Alexis Thomson and Alexander Miles - Manual of Surgery

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#Errors of Development.#--These include congenital dislocations and
other deformities of intra-uterine origin, such as abnormal laxity of
joints, absence, displacement, or defective growth of one or other of
the essential constituents of a joint. The more important of these are
described along with the surgery of the Extremities.

DISEASES OF JOINTS

#Bacterial Diseases.#--In most bacterial diseases the organisms are
carried to the joint in the blood-stream, and they lodge either in the
synovial membrane or in one of the bones, whence the disease
subsequently spreads to the other structures of the joint. Organisms may
also be introduced through accidental wounds. It has been shown
experimentally that joints are among the most susceptible parts of the
body to infection, and this would appear to be due to the viscid
character of the synovial fluid, which protects organisms from
bactericidal agents in the tissues and fluids.

PYOGENIC DISEASES

The commoner pyogenic diseases are the result of infection of one or
other of the joint structures with _staphylococci_ or _streptococci_,
which may be demonstrated in the exudate in the joint and in the
substance of the synovial membrane. The mode of infection is the same as
in the pyogenic diseases of bone, the metastasis occurring most
frequently from the mucous membrane of the pharynx (J. B. Murphy). The
localisation of the infection in a particular joint is determined by
injury, exposure to cold, antecedent disease of the joint, or other
factors, the nature of which is not always apparent.

The effects on the joint vary in severity. In the milder forms, there is
engorgement and infiltration of the synovial membrane, and an effusion
into the cavity of the joint of serous fluid mixed with flakes of
fibrin--_serous synovitis_. In more severe infections the exudate
consists of pus mixed with fibrin, and, it may be, red blood
corpuscles--_purulent_ or _suppurative synovitis_; the synovial membrane
and the ligaments are softened, and the surface of the membrane presents
granulations resembling those on an ulcer; foci of suppuration may
develop in the peri-articular cellular tissue and result in abscesses.
In _acute arthritis_, all the structures of the joint are involved; the
articular cartilage is invaded by granulation tissue derived from the
synovial membrane, and from the marrow of the subjacent bone; it
presents a worm-eaten or ulcerated appearance, or it may undergo
necrosis and separate, exposing the subjacent bone and leading to
disintegration of the osseous trabeculae--_caries_. With the destruction
of the ligaments, the stability of the joint is lost, and it becomes
disorganised.

The _clinical features_ vary with the extent of the infection. When
this is confined to the synovial and peri-synovial tissues--_acute
serous_ and _purulent synovitis_--there is the usual general reaction,
associated with pyrexia and great pain in the joint. The part is hot and
swollen, the swelling assuming the shape of the distended synovial sac,
fluctuation can usually be elicited, and the joint is held in the flexed
position.

When the joint is infected by extension from the surrounding cellular
tissue, the joint lesion may not be recognised at an early stage because
of the swollen condition of the limb, and because there are already
symptoms of toxaemia. We have observed a case in which both the hip and
knee joints were infected from the cellular tissue.

If the infection involves all the joint structures--_acute
arthritis_--the general and local phenomena are intensified, the
temperature rises quickly, often with a rigor, and remains high; the
patient looks ill, and is either unable to sleep or the sleep is
disturbed by starting pains. The joint is held rigid in the flexed
position, and the least attempt at movement causes severe pain; the
slightest jar--even the shaking of the bed--may cause agony. The joint
is hot, tensely distended, and there may be oedema of the peri-articular
tissues or of the limb as a whole. If the pus perforates the joint
capsule, there are signs of abscess or of diffuse suppuration in the
cellular tissue. The final disorganisation of the joint is indicated by
abnormal mobility and grating of the articular surfaces, or by
spontaneous displacement of the bones, and this may amount to
dislocation. In the acute arthritis of infants, the epiphysis concerned
may be separated and displaced.

When the _joint is infected through an external wound_, the anatomical
features are similar to those observed when the infection has reached
the joint by the blood-stream, but the destructive changes tend to be
more severe and are more likely to result in disorganisation.

The _terminations_ vary with the gravity of the infection and with the
stage at which treatment is instituted. In the milder forms recovery is
the rule, with more or less complete restoration of function. In more
severe forms the joint may be permanently damaged as a result of fibrous
or bony ankylosis, or from displacement or dislocation. From changes in
the peri-articular structures there may be contracture in an undesirable
position, and in young subjects the growth of the limb may be interfered
with. The persistence of sinuses is usually due to disease in one or
other of the adjacent bones. In the most severe forms, and especially
when several joints are involved, death may result from toxaemia.

The _treatment_ is carried out on the same principles as in other
pyogenic infections. The limb is immobilised in such an attitude that
should stiffness occur there will be the least interference with
function. Extension by weight and pulley is the most valuable means of
allaying muscular spasm and relieving intra-articular tension and of
counteracting the tendency to flexion; as much as 15 or 20 pounds may be
required to relieve the pain.

The induction of hyperaemia is sometimes remarkably efficacious in
relieving pain and in arresting the progress of the infection. If the
fluid in the joint is in sufficient quantity to cause tension, if it
persists, or if there is reason to suspect that it is purulent, it
should be withdrawn without delay; an exploring syringe usually
suffices, the skin being punctured with a tenotomy knife, and, as
practised by Murphy, 5 to 15 c.c. of a 2 per cent. solution of formalin
in glycerin are injected and the wound is closed. In virulent infections
the injection may be repeated in twenty-four hours. Drainage by tube or
otherwise is to be condemned (Murphy). A vaccine may be prepared from
the fluid in the joint and injected into the subcutaneous cellular
tissue.

Suppuration in the peri-articular soft parts or in one of the adjacent
bones must be looked for and dealt with.

When convalescence is established, attention is directed to the
restoration of the functions of the limb, and to the prevention of
stiffness and deformity by movements and massage, and the use of hot-air
and other baths.

At a later stage, and especially in neglected cases, operative and other
measures may be required for deformity or ankylosis.

#Metastatic Forms of Pyogenic Infection#

In #pyaemia#, one or more joints may fill with pus without marked
symptoms or signs, and if the pus is aspirated without delay the joint
often recovers without impairment of function.

In #typhoid fever#, joint lesions result from infection with the typhoid
bacillus alone or along with pyogenic organisms, and run their course
with or without suppuration; there is again a remarkable absence of
symptoms, and attention may only be called to the condition by the
occurrence of dislocation.

Joint lesions are comparatively common in #scarlet fever#, and were
formerly described as scarlatinal rheumatism. The most frequent clinical
type is that of a serous synovitis, occurring within a week or ten days
from the onset of the fever. Its favourite seat is in the hand and
wrist, the sheaths of the extensor tendons as well as the synovial
membrane of the joints being involved. It does not tend to migrate to
other joints, and rarely lasts longer than a few days. It is probably
due to the specific virus of scarlet fever.

At a later stage, especially in children and in cases in which the
throat lesion is severe, an arthritis is sometimes observed that is
believed to be a metastasis from the throat; it may be acute and
suppurative, affect several joints, and exhibit a septicaemic or pyaemic
character.

The joints of the lower extremity are especially apt to suffer; the
child is seriously ill, is delirious at night, develops bed-sores over
the sacrum and, it may happen that, not being expected to recover, the
legs are allowed to assume contracture deformities with ankylosis or
dislocation at the hip and flexion ankylosis at the knees; should the
child survive, the degree of crippling may be pitiable in the extreme;
prolonged orthopaedic treatment and a series of operations--arthroplasty,
osteotomies, and resections--may be required to restore even a limited
capacity of locomotion.

#Pneumococcal affections of joints#, the result of infection with the
pneumococcus of Fraenkel, are being met with in increasing numbers. The
local lesion varies from a _synovitis_ with infiltration of the synovial
membrane and effusion of serum or pus, to an _acute arthritis_ with
erosion of cartilage, caries of the articular surfaces, and
disorganisation of the joint. The knee is most frequently affected, but
several joints may suffer at the same time. In most cases the joint
affection makes its appearance a few days after the commencement of a
pneumonia, but in a number of instances, especially among children, the
lung is not specially involved, and the condition is an indication of a
generalised pneumococcal infection, which may manifest itself by
endocarditis, empyema, meningitis, or peritonitis, and frequently has a
fatal termination. The differential diagnosis from other forms of
pyogenic infection is established by bacteriological examination of the
fluid withdrawn from the joint. The treatment is carried out on the same
lines as in other pyogenic infections, considerable reliance being
placed on the use of autogenous vaccines.

In #measles#, #diphtheria#, #smallpox#, #influenza#, and #dysentery#,
similar joint lesions may occur.

The joint lesions which accompany #acute rheumatism# or "rheumatic
fever" are believed to be due to a diplococcus. In the course of a
general illness in which there is moderate pyrexia and profuse sweating,
some of the larger joints, and not infrequently the smaller ones also,
become swollen and extremely sensitive, so that the sufferer lies in bed
helpless, dreading the slightest movement. From day to day fresh joints
are attacked, while those first affected subside, often with great
rapidity. Affections of the heart-valves and of the pericardium are
commonly present. On recovery from the acute illness, it may be found
that the joints have entirely recovered, but in a small proportion of
cases certain of them remain stiff and pass into the crippled condition
described under chronic rheumatism. There is no call for operative
interference.

#Gonococcal Affections of Joints.#--These include all forms of joint
lesion occurring in association with gonorrhoeal urethritis,
vulvo-vaginitis, or gonorrhoeal ophthalmia. They may develop at any stage
of the urethritis, but are most frequently met with from the eighteenth
to the twenty-second day after the primary infection, when the organisms
have reached the posterior urethra; they have been observed, however,
after the discharge has ceased. There is no connection between the
severity of the gonorrhoea and the incidence of joint disease. In women,
the gonorrhoeal nature of the discharge must be established by
bacteriological examination.

As a complication of ophthalmia, the joint lesions are met with in
infants, and occur more commonly towards the end of the second or during
the third week.

The gonococcus is carried to the joint in the blood-stream and is first
deposited in the synovial membrane, in the tissues of which it can
usually be found; it may be impossible to find it in the exudate within
the joint. The joint lesions may be the only evidence of metastasis, or
they may be part of a general infection involving the endocardium,
pleura, and tendon sheaths.

The joints most frequently affected are the knee, elbow, ankle, wrist,
and fingers. Usually two or more joints are affected.

Several clinical types are differentiated. (1) A _dry poly-arthritis_
met with in the joints and tendon sheaths of the wrist and hand,
formerly described as gonorrhoeal rheumatism, which in some cases is
trifling and evanescent, and in others is persistent and progressive,
and results in stiffness of the affected joints and permanent crippling
of the hand and fingers.

(2) The commonest type is a _chronic synovitis_ or _hydrops_, in which
the joint--very often the knee--becomes filled with a serous or
sero-fibrinous exudate. There are no reactive changes in the synovial
membrane, cellular tissue, or skin, nor is there any fever or
disturbance of health. The movements are free except in so far as they
are restricted by the amount of fluid in the joint. It usually subsides
in two or three weeks under rest, but tends to relapse.

(3) An _acute synovitis_ with peri-articular phlegmon is most often met
with in the elbow, but it occurs also in the knee and ankle. There is a
sudden onset of severe pain and swelling in and around the joint, with
considerable fever and disturbance of health. The slightest movement
causes pain, and the part is sensitive to touch. The skin is hot and
tense, and in the case of the elbow may be red and fiery as in
erysipelas.

The deposit of fibrin on the synovial membrane and on the articular
surfaces may lead to the formation of adhesions, sometimes in the form
of isolated bands, sometimes in the form of a close fibrous union
between the bones.

(4) A _suppurative arthritis_, like that caused by ordinary pus
microbes, may be the result of gonococcal infection alone or of a mixed
infection. Usually only one joint is affected, but the condition may be
multiple. The articular cartilages are destroyed, the ends of the bones
are covered with granulations, extra-articular abscesses form, and
complete osseous ankylosis results.

The _diagnosis_ is often missed because the possibility of gonorrhoea is
not suspected.

The denial of the disease by the patient is not always to be relied
upon, especially in the case of women, as they may be ignorant of its
presence. The chief points in the differential diagnosis from acute
articular rheumatism are, that the gonorrhoeal affection is more often
confined to one or two joints, has little tendency to wander from joint
to joint, and its progress is not appreciably influenced by salicylates,
although these drugs may relieve pain. The conclusive point is the
recognition of a gonorrhoeal discharge or of threads in the urine.

The disease may persist or may relapse, and the patient may be laid up
for weeks or months, and may finally be crippled in one or in several
joints.

The _treatment_--besides that of the urethral disease or of the
ophthalmia--consists in rest until all pain and sensitiveness have
disappeared. The pain is relieved by salicylates, but most benefit
follows weight extension, the induction of hyperaemia by the rubber
bandage and hot-air baths; if the joint is greatly distended, the fluid
may be withdrawn by a needle and syringe. Detoxicated vaccines should be
given from the first, and in afebrile cases the injection of a foreign
protein, such as anti-typhoid vaccine, is beneficial (Harrison).

Murphy has found benefit from the introduction into the joint, in the
early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin
in glycerin. This may be repeated within a week, the patient being kept
in bed with light weight extension. In the chronic hydrops the fluid is
withdrawn, and about an ounce of a 1 per cent. solution of protargol
injected; the patient should be warned of the marked reaction which
follows.

After all symptoms have settled down, but not till then, for fear of
exciting relapse or metastasis, the joint is massaged and exercised.
Stiffness from adhesions is most intractable, and may, in spite of every
attention, terminate in ankylosis even in cases where there has been no
suppuration. Forcible breaking down of adhesions under anaesthesia is
not recommended, as it is followed by great suffering and the adhesions
re-form. Operation for ankylosis--arthroplasty--should not be
undertaken, as the ankylosis recurs.

TUBERCULOUS DISEASE

Tuberculous disease of joints results from bacillary infection through
the arteries. The disease may commence in the synovial membrane or in
the marrow of one of the adjacent bones, and the relative frequency of
these two seats of infection has been the subject of considerable
difference of opinion. The traditional view of Konig is that in the knee
and most of the larger joints the disease arises in the bone and in the
synovial membrane in about equal proportion, and that in the hip the
number of cases beginning in the bones is about five times greater than
that originating in the membrane. This estimate, so far as the actual
frequency of bone lesions is concerned, has been generally accepted, but
recent observers, notably John Fraser, do not accept the presence of
bone lesions as necessarily proving that the disease commenced in the
bones; he maintains, and we think with good grounds, that in many cases
the disease having commenced in the synovial membrane, slowly spreads to
the bone by way of the blood vessels and lymphatics, and gives rise to
lesions in the marrow.

#Morbid Anatomy.#--Tuberculous disease in the articular end of a long
bone may give rise to _reactive changes_ in the adjacent joint,
characterised by effusion and by the extension of the synovial membrane
over the articular surfaces. This may result in the formation of
adhesions which obliterate the cavity of the joint or divide it into
compartments. These lesions are comparatively common, and are not
necessarily due to actual tuberculous infection of the joint.

The _infection of the joint_ by tubercle originating in the adjacent
bone may take place at the periphery, the osseous focus reaching the
surface of the bone at the site of reflection of the synovial membrane,
and the infection which begins at this point then spreads to the rest of
the membrane. Or it may take place in the central area, by the
projection of tuberculous granulation tissue into the joint following
upon erosion of the cartilage (Fig. 156).

[Illustration: FIG. 156.--Section of Upper End of Fibula, showing
caseating focus in marrow, erupting on articular surface and infecting
joint.]

_Changes in the Synovial Membrane._--In the majority of cases there is a
_diffuse thickening of the synovial membrane_, due to the formation of
granulation tissue, or of young connective tissue, in its substance.
This new tissue is arranged in two layers--the outer composed of fully
formed connective or fibrous tissue, the inner of embryonic tissue,
usually permeated with miliary tubercles. On opening the joint, these
tubercles may be seen on the surface of the membrane, or the surface may
be covered with a layer of fibrinous or caseating tissue. Where there is
greater resistance on the part of the tissues, there is active formation
of young connective tissue which circumscribes or encapsulates the
tubercles, so that they remain embedded in the substance of the
membrane, and are only seen on cutting into it.

The thickened synovial membrane is projected into the cavity of the
joint, filling up its pouches and recesses, and spreading over the
surface of the articular cartilage "like ivy growing on a wall."
Wherever the synovial tissue covers the cartilage it becomes adherent to
and fused with it. The morbid process may be arrested at this stage, and
fibrous adhesions form between the opposing articular surfaces, or it
may progress, in which case further changes occur, resulting in
destruction of the articular cartilage and exposure of the subjacent
bone.

In rare instances the synovial membrane presents nodular masses or
lumps, resembling the tuberculous tumours met with in the brain; they
project into the cavity of the joint, are often pedunculated, and may
give rise to the symptoms of loose body. The fringes of synovial
membrane may also undergo a remarkable development, like that observed
in arthritis deformans, and described as arborescent lipoma. Both these
types are almost exclusively met with in the knee.

_The Contents of Tuberculous Joints._--In a large proportion of cases of
synovial tuberculosis the joint is entirely filled up by the diffuse
thickening of the synovial membrane. In a small number there is an
abundant serous exudate, and with this there may be a considerable
formation of fibrin, covering the surface of the membrane and floating
in the fluid as flakes or masses; under the influence of movement it may
assume the shape of melon-seed bodies. More rarely the joint contains
pus, and the surface of the synovial membrane resembles the wall of a
cold abscess.

_Ulceration and Necrosis of Cartilage._--The synovial tissue covering
the cartilage causes pitting and perforation of the cartilage and makes
its way through it, and often spreads widely between it and the
subjacent bone; the cartilage may be detached in portions of
considerable size. It may be similarly ulcerated or detached as a result
of disease in the bone.

_Caries of Articular Surfaces._--Tuberculous infiltration of the marrow
in the surface cancelli breaks up the spongy framework of the bone into
minute irregular fragments, so that it disintegrates or crumbles
away--caries. When there is an absence of caseation and suppuration, the
condition is called _caries sicca_.

The pressure of the articular surfaces against one another favours the
progress of ulceration of cartilage and of articular caries. These
processes are usually more advanced in the areas most exposed to
pressure--for example, in the hip-joint, on the superior aspect of the
head of the femur, and on the posterior and upper segment of the
acetabulum.

The occurrence of _pathological dislocation_ is due to softening and
stretching of the ligaments which normally retain the bones in position,
and to some factor causing displacement, which may be the accumulation
of fluid or of granulations in the joint, the involuntary contraction of
muscles, or some movement or twist of the limb. The occurrence of
dislocation is also favoured by destructive changes in the bones.

_Peri-articular tubercle and abscess_ may result from the spread of
disease from the bone or joint into the surrounding tissues, either
directly or by way of the lymphatics. A peri-articular abscess may
spread in several directions, sometimes invading tendon sheaths or
bursae, and finally reaching the skin surface by tortuous sinuses.

Reactive changes in the vicinity of tuberculous joints are of common
occurrence, and play a considerable part in the production of what is
clinically known as _white swelling_. New connective tissue forms in the
peri-articular fat and between muscles and tendons. It may be tough and
fibrous, or soft, vascular, and oedematous, and the peri-articular fat
becomes swollen and gelatinous, constituting a layer of considerable
thickness. The fat disappears and is replaced by a mucoid effusion
between the fibrous bundles of connective tissue. This is what was
formerly known as _gelatinous degeneration_ of the synovial membrane. In
the case of the wrist the newly formed connective tissue may fix the
tendons in their sheaths, interfering with the movements of the fingers.
In relation to the bones also there may be reactive changes, resulting
in the formation of spicules of new bone on the periosteal surfaces and
at the attachment of the capsular and other ligaments; these are only
met with where pyogenic infection has been superadded.

_Terminations and Sequelae._--A natural process of cure may occur at any
stage, the tuberculous tissue being replaced by scar tissue. Recovery is
apt to be attended with impairment of movement due to adhesions,
ankylosis, or contracture of the peri-articular structures. Caseous foci
in the interior of the bones may become encapsulated, and a cure be thus
effected, or they may be the cause of a relapse of the disease at a
later date. Interference with growth is comparatively common, and may
involve only the epiphysial junctions in the immediate vicinity of the
joint affected, or those of all the bones of the limb. This is well seen
in adults who have suffered from severe disease of the hip in
childhood--the entire limb, including the foot, being shorter and
smaller than the corresponding parts of the opposite side.

Atrophic conditions are also met with, the bones undergoing fatty
atrophy, so that in extreme cases they may be cut with a knife or be
easily fractured. These atrophic conditions are most marked in bedridden
patients, and are largely due to disuse of the limb; they are recovered
from if it is able to resume its functions.