Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕

Caries of the articular surface imparts a woolly appearance or irregular contour in place of the well-defined outline of the articular end of the bone. In bony ankylosis the shadow of the two bones is a continuous one, the joint interval having been filled up. The minor changes are best appreciated on comparison with the normal joint of the other limb.

Wasting of muscles is a constant accompaniment of tuberculous joint disease. It is to be attributed partly to want of use, but chiefly to reflex interference with the trophic innervation of the muscles. It is specially well seen in the extensor and adductor muscles of the thigh in disease of the knee, and in the deltoid in disease of the shoulder. The muscles become soft and flaccid, they exhibit tremors on attempted movement, and their excitability to the faradic current is diminished. The muscular tissue may be largely replaced by fat.

Impairment of the normal movements is one of the most valuable diagnostic signs, particularly in deeply seated joints such as the shoulder, hip, and spine. It is due to a protective contraction of the muscles around the joint, designed to prevent movement. This muscular fixation disappears under anæsthesia.

Abnormal attitudes of the limb occur earlier, and are more pronounced in cases in which pain and other irritative symptoms of articular disease are well marked, and are best illustrated by the attitudes assumed in disease of the hip. They are due to reflex or involuntary contraction of the muscles acting on the joint, with the object of placing it in the attitude of greatest ease; they also disappear under anæsthesia. With the lapse of time they not only become exaggerated, but may become permanent from ankylosis or from contracture of the soft parts round the joint.

Startings at night are to be regarded as an indication that there is progressive disease involving the articular surfaces.

The formation of extra-articular abscess may take place early, or it may not occur till long after the disease has subsided. The abscess may develop so insidiously that it does not attract attention until it has attained considerable size, especially when associated with disease of the spine, pelvis, or hip. The position of the abscess in relation to different joints is fairly constant and is determined by the anatomical relationships of the capsule and synovial membrane to the surrounding tissues. The bursæ and tendon sheaths in the vicinity may influence the direction of spread of the abscess and the situation of resulting sinuses. When the abscess is allowed to burst, or is opened and becomes infected with pyogenic bacteria, there is not only the risk of aggravation of the disease and persistent suppuration, but there is a greater liability to general tuberculosis.

The sinuses may be so tortuous that a probe cannot be passed to the primary focus of disease, and their course and disposition can only be demonstrated by injecting the sinuses with an emulsion of bismuth and taking X-ray photographs.

Tuberculous infection of the lymph glands of the limb is exceptional, but may follow upon infection of the skin around the orifice of a sinus.

A slight rise of temperature in the evening may be induced in quiescent joint lesions by injury or by movement of the joint under anæsthesia, or by the fatigue of a railway journey. When sinuses have formed and become infected with pyogenic bacteria, there may be a diurnal variation in the temperature of the type known as hectic fever (Fig. 11).

Relative Frequency of Tuberculous Disease in Different Joints.—Hospital statistics show that joints are affected in the following order of frequency: Spine, knee, hip, ankle and tarsus, elbow, wrist, shoulder. The hip and spine are most often affected in childhood and youth, the shoulder and wrist in adults; the knee, ankle, and elbow show little age preference.

Clinical Variations of Tuberculous Joint Disease.—The above description applies to tuberculous joint disease in general; it must be modified to include special manifestations or varieties.

When the main incidence of the infection affects the synovial membrane, the clinical picture may assume the form of a hydrops, or of an empyema in which the joint is filled with pus. More common than either of these is the well-known white swelling or tumor albus (Wiseman, 1676) which is the clinical manifestation of diffuse thickening of the synovial membrane along with mucoid degeneration of the peri-synovial cellular tissue. It is well seen in joints which are superficial—such as the knee, ankle, elbow, and wrist. The swelling, which is the first and most prominent clinical feature, develops gradually and painlessly, obliterating the bony prominences by filling up the natural hollows. It appears greater to the eye than is borne out by measurement, being thrown into relief by the wasting of the muscles above and below the joint. In the early stage the swelling is elastic, doughy, and non-sensitive, and corresponds to the superficial area of the synovial membrane involved, and there is comparatively little complaint on the part of the patient, because the articular surfaces and ligaments are still intact. There may be a feeling of weight in the limb, and in the case of the knee and ankle the patient tires on walking and drags the leg with more or less of a limp. Movements of the joint are permitted, but are limited in range. The disability is increased by use and exertion, but, for a time at least, it improves under rest.

If the disease is not arrested, there follow the symptoms and signs of involvement of the articular surfaces.

Influence of Tuberculous Joint Disease on the General Health.—Experience shows that the early stages of tuberculous joint disease are compatible with the appearance of good health. As a rule, however, and especially if there is mixed infection, the health suffers, the appetite is impaired, the patient is easily tired, and there may be some loss of weight.

Treatment.—In addition to the general treatment of tuberculosis, local measures are employed. These may be described under two heads—the conservative and the operative.

Conservative treatment is almost always to be employed in the first instance, as by it a larger proportion of cures is obtained with a smaller mortality and with better functional results than by operation.

Treatment by rest implies the immobilisation of the diseased limb until pain and tenderness have disappeared. The attitude in which the limb is immobilised should be that in which, in the event of subsequent stiffness, it will be most serviceable to the patient. Immobilisation may be secured by bandages, splints, extension, or other apparatus. Extension with weight and pulley is of value in securing rest, especially in disease of the hip or knee; it eliminates muscular spasm, relieves pain and startings at night, and prevents abnormal attitudes of the limb. If, when the patient first comes under observation, the limb is in a deformed attitude which does not readily yield to extension, the deformity should be corrected under an anæsthetic.

The induction of hyperæmia is often helpful, the rubber bandage or the hot-air chamber being employed for an hour or so morning and evening.

Injection of Iodoform.—This is carried out on the same lines as have been described for tuberculous abscess. After the fluid contents of the joint are withdrawn, the iodoform is injected; and this may require to be repeated in a month or six weeks.

After the injection of iodoform there is usually considerable reaction, attended with fever (101° F.), headache, and malaise, and considerable pain and swelling of the joint. In some cases there is sickness, and there may be blood pigment in the urine. The severity of these phenomena diminishes with each subsequent injection.

The use of Scott's dressing and of blisters and of the actual cautery has largely gone out of fashion, but the cautery may still be employed with benefit for the relief of pain in cases in which ulceration of cartilage is a prominent feature.

The application of the X-rays has proved beneficial in synovial lesions in superficial joints such as the wrist or elbow; prolonged exposures are made at fortnightly intervals, and on account of the cicatricial contraction which attends upon recovery, the joint must be kept in good position.

Conservative treatment is only abandoned if improvement does not show itself after a thorough trial, or if the disease relapses after apparent cure.

Operative Treatment.—Other things being equal, operation is more often indicated in adults than in children, because after the age of twenty there is less prospect of recovery under conservative treatment, there is more tendency for the disease to relapse and to invade the internal organs, and there is no fear of interfering with the growth of the bones. The state of the general health may necessitate operation as the most rapid method of removing the disease. The social status of the patient must also be taken into account; the bread-winner, under existing social conditions, may be unable to give up his work for a sufficient time to give conservative measures a fair trial.

The local conditions which decide for or against operation are differently regarded by different surgeons, but it may be said in general terms that operative interference is indicated in cases in which the disease continues to progress in spite of a fair trial of conservative measures; in cases unsuited for conservative treatment—that is to say, where there are severe bone lesions. Operative interference is indicated also when the functional result will be better than that likely to be obtained by conservative measures, as is often the case in the knee and elbow. Cold abscesses should, if possible, be dealt with before operating on the joint.

In many cases the extent of the operation can only be decided after exploration. The aim is to remove all the disease with the least impairment of function and the minimum sacrifice of healthy tissue. The more open the method of operating the better, so that all parts of the joint may be available for inspection. The methods of Kocher, which permit of dislocating the joint, are specially to be recommended, as this procedure affords the freest possible access. Diseased synovial membrane is removed with the scissors or knife. If the cartilages are sound, and if a movable joint is aimed at, they may be left; but if ankylosis is desired, they must be removed. Localised disease of the cartilage should be removed with the spoon or gouge, and the bone beneath investigated. If the articular surface is extensively diseased, a thin slice of bone should be removed, and if foci in the marrow are then revealed, it is better to gouge them out than to remove further slices of bone, as this involves sacrifice of the cortex and periosteum.

Operative treatment of deformities resulting from tuberculous joint disease has almost entirely replaced reduction by force; the contracted soft parts are divided, and the bone is resected.

Amputation for tuberculous joint disease has become one of the rare operations of surgery, and is only justified when less radical measures have failed and the condition of the limb is affecting the general health. Amputation is more frequently called for in persons past middle life who are the subjects of pulmonary tuberculosis.

Syphilitic affections of joints are comparatively rare. As in tuberculosis, the disease may be first located in the synovial membrane, or it may spread to the joint from one of the bones.

In acquired syphilis, at an early stage and before the skin eruptions appear, one of the large joints, such as the shoulder or knee, may be the seat of pain—arthralgia—which is worse at night. In the secondary stage, a synovitis with serous effusion is not uncommon, and may affect several joints. Syphilitic hydrops is met with almost exclusively in the knee; it is frequently bilateral, and is insidious in its onset