A Manual of the Operations of Surgery

CHAPTER III.
EXCISION OF JOINTS

Historical.—Beyond a passage ascribed to Hippocrates, but of very doubtful authenticity, and slight allusions in the works of Celsus and Paulus Ægineta, the ancients give us no information whatever on this subject.

Hippocrates says,—"Complete resections of bones in the neighbourhood of joints both in the foot, in the hand, in the tibia up to the malleoli, and in the ulna at its junction with the hand, and in many other places, are safe operations, if that fatal syncope does not at once occur, and continued fever does not attack the patient on the fourth day."

Celsus and Ægineta both advise the removal of protruding ends of bone in compound dislocations, but without giving any cases.

From the days of these classic fathers of Surgery, we have hardly an indication of any attention whatever having been paid to their hints till quite within the last hundred years.

The first distinct publication on the subject was by Henry Park of Liverpool, in a letter to Percival Pott in 1783. He proposed the removal of the articulating extremities of diseased elbow and knee-joints to obtain cures. He says he was led to this by its having been the invariable custom, for more than thirty years, at the Liverpool Infirmary, to take off the protruded extremities of bones in cases of compound dislocation.

The chief credit, however, in practically elevating excisions into the catalogue of recognised surgical operations, is owing, British surgeons most cordially own, to two provincial surgeons of France, the Moreaus (father and son) of Bar-sur-Ornain. They took the lead in the most marked manner, having excised the shoulder in 1786, the wrist and elbow in 1794, knee and ankle in 1792, and had followed this up so well that, in 1803, the younger Moreau could boast, "the town has become in some sort the refuge of the unfortunate afflicted with carious joints, after they have tried all the means usually recommended by professional men, or have had recourse to empirical nostrums, or when amputation seemed to them the last resource."

Moreau's papers and cases, which, between 1786 and 1789, he frequently read to the French Academy, were, some violently opposed, others utterly neglected by his compatriots, and many of them lost and buried in the unpublished papers of that body.

And though diseased joints did not decline in frequency, and though injured ones were extremely numerous during these long years of European war, excisions were but rarely performed.

With the exception of the removal of head of humerus after gunshot injury, hardly any British, and but very few French, limbs were saved by excision taking the place of amputation.

The limbs that were saved by Percy by excision of the head of the humerus really owe their recovery and safety to the elder Moreau; for an operation of his, at which he was assisted by that distinguished military surgeon, gave the latter the hint, which he followed so successfully, that by 1795 he had performed it nineteen times, and had indoctrinated Sabatier, Larrey, and others, and elevated it into a recognised operation of military surgery.

So far, however, as the application of the great improvement of the Moreaus to disease went, the French surgeons have little reason to boast, for it is to English surgery, and especially to one Edinburgh surgeon, that this class of operations owes nearly all its improvement in methods and frequency of performance.

For though (as we shall see under the special heads) here and there one or two cases were performed, it was not till the publication of Mr. Syme's monograph on the excision of diseased joints, in 1831, that the importance and value of the discovery were fairly brought before the profession; and the conservative surgery, of which excision as preferred to amputation is the great type, must ever be associated with British surgeons—Syme, Fergusson, Mackenzie, Jones of Jersey, Butcher of Dublin.

On the Continent—Langenbeck, Stromeyer, Heyfelder, Ollier, Esmarch of Kiel, specially in the surgical history of the first Schleswig-Holstein war, have followed up the example set them here.

Before proceeding to describe the operations on the various joints, one or two questions may be briefly asked and answered by way of introduction.

In what cases, or sorts of cases, are excisions suitable?

1. In cases of compound injury or dislocation of a large joint, as used by Filkin, Park, White, and other English surgeons long ago. In hospital practice, or in private, where there is every advantage of rest, food, and appliances, such operations will frequently be found suitable where the joint is alone or chiefly the seat of injury, and where the general health seems fit to bear a prolonged suppuration. But long and sad experience has shown that, as a general rule in military practice, with the difficulties of transport, the generally bad sanitary state of the hospitals, and the want often of adequate dressings and attention, excisions are much more fatal than amputations, and, except in elbow and shoulder (q.v.), should be as a general rule avoided.

2. Excision for deformity (generally speaking for bony anchylosis) will require for decision the consideration of many points, i.e. the joint affected, the nature of the disease or injury which has caused the anchylosis: and in each case—(1.) the state of health of the patient; and (2.) his occupation, and the consequent position of limb which would suit him best. As a general rule, I believe, experience will prove that such operations on the lower extremity are almost absolutely inadmissible, except under very special urgency on the part of the patient, and a very high condition of health—while in the upper, the elbow-joint is the only one which you will ever be likely to be asked to remedy, or should comply with the request if asked; as the shoulder, even if anchylosed, will (1.) from its own weight generally become so in the most favourable position; and (2.) from the extreme mobility which the scapula can acquire, its anchylosis will not be so much felt.

The elbow, however, from the frequency of fractures of the condyles of the humerus obliquely into the joint, and from the manner in which these are so often neither recognised nor properly treated, very often becomes anchylosed in the most awkward possible position, i.e. nearly straight; and operations undertaken for such deformities are in general both quite safe and very satisfactory. Mr. Syme had one case (resulting from a fall, causing a double fracture), in which both arms were thus firmly anchylosed in such a position that the sufferer could absolutely perform none of the commonest duties of life without assistance. Excision of both joints cured him.

The author excised with success for disease the elbow-joint of a patient whose other arm had required the same operation.

The occupation of the patient must always be taken into consideration when settling the position of an anchylosis, or the necessity or advantage of a resection.

Thus, Bryant⁵³ tells of a painter who wished his arm to be fixed in a straight position, and of a turner whose knee at his own request was permitted to stiffen at a right angle, as that position allowed him to turn his wheel.

3. Excision for Disease of the Joint.—In our cold climate, so cursed by scrofula, and specially among the children of the labouring poor, such joint diseases are very prevalent, and whether the disease commences in the synovial membrane, the articular cartilages, or the heads of the bones, it frequently so disorganises the joint as to make it a question whether something must not be done to preserve the very life of the patient.

The difficulty of diagnosing the cases in which excisions are suitable or necessary is often very great; and we must balance its performance—(1.) against the possibly good results of an expectant treatment; (2.) against amputation of the limb.

(1.) Against expectant Treatment.—The patient has youth on his side, could we give him fresh sea air, good diet, cod oil, etc., we might very likely obtain anchylosis; true, but he may die while trying for this anchylosis, and also this anchylosis, when got, may so lame or deform him that resection may still be required.

These points must all be considered, but as a general rule, I would say that such attempts at preservation of the limb are much more justifiable, and longer justifiable in the hip and knee-joints than in the elbow or shoulder; for the results in the lower limb will probably be as good, if the patient survive, if not better, than those obtained by excision, while the danger of the operation is greater; while in the upper limb, the danger to life in operating is less than that of leaving the limb on, and the results obtained by a successful operation, with well-managed after treatment, are far more satisfactory than the best possible anchylosis.

Another point bearing on this, of very great importance: In children, the most frequent subjects of such disease, excision of the lower limb may, by removing the epiphyses, cause to a very considerable degree disparity in their length, thus rendering them nearly useless, while in the upper such disparity is neither so extensive nor so injurious to the usefulness of the limb, which is not required for purposes of progression.

In the hip-joint especially, all the resources of the art should be tried in the expectant treatment, for amputation at the hip-joint is hardly ever admissible for disease of the joint, while excision has anything but satisfactory statistics.

(2.) Against Amputation.—Many questions must be considered, chiefly under the heads of the separate joints:—

1. As to the difficulties and dangers of the operations contrasted.

Such as the following:—

Excisions give the surgeon more trouble, require more manual dexterity; take longer to perform; are very painful operations. Not valid objections in these days of chloroform and operative surgery on the dead body.

Excisions have the special peculiarity and danger of dealing chiefly with cancellated bone, broadened out, open, with numerous patulous canals for large veins, tending on any irritation or inflammation to set up a diffuse suppuration, and to culminate in phlebitis, myelitis, and other pyæmic conditions.

Excisions are performed through degenerate or disorganised, amputations through healthy, tissue.

Excisions require extreme care and absolute rest (i.e. in lower limb) for many weeks and months after the operation.

But, on the other hand,—

Amputations remove a portion of the body; excisions a much less one. Amputations are always necessarily nearer the centre than the corresponding excisions, and statistics show that the fatality of operations increases in exact proportion as they approach the centre.

A successful excision, especially in arm, saves a limb nearly perfect; an amputation at best is only the stump for a wooden one.

On the whole, there is actually very little difference in the mortality of excisions and amputations.

2. As to the results of the operation on the usefulness of the limb, depending on joint involved, age of patient, and amount of bone removed:—

A. Joint involved.—These must be noticed separately, but one thing is absolutely certain, that a much higher standard of usefulness, both in equality of length, amount of anchylosis, and position, is needed in the lower than in the upper limb. For a leg hanging like a flail, or shortened by some inches, is not so good for purposes of locomotion as a wooden leg is, while an arm, even though powerless at the elbow, and perhaps much shortened, can be so strengthened and supported by slings and bandages as to give a most useful hand, the complex movements and uses of the fingers of which no mechanism can at all imitate.

B. Age of Patient.—It must be remembered that excision in a child removes the epiphyses by which in great measure the growth of the bone is to be managed, and the stunted limb, especially in the leg, will eventually be of little advantage, though after the operation it looked excellently well, if a few years later it be found to be seven or eight inches shorter than its neighbour.

C. Amount of Bone removed.—From an erroneous view of the pathological changes in the bone affected, far too much was removed by many of the earlier operators, especially Moreau and Crampton.

The reason that this is often still the case, is well seen in many preparations. The bones are thickened to a considerable distance, and covered with irregular warty excrescences. These, which used to be considered evidences of disease, are only compact new healthy bone, thrown out like the callus of a fracture in consequence of the irritation.

In a word, what we require to remove is the following:—

1. All the cartilage, dead or alive, healthy or diseased.

2. Only the bone involving the articular extremities, in thin slices, or with the occasional use of the gouge, till a healthy bleeding surface is obtained.

3. The synovial membrane, however gelatinous or thickened looking, really requires very little care or notice; it will disappear of itself, partly by sloughing, partly by absorption during the profuse suppuration.⁵⁴

Excision of the Shoulder-Joint.—Before considering the method of operating, a word or two is required on the subject of how much is to be removed, and in what cases the operation should be performed. The shoulder and hip joints are the only ones in which partial excision is ever admissible, indeed, in the shoulder excision of the head of the humerus only is in many cases found to be all that is necessary, while in all it is much less dangerous to life than when the glenoid cavity also requires to be interfered with.

It is rarely necessary to remove more of the bone than merely its articular extremity (when performed for disease of the joint), and if possible this should be done inside the capsule, i.e. through an incision in the capsule, but without involving its attachment to the neck of the bone. When the glenoid is also diseased, mere gouging or scraping the cartilaginous surface will not suffice, but the neck must be thoroughly exposed, so that the whole cup of the glenoid may be removed by powerful forceps.

Cases suitable for Excision.—Cases of chronic disease of the head of the humerus (generally tubercular), or of chronic ulceration of the cartilages which has resisted counter-irritation. Cases of gunshot injury of the joint, or of compound dislocation, or fracture involving the joint. Cases of limited tumours affecting merely the head and upper third of the bone, and non-malignant in character. Anchylosis very rarely requires and would not be much benefited by such an operation.

Operation.—Though perhaps not the easiest, the following method is the one followed by the best results. It is suited especially for cases of caries or other disease of the joint, where the head of the humerus is either alone or chiefly affected:—

A single straight incision (Plate I. fig. a.) is made from a point just external to the coracoid process downwards along the humerus for at least three inches. It corresponds almost exactly to the bicipital groove, and has the advantage of avoiding the great vessels and nerves. The long head of the biceps may then be raised from its groove, and drawn to a side so as to be preserved. This is deemed of importance by Langenbeck and others. Mr. Syme, however, did not attach much value to its preservation, as it is often diseased. The capsule, which is often much altered, perhaps in part destroyed, is then opened, and the tendons of the muscles which rotate the head of the humerus divided in succession, while the elbow is rotated first inwards and then outwards by an assistant so as to put them on the stretch. The arm being then forced backwards, the head of the bone can be protruded through the wound, and sawn off at the necessary distance down the shaft. The glenoid must then be carefully examined, and any diseased bone removed by the cutting pliers. One or two small branches supplying the anterior fold of the axilla are the only vessels divided, and may not even require ligature, unless, indeed, from necrosis, or to remove a tumour, a larger portion of the humerus than usual has been removed. If the limit of capsule has been infringed on below, the circumflex vessels may probably be cut, in which case the bleeding may be considerable.

N.B.—In cases of fracture of neck of humerus, or of compound gunshot injury, or where the head has been separated by necrosis from the shaft, or where, as has happened to Stanley and others, the bone broke in the endeavour to tilt the head out, the surgeon will require to seize the detached head with strong forceps, and dissect it out with care.

Other methods of Resection.—When from great thickening and induration of the soft parts, enlargement of the head of the bone, or other reason, the straight incision may be deemed insufficient for the purpose (and we may remark that there are comparatively few cases in which it is insufficient), access may be obtained to the joint by raising a flap from the deltoid (Plate III. fig. a). Its shape—V-shaped, semilunar, or ovoid—is not of much consequence, for there are no great nerves or vessels to wound on the outside of the joint, and the surgeon should be guided, as in all other operations on the joint, very much by the position of any pre-existing sinuses. This flap being raised upwards towards its base, very free access is gained to the joint.

In these cases, fortunately comparatively rare, in which there is reason to believe that the glenoid is chiefly involved in disease, and yet that the disease can be removed without amputation, access will be gained most easily by an incision (Plate III. fig. b.) on the posterior surface of the joint, corresponding in size and direction to the linear incision in front. This gives a much easier mode of access to the glenoid. I have seen this practised in one very remarkable case by Mr. Syme, in which the glenoid cavity and neck of the scapula were extensively diseased, while the head of the bone was quite sound.

After-treatment is exceedingly simple; for the first day or two the shoulder is to be supported on a pillow with a simple pad in the axilla, if there is any tendency for the arm to drag inwards; after this the patient should be encouraged to sit up and move about with his arm in a sling, the elbow hanging freely down.

Results.—Hodge records ninety-six cases in which this excision was performed for gunshot injury, of which twenty-five proved fatal, and fifty for disease, of which only eight died,—results which are more encouraging than those of amputation at the shoulder-joint for disease; though for injury the mortality is much greater than Larrey's famous Statistics of Amputation, q.v. p. 65.

Spence had thirty-three cases, with three deaths. He generally made a counter-opening behind to get rid of discharges, and inserted a drainage-tube.

Gurlt's statistics of excision for gunshot injury give of 1661 cases 1067 recoveries, 27 doubtful results, and 567 deaths, the mortality being 34.70 per cent.

Excision of the Elbow-Joint—In what cases should it be performed?—1. For disease of the elbow-joint which has resisted ordinary remedies, and is wearing down the patient's strength, including caries, ulceration of cartilages, and gelatinous synovial degeneration.

2. For wounds of the elbow penetrating the joint, the prognosis both as to the patient's life and the usefulness of his arm is much better after excision than after endeavours to save the joint without excision. This is especially the case when the wound of the joint is small and punctured, but if the case is seen early and treated by free drainage, with antiseptic precautions, excision may not be required.

3. For anchylosis, in cases where after disease or injury the limb has stiffened in a bad position, especially when, with a straight elbow, the hand is rendered almost perfectly useless.

How much should be removed?—In the elbow-joint, more than any other joint in the body, complete excision is absolutely necessary; any portion of the articular surface being left proves a source of unfavourable result.

The surgeon is apt to err rather in removing too little than too much. For the removal of too little bone is, on the one hand, apt to result in long-standing sinuses, on the other, to induce anchylosis.

In making the section of the bones, the saw ought to be applied to the humerus transversely just at the commencement of its condyloid projections, and to the radius and ulna, at least at a level with the base of the coronoid process of the ulna.

But while removing enough, we must not be led into the error of removing too much. If this is done, as was done by Sir Philip Crampton in his first case, and as happens occasionally of necessity in cases of excision for gunshot wounds or other accidents, much of the power of the arm is lost as a consequence of the shortening and excessive mobility.

A mistaken pathology sometimes deceives in the examination of the state of the bones, and causes an unnecessary amount to be removed. For in many cases of disease the bones in the neighbourhood of the joint are stimulated to an excessive amount of what is in reality Nature's effort at repair, and while the cartilaginous surfaces are denuded of cartilage, soft, and porous, the bones close by are roughened with a stalactitic-looking growth, projecting in knobs and angles. Now, if this be mistaken for disease and removed, too much will almost certainly be taken away, and the result will be unsatisfactory.

Much less care need be taken exactly to discriminate and remove the diseased soft parts; indeed they may be left alone; the synovial membrane in a state of gelatinous degeneration sometimes presents a very formidable appearance of disease, but if the bones be properly removed, all this swelling will soon go down, and a healthy condition of parts succeed, without any clipping or paring on the surgeon's part.

Operation.—The back of the joint is of course chosen for the seat of the incisions, both because the bones are there just under the skin, and because the great vessels and nerves lie in front of the joint. The form and number of the incisions vary considerably, and ought to vary according to the nature of the case and the amount of disease or injury.

Though it is now little used, for historical interest I retain the description of the H-shaped incision (Plate III. fig. c.), used first by Moreau, and re-introduced by Mr. Syme, and used by him for most of his very numerous cases.

The posterior surface of the joint being exposed, the surgeon, with a strong straight bistoury, makes a transverse incision into the joint just above the olecranon. It should begin just far enough outside of the internal condyle to avoid the ulnar nerve, which the surgeon should protect by the forefinger of his left hand, and should extend transversely across to the outer condyle. From each end of this incision the surgeon should next make at a right angle two incisions, each about one inch and a half or two inches long, right down to the bone, thus marking out two quadrilateral flaps. These should next be raised from the bones, up and down, as much of the soft parts being retained in them as possible, so as to add to their thickness. The olecranon is thus exposed, and should be removed by saw or pliers by cutting into the greater sigmoid notch; the lateral ligaments must then be cut, if they are not already destroyed by the disease, and the humerus protruded, a proper amount of which is then to be sawn off in a transverse direction. The head of the radius is then easily removed by the bone-pliers, and the ulna also protruded, the attachment of the brachialis anticus to the coronoid process divided, and the bone sawn across just at the base of that process.

Few vessels, if any, will require ligature, and the arm being bent to nearly a right angle, the transverse incision must be very carefully sewed up with silver sutures closely set and deeply placed, as much of the future success of the joint depends on the completeness of the primary union of this incision. The external incision may also be accurately adjusted, the internal one not so completely, to allow free vent for the discharge, which is aided by the ligatures, if any are required, being brought out at its lower angle. A figure-of-8 bandage should be applied over pads of dry lint, and the limb laid on a pillow. No splint is necessary; in a few days the patient will be able to rise and walk about.

Passive motion should be begun so soon as the first inflammatory symptoms have passed off.

If properly performed, in a tolerably healthy subject, the surgeon should not be satisfied with any results short of almost perfect restoration of motion in the joint. Flexion and extension to their full extent, with a very considerable amount of pronation and supination, are to be expected, with proper care, in a patient of average intelligence.

Numerous cases are now on record where almost perfect performance of all the duties of life was retained after excision of the elbow-joint.⁵⁵

In most cases it is possible, and in nearly all advisable, to excise the joint by means of a less complicated incision. Thus one long vertical incision at the posterior surface, with its centre about midway between the ulna and the external condyle, with a transverse incision at right angles to it, and reaching almost to the internal condyle, has been often practised with a very good result.

By nearly universal consent this single straight incision is now used, and when it is properly dressed and drained gives admirable results.

A single vertical incision (Plate III. fig. d.) without any transverse one, as long ago recommended by Chassaignac, is, in most cases, quite sufficient to give access. It is most suitable in cases of anchylosis, where there is little deposit of new bone, or in cases of disease of the joint, accompanied with little swelling or thickening of surrounding tissues. It has the advantage of avoiding the cicatrix of a transverse incision, which doubtless may, if at all a broad one, somewhat interfere with the future flexion of the limb, but, on the other hand, unless care is taken, it does not give such free egress for the discharge, and when there is much delay in healing, the vertical incision may leave a cicatrix nearly as troublesome as the other.

The following modification, suggested and practised by the late Mr. Maunder, seems to be a step in the right direction when it is practicable. "After a longitudinal incision crossing the point of the olecranon I next let the knife sink into the triceps muscle, and divide it longitudinally into two portions, the inner one of which is the more firmly attached to the ulna, while the outer portion is continuous with the anconeus muscle, and sends some tendinous fibres to blend with the fascia of the fore-arm. It is these latter fibres that are to be scrupulously preserved.

"Two points have to be remembered: first, the ulnar nerve, often unseen, must be lifted from its bed, and carried over the internal condyle to a safe place, and then the outer portion of the triceps muscle with its tendinous prolongation, the fascia of the fore-arm and the anconeus muscle must be dissected up, as it were, in one piece, sufficiently to allow of its being temporarily carried out over the external condyle of the humerus."⁵⁶

This method aids in retaining the power of active extension of the elbow-joint.

Excision for osseous anchylosis in the extended position of the joint may be sometimes rendered very difficult by the density, firmness, and extensive hypertrophy of the bones, which become fused into one solid mass. Any attempt to isolate the bones, and remove the anchylosed joint entire, by incising the bones as if for disease, will both prove very laborious, and also probably end in doing some damage to the vessels and nerves in front. But by sawing through the anchylosis about its centre, as was pointed out many years ago by Mr. Syme, the fore-arm may be flexed, and the bones as easily displayed, cleaned, and removed, as in the operation for disease. In this operation, as there is less thickening of the skin and subjacent textures, and in consequence more risk of deficiency and even sloughing of the flaps made by the H-shaped incision, a single straight incision will serve the purpose admirably.

Partial incisions of the elbow-joint are, as a rule, less successful and more dangerous to life than complete ones, except in cases of excision for anchylosis. Even in gunshot wounds, where the bones were previously healthy, and where uninjured portions might have been left with some hopes of success, this is the case.

Dr. Heron Watson has devised the following operation for cases of anchylosis the result of injury:—(1.) A linear incision over ulnar nerve at inner side of olecranon. (2.) The ulnar nerve to be carefully turned over the inner condyle. (3.) A probe-pointed bistoury to be introduced into the elbow-joint in front of the humerus, and then behind and carried upwards, so as to divide the upper capsular attachments in front and behind. (4.) A pair of bone-forceps to be next employed to cut off the entire inner condyle and trochlea of the humerus, and then introduced in the opposite diagonal direction so as to detach the external condyle and capitulum of the humerus from the shaft. (5.) The truncated and angular end of the humerus to be divided, turned out through the incision, and smoothed across at right angles to the line of the shaft by means of the saw, whereby (6.) room might be afforded, so that partly by twisting and partly by dissection the external condyle and capitulum are removed without any division of the skin on the outer side of the arm.⁵⁷ Six cases have had satisfactory results.

The mortality from this operation is considerably less than that from amputation of the arm. Of a series of excisions for disease, injury, and anchylosis, 22.15 per cent. died, while out of a similar series of amputations of the arm the mortality was 33.4 per cent.⁵⁸ Our mortality of excision of the elbow here is certainly much less than the above. All of the cases, between thirty and forty, in which I have done it have recovered with but one exception, and Mr. Syme lost only one during the time I was his assistant.