sive su]ipuration about the knee, in the thigh, and in the calf. The
sujipuratiou will finally have its effect U]K>n the constitutiim — emaciation,
amyloid changes in liver and kidney, etc. etc.
Pain is not a persistent symjittmi, but is present in all exacerljations ;
it is very severe when an abscess has just begun to form, especially if
the abscess be deep-seated and the pus presses upon important structures
in its attempt to get to the surface.
In an analysis of 300 cases, made in 1893,1 found that 140 had
abscesses, 160 never had al)scesses at any time ; 40 died. The cause of
death was tubercular meningitis in 6 ; exhaustion after j)rolonged sup-
puration in 14 ; phthisis in 3 ; dysentery in 2 ; amyloid degeneration in
2 only; and 12 of this number from intercurrent affections which had
no connection whatever with the disease ; 1 died from shock after an
excision. AA'ith 22 deaths as a direct result of the disease we have a
mortality of 7| per cent.
Diagnosis. — From the clinical iiistorv the diagnosis should be
comparatively easy. It is not ditficnlt if one makes a careful and
comparative examination of the limbs. The same remarks apply
with equal force to diagnosis here as in affections of the hip and spine.
In makins: a differential diagnosis one must be able to rule out
acute prmiary synovitis, a se^â– ere strain or contusion, a periartliritis, a
rheumatic arthritis, a bursitis, derangement of the cartilages, and
neurosis.
An acute synovitis is very distinctive. The synovial sac is distended
with fluid, and no other jiarts of the knee, such as the sides and poste-
rior aspects, are involved. Tliere is a certain amount of flexion de-
pendent upon the amount of fluid in the knee. There is a history of a
trauma, usually in close relationship with the symptoms. It is true a
synovitis may be but an exjiression of an exacei'bation, and it may
appear during the first exacerbation. In this case a differential diag-
nosis cannot be made at a single observation.
Severe strain or contusion is attended with signs of injury to the
soft parts, such as laceration of the skin, ecchymosis, and superficial
swelling. It of course has the history of injury immediately preceding
or preceding bv one or two days onh'. if the deeper structures are
involved, the diagnosis must be made by exclusion ; that is, one must
exclude a dislocation of the semilunar cartilage, a detachment of some
of the fibres of this cartilage, a chiiiping off of the patella or the tibia
about where the ligamentum patella is attached.
A periarthritis is usually a cellulitis, involves the soft structures, is
often phlegmonous in character, and need not depend ujion trauma as a
cause. It is acute as a rule. The remai'ks just made apply to the
TUBERCULAR OSTITIS OF THE KNEE. 349
periarthritis as it occurs in children. In adults we have a rheumatoid
or rheumatic [)eriarthritis, wliich involves the capsular ligament and the
structures intimately surroundinii' the joint. If one can feel a distiuct
grating like that of rice-bodies or sand as tiie knee is flexed and ex-
tended, a diagnosis of rheumatic periarthritis can be easily made. If
the signs just mentioned are absent, then the case will require a little
closer observation. Examination of the urine will sometimes assist in
completing the evidence in the case.
Rheumatic arthritis is usually associated with a periarthritis, l)ut
may be entirely indejicndent of any periarticular lesion. The sensation
imparteil to one's hand as the limb is moved is significant, and if to this
be added a .similar sensation in other joints, especially the other knee,
ostitis can be easily eliminated.
The bursa; about the knee are not infrequently involved in a suli-
acute form of inflammation, depending upt)n trauma and occurring
usually in l)all-]ilayers or athletes generally. The bursa in the popliteal
space is sometimes affected by a sharp flexion of the limb, and a severe
concussion or bruising added to this. The diagnosis is made when such
is the case by a careful comparative examination of the limbs, by close
attention to the history given, and l)y the absence of signs pointing to a
lesion in the joint or in the parts in the anterior sin-face of tiie limli.
A rare form of Imrsitis occurs in the bursa between the ligamentum
patella and the top of the til)ia. This can ])e made out by a comparative
examination and by a process of exclusion. The bursa between the
quadriceps extensor tendon and the thigh has a communication with
the joint itself, and it is difiieult to dissociate the Imrsitis here from an
arthritis. If this liursa can be made t)Ut very much enlarged and the
joint itself ])roves to Ijc very slightly affected, then one can easily speak
of a l)ursitis in this locality. Where other bursje are involved it is more
than liki'ly that they must be associated with a general arthritis or
periarthritis.
By derangement of cartilages is meant either a luxation or a sub-
luxation of the semilunar cartilage, varying in degree and including
lacerations of the ]TO-<terior or anterior attachments. A complete dis-
location of the semilunar cartilage is so rare that an extended descrij)ti(in
is unnecessary. The subluxated semilunar cartilages are most frequently
met with, and are produced by a sharp flexion of the knee with a rota-
tion inward or outward. If outward, the internal semilunar, if inward,
the external semilunar, cartilage is sligiitly displaced. If one can ex-
amine shortly after the trauma which is nearly always the cause, the
cartilage itself can be recognized lying along the upper border of tiie
tibia, and can be brought out in relief by siiarply flexing the knee while
the examination is made. The existence of tenderness along this line,
with the absence of tenderness in other parts of the joint either within
or without, enaliles one to make a diagnosis. If the examination is not
made shortly after tiie original injury, but at a later period, one must
look for a history of exacerbations, and the jiatient will usually describe
certain slipping sensations when the liml) is flexed, associated with inter-
nal or external rotation. It must be understood also that these exacer-
bations are attended ^vitll a limited area of arthritis, sometimes peri-
arthritis. If tliis is understood, then the significance of the artiiritis
350 OBTHOPJEDIC SURGERY.
can be properly estimated and the essential points of the diagnosis be
establi.slied.
Loo.'se bodies may be classed under internal derangement of the knee.
These are known as loose cartilages sometimes, and occasion often a
I'athcr acute attack of arthritis. They slip about just as a semilunar
cartilage does, with the exception that their location is different. The
sensation of the jtatient can be relied on a good deal in making a diag-
nosis, for the bodies themselves can be distinctly felt at times.
The neuroses of the knee are characterized simply by an absence of
any physical signs other than a flexion. This flexion is clearly due to
spasm of the hamstring grouj), and is associated with irritable spine.
The points brought out in differential diagnosis of the hip are applicable
to the knee (piite as well.
" Charcot's knee," as it is called, is associated with tabes dorsalis,
and may in the earlier stages present signs that will be extremely con-
fusing. The extreme laxity of the joint-structures with lateral de-
formity, sometimes marked subluxation and even luxation, are charac-
teristic signs in the tabetic joint. Occasionally an extreme degree of
hydrarthrosis is present.
In enumerating the points in differential diagnosis no reference was
made to sarcoma. It is just as well, however, to include this in the
differential diagnosis. In sarcoma the bony enlargement extends some
distance above or below the joint, and is really a sarcoma of the femur
or of the tibia. The joint itself participates only secondarily, yet so
long as it is involved the signs are those of osteo-arthritis. One pre-
dominant feature is continuous boring pain. To this is added a slow
growth, with often a pulsation imparted to the hand. This pulsation is
almost pathognomonic of sarcoma. While it is not present in all cases,
when found it is of great value.
Treatment. — To successfully cope with tubercular ostitis of the knee
one nuist be prepared to carry out the most efficient protective meas-
ures over a long ])eriod of time, as well as to interfere with operative
procedures when occasion demands. The treatment, thei'efore, is me-
chanical and operative. The term " expectant" is very often used,
meaning the treatment without resort to operation, but in the broader
sense of the term " expectant" operations are frequently demanded. For
example : The term itself means to treat symptoms and signs as they
arise, to combat abscess, deformity, and destructive bone-changes. The
aim is to conduct the joint through the different stages of disease to the
best ])ossible function, such as a good range of motion and freedom from
shortening and deformity. The surgeon, therefore, who treats a case
expectantly must not only prevent the reflex spasm which is an import-
ant element in the causation of pain, but resort to the correction of the
deformity by mamuil force, mechanical appliances, or the knife, saw,
and chisel. The better division, therefore, to make, in my judgment,
is mechanical and (ijterative. At the same time, it must be understood
that one sup})lemcnts the other — that even after operative interference
mechanical appliances are to be employed, that the best possible results
of the operation may be attained.
Sj)lints of various kinds are used to immobilize the joint. Immo-
bilization of itself is a very important element in the management of
TUBERCULAR OSTITIS OF THE KNEE.
351
ostitis, but rest to the articulation is (|uite as important. We speak,
tlierefbre, of fixation and rest as necessary to adequate protection.
To fix a joint so that no motion can taice place, and yet allow the
patient to l>ear the weight of the l)ody upon the foot, is, in my
opinion, a very repreheusiljle treatment in the acute stages of an
exacerbation, and — as exacerbations are frequent and come on with
very slight provocation — it is unsafe to rely upon periods of quiescence
during which the joint may not need rest. The trauma that comes from
use is the chief cause of exacerbations, especially mIicu fixation is em-
ployed. The trauma that comes from reflex spasm, of course, is quite
as baneful as the trauma from use. To be more explicit : Let us assume
that a case comes under treatment in the early stage, the stage just
prior to deformity. The simplest form of treatment is a snug plaster-
of-Paris bandage from the upper third of the thigh to the lower third
of the calf, applied over a snug-fitting stocking or over a simple cheese-
cloth bandage. Tiie jilaster should not be made removable unless one
desires to employ counter-irritation, which, by the way, is sometimes a
very good adjunct to the treatment by fixation and rest. The patient
should either be confined to a bed or a Avheeled chair, or allowed to use
axillary crutches with a high shoe or patten on the foot of the well side.
Where there is much ]iain on one or the other side of the knee the
Paquelin cautery should be employed two or three times a week. In
this case a plaster splint may be made such as is shown in Fig. 343,
riaster knee-splints.
which represents a side and fn mt view. This splint can be easily re-
moved and reap]>lied, and is secured, as will l)e seen, by a lacing'over
shoe-hooks. Adhesive strips of ])laster cau be employed in place of
shoe-hooks, or straiis with l)uckles.
sryi
ORTHOPEDIC SURGERY.
The plan just detailed can be made efficient throughout the entire
course of the disease, assuming that the case has come under observation
in the early stage. It can be employed even in later stages with great
advantage. Other measures are neediMl, such as correction of deformity,
the difl'erent procedures for the treatment of al)scess, artJu'ectomy, the
removal of foci, etc. etc.
A popular impre.ssion, which is shared to a great extent by the pro-
fession as well, is that fixation of a limb in plaster of Paris or any
splint or dressing which inunobilizes is sure to result in ankylosis, and
one, therefore, who may resort to the metliod just descrilicd will en-
counter throughout the entire course a most olistinate ankylojihobia in
the parents, as well as in the physicians who may come in contact with
the case. This one fact has within the last few years been most fully
established — namely, the best way to prevent ankylosis is to secure the
most perfect innnobilization in a joint near which or in which disease
exists. Time and again I have heard surgeons of large experience give
advice like tJiis in tJie consulting-room: " I'ut the limb in plaster, and
let the patient get ankylosis as soon as possible." Ankylosis results
from incomplete immobilization and poorly-fitting splints, because the
inflammatory products that result from the trauma of muscular spasm
and from use produce periarticular as Mell as intra-articular adhesions.
I have mvself on many occasions observed inflannnatorv products about
a joint undergo resolution under absolute innnobilization conjoined with
rest.
Inasmuch as many are not accustomed to the use of plaster, other forms
of fixation may be mentioned, such as posterior splints of leather — an
example of which can be seen in Fig. 344 — of wood, of steel bars on
either side of tlie linil), joined at top and
bottom by bands which partly encircle
the limb and are secured in position by
roller bantlages. Such a lu'ace is known
at the hospital as the Knight knee-brace,
and is a very serviceable sjilint. The
various forms of traction ajtjiaratns, such
as the Sayre splint and the various ones
of the shops, which are largely figured
in all the text-books, may be used if
care is taken to ajijily them so that pro-
tection is ample. The splint which has
proven most valuable in my own hands
is the Thomas knee-splint, which is
shown in Fig. 345. This is, in fact, an
ischiatic crutch, and when supplemented
by fixation of the joint really meets all
the indications for an ideal treatment.
The patten or high shoe should be at
least three and a half inches in heiglit.
Four or four and a half is jircferablc,
even if it be necessary to employ ankle-
Fir, 344.
Fig. 345.
~?
Leather knee-spliut
(Marsh).
Thomas's knee-
splint.
supports on the high shoe. The late
IMr. Thomas himself insisted always on a very high patten, for the rea-
TUBERCULAR OSTITIS OF THE KXEE. :i53
son that the foot on the aifeeted side would not touch the floor, and as
the ehihl i;re\v tliere wouhl be no danoer t)f tlie splint growing too short
between the dates for observation. A knee thus protected really requires
very little attention. The ])arents can be easily instructed in the ordi-
nary details of home-management. In private practice objection is otten
made to the height of the shoe, and to obviate this I have had the splint
made extensible. In order to prevent the toe touching I have employed
a pretty taut check-strap between the bars just back of the heel. This
check mav be of leather and broad enough to prevent the heel from rest-
ing on top of it. The ordinary leather trough, as figured in the cut, was
regarded as all-sufiicient by Mr. Thomas, because he bandaged the knee
back into this trough and securetl a very fair degree of innnobilization.
I have found plaster of Paris much more serviceable and much more
reliable.
Convalescing treatment, which should not even be suggested until
after all inflanimatory signs have disappeared from about the knee and
until a small range of motion has been secured, is this same splint with
the foot-piece cut oft' and the ends of the stems turned at right angles so
as to make a caliper splint. These turned ends of the stems are insert-
ed into a hole through the front jiart of the heel of the shoe. The high
shoe is, of course, discarded now, and the patient is sufficiently protected
ao-ainst traumatic influences.
In my analysis to which I have made reference (the paper was pub-
lished in the American Journal of the Medical Science.'^ for October,
1893) the very best results were obtained by the Thomas splint conjoined
with fixation by plaster of Paris.
The (iccurrent'e of abscess is not by any means a bar to the treatment
now under discussion. On the contrary, the abscess cases are alnmst
as easily managetl as those in which abscess has never occurred. For
instance, I find this paragraph in my resume : " By the protective plan
where abscess occurred (19 cases), 16 had motion and 3 were ankylosed.
Where abscess did not occur (18 cases) all had motion, none were ankv-
losed."
The deformity can be corrected by various forms of apparatus by the
sim])le use of plaster of Paris. A snug-fitting plaster bandage can be
applied to a knee in a high degree of deformity. The patient can be
allowed to walk about on a pair of axillary crutches. At the end of a
fortnight the plaster can be removed and a little better position will be
found — that is, less deformity ; plaster again applied, and so on nntil
very nearly all deformity will have disappeared. This is rather a slow
process, but is one that is safe, and in a certain proportic)n of cases effi-
cient. An excellent method is weight and pulley in bed on a double
inclined plane. I have seen acute-angled deformi+ies overcome within
a few weeks by this method, and M'ith very little pain or discomfort
attending the wimle process of correction. The posterior sj)lint of
Knight is applicai)lc to a certain number of cases. This splint, it must
be understood, relies for its efficiency on the proper use of the roller
bandage.
Tiie Billroth splint, which is veiy similar to the sector splint of the late
Dr. Stillman, is about the best means for correcting the average deformity
with wliich I am familiar, or it may be that I have used this to the exclu-
VoL. II.— 2.'?
354 orthopjEdic surgery.
sioii of many otliers on account of its simplicity and general ap])licability.
I shall take the liberty of presenting a cjuotation from a paper published
in the Medical and Surgical Eipoticr for June 9, 1888 : " The method
may be described as follows : Two fan-shaped pieces of tin or steel, each
applied to an iron bar, are connected at the smaller expansion by a joint.
One fan-shaped piece fits the outer surface of the thigh, the other the
outer surface of the leg, the joint being at the knee, a similar instrument
being applied to the inner side. The whole is of very simple construc-
tion, and can be made by yourself or by any smith. The leg is then
covered by a skin-fitting stocking or flannel bandage ; some turns are
made around the limb with the ])laster-of-Paris bandage ; then this in-
strument is applied and covered with the plaster of I'aris. The lower
part of the patella, bordering on the ligamentum patella, should be left
exposed, not covered l)y the plaster. The bandage should be applied
very thickly in the poj)liteal space. The limb should be put up in the
position you find it, without any extension being made. While the cast
on the leg is still damp take your knife and make a transvei'se section of
it down to tlie skin throngli the popliteal sjiace. This completes the first
dressing. The patient should now be allowed to go home, and the cast
to become completely hardene<l before you do anything further. After
twent}-four hours, and from day to day — if necessary from week to
\\eek — you can proceed to straighten the limb with manual force by
degrees, maintaining what you gain at each visit by inserting a piece of
cork between the divided portions of the plaster cast in tlie popliteal
space. A piece of adhesive plaster passing over the cork to the cast on
either side will retain it in position."
After the knee has been brouglit to about 175° it is difficult to effect
further correction without the employment of more force than is usual,
and my plan is to employ a solid plaster-of-Paris bandage at this period,
making a little extra extension while the plaster is setting. The limb,
once straight, is very easily treated by the use of the Thomas knee-
splint.
The operations for the correction of deformity are manual force under
an anaesthetic, division of hamstring tendons conjoined with manual
force, osteotomy above the condyles, cuneiform osteotomy through the
joint, and excision of the knee. The ojierations for the removal of
disease are curetting ; gouging out of foci, which is known as partial
arthrectomy ; complete arthrectomy ; which is removal of all the soft
structures which go to make up the joint, supplemented by removal of
any foci that may be within reach ; and excision of the knee.
IMy experience in correcting deformity by means of mechanical ap-
pliances under an ansesthetic inclines me to a preference for the correction
under manual force, supplemented by division of the hamstring tendons
subcutaneously. For one who prefers mechanical devices for this pur-
pose the genuclasts of Bradford and of Goldthwait of Boston are spe-
cially recommended. An illustration of the Bradford genuclast is fur-
nished in Bradford and Lovett's work on Orfhopwdic Surgery. The
treatment of abscess is based upon the same princijiles as those depend-
ing upon disease of the spine and disease of the hip.
The indications for arthrectomy are not always clear, for the reason
that extensive suppuration is often relieved by curetting and by the
TUBERCULAR OSTITIS OF THE KNEE. 355
proper protection of the joint. The advantages offered by arthrectomy
when excision is coutemjilated are that tiie function of tlie juint may be
retained or restored and that shortening of the limb will not result. In
my own practice I very seldom have occasion to even recommend artli-
rectomv, because of the uniformly good results which can be obtained
in cliildrcn, and because in adults excision seems to me to offer certain
advantages.
Excision is done most frecjuently in adult patients, and the operation,
when done tiioroughly, gives a very useful limb. It is diflicult to lay
down any hard-and-fast rules for excision, but it is certainly a good
operation to recommend for tubercular disease of the knee in adult
patients or in patients who have passed the age of childhood, espe-
cially if thev Ijelong to the poorer classes. Where one can afford the
time and the expense of a prolonged course of mechanical treatment,
and where the case is not complicated by severe pain or deep-seated
supjiuration, a successful result can be attained by efficient mechanical
appliances. A case, however, which has had inadequate protection
during the first year or two of the disease and has gone through various
metiiods of treatment imperfectly carried out should really be treated by
excision. There are in all large cities a great numlier of unsteady,
painful knees in which disease has existed for many years, and where
various futile efforts have been made to secure a tiseful limb. Such cases
exist largely among the poor in the laboring classes, and it is idle to talk
about treatment with apparatus. It is not necessary to wait for an
abscess in such cases, but (ince the diagnosis is established and the con-
ditions above stated found to exist, then the sooner the operation is done
tlie l)etter.
Prognosis. — In children a good result can, in a large proportion of
cases, be secured. By " good result " is meant a straight limb, very often
a knee with the functions very nearly restored, arrest of all disease, no
shortening, and little if any lameness. It is the exception to have short-
ening in this disease where deformity has been prevented, or where it
has been corrected early and a good position maintained until all symp-
toms and signs have subsided.
In the paper to which I have already made reference my analysis
showed that motion was ol)taiued more frefpiently in those treated by the
protection plan. In 1(5 of the cases wiiere abscess occurred tiiere was,
as final result, 90° of motion, while in those wiiere abscess did not occiu"
25 could be moved voluntarily over an arc of 90°. Relapses are not
very frequent, and of all the cases, whether they recovered with motion
or without, 150 out of the 300 ]iresented subluxation of the tibia,
against 48 where there was no suljluxation. Only 2 of the whole
number jn-esented complete luxation. In 183 tases where the con-
dition of the patella was noted, 124 gave a movable patella, while in