Calcified mass in old “cold abscess” about hip-joint. (Buffalo Clinic. Skiagram by Dr. Plummer.)
To incision with or without drainage is given the name arthrotomy. When the joint is widely opened and portions removed with the sharp spoon or otherwise, it is known as arthrectomy. When bone is removed irregularly the measure is called atypical resection. When entire bone ends are removed the operation becomes an exsection or resection. The ordinary arthrectomy is not sufficient when foci are present in the epiphyses. Here at least atypical resection is called for. Arthrectomy may properly include a wide exposure of articular surfaces and the removal of the thickened and diseased synovia, with its fringes, or with the cartilages, by which cancellous structure is more or less widely exposed. When arthrectomy is undertaken it should be thoroughly made and by a large incision, since the more completely the joint cavity can be inspected and attacked the better are the interests of the patient subserved. All fresh or cold abscess cavities which connect with the joint or lie in contact with it should also be attacked at the same time, and those which do not communicate with it should be separately drained. While drainage by tube or other means will usually suffice, there are cases where the disease is so extensive that it will pay to pack the cavity with balsam gauze for a few days, placing secondary sutures by which the incision can be closed after its removal. In the shoulder and hip, for instance, such a method will give satisfactory results.
The advantage of avoidance of resection is the non-interference with the epiphyses and their junctions, thus permitting the growth of the bone to continue. Therefore complete and typical excisions should be practised as seldom as possible, especially in growing children. They may be practised to advantage even in advanced age, and the writer has seen satisfactory results after complete excision of tuberculous joints in senile cases. When operating upon a tuberculous tarsal joint the surgeon is likely to find one or more of the tarsal bones so much involved in the tuberculous disease that he is compelled to scrape it out and thus leave a cavity almost the size of the bone itself. Should he have to do this to a series of the bones it would be better to make a formal resection of the tarsus or possibly an amputation. The cavity should be left open with a sufficiently large incision so that it may be easily packed. A cavity of this kind left unpacked will fill up with clot, which will disintegrate and the result will be much less satisfactory. In the former case there is an open cavity which fills with granulations, but this can be kept accessible under observation and with more effect and comfort. This is equally true of those cavities where both arthrectomy and bone curettage have been practised.
MOVABLE BODIES IN THE JOINTS.
Several different terms have been applied to loose and movable bodies, even in the various joints, depending on their size, arrangement, and appearance. Thus we have the rice-grain or melon-seed bodies (corpora oryzoidea), which have already been described and are now supposed to indicate a form of tuberculous synovitis which has undergone a partial if not complete subsidence. Again we have larger masses occurring singly or in very small number, especially in the knee, to which the Germans have given the significant name of joint mice. Also in the knee, owing to its peculiar construction, another form of movable body is met with, i. e., a displaced and more or less motile semilunar cartilage. This condition was first described by Hey, and especially studied by Allingham, who made it a prominent feature of what he described as “internal derangement of the knee.” Lastly, in those joints in which synovial fringes occur, the knee especially, it is held that portions may become detached by having been infiltrated and cast off or broken loose, and thus form a fourth variety of floating body. The joints most often affected are the knee and the elbow. In many instances there is a history of injury, especially when the mass is of considerable size. The theory of an “osteochondritis dissecans” has also been invoked to account for the resemblance between some of these bodies and the articular cartilages. Some pathologists have held that they may result from the organization of clots, which are subsequently rounded off and shaped by attrition ([Fig. 209]). These bodies then may consist of condensed fibrinous material, of cartilage, of true bone, or of hyperplastic and fatty synovial tassels. To these may be added rare instances of mucoid connective tissue.
Fig. 209
Floating bodies—“joint mice”—from knee-joint. (Lexer.)