where the operation was made.

Exsection of the knee-joint is generally considered a serious, not to say dangerous, operation. We shall now first consider this point; then its indications in general and in this case; and, finally, the methods of operating which this case is intended to illustrate.

For the danger to the life of the patient we must seek information in the statistics.

A series gathered by König† is as follows:

These statistics were gathered about 1870, and show a mortality of about 30 per cent. This is the death-rate of the statistics of Pénières,‡ who found in 431 cases of excision of knee-joint for white swelling 131 deaths, that is, 30 per cent.

From English surgeons, however, we have smaller series of operations, with far better results.

In considering the value of the statistics there are two interesting

facts:

1. The age of the patient has great influence on the death-rate, as shown by Pénières:

* Chicago Med. Jour. and Examiner, 1880, vol. xli, p. 7

+"Beiträge zur Resectionen des Kniegelenkes," Langenbeck's Archiv, 1867, Bd. ix, p. 177, and Holmer, "Optegnelser of praktisk Lägekunst," Hospitalstidende, 1872.

Des resections de genoux, Paris, 1869.

In one series of Pénières were 30 excisions in children from nine to eleven years without a death. The death-rate is lowest, therefore, in children from five to about twenty, and the danger as the age advances gradually increases.

2. The period in which the operation was performed is next in importance, insomuch that we find the death-rate from the early days of this operation by surgeons to a recent date to be steadily decreasing. Pénières gives the following statistics on this point:

From 1762 to 1830 there were 11 excisions, 6 deaths.

54.5 per cent.
52.3

27

27

66

46

Better methods of operating, better after-treatment, and better knowledge of the indications for the operation may account for this decrease in death-rate. But even in 1873 the average death-rate was not below 27 per cent. Exceptions were Fergusson's second series, 25 per cent.; Humphrey's series, 15 per cent.; and Jones' series, 10.6 per cent.

In Germany up to this time (in 1873) the death-rate is considered by Volkmann to be about 50 per cent.* Very naturally, therefore, Volkmann preferred the expectant treatment in white swellings of the kneejoints in the absence of fever and wasting discharges that threaten the life of the patient.

The next and latest important step toward a more favorable result for this operation is Lister's method of operating and dressing.

In 1872 Holmer, of Copenhagen, made four excisions for white swelling, with three good results, one secondary amputation, and no deaths.

In 1875, 1876, and 1877 Volkmann made 32 excisions for the disease, with no deaths from the operation. One patient died several weeks later of tubercular meningitis.

It is now impossible to know the exact danger to life from this operation. We cannot expect to reduce the death-rate to zero by antiseptic methods, for that would be perfection. We can only hope to come nearer and nearer the ideals without ever reaching them. But the latest statistics from other fields of operative surgery give us the right to expect that excision of the knee-joint will henceforward be an operation. devoid of very great danger, whenever all its details and after-treatment are performed with strict antiseptic precautions. But the surgeon must have patience to attend to all the little details of the antiseptic method, on each of which the life of a patient may depend.

The object of excision of the knee-joint is obvious. It is to save a limb that otherwise must be lost sooner or later by amputation, this latter operation being finally required in cases where recovery is hopeless by abatement of the inflammation or by such firm ankylosis in a false position as will not give the patient a useful limb.

* R. Volkmann: “Die Resectionen der Gelenke," Sammlung klin. Vorträge, 1873, No.

31, p. 291.

By this operation we create a firm ankylosis which the patient can use continuously without pain or fatigue.

The question now is, can we accomplish this purpose of the operation without months of confinement and suffering in bed for the patient, with such abundant suppuration as would endanger his life from exhaustion, amyloid degeneration of the kidneys, liver, and spleen, even if he should escape pyemia?

From Hodges' statistics, Gant puts the average time of after-treatment at eight months. This is a long time if the patient must remain in bed and sustain a constant suppuration.

Fortunately, this is not the case. As soon as a solid osseous union has taken place between the cut ends of the femur and tibia, we may allow the patient to be about on crutches. Fergusson has had patients up in this way in three to six weeks after the operation; but such cases are regarded as fortunate exceptions. Holmer had his patients up and on crutches after three or four months.

Under the Lister dressing suppuration is sometimes reduced to a mere trifle, generally to a moderate amount; so there is no danger from exhaustion.

If, then, the patient can expect to be up after an average of three months, and be sure of a useful limb after another three or six months, he is far better off than he could be without the operation.

Tuberculosis of the knee-joint. Excision by Dr. Ch. Fenger.

James C., aged fifteen years, clerk (in chair factory), entered Cook County Hospital July 15, 1879. None of his relations have suffered from consumption or cancer. Had measles and typhoid fever in childhood; always healthy since. Two years ago he received a kick from a playfellow upon his left knee. Pain disappeared in a few days and there was no swelling. Three or four months later the knee-joint began slowly to swell and be occasionally painful, and motion became gradually impaired. The joint felt to him stiff. The knee remained in this condition about six months, during which time he could walk, run, and jump without much pain. Then one day, when jumping, he suddenly felt severe pain in the joint, and he was obliged to sit down two hours. The pain gradually subsided, and soon he was able to run about again for a short time. But gradually the swelling increased, pain came on, and he got easily tired.

About a year ago abscesses formed and opened on the outer and inner sides of the joint, near the hamstring tendons. Fistulas were left which discharged six months; they closed, to break open later again and again close up. No spicules of bone were discharged to his knowledge.

Contracture now came on, and the leg was at last flexed at nearly a right angle, and motion was limited to 20 degrees. In spite of this condition he could, most of the time, hobble about, bearing some weight on the leg; but the leg easily tired, and on stepping upon an uneven surface or jarring the knee, pain was produced. He is constantly afraid to have any one come near the limb for fear of hurting it.

On July 3d (twelve days ago), while at work, a sudden pain came on and the knee got worse. Now any considerable motion causes pain. In perfect quiet pain is absent. As to previous treatment, he says at one time a doctor tried to aspirate the joint, getting no fluid. Another time a blister was applied over the joint, with the effect of ameliorating the condition.

He is now slender, pale, and lean. The heart, lungs, and abdominal organs are

healthy. The urine has no sugar or albumin. The left knee is enlarged, forming a prominent round tumor. The joint is flexed to about 110 degrees, and motion is allowed of only 10 degrees; attempts to increase the range of this causes pain.

The relative position of the crus to the thigh at the joint is that of genu varum— knock-knee. This means a partial dislocation, due to weakening or partial destruction of the internal lateral ligaments. On the sides of the joint are depressed reddish spots, the seats of the closed sinuses. The patella is immovably fixed to the fossa of the condyles of the femur. The swollen soft tissues form a uniform, softish, somewhat elastic mass, like india-rubber of medium hardness. There is no fluctuation or other evidence of fluid in the capsule or outside the joint. Pressure upon the mass does not cause pain, except at two points on the sides corresponding to the spaces between the joint surfaces covered by the lateral ligaments.

We have here a chronic fungous arthritis or white swelling.

The constituents of the joint are already partially destroyed, as prove the adherent patella and weakened internal ligaments and the partial ankylosis, i. e., the impaired motion.

We have now to ask what would be the result of this case without operation.

The destructive inflammation here has been slowly progressing; motion has grown less and less, partly from tenderness and pain, partly from false position. We have for the three weeks he has been in the hospital tried gradual extension (by weight and pulleys) to correct the flexion, and hot fomentations for the pain. The treatment has not had the slightest effect. We then have left the choice between forcible extension of the joint under anesthesia, and immobilization with plasterof-Paris or starch, and excision.

The liability of the inflammation at the bottom of the old sinuses to be lighted up anew speaks against immobilizing bandages. They would have to be removed at intervals. This would make recovery by ankylosis in good position unlikely to occur. This treatment would probably be interrupted by abscesses that might extend up and down between the muscles and make amputation necessary, and excision, if it was to be made, much more uncertain of a good result.

The age of the patient is in favor of excision, and a solid union of the bones with diseased soft parts removed is decidedly preferable to a more or less complete ankylosis with diseased tissues remaining between and around the epiphysis of the bones, because in this case there would always be a liability to a relapse of the inflammation.

Excision being then decided on, the next question is the plan of operating.

1. Esmarch's bandage for operating without blood-shed should be used when there is no danger of pressing pus or infectious thrombi of the veins up into the healthy soft parts above the seat of operation. As there are no abscesses and no edema, we shall use it here. Besides avoiding blood-loss, this method enables us to distinguish the character of tissues with much more exactitude than we could without it. It is not only consistence but color that indicates what tissues are to be removed and what not. The well-known light yellowish-gray color of cheesy

matter means fatty degeneration of the tissue-that it is dead or dying and must be removed.

2. The incision that gives the easiest access to all the different parts of the joint is the semilunar cut, commencing at the tuberosity of one of the condyles of the femur; a right-handed operator will commence it at the internal condyle of the right knee and the external of the left, coming down toward the tuberosity of the tibia and returning to the other condyle. It divides the inferior patellar ligament and subjacent adipose tissue. These parts lifted up give an easy access to the joint.

3. After division of the lateral and crucial ligaments a forcible flexion of the joint will show us the condition of the joint and enable us to bring the epiphyses to turn out, so that the diseased part may be sawed off. For this purpose we use Butcher's saw and cut the femur from the joint backward.

As to the line of the cut, if this is parallel to the line uniting the lowest points of the two condyles, we will remove too much of the external condyle and get, after coaptation, a position of knock-knee. If we cut in a line perpendicular to the longitudinal axis of the femur, we remove too much of the internal condyle, and the opposite deformity is the result, i. e., bow-legs. Linhard advises to cut just between the two lines described. Of the epiphysis of the tibia we remove a disc, cutting from the posterior surface anteriorly and parallel to the articular surface.

As to the thickness of the discs to be removed, we should remove all the bone diseased, but not a particle more. We should endeavor, furthermore, to have two even surfaces of equal size of bone, that perfect union by first intention may, if possible, take place.

In children the epiphyseal line has a certain importance for the future growth in length of the bones of the limb. If possible, we should spare the whole or a part of the epiphyseal cartilage. Anatomic investigations by Giraldès place the limits beyond which we are not to go as follows: In the condyles of the femur, 2 cm.; in the intercondyloid fossa, 1.5 cm.; in the tibia, 1.5 cm. Still more exact details are given by König.* The epiphyseal line is situated in a child of eleven as follows (from the articular surfaces): Internal condyle of femur, 2.4 cm.; external condyle, 2.1 cm.; anterior portion of intercondyloid fossa, 1.6 cm.; posterior part, 1.4 cm.; anterior part of tibia (near tuberosity), 3.8 cm.; posterior part, 1.5 cm.; medium inner part, 1.5 cm.; external lateral half, 1.4 cm. Each additional year adds 1 mm. to the depth of the epiphyseal cartilage. In the present case we shall cut off 2 cm. of the femur and 2 to 1 cm. of the tibia, and then, if the surfaces are healthy, unite them; if local diseased foci are present, scoop them out with the gouge rather than remove a larger portion of the epiphyseal cartilage. Should the whole epiphysis, clear to the medullary cavity, be diseased, we may have to amputate.

The patella, if diseased, is to be removed. If not, shall it be left? From Pénière's statistics we learn that saving the patella raises the deathrate 30 per cent., and more than doubles the chances for the necessity

* Langenbeck's Archiv, 1867, ix, p. 177.