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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.
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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."
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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
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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.)
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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)
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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.
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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
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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-
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
(1) Depage: Contribution à l'étude des plaies articulaires. Bulletins et mémoires de la société de chirurgie de Paris, November 29, 1916, xlii, 2722.
(2) Cotton, Frederic J.: Dislocations and Joint Fractures. W. B. Saunders & Co., Philadelphia and London, 1910, 34.
(3) Willems, Charles: Immediate Active Mobilization in the Treatment of Gunshot Wounds of Joints. Medical Record, New York, June 7, 1919, xcv, 953.
(4) Cook, Franklin: Gunshot Wounds of Joints; their Pathology and Treatment. Lancet, London, May 12, 1917, i, 711.
(5) Dowden, J. W.: The Curse of Immobilization. British Medical Journal, London, November 23, 1918, ii, 570.
(6) Willems, Charles: Treatment of Purulent Arthritis by Wide Arthrotomy Followed by Immediate Active Mobilization. Surgery, Gynecology, and Obstetrics, Chicago, 1919, xxviii, No. 6, 546.
(7) Hughes, Basil, and Banks, H. S.: War Surgery from Firing Line to Base. Balliéere, Tindall and Cox, London, 391; 401.
(8) Tuffier and Nové -Josserand: De la valeur des membres qui ont subi des résections articulaires pour plaies de guerre. Presse médicale, Paris, May 18, 1916, xxiv, 224.
(9) Leriche, R.: Traitement des fractures. Masson et Cie., Paris, 1916-18.
(10) Murphy, John B.: Tuberculosis of the Patella. Surgery, Gynecology, and Obstetrics, Chicago, 1908, vi, No. 3, 262.
(11) Pool, Eugene H., and Jopson, John H.: Treatment of Recent Wounds of the Knee-Joint. Annals of Surgery, Philadelphia, 1919, lxx, No. 3, 266.
(12) Mouchet, Albert and Pamart: Résultats éloignés des arthrotomies du genou. Bulletins et ménoires de la société de chirurgie de Paris, April 24, 1918, xliv, 768.
(13) Le Fur, Rene : Résultats éloignés des résections du coude. Paris chirurgical, March 30, 1916, viii, 233.
(14) Chutro, Pedro: Infected Wounds of the Ankle. Journal of Orthopedic Surgery, Boston, 1919, xvii, No. 9, 521.
(15) Guénard: Arthrites purulentes du genou. Les abscès migrateurs d'origine articulaire et leur traitement. Journal des praticiens, Paris, 1917, xxxi, No. 12, 179.
(16) Blake, Joseph A.: Gunshot Fractures of the Extremities. Masson et Cie., Paris, 1918.
(17) Rankin, W.: On the Treatment of Certain Selected Cases of Septic Arthritis of the Knee. British Medical Journal, London, September 1, 1917, ii, 287.
(I8) Chaput, E.: Nouveau mode de drainage des plaies articulaires de guerre et des arthrites purulentes communes du membre supérieur. Paris médical, 1916, xxi, No. 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 chirurgical, 1918, xv, No. 4, 399.
(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 and the Transport Splints. Pennsylvania Medical Journal, Athens, Pa., 1919, xxii, No. 4, 205.
