Manual of Surgery Volume II Part 25

The indications for _operative treatment_ are: (1) marked symptoms of destruction of the articular cartilages; (2) a deformed att.i.tude incapable of being rectified without operation; (3) a condition of the general health which requires that the disease should be got rid of as speedily as possible; (4) progress or persistence of the disease in spite of conservative treatment. When there is no prospect of recovery with a movable joint it is a waste of time and a possible source of danger to persevere with conservative measures. Operation permits of the disease being eradicated and the restoration of a useful limb within a reasonable time, averaging from three to six months.

In adults, the operation consists in excising the joint; in children the aim is to remove the diseased tissues without damaging the epiphysial cartilages.

Amputation is performed when the disease has relapsed after excision and there is persistent suppuration, and when life is threatened by the occurrence of tuberculosis in the lungs or elsewhere.

#Treatment of Deformities resulting from Antecedent Diseases of the Knee.#--Flexion is the commonest of these; when due to contracture of the soft parts, these are either stretched by degrees, the limb being encased in plaster after each sitting, or they are divided by open dissection in the popliteal s.p.a.ce. If there is fibrous or osseous ankylosis, the choice lies between arthroplasty, the removal of a wedge of bone which includes the joint, or, in patients who are still growing, of a wedge from the femur above the level of the epiphysial cartilage. Backward displacement of the tibia, genu recurvatum, and genu valgum also require operative treatment.

OTHER DISEASES OF THE KNEE-JOINT

#Pyogenic diseases# result from infection through the blood stream, from one of the adjacent bones, or from a penetrating wound of the joint. The commoner types include the _synovitis_ a.s.sociated with disease in the adjacent bone, _acute arthritis of infants_, joint suppuration in _pyaemia_, _pyogenic arthritis_ following upon penetrating wounds, and the affections which result from _gonorrhal_ or _pneumococcal_ infection.

_Treatment._--The limb is immobilised on a posterior splint so padded as to allow slight flexion at the knee, and extension applied with sufficient weight to relieve the pain; it is also of benefit to induce hyperaemia by one or other of the methods devised by Bier. To tap the joint, the needle is introduced obliquely into the supra-patellar pouch, and if it is necessary to open the joint, the incision is made on one or on both sides of the patella, and Murphy's plan of inserting formalin-glycerine may be employed. If the infection progresses and threatens the life of the patient, it may be necessary to lay the joint freely open from side to side, sawing across the patella, and, the limb being flexed, the whole wound is left open and packed with gauze. As the infection subsides, the limb is gradually straightened.

If these methods fail, amputation through the thigh may be the only means of saving life.

#Arthritis deformans# affects the knee more frequently than any of the other large joints. The changes related to the synovial membrane here attain their maximum development, and may a.s.sume the form of hydrops with or without fibrinous bodies, or of overgrowth of the synovial fringes and the formation of pedunculated loose bodies. It is suggested that these synovial changes follow upon repeated sprains or upon a previous pyogenic infection of the joint. The effusion and stretching of the ligaments that follow upon a sprain are incompletely recovered from; the synovial membrane becomes puckered, the quadriceps atrophies and no longer puts the ligamentum mucosum on the stretch; and the infra-patellar pad of fat, not undergoing the normal compression during extension, is readily nipped between the femur and tibia. Each nipping implies a fresh sprain, with return of the effusion, and so a vicious circle is set up which terminates in what has been called a _villous arthritis_, with fringes and loose bodies; in time, the articular cartilage at the line of the synovial reflection undergoes fibrillation and conversion into connective tissue, and the process spreading to the articular surfaces, the picture of a rheumatoid arthritis is complete. Fibrillation of the cartilage imparts a feeling of roughness when the joint is grasped during flexion and extension, and lipping of the margins of the trochlear surface of the femur may be felt when the joint is flexed; it is also readily seen in skiagrams. When a portion of the "lipping"

is broken off, it may give rise to a loose body. In advanced cases with destruction of the cartilages, there may be movement from side to side, with grating of the articular surfaces.

In the early stages, treatment consists in limiting the movements of extension by means of a splint provided with a hinge that locks at thirty degrees from full extension and vigorous ma.s.sage of the quadriceps. In the dry, creaking forms of arthritis, the symptoms are relieved by introducing liquid vaseline into the joint. When the symptoms are due to the presence of fringes and loose bodies, these may be removed by operation. When the disease is of a severe type, and is confined to one knee, the question of excising the joint may be considered.

_Bleeder's knee_, _Charcot's disease_, _hysterical knee_, and _loose bodies_ in the joint have already been described.

THE ANKLE-JOINT

There is a common synovial cavity for the ankle and the inferior tibio-fibular joints. The epiphysial cartilage of the tibia lies above the level of this synovial cavity, but that of the fibula is included within its limits (Fig. 93). The talus is related to three articulations--the ankle above, the talo-navicular joint in front, and the calcaneo-taloid joint below. The tendon sheaths, especially those of the peronei and of the tibialis posterior, are liable to be infected by the spread of infective disease from the joint.

#Tuberculous Disease.#--Tuberculous disease at the ankle is met with at all ages. In the majority of cases the disease affects both bone and synovial membrane. Gross lesions in the bones are comparatively rare, and are chiefly met with in the head or neck of the talus.

_Primary synovial disease_ usually exhibits the features of white swelling, projecting beneath the extensor tendons on the dorsum, and, posteriorly, filling up the hollows on either side of the tendo Achillis and below the malleoli (Fig. 126). The foot may retain its normal att.i.tude, or the toes may be pointed and adducted. The calf muscles are wasted, there is little complaint of pain, and the movements of the joint may be so little interfered with that the patient can walk without a limp. When the disease involves the articular surfaces, there is pain and sensitiveness, the movements are restricted or abolished, and the patient is unable to put the foot on the ground.

[Ill.u.s.tration: FIG. 126.--Tuberculous Disease in a man aet. 35, of six weeks' duration.]

_A primary focus in the bone_ causes localised pain and tenderness, and a limp in walking, but the first sign may be the formation of abscess or the rapid development of articular symptoms. In such cases skiagrams afford valuable information.

Abscess formation is an early and prominent feature, whether the disease is of osseous or synovial origin, and sinuses are liable to form around the joint. Outlying abscesses and sinuses are usually the result of infection of the tendon sheaths in the neighbourhood.

_Diagnosis._--When teno-synovitis occurs independently of disease of the ankle, the swelling is confined to one aspect of the joint. In sarcoma of the lower end of the tibia, the swelling lacks the uniform distribution of that met with in joint disease. In Brodie's abscess of the lower end of the tibia there may be swelling of the ankle, but there is an area of special tenderness on percussion over the bone.

_Treatment._--The foot is immobilised at a right angle to the leg by splints or plaster of Paris; if articular symptoms are absent or have subsided, a Thomas' knee splint should be applied to enable the patient to move about without bearing his weight on the affected foot (Fig. 125). To inject iodoform, the point of the needle is inserted below either malleolus, and is then pushed upwards alongside of the talus. If localised disease in one of the bones is recognised before the joint is infected, it should be eradicated by operation.

When the disease is diffuse and resists conservative treatment, excision should be performed, the articular surfaces of the const.i.tuent bones being removed, and if necessary the whole of the talus.

Amputation is only called for in adults with rapidly progressing disease and diffuse suppuration, and in cases which have relapsed after excision.

The other diseases of the ankle include _pyogenic_, _gonorrhal_, _rheumatic_, _gouty_, and _hysterical_ affections, _arthritis deformans_, and _Charcot's disease_. The last-named is generally a.s.sociated with a rapid and painless disintegration of the bones of the ankle and tarsus, resulting in great deformity and loss of the arch of the foot--sometimes a.s.sociated with perforating ulcer of the sole.

Tuberculous disease in the #tarsus#, #metatarsus#, and #phalanges# has been considered in the chapter on Diseases of Bone.

CHAPTER X

DEFORMITIES OF THE EXTREMITIES

The origin of deformities: (1) Those arising before birth; (2) those produced during birth; and (3) those acquired after birth.

Palsies of children: _Anterior Poliomyelitis_. Cerebral palsies: _Spastic paralysis_.

THE LOWER EXTREMITY: Congenital dislocation of hip--Snapping hip--Paralytic deformities--Contracture and ankylosis of hip--c.o.xa vara and c.o.xa valga--Congenital dislocation of knee and patella--Genu recurvatum--Paralytic deformities--Contracture and ankylosis of knee--Genu valgum and genu varum--Congenital deformities of leg--Bow-leg--Club-foot: _Talipes equino-varus_; _Pes equinus_; _Pes calcaneus_; _Pes calcaneo-valgus and varus_; _Pes cavus_; Flat-foot and pes valgus--Painful affections of heel--Metatarsalgia--Hallux valgus and bunion--Hallux varus--Hallux rigidus and flexus--Hammer-toe--Hypertrophy of toes--Supernumerary toes--Webbed toes.

THE UPPER EXTREMITY: Congenital absence of clavicle--Elevation of scapula--Winged scapula--Congenital paralytic deformities of shoulder--Deformities of elbow--Club-hand--Deformities of wrist--Madelung's deformity--Deformities of fingers--Dupuytren's contraction--Polydactylism.

The surgery of the extremities is so largely concerned with the correction of deformities that it is necessary at the outset to refer briefly to some points relating to the time and mode of origin of these.

1. _Congenital deformities_--that is, those which originate _in utero_ and are present at birth--are comparatively common and may be due to a variety of causes. Some result from errors of development--for example, supernumerary fingers or toes, and deficiencies in the bones of the leg or forearm. A larger number are to be attributed to a persistent abnormal att.i.tude of the ftus, usually a.s.sociated with want of room in the uterus--for example, the common form of club-foot and congenital dislocation of the hip. Less frequently amniotic bands so constrict the digits or the limbs as to produce distortion, or even to sever the distal part--_intra-uterine amputation_. Lastly, certain diseases of the ftus, and particularly such as affect the skeleton--for example, achondroplasia--cause congenital deformities.

2. _Deformities originating during birth_ are all traceable to the effects of injuries sustained in the course of a difficult labour.

Examples of these are: wry-neck resulting from rupture of the sterno-mastoid; lesions of the shoulder-joint and brachial plexus due to hyper-extension of the arm; a spastic condition of the lower limbs--Little's disease--resulting from tearing of blood vessels on the surface of the brain with haemorrhage and interference with the function of the cortical motor area.

3. _Deformities acquired after birth_ arise from widely different causes, of which diseases of bone, including rickets, diseases of joints, and affections of the nervous system attended with paralysis, are amongst the commonest. Other deformities are produced by unsuitable clothing, such as a tight corset, or ill-fitting shoes distorting the toes, prolonged standing in growing subjects overstraining the mechanism of the foot and giving rise to the common form of flat-foot.

The part played by the palsies of children in the surgical affections of the extremities necessitates a short description of their more important features.

#Anterior poliomyelitis# is the lesion underlying what was formerly known as _infantile paralysis_--a name to be avoided, because the condition is not confined to infants and it is not the only form of paralysis met with in young children. Anterior poliomyelitis is characterised by an illness attended with fever, in which the child is found to have lost the power of one, less frequently of both lower extremities; or, it may be, of one or both arms. After a period, varying from six weeks to three months, the paralysis tends to diminish both in extent and degree, and in the majority of cases it ultimately persists only in certain muscles or groups of muscles. At the onset of the paralysis the affected limb is helpless and relaxed, the reflexes are lost, the muscles waste, and those that are paralysed exhibit the reaction of degeneration. In severe cases, and especially if proper treatment is neglected, the nutrition of the limb is profoundly affected; its temperature is subnormal, the skin is bluish in cold weather and readily becomes the seat of pressure sores. In course of time the limb lags behind its fellow in growth, and tends to a.s.sume a deformed att.i.tude, which at first can easily be corrected, but later becomes permanent.

[Ill.u.s.tration: FIG. 127.--Female child showing the results of Poliomyelitis affecting the left lower extremity; the limb is short and poorly developed, the pelvis is tilted and the spine is curved.]

When the acute stage of the illness is past, the chief question is to what extent recovery of function can be looked for in the paralysed muscles.

It would appear to be established that if a muscle reacts to faradism it will recover, but the contrary proposition does not follow. It was formerly accepted that a muscle which exhibits the reaction of degeneration is incapable of recovery, but observation has shown that this is not the case. Complete destruction of the motor cells in the anterior horn of grey matter as a result of poliomyelitis is now known to be exceptional; as a matter of fact, damage to the nerve cells is usually capable of being repaired. The muscles governed by these cells may appear to be completely paralysed, but with appropriate treatment their functional activity can be restored. As functional disability is frequently due to the affected muscle being _over-stretched_, it is of the first importance, when the acute symptoms are on the wane, that every care should be taken to prevent the weak muscular groups being put upon the stretch, and the greatest attention should be paid to _the posture of the limb during convalescence_. For example, if the child is allowed to lie with the wrist flexed, the flexor muscles undergo shortening, and the extensors are over-stretched and are therefore placed at a mechanical disadvantage. As the inflammatory changes in the anterior horn of the cord subside, the flexor tendons, from their position of advantage, are in a condition to respond to the first stimuli that come from their recovering motor cells, while the extensors are not in a position to do so. If, on the other hand, the wrist and fingers are maintained in the att.i.tude of extreme dorsiflexion, the extensors become shortened, and, relieved of strain, they soon begin to respond to the stimuli sent them from the recovering nerve cells. Similarly in the lower extremity, when, for example, the muscles innervated through the peroneal (external popliteal) nerve are paralysed, if the foot is allowed to remain in the att.i.tude of inversion with the heel drawn up--paralytic equino-varus--an att.i.tude which is rendered more p.r.o.nounced by the pressure of the bedclothes, the chance of the muscles recovering their function is seriously diminished. Another potent factor in preventing recovery, especially in the lower limbs, is _erroneous deflection of the body weight_. If, for example, there is weakness in the tibial group of muscles, and the child is allowed to walk, the eversion of the foot will steadily increase, the tibial muscles will be more and more stretched, the opposing peroneal muscles will shorten, and, in time, the bones of the tarsus will undergo structural alterations which will perpetuate the deformity. If, on the other hand, by some alteration of the boot, the foot is maintained in the att.i.tude of inversion, the weakened or paralysed tibial muscles are placed in a much more favourable condition for recovery.

It must be emphasised that no operation should be performed in these cases until the question whether it be possible or not to restore the apparently paralysed muscle is settled. The clinical test of the recoverability of a muscle is to keep it for a long period--six or even twelve months--in a condition of relaxation. This test should be made, no matter how many months or years the muscle may have been paralysed.

The first stage in the treatment, therefore, is the correction of existing deformity, after which the limb should be kept immovable until the ligaments, muscles, and even the bones have regained their normal length and shape. The slightest stretching of a muscle which is in process of recovery disables it again.

The age of the patient influences the method of treatment. In young children in whom the structures are soft and yielding, gradual correction of the deformity is to be preferred to the more rapid methods employed in older children. The proper sequence consists in correcting the deformity, providing the simplest apparatus to keep the limb in good position, preventing erroneous deflection of body weight during walking, and then allowing the child to grow and develop until he has reached the age of five before considering such an operation as transplanting tendons, and the age of ten before deciding to ankylose a flail-like joint.

_Reposition, Manipulations, Supports._--An attempt is made to correct the deformity by manipulation, and the proper att.i.tude is maintained by a mechanical support. If the foot has become rotated so that the sole looks laterally, the medial side of the boot must be raised, and an iron worn which extends from the knee down the lateral side of the leg, to end, without a joint, in the heel of the boot. In pes equinus, the iron is let into the back of the heel and extends forwards into the waist of the boot, to keep the foot at right angles to the leg and to relax the weak extensor muscles.

_Division of Contractions._--Bands of fascia and contracted tendons which prevent correction of deformity may have to be divided or lengthened. This is best done by the open method.

_Removal of Skin._--To a.s.sist in maintaining the desired att.i.tude, Jones recommends the plan of excising an area of the redundant skin on the weaker aspect of the limb; in equinus, the skin is taken from the dorsum; in equino-varus, from the front and lateral aspect of the foot. When the edges of the gap have united, the foot is maintained in the desired att.i.tude for some months, even if parents carelessly remove the iron support to let the child run about.

_Tendon transplantation_, a procedure introduced by Nicoladoni, is to be considered in children of five and upwards. It may be employed for different purposes: (1) To reinforce a weak muscle by a healthy one--for example, by transplanting a hamstring tendon into the patella to reinforce a weak quadriceps, or reinforcing the weak invertors of the foot by a transplanted extensor hallucis longus. (2) Transplantation may also be performed to replace a muscle which is quite inactive and does not show any sign of recovery--for example, the tibiales being paralysed, the peroneus longus may be implanted into the navicular or first metatarsal to act as an invertor of the foot.