ARTHRODESIS.
This term applies to the intentional production of ankylosis in a joint previously healthy or nearly so, with the intention of stiffening a useless limb and thus enhancing its usefulness. The measure applies mainly to those cases of infantile paralysis, with loss of control of the knee or ankle, or both, when by stiffening the limb it can be made to serve the purpose of a crutch. It is the last resort in this direction when there is no possibility for tendon grafting. Long confinement of a limb in a fixed dressing will lead to considerable stiffening of the joint, yet a joint so immobilized lacks that firmness of support called for in cases above mentioned. Therefore when it is desired to perform arthrodesis the joint is usually opened and more or less of its articular surface removed, the intent being to produce the effect in the shortest time and in the best way. It can be better attained by a removal of articular surfaces with the saw and the apposition of fresh bone surfaces to each other, their retention being ensured either by sutures (tendon or wire) or accurate fixation in plaster of Paris. Under these circumstances drainage should not be necessary, and limbs can be completely enclosed in a fixed dressing.
MAJOR OPERATIONS ON JOINTS.
Aside from arthrotomy and partial or complete arthrectomy, as above mentioned, the latter, including removal of synovia or cartilage, and perhaps curetting of bone foci, the formal resections or excisions of joints remain to be considered. The latter is the preferable term, as it is meant to include removal of the component parts that enter into the construction of joints, while the term resection implies rather the removal merely of portions of bone.
Joint excisions are practised especially for the following purposes: (a) To atone for the result of old unreduced dislocations; (b) in certain compound dislocations, with or without fracture; (c) in certain comminuted fractures where there is no prospect of recovery with useful joints; (d) in the destructive forms of acute arthritis where the entire joint is disorganized and the bone ends carious; (e) in tuberculous arthritis or panarthritis, with or without suppurative complications; (f) in occasional instances of disabling osteo-arthritis; (g) for relief of ankylosis, either for improvement of position (knee) or restoration of motion; (h) occasionally after gunshot injuries. Excisions required by the exigencies of traumatisms should be promptly done. If the case be complicated with septic infection the prognosis is much less favorable. For convenience of description excisions may be classified as primary, intermediary, and secondary. According to the joint involved, as at the knee, the purpose underlying the operation is to effect an absolutely rigid bony ankylosis.
The development and perfection of the general method of joint excisions is a matter of but little more than a century. Previous to that time amputation was almost the only resort when destruction had occurred. The most prominent surgeons in the early development of the measure were Park, of Liverpool, and Moreau, of France. During the latter part of the past century Ollier, of Lyons, greatly improved the technique by demonstrating the importance of the periosteum and by introducing the so-called subperiosteal methods. This is of great value in uninfected cases. It is a mistake, however, to endeavor to save periosteum which has become involved in the tuberculous process; in fact, in the presence of tuberculous disease we cannot be too radical in the removal of all affected tissue.
In the so-called subperiosteal method the operator endeavors, so far as possible, to preserve the periosteum of the parts exposed to attack, and, if possible, the capsular ligament as well. Thus at the elbow the capsule, if not diseased or obliterated, should be preserved, the osseous tissue being shelled out from within, so far as possible. The less, then, the connections between the capsule and the periosteum are disturbed the better. The French apply to this method the term “subcapsular periosteal.” When the bone covering can be preserved new bone is easily formed to replace that which has been lost, especially during adolescence, while the preservation of the capsule, with its ligamentous connections, affords a better joint cavity than will the substitute which results from natural processes. Furthermore the surrounding tendons are less disturbed and the condition remains more like the original. Nevertheless one does not exsect healthy joints, and the method is not always easy nor even possible of performance. It will suffice to say that it should be adhered to only as far as circumstances may justify or permit.
Surgeons, however, have not been satisfied with the older methods, and have endeavored to still further enhance motility in operated joints. (See above—[Arthroplasty].) To this end the interposition of muscle, fascia, or of foreign membrane has been suggested. Thus, after removal of the head of the femur a strip of fascia lata may be interposed between the raw-bone surface and the cavity of the acetabulum, being fastened there by catgut sutures. In the shoulder a similar procedure has been carried out, utilizing a strip of deltoid muscle. At the elbow a piece of the pronator radii teres may be detached and fixed by sutures to the brachialis anticus. In every case the method should be adapted to the demands made, the intent being to cover divided bone ends with tissue which will prevent osseous union, as it is known to do in many cases of fracture where such interposition produces non-union. In so far as one attempts here to imitate conditions which are considered undesirable in certain other traumatisms, Murphy has done more than any other American surgeon, both in the experimental and clinical study of this subject. (See above.)
For the joints below the hip and shoulder the bloodless method will facilitate operative work. In case of a septic joint, however, it would not be advisable to apply the elastic bandage below and then over and around the joint, as by the pressure thus made some septic material may be forced into the absorbents. In clean cases the rubber bandage is a great advantage to the operator. It has this objection, however, in that hemorrhage which does not occur during the operation has to be checked after its conclusion, and I have often thought it advisable to avoid the use of the bandage and to secure vessels as they are divided, in order that when bleeding has once ceased there be no fear of its recurrence later.
The question of drainage is one of importance. In a general way one may feel that in an absolutely clean case drainage is not required, save possibly a small opening for escape of blood. If practised at all it should be thoroughly done. Drainage tubes are often too small and do not permit the escape of either clotted blood or debris of injured tissue.