Surgery in the Treatment of Chronic Arthritis

SURGERY IN THE TREATMENT OF CHRONIC ARTHRITIS H.

KELIKIAN,

M.D., F.A.C.S.*

PERFECTIONISTS need not bother treating patients with chronic arthritis. The outcome of any effort directed towards the management of this disease is far short of the ideal. Improvements are relative. The best one can hope is some gain in useful movements, a measure of stability, or perhaps surcease from pain. But what may seem an insignificant benefit to a well person is often a major boon to one afflicted with a crippling disease. However gnarled and knotted, the patient must not be denied his chances to better his lot. Surgically a great deal can be done towards ameliorating the plight of an arthritic and we have several useful procedures at our disposal which can be directed to this end.

DIFFERENTIATION OF THE TYPES

A joint is a connective tissue organ. It connects and supports parts and permits movement passively. It does not move, but merely allows motion. Muscles make it move. The joint and the structures related to it are derived mainly from the mesoderm. As the primitive connective tissue develops into highly specialized gliding and supporting structures, articular cartilage and subchondral bone, it remains relatively undifferentiated, hence reactive and reproductive, beneath the synovial surface and within the cancellous spaces. Inflammation affects the young connective tissues of the joint as are found in the outer vascular stratum of the synovial membrane and in bone marrow. Wear and tear, or degeneration, involves the specialized, senescent elements as articular cartilage and subchrondral bone. The inflammatory type of chronic, nontuberculous arthritis has been qualified variously as rheumatoid, atrophic, proliferative, infectious, synovial and ankylosing. In the young, it is called Still's disease and a particular variety which affects mainly the axial skeleton has been dubbed spondylitis rhizomelica or Marie-Striimpell type. Adjectives linked with the degen~rative type of chronic arthritis are: osteo- or chondro-osseous, hypertrophic, traumatic, senile, spur-forming and its special variant affecting the vertebral column is given the name Von-Bechterew type of spondylitis. The term arthritis deformans is loosely applied to both types. There are several differences between the two main subgroups of chronic nontuberculous arthritis: 1. Inflammatory or rheumatoid arthritis is a generalized systemic disease; it affects not only joints, but some other tissues arising from From the Department of Bone and Joint Surgery, Northwestern University Medical School, and the Wesley Memorial and Cook County Hospitals, Chicago. * Assistant Professor of Bone and Joint Surgery, Northwestern University Medical School; Attending Orthopedic Surgeon, Wesley Memorial and Cook County Hospitals; ConSUlting Orthopedic Surgeon, St. Bernard's Hospital.

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mesoderm: it may be accompanied by myocardial disease and subcutaneous nodules. Degenerative or osteo-arthritis is confined to joints only, usually a single one. 2. Rheumatoid arthritis starts commonly before the age of 40; it affects mostly pale, asthenic women though its special variant, spondylitis rhizomelica, is seen more often in men; it occurs mainly in light skinned people-people of Northern European extraction. Osteo-arthritis is a disease of the old; except following acute trauma it starts after 40 and affects the hardy and robust and may occur in any race. 3. Rheumatoid arthritis may be associated with foci of infection and manifests a predisposition to allergy, but is not necessarily caused by . them. Osteo-arthritis is related to trauma, to obesity and mechanical misalignments (which are the causes of chronic trauma); to old age (which is protracted trauma); to arteriosclerosis; and to avascular necrosis of the articular ends of bones with death and collapse of the supportive osseous framework and corrugation of the articular cartilage. 4. During its florid phases, rheumatoid arthritis may be accompanied by fever, leukocytosis and increased sedimentation rate, and there is a great deal of pain and stiffness. Symptoms of pain and stiffness are mild or moderate in osteo-arthritis and exacerbations are due to added trauma or increments of weather. 5. Rheumatoid arthritis involves many joints; it tends to predilect joints rich in blood supply and in primitive connective tissues, that is, joints with extensive synovial membrane and bulbous articular ends as for example the metacarpophalangeal and proximal interphalangeal articulations. Osteo-arthritis affects fewer joints, usually one; it favors the traumatized and weight-bearing articulations as the hip and joints farthest from central circulation as the distal interphalangeal articulations. 6. X-ray films of the involved joint in rheumatoid arthritis may show almost uniform narrowing of the cartilage space, subluxations and sometimes complete effacement of joint with osseous trabeculae running from one bone to another; the articulating bones appear radiolucent, porotic, "atrophic." In osteo-arthritis, roentgenograms reveal narrowing of cartilage space at points of pressure and contact and condensation of bony substructure; there may be evidences of marginal spurs, osteocartilaginous loose bodies, widening and mushrooming of the articular ends and cystlike areas in them; but there is usually no sign of subluxation or ankylosis, the articular ends of bones appear dense, "hypertrophic." 7. The primary pathology in rheumatoid arthritis is inflammation of the primitive connective tissue elements of the joint as are found in the outer vascular stratum of the synovial membrane and in the subchondral marrow spaces with secondary erosion and displacement of the specialized elements as articular cartilage and osseous trabeculae. Inflammation proceeds through various phases of hyperemia, edema, cellular infiltration and tissue proliferation. Granulations sprouting from the sub-

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synovial and subchondral spaces invade and erode the bony trabeculae and the articular cartilages; they unite as fibrous strands which may become converted into bone. In osteo-arthritis, the basic change is one of wear and tear, or degeneration of the specialized gliding and supporting elements of the joint. At points of trauma or weight-bearing the articular cartilage thins; it fissures and fibrillates. Since this central portion of the cartilage is avascular, it cannot repair or reproduce itself. The subchrondral bone and the marginal cartilage which receive blood supply react by thickening and piling up of new bone or osteophytes; the opposed joint surfaces file each other, eburnate; they may interlock, but they do not ankylose. There are instances of the so-called "mixed" arthritis. A joint may have been the seat of rheumatoid arthritis, but as a result of destruction of the articular surfaces, subluxation or other mechanical incongruities it becomes subject to self-inflicted trauma and merges into osteo-arthritis. Conversely, in old osteo-arthritis, the synovial membrane may become irritated by osteophytes and osteocartilaginous loose bodies and set up an inflammatory reaction. There are two chronic joint disturbances which cannot be pigeonholed into either group. One of these is the so-called pigmented villonodular synovitis, and the other, synovial chondromatosis and osteochondromatosis. The former starts as proliferation within the out~r or vascular stratum of the synovial membrane: areas of condensed and thickened connective tissue indent the surface layer of the synovial membrane and produce villi; the expanded synovial secreting surface pours out more fluid into the joint. The fluid is not readily absorbed: it distends the joint cavity, enlarges it. But in contrast to rheumatoid arthritis, granulations do not break through the surface layer of the synovial membrane and invade the articular surfaces and erode them. The villi may bruise one another, necrotize and cause intermittent bleeding into the joint cavity: they may even become matted together in a meshwork of friable fibrin; but there is no extensive surface-to-surface adhesion and scarring as in rheumatoid arthritis and the joint movement is not greatly impeded. Clinical differentiation between pigmented villonodular synovitis and villous phase of rheumatoid arthritis can easily be made by aspiration of the joint fluid and arthrograms. In pigmented villonodular synovitis, the joint fluid is pink or brown; it is serosanguineous; arthrograms after introduction of air will show smooth, unbroken, articular contour, a flocculent "bubbly" effect. The joint fluid in villous phase of rheumatoid arthritis is yellow and arthrograms may reveal shadows indicative of intra-articular adhesions or a rugged contour of the synovial pouch. Synovial chondromatosis or osteochondromatosis is a matter of metaplasia of the primitive connective tissue elements within the synovial membrane. The latter arises from the same anlage as bone and cartilage and is capable of reproducing either one of them. In synovial chondromatosis or osteochondromatosis, cartilaginous or bony plaques are laid within the synovial membrane; they invaginate into the joint, hang like 4

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Fig. 42.-Manipulation, traction and exerci8e8 again8t ten8ion. Manipulation, if gentle, is often beneficial and may help in mobilizing quiescent, stiff joints. It is especially useful for frozen shoulders when supplemented with hanging cast, or better still, skeletal traction. Immediately after manipulation of the shoulder, 5 to 15 pounds of weight is connected to the hook screw in the proximal ulna; as pain subsides the patient is encouraged to abduct and adduct his arm, flex it forward against tension and practice muscle setting of the deltoid. When up, 5 to 10 pounds weight is attached to the hook screw and the patient is advised to lean forward and practice circumduction. Forceful manipulations of atrophic bones may cause displacement of the epiphysis in the young, or fractures in adults. This is especially true of the knee where tough adhesions obliterate the suprapatellar pouch and bind the quadriceps tendon to the distal femur. A, Photograph showing skeletal traction by way of a hook screw inserted into

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bunches of grapes, break loose. As detached foreign bodies they in time traumatize the articular surfaces and cause them to break down, producing secondary degenerative changes. SURGICAL AND RELATED MEASURES

Casts, Splints and Corrective Appliances.-Painful joints, whether due to rheumatoid or osteo-arthritis, are better put to rest by enclosing them in casts or splints and elevating the limb. In inflammatory or rheumatoid arthritis, it is especially important that the joirits are splinted in the position of optimum function should ankylosis intervene. It is at times possible to obviate ankylosis by making the cast removable so as to permit periods of guarded exercises. Where there are flexion contractures, one may encase the limb in a plaster cast and correct the deformity by successive wedging or a turnbuckle device incorporated in the cast. Traction, Exercises, Manipulation.-For flexion contractures, traction, preferably skeletal, is perhaps better than the wedge cast or turnbuckle splint since it permits muscle-setting and active exercises. Heavy traction is dangerous and one must be on guard against nerve stretching and paralysis. Occasionally traction and exercises against tension are supplemented by gentle passive manipulation of the joint, under anesthesia. The joints which are most often refractory to manipulation are the elbow and those of the finger. The shoulder responds best to repeated manipulation, aided by skeletal traction through the proximal ulna. In atrophic bones, especially around the knees, one always runs the risk of causing a manipulative fracture (Fig. 42). "Debridement."-Early in the last century, Napoleon's surgeon, Baron Larrey, conceived the idea that pain and spasm in infected war wounds were caused by the bands that bridged their interior. The French verb debriser denotes detaching. The English word bride indicates that which is tied. To debride means to untie. Larrey introduced the term debridement into surgical literature signifying the act of releasing tight bands deep in wounds and not removing the debris. Used in its correct sense, debridement has a place in the treatment of chronic arthritis. Where intraarticular adhesions are tough and unyielding, a scalpel may be slipped into the joint and swept up and down severing all the tight bands that offer resistance. The operation is especially applicable in the knee where most of the adhesions are in the suprapatellar pouch. The knife is introduced under the kneecap and carried up in a plane parallel to the anterior surface of the femur or the posterior articular aspect of the proximal ulna and collar and cuff sling to enable the patient to lean forward and exercise his shoulder against gravity and weight. In bed, the hook screw is connected to a pulley and weight arrangement. B, Photograph of the knee showing firm adhesions binding the quadriceps to the femur. C, Anteroposterior view x-ray film of the knee of a girl, aged 12, with rheumatoid arthritis. Note displacement of the distal femoral epiphysis following manipulation. D, Lateral view x-ray of the knee of a woman with long-standing rheumatoid arthritis and flexion contractures of both knees. Note the manipulative osteoclasis which in this instance turned out to be beneficial since it corrected the flexion contracture of the knee. The opposite knee broke at the same level.

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the patella. Active exercises and quadriceps setting are begun soon afterwards. Joint Aspiration and Lavage, Puncture of the Synovial Pouch and Drilling of the Articular Ends of Bones.-In old cases of rheumatoid arthritis when inflammation has burnt itself out and left a thick, fibrotic capsule the inner surface of the synovial membrane will keep on secreting fluid and fail to resorb. As a result, the synovial fluid accumulates within the joint and distends the articular capsule. Repeated aspirations followed by immobilization of the limb may help. When the aspirated fluid is thick and flocculent, two large needles are inserted into separate pouches of the joint cavity and fibrin and exudate are washed away with saline solution, under gravity. In recurrent effusions, one may advantageously rupture the synovial pouch into the surrounding muscles. In the knee for instance, a forceps is passed into the suprapatellar pouch and poked upwards under the quadriceps group of muscles in an effort to sidetrack the excessive synovial fluid. Based upon the assumption that granulations, which are pent up within rigid cancellous spaces, may be the cause of intractable pain, drilling of the articular ends of bones has been advised. This supposition finds justification in the fact that arthritic patients often obtain symptomatic relief following fractures of the articular ends of bones. Arthrotomy for Removal of Osteocartilaginous Loose Bodies, for Erasion of Incongruities and Chylectomy.-Loose bodies in the joints may originate from the synovial membrane or from the articular ends of bones. When arising from the bones they are due to trauma or interruption of blood supply. In baseball pitchers and tennis players, in the course of forceful hyperextension of the elbow, a sizable piece of bone will often break off the tip of the olecranon process of the ulna. The detached fragment may interlock the joint or erode the articular surfaces. Its timely removal will improve motion and obviate frictional erosion of the articular surfaces. Often in degenerative or osteo-arthritis a large overgrown spur will impinge upon the opposed articular surfaces and impede joint movement. It too may beneficially be excised (Fig. 43). However, in larger weight-bearing joints, as the hip, knee or ankle, excision of osteophytes and smoothing out of the rough, incongruous surfaces accomplishes little. It is not advised for people who have to eke out their living by standing on their feet. Desensitization of the Joint.-Since Charcot's joints are often painless and at times serviceable in spite of the extensive disintegration of the articular surfaces, neurectomy of sensory filaments to the j oint has been advised, especially in malum coxae senilis. One recalls the principle John Hilton formulated almost a century ago: "The same trunks of nerves whose branches supply the groups of muscles moving a joint furnish also a distribution of nerves to the skin over the insertions of the same muscles: and ... the interior of the joint receives its nerves from the same source." Hilton further pointed out that the hip joint not only

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receives sensory filaments from the femoral and obturator trunks, but also from the nerves of the sacral plexus, the superior and inferior gluteal and the sciatic. To isolate each of these sensory branches necessitates different incisions, several sittings and extensive exploration, especially when the articular branch of the sciatic nerve is sought for and severed. Is it not much simpler to cut the sensory nerves where they enter the joint? And are not these nerves severed in performing a mold arthroplasty of the hip or synovectomy elsewhere? A decade or two ago sympathectomy enjoyed a transient vogue in the treatment of rheumatoid

A

B

Fig. 43.-Arthrotomy. The joint cavity is opened for a variety of reasons: For biopsy, for synovectomy, for arthrodesis, and for other intra-articular operations. The term arthrotomy is used here to denote the operation of extracting osteocartilaginous bodies, either floating loosely in the joint cavity or hanging into it by stalk. A, Arthrotomy of the knee showing a mural, extrasynovial osteocartilaginous body hanging into the outer compartment of the knee. This was removed and the eroded articular surface of the patella was shaved (erasion). B, Photograph of the specimen.

arthritis. It yielded no benefits beyond that accrued from postoperative sedation and rest. Synovectomy.-In both villonodular synovitis and synovial chondromatosis or osteochondromatosis, synovectomy is regarded a standard surgical procedure. In inflammatory or rheumatoid type of chronic arthritis it is at times indicated. Rheumatoid arthritis will often resolve into villous synovitis with an extensive secreting synovial surface and persistent hydrops articularis. This so-called villous phase of rheumatoid arthritis is at times amenable to synovectomy. But before undertaking the surgery one must make certain that inflammation has completely

Fig. 44. Figs. 44 to 47.-Synovectomy. In rheumatoid arthritis where inflammation has abated, leaving an extensive inner secreting synovial surface (hydrops articularis and chronic villous synovitis) and a scarred outer layer with diminished absorptive power, synovectomy becomes at times expedient. Preoperatively, attempts should be made towards determining the extent of the inflammatory activity within the particular joint. When the joint is in a chronic state of hydrops, one must suppose that the inflammation is still active, or that the scarred synovial membrane fails to resorb what it pouts out. In the last instance, the joint gai~s in capacity and arthrograms will not only reveal enlargement of the articular cavity, but also show shadows indicative of adhesions and scarring. Another method of ascertaining the extent of inflammatory activity is to introduce a few cubic centimeters of iodized oil into the articular cavity and take x-rays of the joint at periodic intervals. Where inflammation is still active the synovial membrane is hyperemic, the oil will soon pass out of the cavity and at times impregnate the lymphatic tracts and regional lymph nodes. Surgery will only fan smoldering fire. Synovectomy is safe where the oil remains unabsorbed for a month or more. On the whole, however, the results of synovectomy in rheumatoid arthritis are not very good since the hyaline articular cartilage is often irreparably damaged by the time the inflammation has burnt itself out. Synovectomy yields the best results in pigmented villonodular synovitis and synovial chrondomatosis where the articular cartilage remains comparatively intact. Fig. 44.-Presynovectomy studie<: as to the contour and the capacity and communication of the articular cavity. A, Anteroposterior view arthrogram of the knee, of a woman with long-standing rheumatoid arthritis. Note the inordinate enlargement of the articular cavity: the gastrocnemic semimembranosis bursa which ordinarily, is a small outpouching of the synovial membrane has descended as far down as the mid-calf. The contour of the joint cavity casts a jagged shadow indicative of scarring and the effect of irregular loculation is produced by bands of intra-articular adhesions. B, Anteroposterior view arthrogram of the knee of a young girl with bilateral pigmented villonodular synovitis. Her two brothers were similarly affected. Note the extension of the knee joint cavity up towards the midthigh. The joint cavity when filled with air casts a multilocular shadow due to the infolding of the synovial plicae; the shadow cast by the contour of the cavity is smooth. 94

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burnt itself out and is not likely to flare up. The duration of the hydrops, studies of temperature, blood counts and sedimentation rates may help one arrive at a decision. During the activf) hyperemic phases of inflammation the rate of absorption from the articular cavity is rapid; in late stages, due to scarring of the capsule, absorption is sluggish. A few cubic centimeters of iodized oil are introduced into the joint cavity and x-ray

Fig. 45.-Presynovectomy studies in the speed of absorption of iodized oil from the joint cavity. The resorptive power of the synovial membrane is taken as an indirect index of hyperemia within its walls. A, Arthrogram of the knee of a patient with Ruminant rheumatoid arthritis. Iodized oil was introduced into the knee and the films were taken every twenty minutes. Already in the first plate opaque material was seen impregnating a large popliteal node and the lymphatics leading to and away from it. Increased vascularity enhances absorption from the joint cavity. (Reprinted from the author's article, "Chronic Arthritis", Surg., Gynec. & Obst., 76:469-479, April, 1943). B, Arthrogram of a less active knee. The popliteal node became impregnated to the density shown after two weeks. C, Arthrogram of a quiescent knee. Three weeks after the introduction of iodized oil into the joint cavity the popliteal lymph node is only faintly impregnated. Note the jagged contour of the articular cavity which denotes scarring.

films are taken an hour later and then every two weeks. In burnt-out quiescent joints, lipiodol will remain in the articular cavity for weeks and months; when inflammation is active the oil is rapidly absorbed and may even impregnate the regional lymph nodes and tracts within the first hour of its introduction into the articular cavity. Any extensive surgery on the joint with rapid absorption, hence hyperemia, will only fan a

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smoldering fire. Of all the joints, the knee and the elbow are most amenable to synovectomy. (Figs. 44 to 47.)

Fig. 46.-Synovectomy in chrondromatosis of the elbow. The synovial membrane which arises from the same primitive connective tissue but remains relatively undifferentiated can produce both bone and cartilage by metaplasia. Synovial chondromatosis is usually diffuse; not only the detached loose bodies must be evacuated, but the membrane which produces them must be dissected out. A, Photograph of the surgically exposed synovial capsule of the elbow of a woman whose only complaint was regional swelling and tingling along the distribution of the ulnar nerve. X-rays were negative. Note the distended synovial capsule on either side of the triceps tendon and adhesions extending to the ulnar nerve proximally. B, Segment of the chondrified synovial capsule to show its thickness. C, Multiform cartilaginous bodies with which the articular cavity was packed. D, Photomicrograph X800 through a section of the dissected synovial membrane showing nests of cartilage cells. E, and F, Functional results four months after synovectomy.

Capsulotomy.-In flexion contracture of the knee, posterior capsulotomy with stripping of the contracted capsule proximally from the

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femur was a fashionable operation at one time. It was often supplemented by tenotomy of hamstring tendons. Nowadays posterior capsulotomy i;; resorted to only when the opposed articular surfaces remain intact, which is rare when inflammation has been severe enough to cause flexion contractures. The deformity is better corrected by supracondylar osteotomy. Osteotomy.-In severe flexion contractures of the knee, a sizable wedge of bone is resected so as to avoid stretching and paralysis of the peroneal nerve during extension of the limb. The surgical fracture is allowed to heal in a functionally correct position, which in the knee is 5 to 10 degrees short of full extension. In the so-called malum coxae senilis, or degenerative arthritis of the hip, intertrochanteric osteotomy is sometimes resorted to with the idea of shifting weight-bearing points and putting a relatively unworn, mechanically sound, articular surface under the lines of stress and strain. The correction is best accomplished if osteotomy is performed between two guide pins which are used to lever the severed fragments of bone into the alignment desired. Recently osteotomy has been advised for the correction of bowed "bamboo" spine of spondylitis rhizomelica. Well planned and executed osteotomy of deformed fingers will improve their functional usefulness (Fig. 48). Resection of Articular Extremities and Ostectomy.-In non-weightbearing joints, resection of one articular end is to be preferred to the excision of osteophytes from it or effacement of its surface irregularities. In the lower extremity, resection of a non-weight-bearing bone, as the patella, is likewise justifiable and assures better functional result than trimming, rasping and filing of the bone. Where the primary function is movement and stability is not an important factor, as in the temporomandibular joint, a considerable segment of one of the articular ends may be excised without any attempt at adaptive remodeling of the opposed surfaces (Fig. 49). In ankylosis or interlocking of the temporomandibular articulation, the condyle, the coronoid process and the adjacent portion of the proximal ramus of the mandible are resected; the space created is packed with oxycel gauze and skeletal traction is instituted through the chin. When the jaw has remained immobile for a protracted period of time, muscles of mastication become fibrotic; they contract, shorten; they must be put under stretch and made to function against tension so as to regain their length and contractility. Skeletal traction accomplishes this and it also prevents the chin from dropping back against the throat and choking the patient, postoperatively. In osteo-arthritis of the acromioclavicular joint, an inch or more of the outer clavicle is resected (Fig. 50). In posttraumatic mushrooming of the proximal articular surface of the radius with inability to pronate or supinate the forearm, the head of the radius is resected. For the same reason in osteo-arthritis at the distal radio-ulnar articulation, or when the radius has shortened and ulna has advanced farther down towards the carpal bones, an inch or two of the distal ulna is resected. In osteo-arthritis of the wrist following fracture of the carpal navicular

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Fig. 47.-Synovectomy in pigmented villonodular synovitis of both knees. The synovial membrane presents a flattened connective tissue surface towards the joint cavity and an outer vascular stratum where most of the inflammatory processes take place. In rheumatoid arthritis, granulations break through the surface layer of the synovial membrane, invade the interior of the joint cavity, creep over and erode the hyaline articular cartilage and form adhesions. In pigmented villonodular synovitis, the outer stratum of the synovial membrane is thickened by extensive cellular infiltration throwing the surface into numerous folds or rugae; circumscribed lobules hang into the joint cavity as villi or thick stalked nodules. The secreting synovial surface is thus expanded and frictional necrosis of the villi imparts a bloody tinge to the synovial fluid. However, granulations do not seem to break through or erode the articular surfaces as in rheumatoid arthritis; the contour of the joint cavity remains smooth; there may be some matting together of the bruised villi, but there are no extensive adhesions between the opposed articular surfaces. Diagnosis is established by repeated aspiration of serosanguineous fluid in the absence of any history of hemophilia and flocculent bubbly effect shown in arthrograms. A, Photograph of the knee at the time of arthrotomy of a young girl with bilateral pigmented villonodular synovitis. Both of her knees were markedly en-

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and avascular necrosis of the proximal fragment, the dead piece of bone or entire carpal scaphoid or even all the proximal rows of carpal bones are sometimes removed. Resection of the carpal lunate is often performed in arthritis caused by necrosis of that bone and collapse of its articular walls. In arthritis of the metacarpophalangeal and interphalangeal joints, which often follows injuries, the globular head is resected (Fig. 51). Even though it may have been damaged to a greater degree, the base of the phalanx is left undisturbed since it gives insertion to the extensor muscles. The line of resection of the distal articular end of the metacarpus or of the phalanx must pass proximal to the point of reflexion of tht'!! synovial membrane over the head; if the line passes too far distally the blood supply of the head will be impaired and may result in ring sequestra. In the foot, only rarely are metatarsal heads resected since these bones are weight-bearing. Exception is made in arthritis of the metatarsophalangeal joint following avascular necrosis and infraction of the metatarsal head, usually of the second. The nutrient vessel to the second metatarsal bone arises from the terminal perforating branch of the dorsalis pedis artery. It passes outward and plantarward and penetrates the bone nearer its base than its head. As the latter bears the only epiphysis of the metatarsal and constitutes its growing end, the direction of the nutrient vessel in the bone is proximal, towards the bas':). Whether or not this arrangement of the blood supply has anything to do with the infraction of the head is a matter of conjecture. The line of resection of the second metacarpal bone for infraction of the head should pass through where the bone receives adequate blood supply (Fig. 53). The arthritic base of the proximal phalanx is not touched since it would entail dissection of the volar metatarsal ligament which holds the toe in place. In the more common rheumatoid arthritis of the foot with hallux valgus, hammer toes and other deformities, the resection of portions of the proximal row of phalanges or of the entire set of these bones is regarded better surgery than excision of the weight-bearing metatarsal heads (Fig. 54). In hallux valgus type of deformity, the painful exostosis is chiseled off the medial aspect of the head of the first metatarsal and the proximal half of the first phalanx of the great toe is resected; if eroded or mushroomed, the two sesamoids beneath the metatarsal heads are also excised; the dissected aponeurosis of the abductor muscle is partly used to transfix the resected phalanx and its remainder is sutured to the severed adductor tendon. larged, the suprapatellar pouch reaching as high as midthigh (see the arthrogram, Fig. 44, B). Her two brothers presented bilateral enlargement of both knees and chronic effusion. The younger brother had in addition swollen boggy wrists. There was this familial tendency. B, The same after synovectomy: note the intact articular cartilage of the femoral condyles as well as the patella. C, Photomicrograph X800 through one of the villi showing the type of cellular infiltration. D, Photograph showing the degree of flexion seven months after bilateral synovectomy. The knees were opera,ted a,t two-week interva,ls. E, Photograph showing the degree of extension. .

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Fig. 48.-0steotomy. In flexion contractures of the knee, supracondylar osteotomy is a standard operation. Sometimes a considerable wedge or segment of bone is removed to obviate peroneal nerve paralysis on correction of the deformity. In the hip, subtrochanteric osteotomy is at times resorted to with the idea of

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Arthrop1asty.-Except in ankylosis of the temporomandibular articulation where one has no other recourse, it is questionable whether a painless, soundly fused joint should ever be mobilized. However, in some arthritics it becomes expedient to loosen a joint or two so as to enable the patient to feed himself or sit on a stool. When a joint has stiffened with the limb in a functionally useless position, the choice rests between corrective osteotomy and arthroplasty. Generally speaking, in the lower extremity where weight-bearing takes precedence over motion, corrective osteotomy is preferred; in the upper limb where movement is paramount, one may concede in favor of arthroplasty or resection of one of . the articular ends. Distinction ought to be made between the two methods of surgical mobilization of stiffened joints and the indications for each. In articulations, as the temporomandibular or acromio-clavicular, where stability is not a factor, adaptive remodeling of the articular ends is hardly warranted. All that is required is to resect enough bone, create a gap, and resort to such contrivances as would prevent this space from being bridged across by osseous trabeculae. In the elbow and especially the hip, where stability is a necessity, the resected articular ends must be reciprocally reamed and rounded and fitted together in a way that would prevent subluxation under use. Arthroplasty is thus more than mere resection of the articular ends. It denotes creation by art of a joint which will not only permit motion, but provide also a measure of stability under stress. There are some general principles which must be heeded in performing arthroplasty in arthritics, especially in those afflicted with the inflammatory or rheumatoid variety. Before undertaking the mobilization of any joint, one must make certain that inflammation in that particular articulation, not necessarily in others, has burnt itself out and that there shifting weight-bearing points and putting a relatively unworn articular surface under the lines of stress and strain. In the fingers, where osteo-arthritis often follows trauma and the digits deviate due to the obliquity of the damaged articular surfaces, osteotomy will not only correct the deformity but will also enhance the functional usefulness. (The illustrations in this section are reprinted from the author's article, "Osteotomy of the Finger," Quart. Bull., Northwestern Univ. M. School, Chicago, 21 (2) :111, 1947.) A, Photograph of the left hand of a violinist who suffered a handball injury about a year ago. X-ray revealed obliquity of the articular surface of the distal phalanx and degenerative arthritis. When he resumed playing the violin he became dismayed by his failure to hit the scale he intended to resound. Note the radial deviation of the distal phalanx of the long finger. B, X-ray film showing the transfixation of Kirschner wires and osteotome in place, within the substance of the distal phalanx. C, The distal fragment of the osteotomized phalanx has been twisted and levered into the desired position (ulnarward) and the two transfixation wires have been locked in a fixation nut on the ulnar side of the finger. D, Photograph of the same. E, Final photograph of the hand on the stringboard of the violin. The flexed distal phalanx of the long finger falls straight down on the string. It does not deviate sideways nor does it interfere with the play of the adjacent fingers.

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Fig. 49. Figs. 49 to 54.-Resection of the articular ends of bones and ostectomy. In joints, as the temporomandibular or acromioclavieular, where stability is not paramount, resection of the diseased or wornout articular extremity assures favorable results. Degenerative arthritis often follows fracture dislocations of the fingers: here the bulbous distal end of the proximal bone is resected and the base of the phalanx is left undisturbed. In degenerative or osteo-arthritis of the metatarsophalangeal joint of the second toe resulting from avascular necrosis of the metatarsal head, the distal third of that bone is resected. In deformities of the foot resulting from old burnt-out rheumatoid arthritis, the proximal row of phalanges are at times resected. When the resection is partial and confined to the cephalad half of the phalanx, the interphalangeal joints must be fused in order to remedy the hammer toes. In connection with corrective surgery for hallux valgus or rigidus, the ulcerated sesamoid bone is at times dissected out. In osteo-arthritis of the knee where the patella has become extensively denuded of its coat of cartilage, it is likewise excised. Fig. 49.-Resection of the articular ends in ankylosis or interlocking of the temporomandibular joint. Here the eminentia articularisof the temporal bone and the proximal ramus of the mandible and its processes are resected through an osteoperiosteal approach to avoid damaging the nerves and blood vessels. The incision begins about an inch above the proximal pole of the helix of the ear; it curves backward and then forward and downward in the form of a question mark. The lower limb of the incision descends close to the anterior border of the ear behind where the temporal artery can be palpated; it ends at about the level of the tragus. The skin cut is developed down through the temporalis fascia and the muscle to the calvarium. The bulky anterior belly of the temporalis muscle is stripped subperiosteally and reflected forward with the nerves and vessels overlying it until the zygomatic arch, under which its tendon passes to insert into the coronoid process of the mandible, is exposed. An osteotome is placed flush with the squamous surface of the temporal bone and the posterior pillar of the zygomatic arch is chiseled off. With a rongeur the zygomatic arch is severed just behind where it anchors the masseter muscle and the eminentia articularis is resected unroofing the temporomandibular joint and exposing the articular condyle of the mandible. If the condyle is not firmly fused it is dislodged and resected; if it has affected solid bony union its neck is resected and it is left fused to the temporal bone. With a rongeur the coronoid process and the adjacent portions of the proximal ramus of the mandible are bitten off until a space is created which will admit the tip of the surgeon's thumb. This space is snugly packed with oxycel gauze and the fascia and the skin are closed over it. The operation is usually performed on both sides at about ten-day interval. Skeletal traction is instituted through the chin at the end of the second operation. Skeletal traction through the chin serves a three-

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has been a considerable lapse of time, a year or more, since the last flareup. Perhaps more important is the condition of the muscles around the joint. Arthroplasty is out of the question when the segments involved across the ankylosed joint must be levered by muscles which have been primarily involved in the inflammatory process or have shortened and atrophied beyond recovery. Muscles are the prime movers. Joints merely permit motion passively. In joints, as the shoulder, where too many muscles enter into intimate relation with the articular capsule and may have become primarily involved in inflammation, arthroplasty is doomed to fail. In the shoulder, the musculotendinous cuff constitutes the outer articular capsule and it inserts diffusely around the rim of the humeral head, not far from the center of joint action. In attempts at resecting and remodelling the proximal articular extremity of the humerus one cannot help but sever the insertion of the musculotendinous cuff. Being diffuse, the attachment of the cuff cannot be shifted down on the humerus. When the muscles related to the cuff fail to fix the head of the humerus against the glenoid, the deltoid loses its fulcrum and cannot lever the arm into abduction, the most useful motion of the shoulder joint. In the upper limb the elbow is best suited for arthroplasty. The movements of this joint are based on relatively simple mechanics: hinge motion of the radius and ulna on the humerus and rotary m0vement of the radial head. Of the two main muscles which lever the forearm into flexion, only the brachialis anticus hugs the joint capsule and inserts too close to the axis of hinge motion. The brachialis anticus may have been involved in inflammation and its point of insertion into the coronoid process is usually sacrificed during resection and reshaping of the proximal articular end of the ulna. The other great flexor of the elbow, the biceps muscle, spans the joint at some distance from the articular capsule; it is seldom involved in primary inflammation; since the biceps inserts farther down into the radius than does the brachialis into the ulna, it is at a mechanical advantage to lever the forearm into flexion; its insertion need not and should not be sacrificed during arthroplasty of the elbow when the head of the radius is resected in order to liberate pronation fold purpose: postoperatively, it prevents the loosened mandible from dropping backward against the throat and choking the patient; it stretches contracted ligaments and keeps the raw surfaces of bone from coming together; it creates a tension against which the atrophied muscles can function and regain their contractility. In children excessive traction may cause subluxation of the cervical spine: as a precautionary measure the head and the torso are incorporated in a Minerva jacket. (The procedure described is amply illustrated and extended in an article by the author called "Temporomandibular Joint: A Method of Mobilization", to be published.) A, Photograph of the mouth of a man suffering from generalized arthritis with ankylosis at both temporomandibular articulations. Note that the upper set of teeth have overlapped the lower and some of the incisors have dug their way deep into the opposite gum. B, Photograph a week after bilateral operation and institution of skeletal traction through the chin. Note the eroded upper gum into which the lower right canine was lodged.

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and supination of the forearm. For stable hinge motion at the elbow, a semicircular notch is carved out of the proximal end of the ulna and the opposed surface of the humerus is reamed and rounded and made to fit loosely into it. The muscular attachments to the epicondyles may have to be stripped up, but they are not detached. It does not seem to matter greatly with what material the raw surfaces of the humerus and ulna are covered. Of late, oxycel gauze has come into favor. The space between the remodeled surfaces of bone is packed snugly with oxycel gauze

Fig. 50.-Resection of the outer end of the clavicle for arthritis of the acromioclavicular joint due to old trauma. When there is associated calcification of musculor tendinous cuff of the shoulder, the overhanging acromial process and its articulafacet is likewise resected. A, X-ray film before surgery. Note the erosion into the articular surface ofthe clavicle. B, X-ray after resection. C, Photograph showing the range of painless abduction three weeks after surgery.

and the wound is closed over it. A cylinder cast or a posterior mold is applied in order to procure rest and enhance healing of the soft tissues. Two weeks later the cast is removed and active exercises are begun against tension, preferably against skeletal traction through a screw in the proximal ulna. In the lower extremity the hip lends itself best to arthroplasty (Figs. 55, 56). This joint is well supported by strong muscles and is deeply buried in them. It provides the surgeon with sufficient osseous material

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out of which he can carve a ball and socket and create a reasonably stable articulation. The extensive raw surfaces of bone, thus produced, tend to reunite, but this is prevented by the interposition of a vitallium cup or mold. The greater trochanter, which gives insertion to the most important group of muscles around the hip, is transferred farther down on the femur. This shift is regarded as essential to a good arthroplasty of the hip since the tension thus created holds the newly carved and cupped head of the femur firmly against the acetabular roof. Moreover, the transplantation of the trochanter distally on the femur lengthens

Fig. 5l.-Resection of the head of the first phalanx of the finger for arthritis of the proximal interphalangeal joint. A, Photograph showing resection of the head of the first phalanx of the long finger. The bone is dislocated through a longitudinal incision along the ulnar aspect of the finger and the head is resected at about the reflexion of the synovial membrane with a Gigli saw. B, X-ray following resection; note that the base of the second phalanx is left undisturbed. C, Flexion of the hand and finger two months later. D, Photograph showing the range of extension.

the lever-augments the mechanical efficiency of the glutei. The advantages of trochanteric shift are obviously offset if one has to strip the gluteus medius and minimus from their origin on the ilium in order to expose the hip joint. The hip joint is approached through an incision that avoids disconnecting any muscle from its origin. Occasionally in postoperative adductor spasm, the origins of the adductors from the pubis are stripped or the obdurator nerve supplying these muscles is crushed or even severed. However, the adductors are regarded as less important muscles than the abductors and rotators.

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Arthroplasty of the hip defeats its purpose when the glutei have to be stripped off their anchorage to the ilium during surgery or when these muscles are weak and functionally defunct as in long-standing ankylosis due to Marie-Strumpell variety of inflammatory arthritis. The best re-

Fig, 52. Patellectomy, Excision of the patella is now a standard procedure for chondromalacia of the patella due to osteoarthritis of the knee, Eroded articular surfaces of the femoral condyle are left undisturbed but the marginal osteophytes when present are chiseled off. A, Photograph of the knees on arthrotomy. Note the malacic patella and erosion of the articular surfaces of the femoral condyles. The patella was resected and the quadriceps aponeurosis was sutured to the patellar tendon. Band C, Photographs which were taken five months after the operation showing the knee in active extension and flexion respectively.

suIts in arthroplasty of the hip are obtained in young adults with degenerative arthritis as follows Legg-Perthes' disease and old slipped femoral epiphysis with avascular necrosis of the head. In ancient unreduced subluxations and dislocations of the hip, mold arthroplasty is

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difficult to carry out and is likely to fail; in these cases the head of the femur often points in one direction and the acetabulum gapes widely in

Fig. 53.-Resection of the distal articular end of the second metatarsal for arthritis of the metatarsophalangeal joint resulting from avascular necrosis and infraction of the metatarsal head. A, Photograph of the foot showing the swelling over the infracted metatarsal head and the metatarsophalangeal joint. B, X-ray before surgery. C, Photograph of the resected articular end; the scales are in centimeters. D, X-ray after resection of the distal articular end of the second metatarsal.

another; the shallow acetabulum and its thin roof do not lend themselves to carving out a stable socket and are likely to extrude the cup placed in

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them. In subluxations with anteversion of the neck and mushrooming of the head, one may trim out a strut and turn it into the socket and

Fig. 54.-Resection of the phalanges and osteotomy for correction of the deformity of the forefoot resulting from old burnt-out rheumaotid arihritis. Upper, Photograph of both feet before surgery. Lower, Photograph of booth feet two months after operation. Through a curved dorsomedial incision, a flap was developed with its base attached to the abductor muscle of the big toe; the bony overgrowth over the medial aspect of the head of the first metatarsal was chiseled off; the proximal half of the adjacent phalanx was resected liberating the conjoined tendon of the flexor halluc is brevis and of the adductor hallucis; the abductor flap previously developed was split lengthwise and the upper leaf was carried across the head of the first metatarsal and sutured to the tendon of the adductor hallucis muscle; the lower leaf was tacked to the periosteum of the remaining half of the proximal phalanx. The proximal halves of all the first phalanges of the remaining toes were resected and the proximal interphalangeal joints were fused in the manner indicated for the finger in Figure 61.

hold it there by shifting the greater trochanter distally and posteriorly on the femur. In old fractures of the femoral neck with avascular necrosis of the

Fig. 55. Figs. 55 and 56.-Arthroplasty . . In ankylosing or interlocking of the elbow, the hip, and rarely the knee, adaptive remodelling of the opposed articular surfaces becomes at times expedient in order to enable the patient to feed himself and sit on a stool. It is important that the muscles moving the segments linked at the joint have not wasted away altogether and hold considerable promise of regaining their contractile power. At the hip, where a head has to be carved out from the neck, the the lever between the attachment of the muscles to the greater trochanter and the axis of the joint movement is diminished; the trochanter rides high and the tension on the muscles attached to it is nullified. Muscular function can be greatly improved by shifting the trochanter downward on the shaft. Fig. 55.-Arthroplasty of the hip with reconstruction of a head out of the neck without interposition of a mold or cup, or even fascia. A, X-ray picture of the hip of a woman who had limped in childhood but did not have any complaint referable to her left hip until she became pregnant at the age of 22. The osteochondromatosis was interpreted as being due to aseptic necrosis and collapse of the articular end of femur resulting in degenerative arthritis. At operation, the femoral head was seen mushroomed and crumbled and there were over four hundred osteocartilaginous bodies. These were removed. What was left of the femoral neck was reshaped and the greater trochanter was displaced downward on the shaft of the femur and tacked with a metal staple. (Reprinted from the author's article, "Pathological Physiology of Joints", Surg., Gynec. & Obst., 71 :416-436, Fig. 23, Oct., 1940.) B, X-ray of the hip fifteen years after surgery. C, D and E, Photographs showing the stability and the range of movements of the hip. 109

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head and degenerative arthritis and in the so-called malum coxae senilis, the results of cup arthroplasty are variable. In both instances the deciding factors are the age of the individual, the muscles, and the bony substructure. In a weight-bearing joint like the hip, arthroplasty promises better results if the opposed articular ends of bone have hardened with

Fig. 56 -Bilateral cup arthroplasty of the hip for degenerative or osteo-arthritis due to old Legg-Perthes' disease. Both hips were similarly operated at two week interval. A, X-ray of the right hip before surgery. B, The hip at arthrotomy. A probe is passed through a crevice over the head of the femur which tunnels under the articular surface and communicates with a crag posteriorly. C, Anteroposterior view film of the right hip six months after surgery. D, Trendelenburg test of the right hip. E, The extent of leg spread. Note that both hips had been operated. F. Sitting.

closely knit trabeculae since such bones stand up better under pressure; then again these bones are relatively poor in endosteum and postoperatively produce little bone that would block movements. In contrast, in in rheumatoid arthritis, osseous trabeculae are sparse and endosteum is abundant; soft bone crumbles down under pressure; periosteum and endosteum throw off exuberant interlocking osteophytes and undo the

Fig. 57. Figs. 57 to 61.-Arthrodesis. In the larger joints of the lower extremity, as the hips, knees, and especially the ankles, there is no better substitute to surgical fusion. The interphalangeal joints of the toes are occasionally fused for painful hammer toes. In the upper extremity, the wrist, the shoulders, and at times the interphalangeal joints are stabilized. Arthrodesing operations are predominantly successful even though the method of performing them may vary. Opposed articular surfaces are denuded of their coat of cartilage; hard subchondral bone is shaved off and bleeding cancellous surfaces are made to contact as widely as is feasible; they are held together firmly until union takes place. Bone grafts enhance union; internal fixation eliminates the one major cause of pain and nonunion which is movement. Fig. 57.-Arthrodesis as applied to the ankle. A, Photograph showing a longitudinal incision in front of the distal fibula and its malleolus. The incision is carried down to the skeletal plane and the skin flaps are retracted by sutures which are tied behind the leg and under the heel. Two periosteal retractors are passed around the distal fibula about 2 inches above the joint. B, The fibula is severed by a Gigli saw. The distal fibular fragment is dissected backwards exposing the joint. The fibular notch of the tibia, the trochlear surface of the talus, and the fibular malleolus are denuded of their coat of cartilage and cortical bone. C, A tunnel is developed on the fibular aspect of the tibia and the talus and the gougedout spongy bone is packed between the talus and the tibia. D, The distal fibular fragment which had been denuded of cortical bone and articular cartilage but still remains attached laterally and in the back is turned into the talotibial tunnel and secured by a nail or two, sometimes by a screw. E, Anteroposterior view film of the ankle six months after surgical fusion as described above. F, LatEl'ral view film of the same showing solid osteosynthesis. 111

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Fig. 58.-Arthrodesis of the knee and fixation of the femur and tibia with two threaded bolts and long leg cylinder cast. A, Frontal view film five months after surgery. B, Lateral view of the same.

Fig. 59.-Arthrodesis of the hip for degenerative arthritis by means of a long pin passing chrough the femur into the ilium and two nails transfixing the trochanter which was chiseled off and used as an onlay graft. A, X-ray before surgery. B, X-ray six months later showing solid osteosynthesis.

work of arthroplasty. Here one may resort to secondary chylectomy, packing the raw surfaces of bone with oxycel gauze, which is said to retard osteogenesis, or one may resort to a fusion operation.

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Arthrodesis.-For painful, interlocking and contracted articulations there is no better surgical substitute to arthrodesis of the joint with the limb in functionally useful position. This is especially true of the joints of the lower limb where stability is paramount. In some purely weightbearing joints, as the ankle, (Fig. 57), arthrodesis has no other alternative; in the knee (Fig. 58) it yields a more serviceable result than arthroplasty; in elderly patients with unilateral hip joint disease (Figs. 59, 60), it is again preferred to the mobilizing operation. Except in the wrist,

Fig. 6O.-Another method of arthrodesis of the hip using a bent plate and six screws for internal fixation. Three years prior to arthrodesis, a cup had been put elsewhere resulting in painful unstable hip. The glutei must have been stripped off their origin on ilium because the patient manifested positive Trendelenburg on standing and a lurch in walking. The cup was removed and the opposed surfaces of the femur and ilium Were refreshed down to bleeding bone. The metal plate was bent to desired curve; it was countersunk into a groove across the greater trochanter and was transfixed to both ilium and the femur by six screws. A, X-ray before arthrodesis. B, X-ray six months after surgery showing solid osteosynthesis.

where there are no supporting muscles and numerous small bones enter into the articulation, arthrodesis is seldom performed as a remedial measure for chronic nontuberculous arthritis of the joints of the upper limbs. In the shoulder, fusion is occasionally advised for major musculotendinous tears leading to a painful, partly transfixed joint. Arthrodesis may at times be indicated for painful contracted fingers (Fig. 61). Whittling and Amputation.-A deformed finger, which gets in the way of the others or a hammer toe which makes shoe wearing painful, may be disarticulated. In extremely deforming variety of rheumatoid or inflammatory arthritis, both lower extremities are sometimes twisted and

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gnarled beyond any hope of correction. Nursing in these patients becomes an economic problem and the reward of many hours of arduous effort often may be fungating bedsores over the sacrum, malleoli and the heel. Will it not benefit the patient, as well as those who take care of him, if both useless legs were amputated just below the greater trochanter so that the wooden man could occasionally be allowed to sit up or transferred into a wheel chair?

Fig. 61.-Arthrodesis of the finger. A, Photograph of the hand of a young woman, a hairdresser. Note the marked flexion contracture of the small finger. The scar along the ulnar aspect of the finger is the remnant of a previous attempt at lengthening the tendons by a graft, which resulted in failure. B, X-ray of the finger. C, The interphalangeal joints were fused by invaginating the denuded distal ends of the proximal bones into the base of the distal bones. An intermedullary Kirschner wire is threaded to hold the bones together. The wire, and with it, the finger are bent to suit the functional demands made upon this finger by the occupation of hairdressing. D, Photograph of the finger two months after surgery. SUMMARY AND CORRELATION

To recapitulate, a joint is a connective tissue organ. It connects and supports parts and permits motion between them. It does not move. It allows motion. Its function in health is thus passively mechanical: it is structurally adapted to yield to motion and support. In disease, the relatively undifferentiated connective tissues or the yielding elements, as are found in the synovial membrane and in marrow spaces, set up an inflammatory reaction; the specialized structures-articular cartilage and subchondral bone-wear out, degenerate. Numerous adjectives have been coined to qualify the type of chronic arthritis characterized mainly by inflammation in contrast to the one whose salient feature iR degeneration. The terms rheumatoid and osteo-arthritis are the least confusing and are chosen to denote the inflammatory and degenerative variety respectively. It is suggested that pigmented villonodular synovitis is akin to the villous phase of rheumatoid arthritis, yet different from it; synovial chondromatosis or osteochondromatosis has some of

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the features of both main types of chronic arthritis, but is unlike either one of them. Both villonodular synovitis and synovial chondromatosis are amenable to the same surgical measures (syno"vectomy and removal of loose bodies) which have been found useful in the treatment of chronic nontuberculous arthritis. Inflammatory or rheumatoid arthritis is regarded a systemic disease: any measure which will benefit the patient's general health will help to improve the joints involved. Surgery in this disease aims at putting the painful joints at rest (splintage); in overcoming and correcting contractures (traction, turnbuckle splints, wedging of cast, manipulation, debridement, tenotomy, capsulotomy, osteotomy and ostectomy); in eradicating residual inflammation (synovectomy); in mobilization of the already ankylosed joint (arthroplasty); in elimination of a painful articulation (arthrodesis); and in getting rid of gnarled useless limbs (amputation). Degenerative or osteo-arthritis is a local disease. The treatment should aim at the elimination of the causes of trauma to the particular joint as overuse, obesity and mechanical misalignments. Surgery is indicated in the presence of painful or interlocking loose bodies (arthrotomy); when there are incongruities of opposed articular surfaces which might beneficially be eliminated (erasion, chylectomy, resection of non-weightbearing articular ends) ; when there are reasonable chances of procuring a comparatively unworn bearing surface and improved mechanical alignment of weight-bearing segments (osteotomy); when the joint is interlocked and necessitates mobilization (arthroplasty), and when it is painful and needs to be eliminated (arthrodesis). REFERENCES Jaffe, Henry L., Lichtenstein, Louis and Sutro, Charles J.: Pigmented Villonodular Synovitis, Bursitis and Tenosynovitis: A Discussion of the Synovial and Bursal Equivalents of the Tenosynovial Lesion Commonly Denoted as Xanthoma, Xanthogranuloma, Giant Cell Tumor or Myeloplaxoma of the Tendon Sheath, with Some Consideration of This Tendon Sheath Lesion Itself. Arch. Path. 31 (6) :731-765 (June) 1941. Kelikian, Hampar: The Pathological Physiology of Joints. Surg., Gynec. & Ohst. 71 :416-436 (Oct.) 1940. Kelikian, Hampar: Chronic Arthritis. Surg., Gynec. & Ohst. 76:469-479 (April) 1943.

Kelikian, Hampar: Osteotomy of the Finger, A Case Report. Quart. Bull., Northwestern Univ. M. School, Chicago, 21 (2) :111 (Summer Quarter) 1947.