On anchylosis and the treatment for the removal of deformity and the restoration of mobility in various joints

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Introduction

Twenty- four years ago I brought the subject of forcible flexion of auchylosed joints under the notice of the profession, when a communication, together with a series of cases, was published in the { Medico-Chirurgical Transactions/ It was there shown that mobility might be restored to limbs which previously had been considered to be hopelessly stiff — that fibrous anchylosis of the hip-joint, for instance, resulting from gonorrhoeal rheumatism, which had been hitherto deemed irremediable, was amenable to treatment. The treatment which had been employed in the cases which were brought before the Society, and which was recommended for adoption, consisted of immediate flexion of the limb, together with subsequent gradual extension.

Prior to this, gradual extension had been alone employed. Such treatment was found, however, to be entirely nugatory. I have known instances in which this so-called treatment had been continued for years — even for ten years — without alteration in the position of the limb.

It was further shown that the limb being slung, as in Fig. 1, p. 46, and when the patient was under the influence of an anaesthetic, a slight jerk in flexing the limb, the

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INTRODUCTION.

hand alone being used to impart motion, was sufficient to destroy any adhesions and to restore mobility. The same mode of treatment was also advocated for other joints similarly affected.

In immediate flexion of the limb injury cannot accrue to other structures, as in forcible extension of the limb.

The report of the discussion which followed the reading of this paper on the evening of March 24th, 1857^ sufficiently indicates that credence would scarcely have been accorded to the statements which were made had not the patient mentioned in Case 6 been present in the room. His narrative, corroborated by those who were present at the operation, confirmed what had been written. Yet, some years later, Sir William Fergusson expressed extreme surprise on witnessing a similar operation, and as these pages are passing through the press not less surprise was expressed by many who were present at an operation of an exactly similar character.

Therefore it is that after more extended experience I desire to confirm all that has been previously said, and to express my increased confidence in these operations. More than one thousand operations of this description enable me to speak of them as among the most successful in the whole range of surgery. I have never known inflammation to follow such an operation, nor have I ever experienced in any case fracture, neither rupture of any vessel, nor, indeed, an accident of any kind. It would seem impossible that the force employed should act on any other structure than on the adhesions only, in flexion of the limb.

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The adhesions in anchylosis of the hip cannot, except when they are quite recent, be ruptured in extension of the limb, nor can they be affected in the slightest degree by gradual extension. It was on this account that Sir Benjamin Brodie, when he was consulted with regard to the patient referred to in Case 6, said, “ that he must take his stiff joint with him to the grave.” Such was the rule until adhesions were ruptured in flexing the limb. Now, it is my lot very frequently to see cases where a futile effort has been made to liberate a joint, either because extension has been made instead of flexion, or for some other reason ; and where, in consequence, a faulty diagnosis has been pronounced.

Dr. Little1 writes of forcible extension of the hip-joint thus: — “We may mention, in illustration of the comparative difficulty of straightening the hip, that, in an instance of uniform fibrous and vascular membranous adhesion of the head of the femur within the acetabulum after death, the partially anchylosed pelvis and thigh having been removed from the body, we were unable to extend the hip by any power we could exert with our hands until the capsular ligament and some of the adhesions within the acetabulum had been severed with the knife.”

During the week in which I write these pages two cases have come under my care, to which I will briefly allude. One was that of a young lady, eighteen years of age, who seven years previously was chloroformed, and a prolonged attempt was made to overcome the stiffness of the hip-joint, and to set it free. In this, however, the surgeon —

1 ‘ A System of Surgery,’ by T. Holmes, p. 718, vol. iii.

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INTRODUCTION.

and I may mention that there is not any one in the profession better known in the metropolis — was foiled ; and he was so satisfied since his attempt had failed that nothing could be done, that he laid the strictest injunctions on her father never to allow any further attempt to be made to regain mobility. At eighteen, however, the patient herself was exceedingly anxious to know if this decision was to be final.

It was not necessary to employ an anaesthetic to feel assured that the joint might be set free, for it was almost done in making the preliminary examination. It was done instantly when unconsciousness had been produced. Thus, what had been impossible in extension of the limb was easy, even seven years later, in flexion.

The second case was that of a young lady, sixteen years of age, in whom inflammation had been set up in the hip-joint two years before I saw her. Ten days before I saw her a consultation had been held, and it was recommended that the neck of the femur should be divided. On the day following that on which I was consulted she was put under the influence of ether, and although the adhesions were strong they gave way easily, and the limb was immediately free. In one week all the movements of the limb could be performed, and she could bear her weight on the foot. There was no shortening of the limb. In this case the adductors were remarkably rigid before the operation, and, therefore, although there was scarcely the slightest movement at the hip to be obtained, it was certain that the adhesions were fibrous.

I am able to add, at the expiration of three weeks, that

INTRODUCTION.

XI there is only very slight difference in the power of the two limbs, and that there is the same freedom at the hip-joints alike in both.

I seldom use a bandage except to retain a splint, and never for longer than forty- eight hours. And the splint which is most convenient is one that can be readily moulded in the room, and which can be altered as needed. It is always in the first instance applied at the same angle as before the operation. A splint is seldom necessary for the hip. Weights and pulleys may be at once used to steady the limb ; and when tenderness has subsided, in from forty-eight hours to four days, gentle movements will tend to restore the power of the limb.

ON ANCHYLOSIS.

Chapter I. Pathology

Anchylosis is that condition of a joint in which adhesions have formed, or new material has been deposited within or external to the synovial mmebrane, and through which motion is in part or wholly lost. This difference, namely, complete or partial loss of motion, has given rise to distinct terms, which imply more or less the conditions of the parts involved in the disease. Thus, anchylosis is said to be true or false : true anchylosis, or synostosis being bony union of the articular surfaces, the soft structures in the interior of the joint and the cartilaginous coverings of the extremities of the bones having been removed; while false anchylosis is occasioned by membranous or fibrous adhesions within or around a joint, and which interfere more or less with freedom of motion. Muscular contraction alone, resulting from fracture, for instance, may occasion entire loss of motion. This is very rare, however, and quite exceptional. Muscular contraction, impeding the motion of the joint, as it is ordinarily seen, and without adhesions, is not now understood as anchylosis.1 True, complete, or bony anchylosis, or synostosis, then, signifies complete loss of motion in the affected joint ; and false, partial, or fibrous anchylosis, implies that motion is impaired, but not wholly lost.

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1 urther, anchylosis, whether true or false, may be straight or angular, and simple or compound, i.e. complicated with dislocation. This complication with partial or complete dislocation is not rare : it occurs especially after the formation of abscess. Some authors have included unreduced dislocations in their consideration of compound anchylosis. This subject is, however, worthy of separate consideration, and will not be specially considered here.

Every articulation is capable of undergoing bony anchylosis. Some joints, however, are much more liable to this alteration than others ; and, indeed, it may be looked upon as a natural change in certain parts of the skeleton in old age. Thus, it is not uncommon to find that, in advanced age, the ribs are firmly consolidated by osseous matter together with the vertebras, and the vertebrae one to another; and, less frequently, the various bones of the carpus are found in the same manner united, as well as those of the tarsus ; and, also, the sterno-clavicular, and some other articulations. This change may be considered as incident to age ; the diminished secretion of synovia probably giving rise to structural disease and removal of the articular cartilages, as has been suggested by Rokitansky. Also, anchylosis is observed in the aged, as the result of chronic rheumatism. And, wherever undue pressure has been long continued, as, for instance, in old curvatures of the spine, deposits of bone (bridge-like formations and osteophytes), are formed at the margins of the bodies of the vertebrae, and union of their surfaces takes place ; in wry-neck, firm bony union may result between the atlas and the axis ; and in club-foot (in advanced age), the same is occasionally, though rarely, observed between the various bones constituting the tarsus, and especially between the calcaneum, the cuboid, and the fifth metatarsal bones. Whenever anchylosis takes place in the mixed form of articulations (amphiarthroses), it is bony union that occurs. In these articulations, the natural movements are so slight that they would scarcely be diminished by false anchylosis.

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In the movable articulations (diarthroses), both forms of anchylosis — true and false — are observed, but, while true anchylosis is more frequently found in ginglymoid joints, it is much more rare in enarthrodial (ball-and-socket) articulations. Especially is it uncommon in the shoulder-joint, and in that of the jaw.

Besides those causes already mentioned, there are others which tend to produce anchylosis ; such as inflammation of the structures within the joint, whether rheumatic, syphilitic, scrofulous or gouty, traumatic inflammation, and that arising from sprains, contusions, or other mechanical injuries. Also, it may occur as a sequence of deep burns, of phlegmonous erysipelas, of gangrene, and of extensive ulceration. Fracture, also, extending into a joint or occurring in the immediate neighbourhood of a joint may determine complete loss of motion. Again, anchylosis is occasionally observed as a congenital affection. It is then, doubtless, the result of inflammation, equally as when it occurs after birth. The articular apparatus is then entirely absent.

True anchylosis, or synostosis, then, may be induced by any of these causes. Anchylosis of the movable articulations is always the result of inflammation ; consolidation — true anchylosis taking place or fibrous adhesions being formed.

The causes of false anchylosis are every variety of inflammation through which lymph is deposited within or external to the capsule, so as to form adhesions which shall interfere with the free motion of the joint. Adhesions within the capsule are termed “ intra-capsular,” and those which are formed external to the capsule are known as “ extra-capsular/'’

Some forms of inflammation attack especially the structures external to the articulation, while others affect by preference those within the joint. Consequently, the character of the inflammation being known, it may be premised, with more or less certainty, what is the situation

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of the adhesions — whether they are intra- or extra- capsular.

In a large number of cases, the diagnosis may be made with sufficient accuracy, the form of the previous inflammation being considered together with the alteration in the shape of the affected joint and the character of the impediment itself. There are, however, numerous cases in which it is impossible to determine whether the adhesions are intra- or extra -capsular, until the patient is under the influence of chloroform, and force is being applied. Then, when they are being ruptured, it is not difficult to determine both the position and the extent of the adhesions.

Intra- capsular partial anchylosis results from synovitis — acute, subacute, or chronic ; whether of a rheumatic, syphilitic or strumous character ; and extra- capsular anchylosis depends perhaps rather on gonorrhoeal rheumatism, phlegmonous erysipelas, strumous abscesses, and mechanical injuries. There are, however, numerous exceptions to this statement. Extra- capsular adhesions, also, frequently exist together with others within the joint. When extra- capsular adhesions are alone referred to, it is to be understood that the synovial membrane is unaffected, and free from adhesions.

Although it is not my intention to enter upon an inquiry into the diseases of joints in their primary stages, but rather to limit my remarks to the results of such diseases, and to the treatment to be adopted for the removal of the impediments to free notion which have thus been produced, it will be necessary to make some few preliminary observations.

No period of life is exempt from these affections of joints, but the liability to suffer from their several varieties is not alike at all ages. Thus, we find, that childhood is especially obnoxious to strumous affections, and that primary synovial inflammations are comparatively rare at this period. Again, in adults, inflammation of the synovial membranes may be said to constitute the rule, all other

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forms of inflammation being then comparatively rarely met with.

The commencement of disease is here alone referred to ; for, as the synovial membrane may become implicated in disease which has had its origin in other textures, so inflammation, having commenced in the synovial membrane, may proceed to affect every portion of the articulation.

Of intra- articular inflammations some are especially prone to the formation of adhesions, and terminate without involving or only partially involving adjacent structures, while others occasion thickening of the synovial membrane, softening of the ligaments, and displacement of the bones. I will, therefore, describe in some detail the distinguishing points of these several forms of inflammation.

Synovitis may be acute, subacute, or chronic, and it may arise from a local cause. Also, it may be modified, as by rheumatism, scrofula, and syphilis, according to individual diathesis. The inflammatory product is effused into the articulation, bands of lymph are formed between adjacent portions of synovial membrane, which become organised, and act as impediments to motion.

These adhesions do not impede the motions of the joints in proportion to their extent, however, as might a 'priori be supposed ; but, on the contrary, a very slender band may entirely prevent voluntary motion, while with more extensive adhesions there may be freer motion.

Acute synovitis commences with pain, which is soon followed by heat and swelling. The synovial membrane becomes congested, and the natural secretion is poured out in excess. Distension of the capsule may become so great that the sense of fluctuation, which was distinct, is perhaps lost. Fluctuation is to be distinguished most readily in the joint which is least covered ; as, for instance, the knee-joint. Here, by the side of the extensor tendon and of the ligamentum patellse, the fluid protrudes the synovial sac into the spaces between the tendons and the ligaments. The membrane loses its glistening appearance

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and becomes thickened and softened. Flakes of fibrin are found floating in the serous fluid, and, also, adherent to the membrane itself ; and these deposits, connecting adjacent portions of the synovial membrane, become partially organised, and constitute bands of adhesion.

Subacute synovitis is the commonest form of inflammation. It rarely runs on to suppuration ; but it is apt to assume a chronic form. Lymph is effused, which forms membranous adhesions.

Chronic synovitis frequently gives rise to loss of mobility. The synovial secretion is poured out in increased quantity, and is of a more aqueous quality than in health ; and it causes great distension of the capsule and extension of the ligaments of the joint. This distension of the joint leaves, when absorption of the effused fluid has taken place, a relaxed condition of the ligaments ; and, thus, the flexor muscles, when the knee has been affected, may displace the articular extremity of the tibia backwards. The flexor muscles are, for the most part, more powerful than the extensors ; and thus in disease a flexed position of the limb is usually seen both during the continuance of disease and after it has subsided. But, also, a partially flexed position allows of the greatest distension of the joint with the least amount of pain ; for in this position is found the greatest relaxation of the lateral ligaments of the joint. When, on the other hand, the leg is fully extended, the lateral and the crucial ligaments so tightly fix the limb as not to allow either of lateral or of rotatory movements ; and the thigh bone is then pressed into firm contact with the leg bones. After disease has subsided the flexor tendons remain tense and the muscles contracted.

Thus, fibrinous deposits take place within and, also, external to the synovial membrane ; and the membrane becomes more or less thickened through interstitial deposit of lymph ; and the articulation is consequently found enlarged, and its motion is impaired.

No joint causes more trouble than the knee when it

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becomes inflamed. It is less painful than the hip when inflamed, its capsule being less resisting ; but, on account of its large and complicated synovial surface, it is more liable to inflammation than any other joint, and the effects of inflammation are frequently disastrous.

These forms of inflammation may be modified by rheumatism, syphilis or scrofula, which, affecting an articulation, become local manifestations of a constitutional disorder.

Rheumatic synovitis is attended with severe pain. Inflammation commences for the most part in the structures external to the articulation, and it rapidly involves the joint itself : effusion into the synovial sac takes place, and lymph is ultimately deposited on either or both surfaces of the synovial membrane. This form of inflammation usually commences external to the articulation, being confined to the ligamentous and other fibrous structures, and it may not invade the joint itself. The inflammatory product is poured out into the cellular tissue around the joint, giving rise to induration with thickening and consolidation of the soft structures into and about which it is effused. It is not uncommon to find that the cellular and fibrous tissues around the articulation alone have suffered from the inflammatory deposit, the synovial mem brane remaining unaffected and clear, and the interior of the joint free from the effects of inflammation.

The knee more frequently suffers from this form of inflammation than any other joint, being more exposed to vicissitudes of temperature than any other large joint : it is less covered by muscle, and less protected artificially.

Rheumatic inflammation, when it assumes a chronic character, “ chronic rheumatic arthritis,” as it has been termed by Dr. Smith, of Dublin, may induce, by the formation of ossific growths between and upon the articular surfaces, and by alteration in the shape of the articular surfaces themselves, more or less immobility. Slight increase of synovial secretion is followed in the later stages of the affection by exostotic growths, which, encroaching on the articulation, seriously impair its

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mobility. Dr. Robert Adams, of Dublin,1 lias shown that true bony anchylosis is an exceedingly rare result of this form of disease ; but that articular rigidity, or false anchylosis, is not an unusual consequence.

Scrofulous disease occurs in a morbid condition of the system, which has been induced, perhaps, by insufficient nourishment and by exposure to cold, or it results as a sequel of measles, smallpox, scarlet fever, or other exhausting malady. Such a condition being developed, scrofulous disease may be set up by a kick or a sprain, or a fall, or from so slight an accident that it might almost be said to arise without a local cause.

Scrofulous disease of the joints usually commences in the articular extremity of the bone in childhood, and then proceeds to involve the soft structures of the joint. This affection is very common among children : there is none more frequently met with. Articular ostitis commences in the cancellous structure of the extremity of the bone, and anchylosis may take place even without the formation of abscess. Such a course, however, in this form of disease is rare. When the disease terminates without suppuration being established, mobility may not unfrequently be restored ; and even this has been known to take place when a portion of cartilage has been removed. Not uncommonly, the course of this affection is as follows : — Slight pain and swelling are at first experienced, which may or may not subside, leaving, however, more or less tenderness and weakness of the affected joint. At every attempt to use the limb, puffiness about the joint will be observed, and this, as well as the pain, will be sensibly increased by any unusual exertion. Abscess will form and discharge itself; the ligaments will become softened and extended, and the limb will be flexed.

In this form of inflammation the synovial membrane becomes much altered in structure, being thickened and softened, with deposits of curdy lymph upon it, and the 1 ‘ A Treatise on Rheumatic Gout.

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joint becomes disorganised. Again, displacement of the articular surfaces of tbe bones may take place with fibrous adhesions ; or bony anchylosis may form.

But, after suppuration and the removal of necrosed bone from the joint recovery of mobility, after breaking down adhesions, may result. Such a case came under my care at St. George’s Hospital. This patient was fourteen years of age, and when six years old he received a kick on the knee. There had been suppuration ; but when admitted into the hospital there was only a slightly weeping wound, which, being explored, disclosed a large piece of necrosed bone lying behind the joint. The knee was bent at a right angle. The sinus was enlarged, and a large piece of bone, evidently a portion of the head of the tibia was removed. Subsequently, and when the wound had healed, the flexor tendons were divided, some adhesions within the joint having previously been ruptured. The boy left the hospital, having regained the use of the knee-joint, his foot being slightly raised by means of a thickened sole.

Syphilitic synovitis partakes of the characters of both of the above-mentioned forms of inflammation — rheumatic and scrofulous — according to the period of development of the constitutional disease itself. When it occurs in secondary syphilis, it assumes somewhat of a rheumatic character, the fibrous structures being at this period of the constitutional malady especially affected; while in tertiary syphilis inflammation assumes somewhat of a scrofulous character, the tendency of syphilis itself being at this time to resemble scrofula. Thus are formed adhesions which may be intra- or extra- capsular ; or the joint may become disorganised, and, the cartilage being removed, bony anchylosis may result.

In extra-capsular anchylosis adhesions are formed external to the joint through various forms of inflammation. The fibrinous exudation is deposited in the cellular tissue external to the joint ; it becomes consolidated, and immobility of the surrounding parts is produced. The

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exudation is poured out between the muscles and tendons, and they are thus bound together, and the articulation becomes motionless.

There is a form of inflammation, namely, gonorrhoeal rheumatism, where exudation may be confined to the exterior of the capsule, or, on the other hand, effusion into, with great distension of, the capsule may occur.

This inflammation is rheumatic synovitis of a peculiar character, which is preceded or accompanied by urethral inflammation or irritation. Such an affection will be recognised by every practical surgeon.

It is to be regretted that the term “ gonorrhoeal rheumatism ” was ever used. It was adopted in error, on the supposition that this affection of the joints was necessarily consequent on gonorrhoea virulenta.

It is true that this affection of the joints is usually preceded by gonorrhoea, but it is not absolutely necessary that the disease should be preceded or accompanied by urethral discharge. Sir Benjamin Brodie has shown that the use of the bougie may induce “ gonorrhoeal rheumatism/"’1 I will narrate a case, the most remarkable of its kind that I have seen or heard of, where there were four attacks of inflammation, but the last was not preceded by a purulent discharge.

Usually, however, the course of the disease is as it is stated above, namely, that urethral discharge precedes inflammation of the synovial membranes. And not only is it usual that there shall be urethral discharge, but this is generally of a specific character. However, it is clear that this rheumatic affection of the joints may follow any form of urethral discharge.

“ Gonorrhoeal rheumatism ” perhaps never occurs for the first time without urethral discharge, and this is generally of a specific character ; but a second attack may occur without urethral discharge.

Such being the case, the term “ gonorrhoeal rheuma- 1 ‘ Pathological and Surgical Observations on the Diseases of the Joints,’ 1850.

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tism ” is not quite correct, and may lead to erroneous conclusions. The term “ urethral rheumatism ” might, therefore, advantageously be substituted for it.1

The pain attending this form of inflammation is of a most acute character, and the effusion about the joint is often very considerable ; so much so, indeed, that great tension of the integument may be induced. Suppuration, however, never takes place. The fibrinous material is poured out into the cellular tissue around the joint, and, this consolidating-, the articulation becomes fixed. Mobility is impaired in proportion to the intensity of the inflammation, and the consequent deposit of lymph : it may be entirely or only partially hindered. I have seen a great number of anchylosed hip- joints from this form of disease ; and in every instance, the limb has been fully extended. In two or three instances, there has not been appreciable motion, even under chloroform, but there remained elasticity only, showing that union was not bony. In others, the smallest amount of motion — just appreciable motion — remained. I have never seen a case where

the hip was anchylosed in a flexed position from this form of inflammation — the position which is almost always assumed in other forms of inflammation of the hip-joint.

In other joints a flexed position is that which is most commonly met with, a certain amount of motion, perhaps, remaining. For instance, the limb may be semi-flexed ; beyond which extension may be impossible, but further flexion may be perfect. Some years ago I saw such a case with Sir William Gull ; and I allude to it here, for it illustrates well a condition that is not unfrequently seen as a result of this form of inflammation. On attempting to extend the limb, the obstruction was so complete that it was believed by some who had examined the case that the exudation was osseous, so suddenly and harshly 1 The term “ urethral rheumatism/’ which was proposed by Dr. Elliotson, is perhaps more truthful and presents other advantages over that of “ gonorrhoeal rheumatism.” With one exception, however, the specific character of the urethral discharge has been acknowledged in every instance of “ gonorrhoeal rheumatism ” with which I have met.

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was extension of tlie limb stopped. It was determined to extend the limb, using a moderate amount of muscular force ; and, this failing, that the tendons should be divided. As much force was used as seemed to be justifiable, but without success. Then the tendons were divided, and, with a very moderate amount of pressure, the adhesions instantly yielded ; and thenceforth the joint was perfectly free.

The following case is the most remarkable of its kind that I have seen. I introduce it here, for it illustrates several points of interest in this malady. And I may premise that I do so, for this form of inflammation occasions more frequently than any other false anchylosis.

In October, 1859, a gentleman wrote to me, requesting me to go to him ; at the same time excusing himself, being, as he said, so great a cripple that he could not come to me. When I saw him, he related the following history.

In 1848, when he was twenty-five years of age, he had intercourse of a doubtful character, which was followed in seven days by urethral discharge. Some few days later, synovitis of both knee-joints supervened, with considerable pain, followed by effusion. He was confined to the house during two or three weeks, and was then again able to walk about, before, however, the swelling about the knees had quite subsided. The urethral discharge continued for two months, and then ceased. Before three months had elapsed, he had entirely regained the use of his knees. At the expiration of another period of three months, the act of intercourse was repeated, under similar circumstances as before.

The urethral discharge again appeared on the seventh day, and it continued for two months. It was followed, in the course of a few days, by synovitis of the left hip-joint, of both ankle-joints, and of the tarsal-joints (the soles of the feet were not affected). Now, the pain was more acute than on the previous occasion, and the swelling and rigidity also lasted longer ; but after ten months he was