317
SECTION I
GENERAL SURGERY
CHAPTER XIII
WOUNDS
OF JOINTS
The experience gained in the World War
resulted in striking changes in the treatment of
wounds of joints caused by projectiles. During the early years of the
war poor results usually
followed these lesions by reason of an undervaluation, on the part of
surgeons, of the resistance
to infection which the synovial membrane of a joint offers, a failure
to comprehend the proper
operative procedures, and the universal employment of prolonged
immobilization. But in the last
18 months or 2 years methods of treatment were adopted in the allied
armies which gave results
far superior to any that preceded.
PREOPERATIVE MANAGEMENT
Although
attention must be focused upon the operative treatment as the most
important
factor, the preoperative management of the patient can not be
disregarded. As soon as possible
after the receipt of the wound a first-addressing should be applied.
Active hemorrhage, as a rule,
can be controlled by a light pressure bandage over the dressing. This
failing, a tourniquet may be
applied. It must be emphasized, however, that a tourniquet is a
dangerous accessory. It should be
applied close to the wound, and should be removed as soon as possible.
It is essential in joint
wounds that the part be immobilized before the patient is moved. In a
large proportion of cases,
especially when associated with fracture, traction also should be
applied.
For
transportation in the advanced area the following splints are advisable:a For
fractures involving the knee joint the Thomas leg splint and the hinged
half-ring modification
(Blake-Keller) are applicable. A litter bar attached to the stretcher
supports the injured limb
during transportation. For slight injuries of the knee joint without
marked effusion, also for
injuries to the ankle and tarsus, the Cabot posterior wire leg splint
is advisable. This splint
provides immobilization only. For injuries of the hip joint the Thomas
traction leg splint or the
long Liston splint should be used. For injuries involving the shoulder
and elbow the hinged
modification of the Thomas arm splint is useful when fixation and
traction are desirable. The
advantage of this splint is that the injured limb may be brought to the
side of the body for
recumbent transportation, which can not be done with the ordinary
Thomas arm splint. For the
smaller joints, which need only immobilization, the ladder splint or
the wooden coaptation splint
may be used.
The
wounded are received at a front hospital. for instance, a mobile
hospital or an
evacuation hospital, from about 4 hours to 24 hours or more after the
receipt of injury. Their
previous treatment, besides a first-aid dressing for the wound and a
temporary splint for
immobilization, has consisted in the administration of antitetanic
serum and appropriate
treatment for those pre-
a Manual
of Splints and
Appliances for the Medical Department of the United States Army,
1917.
318
senting a condition of shock. The patients on
arrival at the hospital present various degrees of
shock, hemorrhage, laceration of soft parts, and associated lesions.
The wound or wounds
contain pathogenic microorganisms and, in most cases, foreign bodies.
The devitalized tissues
provide an admirable medium for the growth of microorganisms which,
however, lie dormant for
a time, roughly from 6 to 8 hours, after which they become active and
infection progresses with
variable rapidity and intensity.
INDICATIONS
FOR OPERATION
All
wounds of joints by projectiles, except certain perforating
(through-and-through)
wounds by bullets, should be operated upon. Perforating bullet wounds
are not operated upon if
the wounds of entrance and exit are punctate and there is no evidence
of displacement of
fragments or of hemorrhage. Punctate wounds are made by a bullet of
high velocity with no
explosive effect and no deflection during its course through the limb.
In such eases the bullet
cuts through clothing and tissues, carrying few organisms into the
wound and producing little
destruction of soft tissues or comminution of bone. Experience proved
that under these
conditions infection rarely occurs even when a fracture is present.
Therefore these cases do not
demand immediate operation. They should, however, be carefully watched,
and distention of the
joint should be treated in the manner described in the after-care of
operated cases.
In
all other cases operation should be performed as soon as possible after
the receipt of
the injury. Delay increases the danger of and from infection by reason
of the bacterial types
which are usually present and the characteristics of their growth and
penetration in the tissues.
But before operation certain preliminary precautions are essential.
Thus: A careful examination
by the surgeon of the patient and his lesions is essential. The general
examination should be
sufficiently thorough to preclude the possibility of overlooking a
serious associated lesion. The
degree of bone involvement and the presence and position of retained
foreign bodies should be
established by the X ray. The surgeon should satisfy himself as to
whether there is or is not a
nerve lesion; this is especially important in the upper extremity. He
must also examine for arterial lesions, especially in wounds of the
lower extremity; the presence or absence of the
anterior and posterior tibial pulse should be noted. Moreover, the time
elapsed since the wound
was received, the situation of the wound, the extent of injury to the
soft parts, and the general
condition of the patient are factors which must be weighed before a
plan of action can be decided
upon.
ROENTGENOLOGIC EXAMINATION
The
success of the operation depends largely upon the thoroughness of the
roentgenologist's examination and the accuracy of his findings. His
report should be made
according to a definite system. The following routine has been found
the most satisfactory:
Anatomic site
and size of each foreign body in millimeters, depth in millimeters,
position
of the part, if it is not in the anatomic position; bone lesions. For
example: "Right knee, F. B 10
by 15 mm., 50 mm. in depth, under the point marked on the skin, the
limb being in 45 degrees
outward rotation; comminuted fracture of internal condyle; no
displacement."
319
PREPARATION
OF PATIENT
The
local preparation is usually done in the operating room on an extra
table while the
preceding operation is being completed. The wound being protected with
gauze, the surrounding
skin is shaved and scrubbed with soap and water. Application of
chemicals may follow. The
usual procedure is to cleanse with ether, following this with the
application of tincture of iodine.
It is important to prepare a wide field; even to encircle the limb. The
part is draped with towels
and sheets.
A
general anesthetic should be employed save in exceptional cases.
Nitrous oxide-oxygen, administered by an expert anesthetist, is the
least harmful. It should be the anesthetic of
choice for patients in a condition of shock. Ether, however, is
employed in routine cases.
After
careful consideration of the factors enumerated above the surgeon
should proceed
as far as possible in accordance with a definite plan. The choice
between amputation and
conservation of the limb should be made, if possible, before the
operation is begun, so that the
patient may be spared futile efforts to save the limb. Irreparable
mutilation of the soft parts,
excessive comminution of bone, wounds of the main vessels of the limb,
especially in the lower
extremity, irremediable injury to essential nerves, or advanced gas
bacillus infection, are the
main features which call for the consideration of amputation. The
condition of the patient is
often the deciding factor. But the results of conservative treatment
are sufficiently good to weigh
in its favor in cases of doubt. Amputation is indicated in a relatively
small percentage of cases.
Conservative
operative treatment of recent wounds of joints has for its object,
first, the
prevention of infection; second, the preservation of function.
The
important features are thorough débridement, complete closure of the
joint, and
early movements.
The
adoption of these principles by our Allies in the war of 1914-18
followed three well-defined stages: 1. Débrideinent; drainage; irrigation with
antiseptic solutions;
immobilizations. 2. Débridement; Carrel-Dakin treatment of the joint;
immobilization. 3. Débridement; lavage of the joint with Dakin's
solution or ether; joint suture, with drainage of
the joint for about 24 hours; immobilization; passive movements and
massage in 8 to 10 days.
During
the development of these methods the results improved progressively,
but were
not satisfactory, as was demonstrated by Depage1 at La
Panne, Belgium, where these procedures
were conscientiously carried out and the results analyzed. It was
recognized early in the war that
the main features which are of importance in the treatment of battle
casualties of other types,
particularly early operation and thorough débridement, are likewise
indicated in the treatment
of wounds of the large joints. But, whereas in other types of wounds it
is often advisable to leave
the wound unsutured and to supplement the operative treatment by
chemical sterilization before
proceeding to a final closure, it was found that an unsutured joint in
general did not progress
satisfactorily. In such cases postoperative chemical sterilization
could not be depended upon, and
the introduction into the joint of drains, such as rubber
320
tubes, was found to result disastrously, in
that they often introduced infection and caused
pressure necrosis, thus diminishing the resistance of the synovial
membrane and articular
cartilage to infection. Moreover, they failed to accomplish their
purpose, that is, to drain the
joint. Immediate closure of the joint by suture was found to be
essential to success. Therefore
the surgeon must rely upon the primary operation for the prevention of
intra-articular infection,
which is the immediate aim of conservative treatment. The important
factor being the débridement of tissues, the principles of this, as
applied to wounds of the soft, parts, bones,
and cartilage, must be fully understood.
TECHNIQUE
The
details of a conservative operation may be summarized as follows:
Complete débridement of the tract of the projectile through the soft
parts and bone; removal of foreign
bodies; thorough irrigation of the joint; absolute closure of the joint
by suture: primary or delayed closure of the superficial parts
according to the rules laid down for primary suture of the
soft parts alone; finally, early active motion.
The incision
or incisions, must be placed so as to permit not only thorough
débridement of the soft parts but also free access to the foreign body
and involved bone. Though no rules can be formulated, longitudinal
incisions are to be preferred when
FIG. 174.- Gunshot Wound of
knee. A, Incision
for débridement practicable: however, the position of wound of
entrance; B, incision to expose retained foreign of the wound or wounds
and that body. (See fig. 175.) (Keen's
surgery)
of the foreign body are, in general. the
determining factors. The primary incision includes the
wound of entrance and is often supplemented by a second incision. In a
perforating wound the
second incision usually includes the wound of exit; in a penetrating
wound it is placed in such
position as to expose a retained foreign body which otherwise would be
inaccessible. The
incisions must be of sufficient length to give adequate exposure. (Fig.
174.)
321
Through
these incisions débridement of the soft parts (fig. 175) proceeds as in
operations
elsewhere. The technique is practically the same as for wounds of the
soft parts alone, but the
refinements of technique in respect to a sepsis and adequate exposure
must be fully observed,
and traumatization of the synovial membrane should be reduced to a
minimum.
It
is sometimes difficult to identify the opening in the capsule or even
to determine
whether the joint has been penetrated. This difficulty is met most
often in the case of small
perforating and penetrating wounds with little or no bone involvement
in which a fragment of
shell has either perforated the limb, traversing the joint in its
course, or, has penetrated the joint
and lodged in it or in adjacent tissues. But, after the capsule has
been exposed in the débridement, the orifice into the joint must be
demonstrated before the joint is opened. Great care should be exercised
to avoid opening a joint that is uninvolved, and, similarly, not to
neglect proper operative measures in a joint that is involved.
The capsule
and synovial membrane should be opened by a liberal incision with
thorough elliptic excision of or contaminated tissue, conserving,
however, all tissues that can be
left safely. Foreign bodies must be removed. The subsequent steps
depend upon the presence or
absence of a bone lesion. If none exist, the joint is irrigated and
closed; if a bone lesion is
present, it must be appropriately treated before closure of the joint. If none exist, the joint is
irrigated and closed; if a bone lesion is present, it must be
appropriately treated before closure of the joint.
In
all cases contaminated bone surfaces must be cleaned as thoroughly as
possible; that
is, treated on the principle of removal of contaminated tissue.
FIG. 175.- Gunshot
wound of knee. Outer
side: After
débridement of wound and opening of capsule. Dotted lines
indicate extent to which capsule has been opened. Inner
side: Arthrotomy to reach foreign boy in internal condyle.
F, Femur, internal and external condyles, with gutter wound débrided;
C, capsule; VE, vastus externus; ITB iliotibial band; VI, vastus
internus; B, biceps femoris. (Keen's surgery)
322
This is done with gouge,
chisel, or curette,
with the sacrifice of as little bone as possible.
An
intra-articular wound of the bone or cartilage, such as a gutter,
depression, or canal
without complete fracture, constitutes the simplest type of lesion. The
bone wound should be
cleansed as above described.
When
there is an injury to an articular surface consisting in a limited and
incomplete
separation of a laver of cartilage with a thin layer of underlying
bone, it is advisable to remove
the partly separated and poorly nourished cartilage, and with chisel,
gouge, or curette to cleanse
the surface from which it has been detached.
Where
a fracture line has resulted in partial detachment of a large fragment
of bone with
its articular surface, but the fragment retains good contact with the
soft parts, it is left after the
tract has been followed and contaminated surfaces have been cleansed as
thoroughly as possible.
But under such conditions it is important that the fractured surfaces
be left in close contact. An
intervening space interferes materially with union, as Cotton
emphasized years ago.2
If
an attached fragment is to be removed, this should be done if possible
by the
subperiosteal method of Ollier, using the Lériche modification of the
sharp Ollier elevator. By
this method a reformation of the bone is more probable.
In
extensive involvement of the articular surfaces an effort should be
made to save the
joint, provided the conservable articular surfaces and soft parts are
sufficient to warrant a
reasonable hope of securing a useful joint. In this connection it must
be borne in mind that
stability is essential in the knee and ankle; that is, in the
weight-bearing joints.
When
there is such loss of the articular surfaces as to preclude obtaining a
useful joint,
resection should be elected. A classical resection should be done when
stability and rigidity are
desired, as in the knee; otherwise an atypical resection may be made.
The
final steps of the operation in all cases are as follows: Complete
hemostasis should
be secured. The joint is then thoroughly washed with salt solution to
remove blood clots, bone
fragments, and debris. Some operators recommend that this be followed
by lavage with ether
under sufficient pressure to distend the joint. However, this use of
ether is empiric; it is
questionable whether it exerts any beneficial influence. The synovial
membrane and capsule are
closed with fine chromic gut which should be, as far as possible,
extra-articular. When feasible,
these two layers should be sutured independently. Complete closure of
the joint without drainage
is the invariable rule.
When
there is such destruction of the soft parts that the edges of the
capsule can not be
approximated, if an attempt is to be made to save the joint, the defect
in the capsule should be
completely closed with muscle or fascia, using at pedunculated flap, if
necessary. In a few cases
in which this was impossible the writer has seen a partial closure made
and the wound treated by
the Carrel method, the aim being to close the joint subsequently by a
plastic operation. He has
not, however, seen this method successfully carried out without
infection.
323
The
soft parts overlying the capsule may be closed or left open for
subsequent suture. If
the ideal conditions--that is, early and thorough débridement--have
been
approximated and the
case can be watched for some days, primary suture may be made;
otherwise, the wound is left
open and sutured subsequently. In active periods, as during offensive
military operations, with a
consequent large number of wounded, the exigencies of the service
demand haste in the primary
operation, and the case must be evacuated and pass from the operator's
control soon after the
operation. Under such conditions primary suture of the superficial
tissues should not be
considered; it maybe employed only in quiet periods and in hospitals
where patients can be
watched. In this connection it must be urged that cases of wounds of
the large joints, e. g., knee,
should be included in the nontransportable class after operation, when
conditions warrant their
retention.
The
advantages of primary suture are obvious: the disadvantages consist
chiefly in the
danger of closing within a wound, especially within a wound imperfectly
débrided, pathogenic
microorganisms. A resulting gas bacillus infection or virulent pyogenic
infection in a few eases
will counterbalance many successful closures; moreover, primary suture
increases the danger of
joint infection by inward extension of a superficial infection. The
danger, however, is lessened if
interrupted silkworm sutures, placed at rather long intervals, are
employed for the approximation
of skin and subcutaneous tissues.
If
the soft parts are left open, vaseline-saturated gauze or other bland
nonadhering gauze
is placed along the edges of the wound so as to cover the skin edges
and subcutaneous tissues.
This prevents the dressing from adhering and lessens hemorrhage and
pain on its removal. Gauze
soaked in Dakin's solution is placed very loosely in the wound. It
should be so adjusted as not to
cause retention of secretions.
In
cases in which there is an extra-articular lesion of bone in
conjunction with a joint
lesion, the joint is treated and closed as described; the extra-
articular bone lesion is
appropriately treated and the wound of the soft parts is left open.
Every effort should be made to
close such a wound by delayed primary suture, because prolonged
exposure will often result in
infection, and infection will secondarily involve the joint.
POSTOPERATIVE
CARE
The
ultimate aim of treatment is to restore the individual to full
activity, with complete
restoration of function, in as short a time as possible.
EARLY ACTIVE MOBILIZATION
It
must be emphasized that early reestablishment of the function of the
part is dependent
upon early active mobilization. Before the war immobilization for a
considerable period after
operations upon joints was the usual practice. Complete loss of
function, limitation of function,
or delay in return of function frequently resulted.
Having
in view the early and complete reestablishment of functions, Willems,3 of
Hoojstade, Belgium, urged that postoperative immobilization should not
be employed, and
demonstrated the correctness of his claims by
324
a series of brilliant results. Other surgeons
were slow to accept his method to the extent of
adopting immediate mobilization with the elimination of all splinting.
But various operators
practiced short periods of immobilization, and subsequently inaugurated
movements at an
earlier date than was their former practice. Moreover, as the
beneficial results and relative
freedom from complications became evident, they gradually approached
and even followed Willems' plan. An example of the conservatism which
prevailed may be illuminating. Thus, in
1917, Cook 4 advised "that when the object of treatment is
mobility, and the a septicity of a case
has been provisionally established--I. e.. after the temperature has
been normal for about a week-light
FIG. 176.- A convenient
method of recording the range of motion. (Keen's Surgery)
movements are applied. Further treatment in
this direction is regulated by absence of reaction
and comparative freedom from pain."
The
writer was taught the Willems method at La Panne in the winter of
1917-18. The
method, however, was not at that time generally accepted, so in the
early work with the
American Expeditionary Forces at Evacuation Hospital No. he was
somewhat conservative in
its application. In general, he employed a splint for a brief period,
but enforced early movements
whenever practicable. As a means of recording the range of motion he
found it convenient to use
a diagram (figs. 176, 177). The date is entered on the are opposite the
degree of motion.
Dowden5 states without reserve that,
owing to the practice of
immobilizing joint lesions,
thousands of British soldiers have been rendered cripples for life. In
this respect views as to the
treatment of joint injuries have under-
325
gone a radical change as the result of the
experiences on an unprecedented scale in the recent
war.
It
may properly be urged that after operations for recent joint wounds
immediate
mobilization should be employed in all cases in which a fracture does
not contraindicate, or the
character of the wound of the soft parts is not such as to interfere
with repair of the wound. The
patient should be encouraged and directed to move the joint as soon as
the operator feels that this
can be done without interfering with tissue repair. For instance,
following a transverse wound
with removal or suture of the patella or after suture of an extensive
wound of the thigh, a period
of immobilization must be enforced. In the treatment of wounds
associated with fracture,
mobilization of the joint is not indicated if it is likely to interfere
with alignment or union or
promote excessive callus formation. But Willems 3 claims
that constant mobility prevents the
development of intra-articular callus and, therefore, is advantageous
FIG. 177.- The same
method as that shown in Figure 176, of recording motion in the elbow.
(Keen’s Surgery)
rather than harmful. On the other
hand, in the type of wound with little involvement of
bone and soft parts, a splint should not be applied. The patient should
flex and extend the knee
as soon as he has recovered from the anesthesia. The movements must be
active, not passive;
they should be as extensive and frequent as feasible. Little pain is
experienced if the movements are begun early. Supervision by a nurse
for the direction and encouragement of the patient
is essential. Willems 6 recommends that patients with
little or no bone injury should be out of
bed soon after the operation, even as early as the second day. In
wounds of the lower extremity
they are encouraged to walk, gradually increasing the amount from day
to day. Crutches and
cane are used at first, but are soon discarded. In the case of joints
of the upper extremity patients
are directed to scrub and sweep, gradually increasing the period of
work. In cases with a bone
lesion the patient is kept in bed for a longer period, the time being
roughly proportionate to the
degree of bone injury. In cases associated with fracture they are
326
encouraged to get out of bed and use the limb
as soon as this can be done without endangering
alignment and union. Early use of the joint is essential for early
restoration of function.
TREATMENT OF THE WOUND
A
wound which has been closed by primary suture should be examined within
24 hours;
moreover, the general condition of the patient should be carefully
watched. These precautions
can not be too strongly urged. If they are followed there is not much
danger of fatal infection; if
they are neglected, avoidable fatalities will occur.
Obviously,
one of the conditions of early restoration of function is the repair of
the
wound; therefore, when the soft parts have been left open, the wound
should be closed as soon
as possible by delayed, primary, or secondary suture. The distinction
between delayed primary
suture (Duval) and secondary suture is one of tissue repair rather than
of time. Delayed primary
suture is one in which the edges can be approximated and will unite
without excision of tissue;
this is, in general, about one week. Secondary suture is one in which
the epidermis has grown
inward and must be excised to permit proper union. In late secondary
sutures dense granulation
tissue must also be excised from the surface of the wound and the skin
must be mobilized. The
determination as to when a wound may be sutured depends upon
bacteriologic findings and clinical observation. The cooperation of a
bacteriologist is indispensable in making a decision as
to the indications for delayed primary and secondary sutures. In the
consideration as to whether
or not a wound is suturable reliance must be placed chiefly upon
cultures, the important feature
being the determination of the presence or absence of hemolytic cocci.
For this a routine blood-agar examination is essential.
Bacterial
counts are far from exact, yet they give an indication as to the degree
of
bacterial contamination of a wound, especially the progress from day to
day.
Eighteen
to 24 hours after the original d ebridement the wound is dressed and a
culture
and a smear are made. If no organisms are found, suture is indicated;
if hemolytic cocci are
present, suture is not considered. In the absence of hemolytic cocci,
if the wound is clinically
suturable, the presence of a few anaerobes or other organisms
(approximately one in two fields)
does not contraindicate suture. A considerable number of organisms of
any kind indicates the
necessity of caution. Suture in that event should be delayed and a
culture and a smear repeated at
the following dressing.
When
a wound is left open for a considerable time cultures and smears are
made at
regular intervals. The reports contain the approximate number of
organisms per field and the
varieties of organisms. When the organisms in two successive counts are
few, that is,
approximately one in two fields, and a culture shows an absence of
hemolytic cocci, the wound
is considered susceptible of secondary suture, except when the wound
has contained hemolytic
cocci at any time. In that case careful cultures are made from
granulation tissue and from the
discharge from all parts of the wound; and absence of hemolytic cocci
should be established by
two successive negative cultures before
327
suture is made. It has been observed that
streptococci are prone to lie dormant in small numbers
and to flare up and cause virulent infection after closure of the
wound.
Delayed
primary suture is usually made in from two to six days after the
primary
operation. The advantages are the practical elimination of gas bacillus
infection and marked
lessening of the danger of pyogenic infection. The disadvantages are
the possibility of
postoperative contamination of the open wound, the subjection of the
patient to a second
operation, and some interference with the institution of early
movements. However, these
disadvantages do not equalize the risk incurred by primary suture in
cases which can not be
carefully watched.
All
dressings of wounds after the primary operation should be made
according to the
Carrel-Dakin technique. The introduction of tubes to permit frequent
chemical disinfection with
Dakin's solution is indicated only in cases which are infected or which
are evidently destined to
be left open for a considerable time--that is, a week or more.
The
preoperative preparation of the wound for delayed primary or secondary
suture
consists in painting the skin with tincture of iodine after thorough
cleansing, as in the routine
dressing. Some operators also paint the wound surfaces.
POSTOPERATIVE INFECTION
Superficial
infection may require the removal of only a few stitches; more
extensive
infection of the superficial tissues requires reopening of the entire
wound to the capsule. The
wound should then be treated by the Carrel method and may be suturable
subsequently.
If
the joint becomes distended, and infection is suspected, it should be
aspirated
immediately and a culture made. The writer has seen turbid fluid
containing diplococci aspirated
from a distended joint on the third day after operation, and uneventful
recovery follow; also
much turbid fluid evacuated from between the sutures in the capsule on
the second and again on
the fourth day by pressure on the subcrural bursa. In the latter case
the joint was markedly
distended until the fourth day. Possibly, as a result of the
distention, there was no limitation of
motion at any time. This patient quickly regained full motion and in
six weeks was back at the
front, with perfect function.
If
the patient's condition, the local examination, and the character or
culture of the
aspirated fluid indicate pyogenic infection, one or more incisions
should be made at once. But if
the original incision is so placed as to allow satisfactory drainage it
should be reopened and the
treatment for suppurative arthritis begun. Willems' method of drainage
by active movements is
here recommended. The important feature is to begin treatment early; no
drains should be used;
splints are dispensed with or arranged for support without joint
fixation. Free mobility every two
hours should be enforced by active movements so as to evacuate the
joint. Early nonvirulent
infections with little or no bone involvement usually do well. In
severe or long-standing
infections, especially with bone involvement, the treatment has not
proved as satisfactory. The
method will be described in detail in a later paragraph.
328
In
two cases under the writer's care, where purulent intra-articular
infection occurred and
the joint was reopened. Carrel treatment was carried out for a few days
and secondary suture of
the joint was made successfully in eight days. The Carrel treatment is
most appropriate in wide
open joints for at short period and where the joint is opened soon
after the infection has begun.
Hughes and Banks 7 have obtained admirable results by its
use, especially in the elbow and
shoulder, and have been to sterilize the wounds and perform secondary
suture in a large
proportion of cases.
KNEE-JOINT
Certain
details which bear upon individual joints, especially the knee, must be
emphasized. For the initial operation, lateral incisions are to be
preferred; but, as stated above,
the situation of the wound or wounds, and the position of the foreign
body must, as a rule, be the
determining factors. Occasionally the incision may be curved or even
transverse, but division of
the patellar tendon should rarely be made and then only when full
exposure of the joint is
essential, as when a, foreign body lies in the region of the crucial
ligaments. When the wound of entrance is above the patella the joint
may be explored to a considerable extent through the
wound of de bridement. In one of the writer's cases a foreign body
embedded low in the
articular surface of the femur was brought into view above the patella
by acute flexion of the knee. Removal of the foreign
FIG.
178.- Gunshot
wound of the knee.
A, wound of entrance, incision for débridement; B,
stituation of foreign body (Keen’s Surgery)
body and treatment of the bone
injury were effected through this incision (figs. 178, 179).
The
following are the usual procedures followed for the various types of
bone injuries:
(1) A small partially detached piece of articular cartilage should be
removed; (2) articular
cartilage with considerable bone, the whole attached to soft parts,
should be left; (3) extensive
comminution of a condyle which necessitates its removal demands
resection. Removal of one
condyle will
329
result in so much lateral mobility as to
necessitate later resection. In the decision between
primary resection and conservation of an imperfect joint it must be
borne in mind that stability is
essential in the knee; (4) where great disorganization of the articular
surfaces exists immediate
resection is indicated. Tuffier 8 affirms that this method
of treatment forms one of the greatest
advances made in the surgery of the joints, and has caused a large
diminution in the number of
amputations of the thigh. Lériche 9 advises that the tibia
be nailed to the femur
to prevent
dislocation after resection. For this purpose Blake recommends-two
spikes, converging from each side of the tibia upward and inward into
the femur. They are removed when union has taken
place.
When
the bone lesion is so extensive that resection would be necessary
through the
narrow shaft above the condyles, amputation is in general preferable.
Compound
fractures of the patella should be treated by removal of completely
separated
fragments and preservation of large attached fragments which should be
approximated if
possible by suture. Complete removal of the patellar should be avoided.
since
FIG. 179.– Gunshot wound of
the knee, same as
that shown in Figure 178. Incision in capsule after débridement.
Foreign body exposd by acute flexion of knee. A: RF, Rectus femoris; F,
femur articular surface; C, capsule. B: F,
Femur articular surface; T, tibia; P, patella. (Keen’s Surgery)
the functional result is poor. However, when
the patella must be removed a flap from the
quadriceps tendon should be attached to the patellar tendon, as advised
by Murphy. 10
Much
difficulty may be experienced when excision of a portion of the head of
the tibia
has been necessary. The defect in the capsule is difficult to close.
When the loss of articular
surface is slight it may be possible to supplement
330
the deficiency in the capsule by turning a
flap of fascia from an adjoining part and suturing it in
place so as to complete the closure. If the loss of articular surface
is considerable, resection is
usually necessary.
In
compound fractures of the tibia in which the joint is not directly
involved, but with one
or more lines of fracture extending into the joint, intra articular
infection frequently develops. If
hemarthrosis is marked, arthrotomy, irrigation, and closure are
indicated in general, in addition
to the operative treatment of the wound and the fracture. Every effort
should be made to convert the compound into a simple fracture at an
early date by suture under bacteriologic
control.
In
the cases which the writer observed in which an open knee joint was
associated with a
wound of the popliteal or femoral artery, amputation ultimately became
necessary except in two
instances. One of these was an open knee joint without bone involvement
complicated by a
wound of the popliteal artery. Arthrotomy and ligation of the popliteal
artery (Jopson) were followed by a good functional result. The other
was a case operated upon
by Delrez. It was a
penetrating bullet wound of the popliteal space, with division of
popliteal artery and vein. The
bullet was extracted under the method of Hirtz by trepanization of the
condyle. Both vessels
were doubly ligated. Mobilization was begun four days later. There was
almost complete restoration of function in six weeks.
An
analysis of a series of cases of wounds of the knee joint which were
operated upon
and followed by Jopson and Pool 11 affords approximately
the average figures for this type of
wound:
CHART
331
PRIMARY OPERATION
In
all except two eases the joint was sutured primarily. In one case
primary amputation
was necessary, and in another an attempt was made to save a badly
shattered limb, in which the
wound of the knee joint was of secondary importance. This case came to
amputation, but not
for joint infection.
CHART
While joint infection occurred in three
cases, in
only one did this result in ankylosis. In the
others the infection was controlled by prompt reopening and Carrel
treatment for several days. In both of these the joint and soft parts
were sutured successfully after sterilization.
SECONDARY AMPUTATIONS
In
two cases amputation was required before evacuation. In neither was it
done for
infection; in one it was for gangrene following an associated wound of
the popliteal artery and
vein, and in the second for gangrene of the foot, the result of
prolonged pressure by the anklet
used in connection with the Thomas splint, which had been in place for
two days before
admission. In another case, evacuated 24 hours after operation, the
record shows the limb was
amputated later at a base hospital.
END RESULTS
CHART
332
A
review of the above results convinced us that a conservative policy in
dealing with
wounds of the knee joint caused by projectiles is strongly indicated.
It was shown that infection
can be avoided in the great majority of cases; that even when
intra-articular infection develops,
function can sometimes be preserved, or, if lost, that amputation is
not inevitable; finally, that
early and complete restoration of the joint offers the best chance for
an early and complete
restoration of function.
Mouchet
and Pamart 12 reported the late results one year after
early operations on 54
soldiers who had sustained wounds of the knee by projectiles, 49 being
high-explosive shell
fragments.
There
were 39 percent good results; 25 percent fair results; 35 percent
bad results.
They found that the greatest functional deficiency occurred in cases of
arthrotomy for wounds
with bony lesions. The worst results followed U-shaped arthrotomy.
SHOULDER
When
resection is necessary for extensive comminution of the head of the
humerus the
subperiosteal method is strongly recommended by Lériche,9 who urges that great care be taken
to preserve the continuity of the capsule and periosteum. He advises
that the end of the humerus
be immobilized for a time in the glenoid cavity and that movements be
undertaken very
gradually in order to avoid a flail joint. Conservation of bone is
important. The extensive resections which were done during the second
year of the war resulted in almost useless flail
limbs.
ELBOW
In
the elbow the conservation of bone is an object to be especially aimed
at; therefore
classical resections are less often advisable than in the knee. The
head of the radius and the
capitellum can be sacrificed without material loss of function,
especially if active motion
is begun early. When the internal condyle must be removed function is
less perfect and lateral
mobility is to be expected, yet the result may be fairly satisfactory.
In more extensive lesions,
especially when there is such extensive comminution of the articular
surfaces that resection is
necessary, the choice must often be made between a movable flail joint
and ankylosis in a useful
position.
If
resection is performed by the subperliosteal method, which permits
regeneration of
bone, even extensive resection of the lower extremity of the humerus
may be followed by
favorable results. Le Fur13 believes that the bad results
following this method are referable more
to the destruction of the muscles and periarticular tendons than to the
loss of bone. Lériche9 urges subperiosteal resection when the mechanism of the joint is
seriously disturbed; that is,
when the trochlea or the articular surface of the ulna are badly
involved. He states that
callus forms rapidly, that anatomic and functional restitution are
gradually brought about, and
that in many cases within a year after complete resection there is
perfect pronation, supination,
and flexion, with marked solidity. He closes the wound by delayed
primary suture under
bacteriologic check and does not employ the Carrel treatment; the arm
is put up in acute flexion
and full supination; very limited and infrequent active movements are
333
begun in 8 to 10 days. He urges rigidity, and
states that it is a flail joint and not ankylosis that is
to be feared.
Unfortunately,
under the conditions which prevailed in the hospitals of the forward
area,
subperiosteal resections could rarely he performed, nor could the
intensive care which is
necessary in the after-treatment be given the individual case.
ANKLE
In
wounds of the ankle, with considerable involvement of bone,
astragalectomy is usually
indicated, followed by complete closure of the joint. As Chutro14 has emphasized, it is important
to displace the foot backward after astragalectomy in order to provide
a fulcrum of sufficient
length, and to give proper weight-bearing lines. The ankle is one of
the most troublesome joints to treat in the presence of infection.
Suppuration often extends not only to the tarsal joints but
also along the tendons of the foot, and amputation not infrequently
results. Therefore a
successful initial operation is especially important.
WOUNDS PRODUCED BY SHARP INSTRUMENTS
These
should be treated on the principles outlined for wounds caused by
projectiles. The
soft parts should be thoroughly d ebrided; the joint widely opened, a
wound of the bone or
cartilage cleansed with chisel or curette, the joint irrigated, and the
synovial membrane and
capsule closed. The soft parts may be sutured or left open, according
to the rules already laid
down.
LATE
COMPLICATIONS OF WOUNDS CAUSED BY PROJECTILES
In
general, wounds of joints which have been properly treated progress
satisfactorily if
infection does not occur, and at large proportion of the patients
regain full function in a relatively
short time. On the other hand, the occurrence of infection seriously
affects the outcome; not only
is the mortality greatly increased, but even in the more favorable
cases reestablishment of function is often prevented by partial or
complete ankylosis. These two complications, infection
and ankylosis, must be discussed in some detail.
SUPPURATIVE ARTHRITIS
Suppurative
arthritis constitutes the most serious sequel to wounds of joints. As
an early
complication it has been considered under the postoperative treatment
of recent wounds.
Attention must now be directed mainly to the treatment of the later and
persistent phases of joint
suppuration which constitute one of the most difficult and discouraging
problems of military
surgery. A large number of these cases were treated in every base
hospital of the American
Expeditionary Forces. The most important factors which led to the
development of chronic
suppuration were ill-advised conservative measures rather than early
operative treatment of the
wound, failure of the initial operation to prevent infection, or
ineffective early treatment of the
infection itself. It should be stated, however, that in most cases
failure of the initial operation
was due to uncontrollable conditions, such as a long interval between
334
the receipt of the wound and the admission to
the hospital, excessive and prolonged
contamination, especially in association with bone lesions, or early
evacuation with imperfect
supervision of the patient and wound.
Every
effort should be made to recognize the infection early in its
development. If, after
the initial operation or in cases in which no operation has been
performed, the local examination
or the general condition of the patient suggests infection, the joint
should be aspirated. If the
character or culture of the aspirate fluid indicates pyogenic
infection, arthrotomy should be per formed. In the case of
staphylococci or streptococci there should be no delay; but where there
is
distention of a joint with turbid fluid, not containing pyogenic
organisms, delay is warranted and
aspiration may even be repeated. The injection of antiseptic solutions
after evacuation of the
effusion has met with some success.
No
attempt will be made here to describe the appropriate incisions for the
various joints
and the details of dissection; such description may be found in
standard works on surgery. One
or more incisions should le made, unless an existing incision is so
situated as to allow
satisfactory drainage; in that event it should be reopened. Continuous
drainage is best provided
by Willems' method of active movements, especially in the knee joint
(see infra). But if for any
reason this method can not be carried out, for instance, by reason of
extreme suffering, or
considerable bone involvement, the Carrel-Dakin method of chemical
disinfection is the best
substitute. Moreover, in early eases of nonvirulent infection,
especially with little bone
involvement, success may rapidly follow the inauguration of this
treatment. It is evident,
however, that the construction of most joints renders it extremely
uncertain whether irrigation
of the entire joint cavity can be accomplished. Drainage by rubber
tubes is objectionable in that
the tubes produce pressure necrosis and do not drain adequately. They
should never be used in
superficial joints, as the elbow or knee. At times they must be
employed in deep joints, such as
the shoulder and hip. But it must be emphasized that any kind of drain
within a joint is harmful
and should be avoided if possible.
When
cases have not been treated sufficiently early by arthrotomy and active
movements
or by the Carrel-Dakin method, or have failed to respond satisfactorily
to these procedures, a
chronic virulent infection may be expected. The articular cartilages
and adjacent bone become
involved and this renders joint suppuration long and serious. In
general, a well-established
suppurative process continues until the involved cartilage has been
entirely eroded. More- over,
extension of the infection to the cancellous bone of the epiphyses,
which quickly occurs if there
are fissures or lines of fracture, leads to osteomyelitis, which is
peculiarly resistant to treatment.
In many cases the infection also extends to the soft parts, causing
periarticular abscesses.
RESECTION
In
cases which are not progressing satisfactorily under conservative
methods resection
offers a means of establishing satisfactory drainage, and is, in
general, the best method of
treatment. After resection the wound is treated
335
by the Carrel method. It may be allowed to
close by granulation or, when sterile, may be closed
by secondary suture.
Unfortunately,
there is no single indication for resection in suppurative arthritis.
It is this
which makes decision so difficult and often too long deferred. Various
factors must be weighed,
such as the degree of local infection, the extent of bone involvement,
the severity of septic
symptoms, and the general resistance of the patient. The same factors
must be considered in the
decision as to whether resection or amputation should be done.
Amputation
must be practised in a certain proportion of cases of prolonged joint
infection, especially when there is such a degree of sepsis and
diminished resistance that the less
radical procedure of resection with the necessarily long
after-treatment apparently can not be
supported. Amputation is a life-saving measure where resection has
failed or has been too long
delayed, but nice judgment is necessary to determine when it is
indicated. One is always averse
to advise the sacrifice of a limb, and consequently many cases have
been lost by persisting too
long in more conservative measures.
The
general treatment of septic joints having been outlined, certain
specific details which
bear upon individual joints must be considered.
The
knee is the joint in which the most serious infections are encountered
and is one of
the joints most resistant to treatment. As Tuffier emphasizes, its
anatomic structure alone will
explain the frequent failure of irrigation and drainage. "Infection
spreads backward sooner or
later, and no amount of irrigation of the anterior cavity will affect
suppuration in the posterior
pouches." Frequently pus finds its way through the back of the joint
into the deep portion of the
popliteal space and then passes upward or downward along the great
vessels and burrows among
the muscles of the thigh and calf. Abscesses also may extend from the
subcrural bursa anteriorly
between the bundles of the quadriceps, especially between the rectus
and vastus externus
(Guénard).15 Among 40 cases of suppuration of the knee
joint seen by Guénard in the course of a year, such migratory abscesses
were observed 14 times. Drainage of such abscesses by
appropriate incisions is necessary; the occurrence of the abscess in
itself does not, as a rule,
demand more radical procedures. Of the various methods for drainage of
the popliteal space, that
advocated by Abbott is said to be very satisfactory. Through an
incision on the inner aspect of
the leg below the condyle the popliteus muscle is exposed and separated
from the tibia. The
space is thus drained with the muscle between the vessels and the
drainage tract.
The
knee is the ideal joint for the employment of Willems' method. Blake16 states that
functional results are obtained by this method which would be
unattainable by any other
treatment, and believes that this is due largely to the conservation of
the cartilage and synovial
membrane by the maintenance of function.
By
reason of the gravity of wounds of the knee when complicated by
infection radical
measures are often indicated at a relatively early stage, the effort
being made to control infection,
though at the sacrifice of joint function. Therefore when cases have
failed to respond
satisfactorily to conservative
336
treatment and the local and general
conditions are bad and are becoming progressively worse,
adequate drainage should be provided. For this, various methods have
been practised, among
which are: Transverse incision through the ligamentum patellae; the
patella is turned upward,
the semilunar cartilages removed, and lateral and crucial ligaments
divided, the knee is sharply
flexed and held in this position until infection is controlled, when
the joint is resected or, if
possible, extended. Rankin17 advocates a similar
procedure, but opens the joint by means of a
flattened inverted U-shaped
incision through the quadriceps tendon which allows the patella to
be turned down and gives free access to the subcrureus pouch. Chaput18 and Guénard15 advocate patellectomy Fullerton19 recommends resection
with temporary wide separation of the
ends of the bones. Ballance not only resects but removes the posterior
margin of the sawn
condyles in order that drainage of the posterior portion of the joint
may be better ensured. In all
of these methods the Carrel-Dakin treatment has been employed
advantageously after adequate
exposure has been obtained.
Drainage
by resection has led to the best results. Not only is drainage thus
established,
but, in addition, the removal of the articular cartilages and much of
the infected bone favors
repair, since these tissues are largely responsible for the persistence
of the infection.
As
Fullerton 19 describes the operation, a U-shaped incision
is employed, the
patella is
removed, and the articular ends sawn across, removing in all about two
inches. A few stitches
may be introduced in the middle of the flap, the remainder of the wound
being left open. Wide
separation of the ends of the bones is obtained by traction through a
Thomas splint. The wound
is treated by the Carrel-Dakin method. The ends of the bones are not
allowed to approximate
until infection is completely controlled, and then only gradually, the
limb being immobilized in
slight flexion. If union has not taken place when the wounds have
healed, the case may be
operated upon again and the freshened ends brought into apposition as
in a clean case.
Resecting
is indicated when the general condition permits, but in cases of long
standing
infection, with fever and poor general condition, amputation is
sometimes advisable. In the
lower limb its consequences are less serious than in the upper, and the
results of delay are
frequently disastrous.
For
persistent suppuration of the shoulder, elbow, hip, and wrist,
resection is also often
indicated in cases which are doing badly. Details of resection,
including subperiosteal resection,
as well as the proper positions for ankylosis in these joints, are
outlined elsewhere.
For
persistent infection of the ankle, especially if there is an infected
fracture of the
astragalus, astragalectomy gives the best result.
MOBILITY VERSUS STABILITY AFTER RESECTION
When
adequate drainage has been secured by resection of a septic joint the
choice
between mobility and stability must be made. If stability is elected,
the functional usefulness of
the ankylosed joint depends almost entirely upon the angle of
ankylosis. With special reference
to the relative advantages of ankylosis in a favorable position or a
certain amount of motion
imperfectly controlled, Osgood 20 states "that with certain
exceptions after septic compound
337
joint fractures, ankylosis in a
position favorable for function is a result vastly superior to
small degrees of fairly stable motion or large degrees of a more or
less flail-like movement,
always imperfectly controlled by muscle action. This is, without
exception, true with respect to
the shoulder joint, the hip joint, the knee joint, and the ankle joint,
for people who must earn
their livelihood. One exception is the elbow, which may in a few trades
be better even flail than
stiff, though it usually involves the wearing of apparatus. One other
exception is the wrist,
which, with a few degrees of motion, but never flail, may be more
serviceable than a stiff joint.
It will be noted that both elbow and wrist are nonweight-bearing
joints, over which run certain
tendons, all of whose attachments need not be disturbed by the
excision. The muscular control of
the joints may be to some extent thus conserved. Even these exceptions
are debatable." These
arguments seem sound and are sustained by such reports as Tavernier and
Jalifier, 21 who
describe numerous cases of flail joints upon which they operated to
improve the function of the
elbow, shoulder, and wrist. But most surgeons are not as definitely in
favor of rigidity after
resection of these joints. Their views are to some extent supported by
the analysis of large series
of cases, such as that of Tuffier. Osgood's recommendations as to the
best angle of fixation for
the different joints is given in a later paragraph.
FUNCTIONAL RESULTS OF RESECTION
Tuffier 8 has summarized the late results of joint resections. Based
upon the examination
of 1,810 cases, comprising: 630 elbows, 330 shoulders, 282 knees, 231
astragali, 152 wrists, 122
hips, 29 posterior tarsal joints, 14 anterior tarsal joints, he finds:
Elbow, 49 percent solid and
with variable degree of mobility, 30 percent flail, 20 percent
ankylosed. Shoulder, 45 percent
solid and with variable degree of mobility, 38 percent flail, 16
percent ankylosed. Wrist, 64 percent solid and mobile to some extent,
36 percent ankylosed. Hip, 30
percent solid with
restricted mobility; ankylosed, 48 percent. Ankle (astragalectomy), 20
percent solid with some
mobility; ankylosed 70 percent. In the knee the operation does not aim
at mobility, but rigidity.
Ankyloses occurred in 85 percent of the cases.
Resection
of a joint may be indicated at the primary operation when there is such
destruction of the articular surfaces as to preclude saving the joint,
or secondarily for severe
suppuration to obtain adequate drainage, or remotely, in order to give
greater mobility or greater
strength to the limb. The cases analyzed by Tuffier were all of the
first and second of these three
groups.
ACTIVE MOBILIZATION IN PURUTLENT
ARTHRITIS-WILLEMS' METHOD
In
applying mobilization in the treatment of purulent arthritis Willems' 6 original purpose
was to secure efficient drainage after arthrotomy. He found that there
was no system of irrigation
which could be depended upon to limit the extension of the infection,
not even the Carrel
procedure, and that resection solely to ensure drainage appeared too
radical. He therefore
endeavored to drain the joint by squeezing out the pus through active
movements. His early
attempts were convincing. He states that when an infected joint has
338
been opened by unilateral or bilateral
arthrotomny the patient can move the joint without
difficulty. With each movement of flexion and extension pus is
expelled. This expulsion is the
more complete the more extensive the movements and the more vigorous
the muscular
contractions. When these movements are repeated a sufficient number of
times all the secretions
are expelled. The suppuration usually lasts for weeks, first profusely,
then diminishes to a few
drops daily, and finally ceases. For a long time a fistula persists
which closes periodically and
must be reopened in order to drain the small quantity of retained
secretion. The swelling of the
periarticular tissues persists to some extent until after complete
cicatrization. Periarticular
abscesses are practically unknown. The general condition improves very
rapidly. Active mobilization thus accomplishes ideal drainage without
the assistance of any other measures.
The
movements become easier and less painful the oftener they are repeated.
The
muscles are very slightly affected by the arthritis. The quadriceps and
the brachial biceps, which
usually undergo rapid atrophy in purulent arthritis of the knee and
elbow, remain surprisingly
strong. The end of the treatment is usually reached with an almost
negligible degree of atrophy.
As
soon as the articulation becomes dry, a tendency to stiffening is
occasionally noted. In
order to avoid this danger, Willems partially closes the arthrotomy
wounds when the suppuration
has become markedly diminished, only a small opening being left
corresponding to that portion
of the wound where the secretion still persists. By this method the
mobility can almost invariably
be preserved, at least to a great extent; not infrequently it is
perfect. Willems attributes the
satisfactory results to limitation of the infection to the synovia as
the result of perfect drainage,
which militates against its extension to the cartilage and bone.
He
admits that all articulations are not equally well adapted to drainage
by arthrotomy
and active mobilization. The thoroughness of the drainage is
proportionate to the more or less
extensive range of movements of the joint. From this viewpoint the
elbow and the knee, which
can perform wide excursions, are the most favorable. The wrist and
ankle, where extension and
flexion are more limited, expel the secretions less thoroughly, and in
these joints the method has
yielded less rapid and less complete results.
Willems
reports 20 cases of suppuration of the knee, with no deaths, no
amputation, I
resection, 3 cases of ankylosis. The functional results were, in
general, good and in many cases
perfect.
Willems'
technique is as follows:6 In the cases of serous
staphylococcus synovitis it is
sufficient to reopen the original incision. In the presence of
streptococcus infection classical
bilateral arthrotomy is indispensable. The joint must be opened very
widely on both sides. The
wounds are covered with aseptic dressings loosely applied. No
immobilizing appliance is
employed. Hot dressings are applied for the first 48 to 72 hours,
changed every 2 to 3 hours if
considerable joint swelling and local reaction follow the operation.
As
soon as the patient wakes he is instructed to begin active movements.
His confidence
must first be won by having him carry out with the healthy limb the
movements which he is to
do with the wounded limb. In
339
the cases of the knee the procedure is as
follows: First the patient raises the entire limb from the
bed; lie flexes the thigh on the pelvis, then alternately flexes and
extends the leg on the thigh. Delrez considers it a noteworthy fact
that although passive movements are extremely painful,
active movements cause no inconvenience, the patient complaining of
heaviness of the limb, but
not of pain. The first sessions are fatiguing, later ones becoming
progressively easier. The active
mobilization must be repeated at least every hour during the day and
two or three times in the
course of the night. The patient is gotten out of bed as soon as
possible, using his injured arm or
leg if the temperature is low and bone lesions do not contraindicate.
Cases in Delrez's service
were seen walking about with pus escaping from the knee joint at every
step. It was observed
that some patients had to be urged and almost driven to use the limb.
If this was done early,
little pain resulted; if delayed or used only after a long interval,
motion was painful and
restricted. Cessation of movements was usually followed by accumulation
within the joint,
associated with increased pain and temperature reactions. The method
undoubtedly affords a
valuable weapon of defense against suppurative arthritis.
ANKYLOSIS
The
treatment of deformities with impairment of function resulting from
partial or
complete ankylosis has been outlined by Osgood 23 in an
admirable article which is here
summarized: If the joint has been the seat of a serious infection, it
is usually unsafe to undertake
considerable operative procedures for from six months to a year after
the subsidence of the
sepsis. Judgment as to when these surgical attempts are safe is always
difficult. Massage more or
less violent may serve as a guide. If, after such massage, a definite
recrudescence of the car linal signs of inflammation occur, it is
usually unsafe. The absence of this reaction is
suggestive of sufficient quiescence to make operation possible.
The
first determination is whether mobility or ankylosis in a favorable
position for
function is to be sought. It must be recognized, however, that
restoration of perfect mobile
function is rarely possible in these cases. Only the hip and the elbow
should be attempted, the
hip more rarely than the elbow.
The
great majority of the cases in which decision between attempts at
mobility or
ankylosis in a favorable position must be made occur in war surgery
among workingmen whose
wage-earning capacity must be the controlling factor in this decision.
It is a matter of constant
surprise to find how little disturbance of wage-earning capacity is
caused by a completely stiff
joint in a favorable position for his trade. Generally speaking, the
shoulder should be fixed in 50° to 80° abduction, in a plane
about midway between the anteroposterior and
lateral planes of
the trunk; that is, the elbow should come somewhat forward. A single
elbow should be fixed in
such position that the angle which the forearm and upper arm inclose is
about 100°; that is, a
little more obtuse than a right angle. Where both elbows are ankylosed,
one should be a little
more than a right angle (100° to 110° ), the
other a little less than a right angle (70° to 80° ).
In
both these positions the hand should be midway between pronation and
supination. The wrist
should be in dorsal flexion. The hip should be fixed in 5°
to 10 ° abduction, 5° to 10°
outward
rotation, and 10° to 20° of flexion. The
340
knee should be fixed with varying degrees of
flexion up to 45°, depending on theoccupation.
The ankle gives best function in right-anglo dorsal flexion,
with perhaps a little equinus to allow
for the heel of the shoe. We are inclined to believe that in the vast
majority of cases, except
possibly the elbow joint.ankylosis in a favorable position should be
the operation of choice in
war surgery in case of terminal joint deformity.
PARTIALLY ANKYLOSED JOINTS WITH OR WITHOUT
DEFORMITY
The
problem with partially ankylosed joints, according to Osgood,23 is the restoration of
as large a range of mobility as possible. "In joints which have been
the seat of an infection," he
says, "gentleness of manipulation is the rule to be followed almost
without exception. Brisement
force under an anesthetic is rarely successful in gaining greater range
of motion and is often
provocative of a lighting up of the old infection. It is to be
thoroughly discouraged. Light
massage, mechanotherapy, and hydrotherapy are the first procedures,
accompanied by gentle
passive movements and the stimulation of the patient to carry out
active movements. These latter
are by far the most important. Between these treatments, apparatus is
often of great advantage,
both that which retains motion gained in the direction desired and that
which by elastic pull
constantly exerts gentle traction in the appropriate lines. Recovery is
gradual and often seems to
the patient slow and tedious. If his endeavor to gain motion is coupled
with the stimulation of a
definite occupation, which accomplishes a purpose of some sort, time
passes more quickly,
motion increases automatically and almost unconsciously. Tailoring,
carpentry, leather working, brace making, printing, basket making, and
farming are all easily
adapted occupations."
REFERENCES
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chirurgie de
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(2) Cotton, Frederic J.: Dislocations and
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(3) Willems, Charles: Immediate Active
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Record, New York, June 7, 1919, xcv, 953.
(4) Cook, Franklin: Gunshot Wounds of Joints;
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(5) Dowden, J. W.: The Curse of
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1918, ii, 570.
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(8) Tuffier and Nové -Josserand: De la valeur
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224.
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(11) Pool, Eugene H., and Jopson, John H.:
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(12) Mouchet, Albert and Pamart: Résultats
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(14) Chutro, Pedro: Infected Wounds of the
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9,
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(15) Guénard: Arthrites purulentes du genou.
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(16) Blake, Joseph A.: Gunshot Fractures of
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(17) Rankin, W.: On the Treatment of Certain
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(I8) Chaput, E.: Nouveau mode de drainage des
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33, 143.
(19) Fullerton, Andrew: Excision of the
Knee-Joint as a Method of Treatment for Severe Infections. British
Medical Journal, London, November 25, 1916, ii, 709.
(20) Osgood, R. B.: Notes on Excision of
Septic Joints. American Journal of Orthopedic Surgery,
Boston, 1918,
xvi, No. 10, 323.
(21) Tavernier, L. and Jalifier: Traitement
des laxités articulaires consécutives aux résections. Lyon
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(22) Willems, Charles: Traitement de
l'arthrite purulente par l'arthrotomie simple suivie de mobilisation
active
immediate. Bulletins et mémoires de la société de chirurgie de
Paris, June 10, 1918, xliv, 1098.
(23) Osgood, R. B.: Bone and Joint Casualties
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Athens, Pa., 1919, xxii, No. 4, 205.
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