Joint stabilization

J oint

Stabilization

AN EXPERIMENTAL, HISTOLOGIC STUDY WITH COMMENTS ON THE CLINICAL APPLICATION IN LIGAMENT PROLIFERATION GEORGE S. HACKETT, M.D. AND DONALD G. HENDERSON, From tbe Departments of Surgery and Patbology, and A&man Hospitals, Canton, Ohio.

Mercy

HIS tweIve-month Iaboratory study of the histologic effects of a prohferating soIution injected within the tendons of animaIs was undertaken to investigate the modus operandi and the cIinica1 resuhs which have been obtained during the past fifteen years in the strengthening of reIaxed ligaments which re-estabIished joint stabilization in man as reported by Hackett.

T

NEED

FOR SCIENTIFIC DATA

AIthough the authors were satisfied that the cIinica1 resuIts of proIiferation in strengthening reIaxed Iigaments to stabiIize joints were especiaIIy satisfactory, it became increasingIy evident that some physicians were skeptica of the method. It therefore seemed advisabIe to present evidence of the manner in which the cIinica1 resuIts were accompIished. Perhaps some skepticism was justified because the attempt to cure hernias by proIiferation was disappointing. However, the treatment of varicose veins and some other conditions have been highIy successfu1 in competent hands. AIso no previous scientific work had been done which demonstrated the voIume of strong fibrous tissue which couId be generated by the introduction of a proliferant within the joint Iigaments, aIthough the experiments had been made on some other tissue which reveaIed the production of permanent strong fibrous tissue. ProIiferation treatment of Iigaments was initiated fifteen years ago when it became evident to one of the authors that much Iow back disabiIity was due to reIaxation of the joint Iigaments as reveaIed by Mengert, Meisenbach and Magnuson. ProIiferation promised the greatest reward in stabilizing the joint by promoting additiona strength to the Iigaments. American

Journal

of Surgery.

Volume

89.

May,

rggg

HISTORY

M.D.,

Canton,Obio

OF SCIENTIFIC

TISSUE

PROLIFERATION

The scientific rationaIe for the injection of a proIiferant was first estabIished by Warren in 1881 when he reported the production of fibrous tissue which acquired strength in ten to tweIve days. In rg2g Ha11 and Fraser using guinea pigs, monkeys and dogs demonstrated the vigorous new growth of endotheIia1 and connective tissue ceIIs foIIowing the injection of a proIiferant. In 1933 Rice and in 1936 Rice and Mattson reported the histoIogic resuIts of syInaso1 when injected in human tissue after periods from fifteen hours to forty-two days. Tissue sections were made from twenty-five patients. In three days fibroblasts appeared. In five days poIymorphonucIear ceIIs had IargeIy disappeared. At fourteen days fibrous tissue was in dense bundles, and in forty-two days fibrous tissue was in very dense bundIes. In 1936 Harris, White and Biskind demonstrated microscopic iIIustrations of the fibrous tissue formation from two proIiferants. In 1938 ManioI using rats reported that in eight weeks firm scar tissue resuIted without any undesirable histoIogic changes. This is the first report showing the quantitative resuIts of proIiferating soIution as we11 as the histoIogic resuIts, and carried out over a sufficient Iength of time to demonstrate that the new fibrous tissue becomes permanent and that there are no degenerative sequeIae. ANIMAL EXPERIMENTATION AIthough the clinica treatment has been appIied to ligaments, the experimenta work has been done on tendons because there are no Iigaments in the smaIIer animaIs which are of sufficient size and accessibility to carry out the experiments. Ligaments and tendons are composed of non-eIastic bands of simiIar white fibrous tissue, and both are attached to bones.

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Joint

Stabilization

FIG. I. Arrow points to moderate infiltration of lymphocytes forty-eight hours after injection of proliferating solution. Note absence of necrosis in surrounding tissue. FIG. 2. Beginning fibropIastic organization present in adjacent tissues. Arrow points to capiIIary proliferation with modcrate infiltration of lymphocytes. Two weeks after iniection.

the rabbit was seFor this investigation were made on the lected. The experiments gastroc znemius and superficia1 fIexor tendons where they are conjoined to the tuber caIcanei to the of the tibia1 tarsal bone, anaIogous AchiIIe :s tendon in man. The technic was simiIar to that used cliniinjection of IocaI anescaIlv. A preIiminary throughout the fibrous thesis was infiltrated strand: s of the tendon as the needle was inserted. WhiIe the needIe remained in place, the

syringe was replaced 6-7: one containing the proIiferating soIution which was then injected aIong the course of the needIe as it was withdrawn. The corresponding tendon on the other Ieg was not injected and was used as a control. Microscopic views of sections represent effect of proliferating action at periods from one day to one year. (Figs. I to 4.) Ten rabbits were used in the series. The histoIogic examinations and photography were done in the pathology department of AuItman Hospital. 969

Joint

StabiIization

FIG. 3. Fibrous tissue now present. Lymphocytic infiItration minimal. One month after injection. Arrow points to few fibroplasts. Fibrosis now present, lymphocytes absent and sheath thickened and fibrosed nine months after initial injection. Arrow points to junction of tendon and its sheath. Nine months after initial injection.

FIG. 4.

PROLIFERATING

The

proliferating

maximum

SOLUTION

soIution

empIoyed

tive tissue,

was

sIoughing

syInasoI@ which has been used cIinicaIIy by one of the authors in joint stabilization since 1939. SyInasoI, * a miId sodium saIt of fatty acid, was chosen because it has been found by other investigators (Rice; ManioI; Harris, White) to have the foIIowing desirable features:

of permanent white fibrous connec(4) no systemic reaction, and (3) no or destruction of tissue. METHOD

OF INVESTIGATION

The injections of proliferating solution were distributed throughout the tendon from its origin in the muscIe to its insertion into the

(I) causes a minimum of earIy exudate, (2) a minimum of discomfort, (3) stimuIates a * Manufactured by G. D. SearIe and Company.

bone. The after 970

second the first,

injection

was given

and the third

six weeks

or last injection

Joint StabiIization L

R

L

9 months

R

12 months

FIG. 5. Photographs of rabbit tendons nine and twelve months after three injections of proliferating solution were given into the right tendons while the left were used as controIs. The right tendon in each case reveak a 40 per cent increase in diameter. The tendons with bone attached at the upper end reveaI a 30 per cent increase in diameter as compared with the controls. A 40 per cent increase in diameter is equivalent to approximately 100 per cent increase in strength.

I month

OF

control

tendon

that was injected at six weeks and again at five months after the initia1 injection. Permanent white fibrous tissue has formed. There is no infIammatory process present and the sheath has been thickened and joined to the tendon.

was given five months after the first, so that animals in a11 cases under two months’ duration received onIy one injection, those under five months received two injections and the longer cases received a tota of three injections. The tissue was stained with hematoxyIin and eosin. AI1 the photomicrographs were magnified 200 times. The ones seIected for this articIe show the various stages from immediate acute inflammation through generation of new fibrous tissue to permanent white fibrous tissue. RESULTS

3 months

FIG. 6. Arrows denote bone; C indicates and P, proliferated.

QUANTITATIVE

RESULTS

Figure 5 shows the right and Ieft tendons of two rabbits after nine and tweIve months of proIiferating treatment. In both cases the Ieft tendon was not injected and was used as a control. The right tendon in each case received three injections. The second injection was given six weeks after the first, and the third injection was made five months after the initial one. In the nine-month case the tendon sheath remains on both the right and Ieft, and in the tweIve-month case the tendon sheath has been removed reveaIing the norma smooth surface of the contro1 tendon on the Ieft and the rough surface of the right tendon from which the adherent sheath has been forcibIy removed. At the end of nine and tweIve months the injected right tendons in each case revea1 an as comincrease of 40 per cent in diameter pared with the Ieft controls, whiIe the end of the bone with the attached tendon discIoses a 30 per cent inc.-ease in diameter. AIthough no mechanical method of computing the reIative tensiIe strength of tendons was avaiIabIe, it is estimated that an increase in diameter of 40 per cent wouId approximately doubIe the strength of the tendon. Figure 6 shows the proxima1 end of the tibia1 tarsal bone of the rabbit with the attached

EXPERIMENTS

There was no necrosis in any of the specimens and no destruction of any nerves, bIood vesseIs or tendonous bands. As shown in Figure I the early inflammatory process took pIace surrounding the nerves and bIood vessels with Iymphocytic infltration throughout the area between the tendon and its sheath. The infIammation aIso extended within the junction of the two tendons. In Figure 2, which was taken two weeks after the original injection, the acute inffammatory process has begun to subside. The Iymphocytes are Iess evident, new capiIIaries have formed and fibropIastic organization has begun. Figure 3 show tissue one month after the initia1 injection. Fibrous tissue is present and lymphocytic infiItration has diminished aIthough some is still present which indicates the production of new white fibrous tissue is stiI1 being promoted. Figure _I is the section of a nine-month 971

Joint

StabiIization reported by Harris, White and Biskind). This accounts for the vigorous growth and vitaIity of the permanent new fibrous tissue. These experiments were carried out in the same manner as the cIinica1 treatments. LocaI anesthesia was injected ahead of the needIe as it was inserted, and the proIiferating soIution was distributed by injection while the needIe was being withdrawn. Of particuIar significance is the 40 per cent increase in diameter of the tendon and 30 per cent increase in diameter of the tendon at its bony attachment foIIowing three injections of the proIiferant as reveaIed in the photographs of the nine- and tweIve-month experiments. It demonstrates the strengthening of the entire tendon incIuding the bony attachment by the production of permanent white fibrous tissue. It is estimated that an increase of 40 per cent in diameter of the tendon would approximateIy doubIe its strength. It is the opinion of the author that when damage to a Iigament occurs it most often takes pIace at its bony attachment where it is more vuInerabIe. Leriche and Gardner have shown that Iigaments near their bony attachments are richIy suppIied by sensory nerves. Pain is present when reIaxed Iigaments are under norma tension because the fibrous strands of the Iigament extend, and the nerves in the Iigament are pIaced under abnorma1 tension because they do not Iengthen. Some physicians have been getting relief from pain in acute cases of Iigament disabiIity by the injection of a IocaI anesthetic. To accompIish enduring stabilization of the joint, and freedom from discomfort and to avoid recurrences when the Iigaments have become reIaxed, the production of an increased amount of permanent white fibrous tissue is necessary. AIthough the original report of Iigament proIiferation by one of the authors deaIt with fourteen years’ work on the sacroiliac joint, articIes wiI1 soon appear describing the technic of stabiIizing a11 the joints of the spine and peIvis. Arrangements are being made for a source of suppIy of three-dimensiona iIIustrations of the Iumbar spine and peIvis in which the Iigaments have been reconstructed on one side with the tender points of Iigament reIaxation designated. On the other side needIes have been pIaced as in the position of fuI1 insertion during treatment. This has been deemed

gastrocnemius and superficia1 fIexor tendons. The fiIms were made at one and three months after a singIe injection of proIiferant soIution had been distributed throughout the fibrous tissue. It reveaIs soft tissue increase at one month is pronounced due to the presence of inflammatory reaction, whiIe at three months the increase is due to the production of permanent fibrous tissue. It aIso reveals a marked increase of bone at one month as compared with the control and a further increase of bone at three months. The increase of bone is significant because it resuIts in a strong fibro-osseous union where sprains, tears and reIaxation of the Iigament chieff y take pIace and where the sensory nerves are abundant. It accounts for the exceIIent cIinica1 resuIts that have been obtained in the past sixteen years in restoring joint stabiIity. No method has been found to demonstrate whether an actua1 shortening of a Iigament takes pIace during proIiferation or whether the cIinica1 resuIts are due to an increase in strength of the Iigament which prevents it from stretching when under strain. Pain in reIaxed Iigaments whiIe undergoing strain is due to tension on the nerves within the Iigament which do extend as the Iigament stretches. The injection of an anesthetic into the reIaxed Iigament eliminates the pain temporariIy, and proliferation of new fibrous tissue eliminates the disabiIity permanentIy. COMMENTS

The fibrous bands of joint Iigaments crisscross in such a manner that movements of the joint are permitted in different directions, but each movement is restrained within certain Iimits. When the Iigamentous bands become reIaxed so that abnorma1 movement causes discomfort, the injection of a proIiferant within the Iigament wiI1 induce the formation of new fibrous tissue in the spaces between the crisscrossed bands and firmIy attached to the bands. The new tissue becomes permanent in a few weeks and inhibits the excessive movements. The joint is thus stabilized, discomfort eIiminated and normaI activity resumed. FoIIowing injection of the proIiferant in any tissue the inffammatory reaction and newIy developed fibrous tissue surround the existing nerves and bIood vesseIs, and new capillaries deveIop as shown in Figure 2 (previousIy 972

Joint Stabihation necessary because for many years the congested medical college curriculum has precIuded the medical student from dissecting and otherwise acquiring a familiarity with the ligaments of the spine and peIvis. Therefore, three-dimensiona iIIustrations will facilitate both diagnosis and treatment. Investigation is in progress on combining the proliferating solution with a long-acting anesthetic which is desirabIe for the treatment of many ligaments. During the past fifteen years more than 3,000 injections of a IocaI anesthetic and the proliferant have been given into the dorsal ligaments of the Iumbar spine and peIvis. The pressure of the soIution has immediateIy reproduced the 104 pain confirming the diagnosis. FrequentIy also reproduced was the referred pain into the groin, buttock and Iower extremities to within 2 inches of the ankIe but never into the foot. A chart of the referred pain areas 41 soon be pubIished and wiI1 be found useful in the diagnosis of Iow back disabilities. SUMMARY

AND

4. Joint stabilization by. proIiferation has been successfulI? empIoyed m the treatment of various joints mcIuding all of the vertebral and pelvic joints. 3. No unfavorable incident occurred in either the clinical or experimental cases in which approximately 3,000 injections have been given. 6. Pain in reIaxed ligaments is due to tension on the nerves which do not lengthen as do the fibrous bands of the ligament. REFERENCES

E. BIood and nerve supply of joints. Stanfjord M. Bull., I I : 203, 1953. I IACKETT, G. S. Joint stabilization through induced ligament sclerosis. Ohio State M. J., 49: 877~.884,

GAHDNEK,

‘953. I HACKETT, G. S. Shearing injury to the sacroihac joint: ligaments strengthened by proliferation. J. Internat. Call. Surgeons, 22: 631, 1954. IIALL and FRASER. Quoted by Riddle, P. Injection Treatment, p. 3. PhiIadelphia, 1940. IV. B. Saunders Co. I IAHRIS, F. 1. and WHITE, A. S. Injection treatment of hernia, its experimental basis. Cahforniu P West Med., 45: 382, 1936. I IAKRIS, I;. I., WHITE, A. S. and BISKI’VD, G. R. Obsrrvations on solutions used for injection treatment of hernia. Am. J. Surg., 39: I 12, 1938. I.EKICHE, R. Des cffets de I’anesthesie a la novocaine des ligaments et des insertions tendineuses periarticulaires dans certaines maIadies articulaires et dans Ies vices de position fonctionnels des articulations. Gas. d. hop., 73: I 294, I 93”. ~IA(;UCSON, P. B. Differential diagnosis of causes of pain in the lower back accompanied by sciatic pain. Ann. Surg., I 19: 8788891, 1944. .\~AUIOL, L. Histologic effects of various sclerosing solutions used in injection treatment of hernia. Arch. Surg., 36: 171-189, 1938. L~EISENBACH, R. 0. Eighty-four cases of sacroiliac relaxation. Sure., Gynec. P Obst., 12: 41 I, 1911. ,\IE~GEKT, U;. F. Referred pelvis pain especially due to sacroiliac relaxation or strain. South. M. J., 36: 256263, 1943. R~ct:, C. 0. RationaIe of injection treatment of hernia. .Winnesota Med., 18: 623-625, 1935. Rrcx, C. 0. and MATTSON, H. Histologic changes in tissues of man and animals fobowing injection of irritating soIutions intended for cure of hernia. Illinois M. J., 70: 271-278, 1936. WAHKEU, .I. H. Hernia with Cure by Subcutaneous Injection. Boston, 188,. Charles C Thomas.

CONCLUSIONS

I. The injection of a proliferating solution within the fibrous bands of rabbit tendons promotes the production of new fibrous tissue which becomes permanent. The increase in diameter of the tendon was 40 per cent, and the increase in diameter of the bony attachment of the tendon was 30 per cent at the duration of nine and twelve months, although onIy three injections had been made and none after the first five months. This amount of increase would approximately doubIe the strength of the tendon. 2. New fibrous tissue which deveIops betlveen and is attached to the crisscrossed bands of the Iigaments will curtail the abnormal joint movement. 3. The increased fibrous tissue accounts for the clinical resuIts which were reported by one of the authors in the treatment of 293 cases of sacroiIiac reIaxation over a period of fourteen years with 82 per cent of the patients permanentIy relieved of their symptoms.

973