—The best method of treatment should be determined by the original character of the exciting cause, the duration of the condition, the amount of deformity present, and the degree of joint fixation. That which will be possible if done early will be useless if not resorted to until the case is old and chronic. In every acute or subacute condition which may threaten ankylosis every possible precaution should be taken to prevent it. If ankylosis be inevitable it should occur with the limb in the most suitable position. At the elbow, for example, this will be the right-angle position; at the knee, one with the leg almost completely extended. In the lower extremity traction with weight and pulley will serve a useful purpose in many instances, either to overcome a threatening condition or to improve one actually existant. Mechanical measures (i. e., use of various splints or forms of orthopedic apparatus) will sometimes be of great use. These may be arranged for the purpose of providing absolute rest, with fixation in a desirable position rather than in one which is undesirable, or they may be made with such devices as shall permit of frequent change of position.

The mildest operative measure which can be practised in these cases is manipulation, either gentle and frequent, combined with massage, or more violent and painful, such as requires anesthesia for its performance. The question of when to resort to these manipulations is one calling for the soundest judgment, as on one side the surgeon faces the possibility of setting up a renewed and more or less acute disturbance, and on the other of seeing a joint gradually stiffen, perhaps in a bad position. There is also a third difficulty, i. e., the necessity for continuing motion in order to prevent the re-formation of adhesions, and this in spite of the fact that it may be intensely painful to the patient. Fortunately, however, the use of nitrous oxide anesthesia usually permits this to be done as often as may be necessary with a minimum of discomfort.

Firm, fibrous ankylosis will be attacked with great hesitation by the experienced surgeon. Even though he may succeed in restoring the limb to a better position, he may feel quite positive that the patient cannot undergo the pain of the subsequent frequent handling. With bony ankyloses he may feel that nothing short of radical measures will suffice. Here it is rarely a question of restoring motility but rather of overcoming deformity. At the knee a wedge-shaped portion of the joint may be removed, its angle corresponding to the angle of deformity, and thus a crooked leg may be restored to the straight position; in fact, with a raised heel under such a limb it may be made almost as useful as ever. At the hip one may do a subcutaneous osteotomy, dividing the femoral neck either with chisel or with a small and protected saw, and then bringing the limb down into the normal position of extension, allowing the bone to repair itself, and effecting improvement only in position, or, by constantly moving it, securing a false joint; or a more formal exsection may be made and by removing the head of the femur and clearing out the acetabulum a degree of motion may be established at this point. At the wrist, elbow, and shoulder-joint resections will usually give good results if the operation be performed before the muscles have almost disappeared by atrophic processes.

Danger attaches to the performance of the so-called bloodless operations, in that there is a possibility of laceration of nerve trunks or of large vessels which may have become fixed in the condensed tissues and be torn with them. There is more danger of this perhaps at the knee than in other joints, and ruptures of the popliteal vessels and nerves have been repeatedly reported. The first attempt in breaking up such a joint should be to increase the degree of flexion. If by efforts in this direction the tissues can be first released, then there is less danger of their yielding when extension is made. Another danger which threatens in all resistant cases, and especially in elderly people, is fracture of bones. The writer has seen the upper end of the tibia as well as the neck of the humerus yield under these circumstances. In the latter event one should endeavor to prevent bony union, and thus to gain a false joint in place of the original.

In regard to the nature of the operative attacks upon the above types, the following is copied from Murphy:[33]

A. Extracapsular disease- 1. Tendon elongation (tendoplasty).
2. Tendovaginitis (exsection of sheath).
3. Cicatrices (removal).
B. Intracapsular- 1. Adhesive synovitis (exsection of capsule).
2. Replacement by aponeurosis or muscle.
C. Osseous- 1. Disconnect bones.
2. Remove neighboring bony processes or prominences.
3. Liberate soft parts.
4. Prevent subsequent bony contact.
5. Interpose tissue to form hygroma or fibrous surface.
D. Joints suitable for operation.- 1. Mandibular.
2. Hip.
3. Shoulder.
4. Elbow.
5. Knee.
E. Technique- 1. Flap formation (skin flap with fascia, or muscular).
2. Exposure of ankylosed area.
3. Osseous separation.
4. Transplantation and fixation of interposition flap.
5. Replacement of bone.
6. Fixation of parts.
7. Drainage.
F. Subsequent treatment- 1. Passive motion
2. Active motion.
3. Forced traction.

[33] Journal American Medical Association, May 20, 1905, p. 1573.

To the various expedients which may be adopted for making stiffened joints more useful may be given, in a general way, the term arthroplasty. A variety of mechanical contrivances have been resorted to in the past, operators hoping to be able to secure, for instance, a movable knee instead of one which is stiff. Artificial joints, made of celluloid, ivory, etc., have been used for experimental purposes, but while occasionally they have given good results in animals, they have rarely been satisfactory in man. For the prevention of re-adhesion, plates of celluloid, thin metal, gutta-percha, rubber, etc., have been used. These are either wrapped around a bone end or are used for lining a bone cavity, and rapidly accumulating experience is showing that this may be done with great benefit.

Thoroughness of operative work is one of the important contributing agents to the securement of wide range of motion, especially in complete removal of synovial membrane, capsule, and ligaments. Soft parts should be liberated thoroughly. Of the materials which can be interposed between bone ends in order to prevent reunion, muscular aponeurosis, with a certain amount of fatty tissue, makes the best material for interposition. When aponeurosis cannot be secured, then muscle should be tried, with some fat, as the former flattens out and undergoes structural changes, with conversion into fibrous tissue.

It should be represented to the patient as a legitimate scientific experiment, and in such a way that no matter what may happen no blame can be attached to the operator. In general it may always be stated that the older the lesion the less satisfactory will be any measure of treatment except possibly resection and arthroplasty.