THE IMPROVISED KNEE-JOINT.

607 of regaining a useful knee-joint outweighs other considerations. Such, for instance, was a cavalry onicer whose future career depended on his being able to ride ; he formed one of Prof. PuTTI’s most brilliant successes. Surgeons who desire to be in a position to help such cases should study a recent article by ALBEE.! He supplies valuable statistical information of results of operations by various surgeons and describes a modification of technique which has given good results in his hands. This modification is ingenious, resulting from his observation of certain defects in the remote results of some of MURPHY’S cases. Supposing that the wound has run an aseptic course-and no surgeon whose technique is not reliable in this respect should dream of attempting arthroplasty-the chief causes of functional failure are (1) deficient range of flexion and extension, and (2) too great lateral laxity allowing deviation of the leg into genu valgum or genu varum. With the view of preventing lateral instability, which he thinks is a more common cause of failure than lack of flexion, ALBEE substitutes a wedge-shaped for a rounded articular surface of the femur, making a closely corresponding surface on the head of the tibia. Mechanically this is a sound theory, for, as ALBEE says, weight-bearing forces the apex of the wedge-shaped end of the femur so firmly into the tibia that the danger of lateral instability is practically eliminated." There is no reason to doubt that this is true also in practice, but the conditions which ALBEE postulates as necessary for the lateral security of the joint seem likely to hinder flexion. He insists that each of the two faces of the wedge, which are to lie at an angle of 120° with each other, should be plane, a form which is not likely to allow much angular antero-posterior movement, unless there is great laxity of soft parts. This difficulty does not arise when the rounded shape of the bone ends is adopted. It must be admitted that the photographs reproduced give no indication that his technique has led to restriction of antero-posterior movements of a degree to prevent a useful amount of flexion. All operators are agreed that bony ankylosis of the knee is more suitable for arthroplasty than fibrous. The difference is probably due largely to the fact that among cases of fibrous ankylosis are included all cases of healed tubercle. Yet there seems no theoretical reason why a tuberculous knee in which the disease has long ceased to exist should not afford as good a result as one with osseous ankylosis due to an acute non-tuberculous infection. Even with modern means of examination such as X rays, however, it may not be possible to determine beforehand whether the inflammatory process is completely organised or only quiescent. But when a knee-joint has been successfully excised for tubercle it is probable that all diseased tissue has been removed, and the subject of such an operation might be given a new joint if he finds his disability distressing, without fear of stirring up a latent infection. ALBEE reports a most satisfactory result of arthroplasty in a knee formerly tuberculous. He adds a useful hint as to the choice of cases. Patients who are neurotic, unstable, and timorous are not likely to be such good subjects for arthroplasty as the bold and calmly hopeful who have shown pluck under previous sufferings and perseverance in making the best of their disabilities. Convalescence is a tedious affair, and the final result depends largely on the prolonged cooperation of the

hope

THE

LANCET.

LONDON: SATURDAY, SEPTBMBER 22, 1928.

THE IMPROVISED KNEE-JOINT. THE operation of arthroplasty of the knee, or the replacement of a .joint that has been lost through disease or surgical operation, has taken a long time to make progress in the favour of surgeons. More than a quarter of a century has passed since MURPHY, of Chicago, whom Sir BERKELEY MoYNIHAN has described as one of the supremely great men in medicine through all generations, succeeded in making useful new joints in the place of pre-existing bony ankyloses. Other surgeons have been slow in following up his methods, until PUTTI, of Bologna, reopened the subject soon after the war, and showed a number

of remarkably successful results from this operation. Even now only a small number of surgeons seem to be adopting the technique, among them being Prof. HEY GROVES, Dr. W. R; MAcAusLAND, and in the last few years Dr. F. H. ALBEE. The reasons for a cautious advance are not far to seek. Interference with the joints of the upper limb when properly performed often give excellent results, but the conditions are very different in the lower limb, which has to bear the weight of the body besides taking a large part in its propulsion. The knee is the joint which owes its stability least to the shape of the ends of the bones which enter into it and most to the surrounding muscles, the ligamentous and cartilaginous apparatus. Hence it is obvious that the mere re-forming of bone-ends is not likely to produce a useful joint, while to attempt to make new ligaments such as normally exist inside as well as around the site of the articulation would be a hopeless task. Long atrophied muscles, moreover, do not seem to offer good hopes for a secure control of the joint. Add to this the fact that the newly made knee-joint must bear the whole body-weight at least, and often much more than that, and it is not surprising that some of the most enterprising and skilful surgeons have shrunk from attempting the operation. Besides anatomical and mechanical objections, there are others of a functional nature. The patient who has a firm bony or even fibrous ankylosis in a. good position is already in the possession of an exceedingly useful, strong, and painless limb. It is true that he finds it awkward in public conveyances, supposing that he is so fortunate as to secure a seat, and in the balconies of theatres. He is handicapped in the pursuit of the more athletic sports, and riding on horseback is practically forbidden to him. When such a patient is warned that the operation is a severe one, not without dangei to limb and even to life, and that the after-treatment is long, likely to be painful, and sure to call severely upon his powers of perseverance and endurance, also that complete restoration of function cannot be guaranteed, he may well decide to leave things as they are. Moreover, the workman whose trade may require him to flex his knee-joint to its full normal extent has little to hope for from arthroplasty, since even passive flexion beyond a right angle is rarely possible after the operation. There are, however, exceptional cases in which the

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patient. 1 Original Features in Arthroplasty of the Knee with improved Prognosis. By Fred. H. Albee, M.D., F.A.C.S., Surgery, Gynecology, and Obstetrics, September, 1928, p. 312.