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Extra-articular arthrodesis of the knee joint
EXTRA#ARTICULAR DON Associate
KING,
M.D.,
ARTHRODESIS OF THE KNEE JOINT*
F.A.C.S.
SAN
0
AND
Professor of Surgery, Stanford University Medical School
VICTOR Assistant
FRANCISCO,
in spite of the utmost care in selecting the time for operation, surgica1 invasion of a
CCASIONALLY,
The realization that fusion operations couId not compIeteIy eradicate the tubercuIous process, and that the most that could
state completed; place.
both
grafts
in
be accompIished was its inactivation by preventing useIess and dangerous motion, stimulated French orthopedists to develop an extra-articular method, as is done in the spine and hip. In 1933, DeIahaye 1 first recommended such a method for fusing tuberculous knees in chiIdren. He empIoyed an extra-articuIar femoro-pateIIo-tibia1 arthrodesis, using a long, suppIe graft taken from the opposite tibia. Two years Iater (1935) Brandwayn,’ a reviewed thirty-two pupil of DeIahaye, cases (ages six to fourteen), in which the patients had been operated upon by this technic. None of these cases were more than two years postoperative. Pseudoarthroses and fractures of the grafts were frequent but were considered due to imperfection in technic. Two patients had deveIoped secondary deformities, one a genu valgum and the other a genu recurvatum. The subsequent growth of the Iimbs had been symmetrica in a11 cases. CaIvet in 19373 reviewed seventeen cases of knee joint tubercuIosis in children treated by extra-articuIar fusion. Here again the cases were only one to one and a
FIG. 1. PatelIar ligament divided and turned upward; graft in place.
knee is folIowed by direst Fistulae may foIIow the
FIG. 2. Diagram to show source of graft.
operative procedure, secondary infection ensue, and amputation eventuaIIy become necessary. * From the Division of Orthopedics,
M.D.
CALIFORNIA
FIG. 3. Second
tubercuIous consequences.
RICHARDS,
Resident in Surgery, Stanford University Hospitals
Stanford University HospitaIs and Stanford Surgical Service, San Francisco Hospital, San Francisco. 208
NEW SERIES VOL. LIII,
King,
No. z
Richards-Arthrodesis
haIf years postoperative, but he also concIudf :d that the graft grows at an equa1 rate with the limb. He reported two failures, one
C
FIG. 4. Case I.
A
and B, preoperative
Journal
of Surgery
209
chiIdren which had been fused in 15135 extra-articuIarIy, and in which the resu Its were unfavorabIe. In these cases the gra fts
D
x-rays; c, immediateIy postoperativeIy.
due I;o fracture of the graft, and the other to a pseudoarthrosis. In rg3g SorreI, Richard and Rouge4 rePorte :d nine cases of tuberculous knees in
American
E
foIlowing first stage; D and E, four years
had either fractured, had become detach led from their insertions, or genu recurvatl lrn had deveIoped. They expIained these uncdedo sirabIe results by stating that the g&s
210
American
King,
Journal of Surgery
Richards-Arthrodesis
not gww at an equal rate with the limb. in discussing Both Lance and Delahaye, this anticle, stated that in their experience had occurred frequentIy, genu recurvatum after a period of two to three years.
articmar arthrodesis did seem ration ial for the aduIt knee, and had sufficient apF Beal to Iead us in 1936 to deveIop a suitable (operative technic. For children Delahaye” recommen ded a
C
FIG. 3. Case II. A and
AUGUST, 1w.r
D
B,
preoperative
x-rays;
EXI ;ra-articuIar fusion for chiIdren has never appeaIed to us because the smal1 size character of the pateha and c,artiIaginous make it an unfavorable receptor for a graft. Furth lermore, there is danger of growth arrest : anteriorIy from the graft crossing the epiph ysea1 Iines. On the other hand, the concept of extra-
c and D, four years postoperatively.
Iong, supple, tibia1 graft, fastened t#o the femur above, passing downward thr rough the pateha into the tibia, in short, an textraarticuIar femoro-pateIIo-tibiaI fusion. This technic cannot be used in adults becal use of the impossibiIity of securing such a Iong IIexibIe graft. As possible sources of bone for the graft we considered rib and iliac
NEW
SERIES
VOL. LIII,
No.
King,
z
c
FIG. 6. Case III.
A,
Richards-Arthrodesis
Amencan
Journal
D
preoperatively; B, two years postoperatively; four years postoperativeIy.
c and
D,
of Surgery
211
212
King,
American Journal of Surgery
Richards-Arthrodesis
C
FIG. 7. Case IV. A and B, preoperativeIy;
AUGUST,
D
c and
D,
four years postoperativeIy.
1941
NEW SERIESVOL. LIII, No. 1
King,
Richards-Arthrodesis
crest. Rib seemed unsuitabIe because of its weakness. IIiac crest couId not be used because of its two-directiona curve. We decided to do the operation in two stages using short tibia1 grafts. This paper brieff y describes the operative technic and the present status of four patients so treated four years ago.
TECHNIC
OF
OPERATION
First Stage. The incision begins at the superior border of the pateIIa, passes downward over the media1 surface of the tibia1 condyIe and proxima1 shaft of the tibia. The pateIIar Iigament is divided in a doubIe “L” manner (Fig. I) and retracted from the fieId of operation. The periosteum and tendinous attachments are elevated from the media1 surface of the upper tibia and a cortica1 graft about five inches Iong is cut from the curved surface of the media1 tibia1 condyIe. The upper end of the graft is about one and one-half inches wide and its Iower end is about one inch wide. (Fig. 2.) A smaI1 amount of infrapateIIar fatty mass is now excised and the beds for the graft ends are made by inserting an osteotome into the inferior two-thirds of the patella and in the canceIIous bone of the tibia just under the bursa Iying beneath the pateIIar Iigament. The wide end of the graft is now placed in the pateIIa and the narrow end in the tibia. The graft is reenforced by muItipIe chips of bone. The pateIIar Iigament cIoses snugIy over the graft, serving to hold it in pIace. A Iong Ieg cast is appIied and Ieft in pIace six weeks. Second Stage. A tibia1 graft is first removed from the opposite tibia. It is important to remove it high on the condyIe so that it wiI1 be curved and pIiabIe. The oId incision over the pateIIa is now opened and extended directly upward a distance of eight inches. The rectus femoris tendon is exposed and incised along with the muscIe fibers overIying the synovia1 pouch where it extends upward under the quadriceps muscIe. By carefu1 dissection one can
American
Journal
of Surgery
213
expose the superior border of this pouch, and, in fact, by using a periostea1 eIevator, can displace it downward somewhat, so as to pIace the graft sIightIy farther distaIward. A number of hoIes are now driIIed through the cortex of the anterior surface of the femur just above the femora1 condyIe and the narrow end of the graft inserted. The wide fIexibIe end is inserted into the superior border of the pateIIa. The quadriceps muscIe and tendon are cIosed firmIy over the graft and a hip spica cast appIied. (Fig. 3.) After six weeks’ time the spica is removed, an unpadded long Ieg cast is appIied and the patient then becomes ambuIatory. When the fusion is cIinicaIIy and roentgenoIogicaIIy soIid the patient is fitted with a Iong doubIe upright brace. CASE
REPORTS
CASE I. An American housewife, age twentytwo years, with no pulmonary tuberculosis, had a painful, swoIIen left knee for five years. The test was positive for tubercuIosis (Guinea pig). The first stage of the operation was performed on January 25, 1936; the second stage on February 20, 1936. The Ieg was kept in plaster for six months, foIlowed by a brace for six months. She has been waIking unsupported, doing her own work for one year. October, 1939. The patient uses her leg normaIIy; solid ankyIosis has occurred in compIete extension. She had had two draining sinuses, one in scar anteriorly just above patella, and the other in the popliteal fossa, but they have been heaIed for six months. There is no pain or inflammation. CASE II. An irish housewife, age twentyeight years, had been under observation at Stanford Chest Clinic since 1932 for pleurisy and puImonary tubercuIosis. She had a painful, swoIIen right knee for six months. The test was positive for tubercuIosis (biopsy). A Iong ieg cast for four months had been appIied before operation. The first stage of the operation was performed on January 22, 1936; the second stage on March I, 1936. June, 1938. Plaster fixation totaIed nine months. She deveIoped a sinus anteriorIy which was stiI1 draining, but the patient walked unsupported without pain.
214
American
Journal
of Surgery
King,
Richards-Arthrodesis
October, 1939. The patient used Ieg normaIIy. Solid ankyIosis occurred in compIete extension. Two sinuses anteriorIy never heaIed. She can hop and jump without pain. CASE III. A coIored gir1, age seventeen years, with puImonary tuberculosis, had pain and sweIIing in knee for nine months. The test was positive for tubercuIosis (Guinea pig). The first stage of the operation was performed on March 23, 1936; the second stage on May 3, 1936. June,
1938. Plaster fixation Iasted nine months. She waIked unsupported without pain and there were no sinuses. October, 1939. The patient uses Ieg normaIIy. SoIid ankyIosis took pIace in compIete extension. There were no sinuses and no pain or inff ammation. CASE IV. A Mexican bootblack, age thirtyseven years, had pain, stiffness, and sweIIing of the Ieft knee for five years. The test was positive for tubercuIosis (Guinea pig). The first stage of the operation was performed on January 30, 1936; the second stage on February 27, ‘936. June, 1938. PIaster fixation lasted for six months. A Iong double upright brace was used for six months. He returned to work in six months. There were no sinuses and no pain. October, 1939. The patient used leg normally. Solid ankyIosis occurred in complete extension. He jumped and hopped on Ieg without pain and there were no sinuses.
Aucusr,
,041
CONCLUSIONS
We have reviewed the pertinent Iiterature on extra-articuIar arthrodesis of tubercuIous knee. Most of this work has been done by French surgeons on chiIdren, using long, suppIe tibia1 grafts. These grafts may fracture, shorten the Iimb or produce a secondary recurvatum deformity. Four years ago we experimented with an extra-articuIar two-stage technic on four aduIts with tubercuIous knees. At this time the knees are soIidIy ankyIosed. There have been no fractures or pseudoarthroses of the grafts, which in fact, have hypertrophied to an astonishing degree. In only one, Case IV is there an osseous fusion across the joint. The disease process is quiescent in a11 cases, aIthough one patient stiI1 has a draining sinus. REFERENCES I.
DELAHAYE
extra-articulaire 2.
3. 4. 5.
Sur un procede d’arthrodese du Genou. Rev. d’ortbop., 2 I : 672,
ET RICHARD.
1934. BRANDWAYN. L’Arthrodese extra-articuIaire du Genou. Tbese de Paris, 1935. CALVET. Le Traitement de Ia tumeur bIanche du genou chez I’enfant. J. de Cbir., 48: 64&666, 1937. SORREL, RICHARD, ROUGE. Resultats de I’Arthrodese Extra-Articulaire du Genou Chez L’Enfant. Mbm. Acad. de Cbir., 64: 1237-1246, 1939. DELAHAYE. Extra-ArticuIar Arthrodesis of the Knee in ChiIdren. J. Bone Ed Joint Surg., 18: 5 I53. 1936.
KING,
M.D.,
ARTHRODESIS OF THE KNEE JOINT*
F.A.C.S.
SAN
0
AND
Professor of Surgery, Stanford University Medical School
VICTOR Assistant
FRANCISCO,
in spite of the utmost care in selecting the time for operation, surgica1 invasion of a
CCASIONALLY,
The realization that fusion operations couId not compIeteIy eradicate the tubercuIous process, and that the most that could
state completed; place.
both
grafts
in
be accompIished was its inactivation by preventing useIess and dangerous motion, stimulated French orthopedists to develop an extra-articular method, as is done in the spine and hip. In 1933, DeIahaye 1 first recommended such a method for fusing tuberculous knees in chiIdren. He empIoyed an extra-articuIar femoro-pateIIo-tibia1 arthrodesis, using a long, suppIe graft taken from the opposite tibia. Two years Iater (1935) Brandwayn,’ a reviewed thirty-two pupil of DeIahaye, cases (ages six to fourteen), in which the patients had been operated upon by this technic. None of these cases were more than two years postoperative. Pseudoarthroses and fractures of the grafts were frequent but were considered due to imperfection in technic. Two patients had deveIoped secondary deformities, one a genu valgum and the other a genu recurvatum. The subsequent growth of the Iimbs had been symmetrica in a11 cases. CaIvet in 19373 reviewed seventeen cases of knee joint tubercuIosis in children treated by extra-articuIar fusion. Here again the cases were only one to one and a
FIG. 1. PatelIar ligament divided and turned upward; graft in place.
knee is folIowed by direst Fistulae may foIIow the
FIG. 2. Diagram to show source of graft.
operative procedure, secondary infection ensue, and amputation eventuaIIy become necessary. * From the Division of Orthopedics,
M.D.
CALIFORNIA
FIG. 3. Second
tubercuIous consequences.
RICHARDS,
Resident in Surgery, Stanford University Hospitals
Stanford University HospitaIs and Stanford Surgical Service, San Francisco Hospital, San Francisco. 208
NEW SERIES VOL. LIII,
King,
No. z
Richards-Arthrodesis
haIf years postoperative, but he also concIudf :d that the graft grows at an equa1 rate with the limb. He reported two failures, one
C
FIG. 4. Case I.
A
and B, preoperative
Journal
of Surgery
209
chiIdren which had been fused in 15135 extra-articuIarIy, and in which the resu Its were unfavorabIe. In these cases the gra fts
D
x-rays; c, immediateIy postoperativeIy.
due I;o fracture of the graft, and the other to a pseudoarthrosis. In rg3g SorreI, Richard and Rouge4 rePorte :d nine cases of tuberculous knees in
American
E
foIlowing first stage; D and E, four years
had either fractured, had become detach led from their insertions, or genu recurvatl lrn had deveIoped. They expIained these uncdedo sirabIe results by stating that the g&s
210
American
King,
Journal of Surgery
Richards-Arthrodesis
not gww at an equal rate with the limb. in discussing Both Lance and Delahaye, this anticle, stated that in their experience had occurred frequentIy, genu recurvatum after a period of two to three years.
articmar arthrodesis did seem ration ial for the aduIt knee, and had sufficient apF Beal to Iead us in 1936 to deveIop a suitable (operative technic. For children Delahaye” recommen ded a
C
FIG. 3. Case II. A and
AUGUST, 1w.r
D
B,
preoperative
x-rays;
EXI ;ra-articuIar fusion for chiIdren has never appeaIed to us because the smal1 size character of the pateha and c,artiIaginous make it an unfavorable receptor for a graft. Furth lermore, there is danger of growth arrest : anteriorIy from the graft crossing the epiph ysea1 Iines. On the other hand, the concept of extra-
c and D, four years postoperatively.
Iong, supple, tibia1 graft, fastened t#o the femur above, passing downward thr rough the pateha into the tibia, in short, an textraarticuIar femoro-pateIIo-tibiaI fusion. This technic cannot be used in adults becal use of the impossibiIity of securing such a Iong IIexibIe graft. As possible sources of bone for the graft we considered rib and iliac
NEW
SERIES
VOL. LIII,
No.
King,
z
c
FIG. 6. Case III.
A,
Richards-Arthrodesis
Amencan
Journal
D
preoperatively; B, two years postoperatively; four years postoperativeIy.
c and
D,
of Surgery
211
212
King,
American Journal of Surgery
Richards-Arthrodesis
C
FIG. 7. Case IV. A and B, preoperativeIy;
AUGUST,
D
c and
D,
four years postoperativeIy.
1941
NEW SERIESVOL. LIII, No. 1
King,
Richards-Arthrodesis
crest. Rib seemed unsuitabIe because of its weakness. IIiac crest couId not be used because of its two-directiona curve. We decided to do the operation in two stages using short tibia1 grafts. This paper brieff y describes the operative technic and the present status of four patients so treated four years ago.
TECHNIC
OF
OPERATION
First Stage. The incision begins at the superior border of the pateIIa, passes downward over the media1 surface of the tibia1 condyIe and proxima1 shaft of the tibia. The pateIIar Iigament is divided in a doubIe “L” manner (Fig. I) and retracted from the fieId of operation. The periosteum and tendinous attachments are elevated from the media1 surface of the upper tibia and a cortica1 graft about five inches Iong is cut from the curved surface of the media1 tibia1 condyIe. The upper end of the graft is about one and one-half inches wide and its Iower end is about one inch wide. (Fig. 2.) A smaI1 amount of infrapateIIar fatty mass is now excised and the beds for the graft ends are made by inserting an osteotome into the inferior two-thirds of the patella and in the canceIIous bone of the tibia just under the bursa Iying beneath the pateIIar Iigament. The wide end of the graft is now placed in the pateIIa and the narrow end in the tibia. The graft is reenforced by muItipIe chips of bone. The pateIIar Iigament cIoses snugIy over the graft, serving to hold it in pIace. A Iong Ieg cast is appIied and Ieft in pIace six weeks. Second Stage. A tibia1 graft is first removed from the opposite tibia. It is important to remove it high on the condyIe so that it wiI1 be curved and pIiabIe. The oId incision over the pateIIa is now opened and extended directly upward a distance of eight inches. The rectus femoris tendon is exposed and incised along with the muscIe fibers overIying the synovia1 pouch where it extends upward under the quadriceps muscIe. By carefu1 dissection one can
American
Journal
of Surgery
213
expose the superior border of this pouch, and, in fact, by using a periostea1 eIevator, can displace it downward somewhat, so as to pIace the graft sIightIy farther distaIward. A number of hoIes are now driIIed through the cortex of the anterior surface of the femur just above the femora1 condyIe and the narrow end of the graft inserted. The wide fIexibIe end is inserted into the superior border of the pateIIa. The quadriceps muscIe and tendon are cIosed firmIy over the graft and a hip spica cast appIied. (Fig. 3.) After six weeks’ time the spica is removed, an unpadded long Ieg cast is appIied and the patient then becomes ambuIatory. When the fusion is cIinicaIIy and roentgenoIogicaIIy soIid the patient is fitted with a Iong doubIe upright brace. CASE
REPORTS
CASE I. An American housewife, age twentytwo years, with no pulmonary tuberculosis, had a painful, swoIIen left knee for five years. The test was positive for tubercuIosis (Guinea pig). The first stage of the operation was performed on January 25, 1936; the second stage on February 20, 1936. The Ieg was kept in plaster for six months, foIlowed by a brace for six months. She has been waIking unsupported, doing her own work for one year. October, 1939. The patient uses her leg normaIIy; solid ankyIosis has occurred in compIete extension. She had had two draining sinuses, one in scar anteriorly just above patella, and the other in the popliteal fossa, but they have been heaIed for six months. There is no pain or inflammation. CASE II. An irish housewife, age twentyeight years, had been under observation at Stanford Chest Clinic since 1932 for pleurisy and puImonary tubercuIosis. She had a painful, swoIIen right knee for six months. The test was positive for tubercuIosis (biopsy). A Iong ieg cast for four months had been appIied before operation. The first stage of the operation was performed on January 22, 1936; the second stage on March I, 1936. June, 1938. Plaster fixation totaIed nine months. She deveIoped a sinus anteriorIy which was stiI1 draining, but the patient walked unsupported without pain.
214
American
Journal
of Surgery
King,
Richards-Arthrodesis
October, 1939. The patient used Ieg normaIIy. Solid ankyIosis occurred in compIete extension. Two sinuses anteriorIy never heaIed. She can hop and jump without pain. CASE III. A coIored gir1, age seventeen years, with puImonary tuberculosis, had pain and sweIIing in knee for nine months. The test was positive for tubercuIosis (Guinea pig). The first stage of the operation was performed on March 23, 1936; the second stage on May 3, 1936. June,
1938. Plaster fixation Iasted nine months. She waIked unsupported without pain and there were no sinuses. October, 1939. The patient uses Ieg normaIIy. SoIid ankyIosis took pIace in compIete extension. There were no sinuses and no pain or inff ammation. CASE IV. A Mexican bootblack, age thirtyseven years, had pain, stiffness, and sweIIing of the Ieft knee for five years. The test was positive for tubercuIosis (Guinea pig). The first stage of the operation was performed on January 30, 1936; the second stage on February 27, ‘936. June, 1938. PIaster fixation lasted for six months. A Iong double upright brace was used for six months. He returned to work in six months. There were no sinuses and no pain. October, 1939. The patient used leg normally. Solid ankyIosis occurred in complete extension. He jumped and hopped on Ieg without pain and there were no sinuses.
Aucusr,
,041
CONCLUSIONS
We have reviewed the pertinent Iiterature on extra-articuIar arthrodesis of tubercuIous knee. Most of this work has been done by French surgeons on chiIdren, using long, suppIe tibia1 grafts. These grafts may fracture, shorten the Iimb or produce a secondary recurvatum deformity. Four years ago we experimented with an extra-articuIar two-stage technic on four aduIts with tubercuIous knees. At this time the knees are soIidIy ankyIosed. There have been no fractures or pseudoarthroses of the grafts, which in fact, have hypertrophied to an astonishing degree. In only one, Case IV is there an osseous fusion across the joint. The disease process is quiescent in a11 cases, aIthough one patient stiI1 has a draining sinus. REFERENCES I.
DELAHAYE
extra-articulaire 2.
3. 4. 5.
Sur un procede d’arthrodese du Genou. Rev. d’ortbop., 2 I : 672,
ET RICHARD.
1934. BRANDWAYN. L’Arthrodese extra-articuIaire du Genou. Tbese de Paris, 1935. CALVET. Le Traitement de Ia tumeur bIanche du genou chez I’enfant. J. de Cbir., 48: 64&666, 1937. SORREL, RICHARD, ROUGE. Resultats de I’Arthrodese Extra-Articulaire du Genou Chez L’Enfant. Mbm. Acad. de Cbir., 64: 1237-1246, 1939. DELAHAYE. Extra-ArticuIar Arthrodesis of the Knee in ChiIdren. J. Bone Ed Joint Surg., 18: 5 I53. 1936.