Manual of Surgery Volume I Part 55

#Clinical Features.#--These vary with the different anatomical forms of the disease, and with the joint affected.

Sometimes the disease is ushered in by a febrile attack attended with pains in several joints--described by John Duncan as _tuberculous arthritic fever_. This is liable to be mistaken for rheumatic fever, from which, however, it differs in that there is no real migration from joint to joint; there is an absence of sweating and of cardiac complications; and no benefit follows the administration of salicylates.

In exceptional cases, tuberculous joint disease follows an acute course resembling that of the pyogenic arthritis of infants. This has been observed in children, especially in the knee, the lesion being in the synovial membrane, and attended with an acc.u.mulation of pus in the joint. If promptly treated by incision and drainage, recovery is rapid, and free movement of the joint, may be preserved.

The onset and early stages of tuberculous disease, however, are more often insidious, and are attended with so few symptoms that the disease may have obtained a considerable hold before it attracts notice. It is not uncommon for patients or their friends to attribute the condition to injury, as it often first attracts attention after some slight trauma or excessive use of the limb. The symptoms usually subside under rest, only to relapse again with use of the limb.

The initial local symptoms may be due to the presence of a focus in the neighbouring bone, perhaps causing neuralgic pains in the joint, or weakness, tiredness, stiffness, and inability to use the limb, these symptoms improving with rest and being aggravated by exertion.

It is rarely possible by external examination to recognise deep-seated osseous foci in the vicinity of joints; but if they are near the surface in a superficial bone--such as the head of the tibia--there may be local thickening of the periosteum, dema, pain, and tenderness on pressure and on percussion.

_X-ray Appearances of Tuberculous Joints._--Gross lesions such as caseous foci in the marrow of the adjacent bone show as clear areas with an ill-defined margin; a sclerosed focus gives a denser shadow than the surrounding bone, and a sequestrum presents a dark shadow of irregular contour, and a clear interval between it and the surrounding bone.

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 anaesthesia.

_Abnormal att.i.tudes of the limb_ occur earlier, and are more p.r.o.nounced in cases in which pain and other irritative symptoms of articular disease are well marked, and are best ill.u.s.trated by the att.i.tudes a.s.sumed 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 att.i.tude of greatest ease; they also disappear under anaesthesia. 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 a.s.sociated 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 bursae 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 pa.s.sed to the primary focus of disease, and their course and disposition can only be demonstrated by injecting the sinuses with an emulsion of bis.m.u.th 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 anaesthesia, 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 a.s.sume 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 appet.i.te 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 att.i.tude 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 att.i.tudes of the limb. If, when the patient first comes under observation, the limb is in a deformed att.i.tude which does not readily yield to extension, the deformity should be corrected under an anaesthetic.

_The induction of hyperaemia_ 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 DISEASE

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 and progress, the patient usually being able to go about.

In the _tertiary stage_ the joint lesions are persistent and destructive, and result from the formation of gummata, either in the deeper layers of the synovial membrane or in the adjacent bone or periosteum.

_Peri-synovial_ and _peri-bursal gummata_ are met with in relation to the knee-joint of middle-aged adults, especially women. They are usually multiple, develop slowly, and are rarely sensitive or painful. One or more of the gummata may break down and give rise to tertiary ulcers. The co-existence of indolent swellings, ulcers, and depressed scars in the vicinity of the knee is characteristic of tertiary syphilis.

The disease spreads throughout the capsule and synovial membrane, which becomes diffusely thickened and infiltrated with granulation tissue which eats into and replaces the articular cartilage. Clinically, the condition resembles tuberculous disease of the synovial membrane, for which it is probably frequently mistaken, but in the syphilitic affection the swelling is nodular and uneven, and the subjective symptoms are slight, mobility is little impaired, and yet the deformity is considerable.

_Syphilitic osteo-arthritis_ results from a gumma in the periosteum or marrow of one of the adjacent bones. There is gradual enlargement of one of the bones, the patient complains of pains, which are worst at night.

The disease may extend to the synovial membrane and be attended with effusion into the joint, or it may erupt on the periosteal surface and invade the skin, forming one or more sinuses. The further progress is complicated by the occurrence of pyogenic infection leading to necrosis of bone, in the knee-joint, for example, the patella or one of the condyles of the femur or tibia, may furnish a sequestrum. In such cases, anti-syphilitic treatment must be supplemented by operation for the removal of the diseased tissues. In the knee, excision is rarely necessary; but in the elbow it may be called for to obtain a movable joint.

In #inherited syphilis# the earliest joint affections are those in which there is an effusion into the joint, especially the knee or elbow; and in exceptional cases pyogenic infection may be superadded, and pus form in the joint.

In older children, a gummatous synovitis is met with of which the most striking features are: its insidious development, its chronic course, symmetrical distribution, freedom from pain, the free mobility of the joint, its tendency to relapse, and its a.s.sociation with other syphilitic stigmata, especially in the eyes. The knees are the joints most frequently affected, and the condition usually yields readily to anti-syphilitic treatment without impairment of function.

JOINT DISEASES ACCOMPANYING CERTAIN CONSt.i.tUTIONAL CONDITIONS

#Gout.#--_Arthritis Urica._--One of the manifestations of gout is that certain joints are liable to attacks of inflammation a.s.sociated with the deposit of a chalk-like material composed of sodium biurate, chiefly in the matrix of the articular cartilage, it may be in streaks or patches towards the central area of the joint, or throughout the entire extent of the cartilage, which appears as if it had been painted over with plaster of Paris. As a result of this uratic infiltration, the cartilage loses its vitality and crumbles away, leading to the formation of what are known as gouty ulcers, and these may extend through the cartilage and invade the bone. The deposit of urates in the synovial membrane is attended with effusion into the joint and the formation of adhesions, while in the ligaments and peri-articular structures it leads to the formation of scar tissue. The metatarso-phalangeal joint of the great toe, on one or on both sides, is that most frequently affected. The disease is met with in men after middle life, and while common enough in England and Ireland, is almost unknown in hospital practice in Scotland.

The _clinical features_ are characteristic. There is a sudden onset of excruciating pain, usually during the early hours of the morning, the joint becomes swollen, red, and glistening, with engorgement of the veins and some fever and disturbance of health and temper. In the course of a week or ten days there is a gradual return to the normal. Such attacks may recur only once a year or they may be more frequent; the successive attacks tend to become less acute but last longer, and the local phenomena persist, the joint remaining permanently swollen and stiff. Ma.s.ses of chalk form in and around the joint, and those in the subcutaneous tissue may break through the skin, forming indolent ulcers with exposure of the chalky ma.s.ses (_tophi_). The hands may become seriously crippled, especially when the tendon sheaths and bursae also are affected; the crippling resembles that resulting from arthritis deformans but it differs in not being symmetrical.