KNEE-JOINT DISEASE.
The treatment of simple inflammatory affection of the synovial mem brane of the knee is dealt with under Synovitis. Arthritis of septic nature, when involving the joint, is treated as described in the article on Joint Disease by immobilising the limb, by inducing hyperaemia, and when extensive suppuration occurs by freely laying open the joint, thoroughly cleansing the cavity with normal saline solution and ether, and providing for drainage by tubes which, however, ought not to penetrate the joint cavity.
Chronic disease of the knee-joint in the great majority of cases, when rheumatic affections are excluded, may be accepted as of tuberculous origin. The measures detailed under llip-Joint and Joint Disease are to be carried out in addition to open air, improved feeding and perfect hygiene.
Local measures, as already mentioned, will embrace prolonged absolute rest by means of splints and extension to correct any abnormal position of the limb. Whilst active mischief is present the entire limb should be rendered immovable. Pain is to be met mainly by rest, but also by cold or warm applications, counter-irritation by means of blisters or the cautery iron, leeching, or anodyne liniments, or lotions. As the more active symptoms subside and abnormal position of the limb is rectified it is of the very greatest moment that the patient should be rescued from the atmosphere of his bedroom and tempted to spend as large a portion of the day as possible in the open air. By means of a Plaster of Paris casing or a leather splint this may be managed without much danger, but the applica tion of a neatly fitting Thomas's Knee Splint is much better. When it is in use the joint is open to daily inspection or to the convenient application of local remedies, as strapping over Scott's dressing. Iodine, &c., or the application of a Martin's rubber bandage. With an accurately fitting splint and a thick sole on the boot of the sound foot the patient can be permitted to move about.
When the disease is confined to the svnovial membrane a good result in young subjects may be expected without resorting to operative measures.
When signs of abscesses occur these should invariably be incised before the skin is allowed to become infected; rigid antiseptic precautions being undertaken, the joint should be opened and a stream of warm liquid employed to thoroughly cleanse and sterilise the cavity. Eusol or other hypochlorite solution is very suitable for this purpose. After its use the wound should be carefully sealed up without drainage.
Where evidence of considerable disintegration of the joint exists the best procedure is to resort to arthrectomy or erasion provided the disease is inactive. An elastic bandage and tourniquet being applied, the joint should be freely opened by turning up a rectangular flap, the tubercle of the tibia being divided without separating it from the patella and without cutting, if possible, the ligamentum patellm. Every recess in the cavity being thus exposed, the synovial membrane is dissected or curetted off the bones and from the lateral and posterior ligaments; the crucial ligaments together with the semilunar cartilages are next removed, and the surfaces of the bones scraped or gouged so as to leave no trace of diseased tissue behind. The tubercle of the tibia is fixed in position, the joint is sealed up by suturing without any provision for drainage, and immobilisation being secured by a suitable splint, firm ankvlosis may be expected within a period of about 12 months. Occasionally some degree
of mobility of the joint may be obtained, but as a rule it is not wise to try for this, as recrudescence of inflammatory action is liable to supervene after attempts at passive movements. The best results as regards mobility are obtainable in those cases undertaken early, before the destruction of the crucial ligaments has occurred.
If upon opening the joint by a free semilunar incision the articular surfaces are found to be extensively and deeply diseased, the best pro cedure is to resort to excision of the joint. The patella, if found to be sound, is turned upwards, or sawn across, its cartilaginous layer being afterwards sliced away, the lateral and crucial ligaments are divided, and the saw being laid on, a slice of bone is removed from the lower end of the femur and from the upper end of the tibia, taking care that the sections are made in the horizontal plane, so that ultimately firm osseous union will occur between the femur and tibia in a straight line. To facilitate this desideratum some surgeons resort to the use of ivory pegs, steel nails or a thick silver wire suture in order to avoid angular deformity by keeping the leg in exact line with the thigh; where deformity already exists, the hamstring tendons should be divided. Complete immobility must be secured, as after the operation of erasion, by the use of a long back-splint or a plaster or a leathern casing, which must be worn for at least a year in order to prevent the yielding of the new osseous tissue. The best results are obtainable in operations undertaken after puberty and before the age of about 3o years. Excision of the knee-joint will shorten by almost a year the treatment of a case of tuberculous disease of the knee joint.
Amputation will be the only course open to the surgeon when the above methods have failed; or when, during past middle life, septic infection has been added to the tuberculous.
Genu Valgum (knock-knee) and Varian (bow-knee) are described upon p. 32S.
Deformities arising from ankylosis in the semiflexed position must be met not by forcible extension, and as a rule the weight and pulley cannot be relied upon. The best procedure is to excise a wedge of the region of the deformed knee-joint, including the articular surfaces of the femur and tibia, and bringing the sawn surfaces into contact so as to main tain the limb in the straight position.
Loose Cartilages may often be dealt with successfully by transfixing them with a strong steel needle, after which they can be cut down upon by a deep incision and turned out. More frequently, however, it will be neces sary to perform an arthrectomy, and after opening the joint by an incision at the side of the patella the cartilage should be dissected out, the joint washed by a stream of sterilised saline and sealed up. It is worth while in the ease of adults to try the effect of a suitable apparatus applied to the limb which will prevent all movements save those of flexion and extension before resorting to arthrectomy.
.Morison has pointed out that the chief cause of internal derangement of the knee-joint is not merely looseness, but fracture of the semilunar cartilage, which must be removed by operation when an active life is necessary, and he emphasises the great dangers of sepsis following all operations on the knee-joint.