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CIHM/ICMH 
 
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(E(jmuled from the Montreal Medical Journal, November, I8fl0.) 
 
 NOTE ON EXCISION OF THE KNEE JOINT.' 
 
 BT 
 
 Sir Jamks Grant M.D. 
 
 The knee-joint, tlie most complicaU'd anatomically in the liuman 
 system, lias bcio subjecterl to exc.isicjn, chiefly for three conditions 
 
 lat. Chronic disease of the articulati(m. 
 
 2nd. AnchyloMs, whethei" fibrous or bony. 
 
 3rd. Compound fracture i>r <lislocatioii. 
 
 The first excision of the " knee-joint " successfully, was performed 
 V>y Filkin of Norwich, in 1702, and ai^ain by Park, in 17<S1, 40 years 
 ago, ic has been performed in all less than 25 times, owinjT chiefly to its 
 receiving; but little favt)ur. This operation has been very consider- 
 ably revived by Textor of (Jermany, and the late Sir Win. Ferguson, 
 of London. The first excision of this joint in the United States, 1856 
 was peiformed liy Dr. Kinloch of Charleston ; and in March, 1865, in 
 the Protestant Hospital, by myself, this being on(! of the first 
 Knee excisions in (.anada." The term excision has (juite a different 
 signification now, from what it had thirty years ago. Then it meant 
 somewhat free removal of much of the structures essential to the 
 functions of the articulation At present it means, in many cjises, 
 very partial interference with the structures essential to the joint, 
 while it ain>s in every ca.se, at the complete removal of the diseased 
 tissues. To dig out sequestra fnMii the surfaces of 1m >nes, and .scrape 
 the latter, and thus not shorten the limb, is the order of the day 
 Quite a change from former timers, when the ends of tlu' bones would 
 1)6 sawn off, in order to coapt parts and form a mechanical joint with- 
 out nuich consideration as to future usef'ilne.ss. Such, however, 
 was more the result of a want of knowledge of our present advanced 
 pathology than otherwi.se. The term " arthrectomy " was for a time 
 spoken of as meaning partial excisi()n of the joint, where the diseased 
 .synovial membrane is chiefly or solely removed and " excision " 
 to removal of the ends of the bones completely. These; terms arthrec- 
 tomy and excision so overlap each other, and fail to define the exact 
 meaning, that the terms partial ami complete excision are now gener- 
 ally adopted, and chiefly owing to the fact that it is exceedingly rare 
 to meet with a case of knee-joint disease in which the whole of the 
 
 synovial membrane requires extirpation and yet none of the lx)ne. 
 
 ^__.^— — »i . ____________ _______^_ 
 
 > Rea<J before the Ottawa Mt-rllcAl Society, Feb., 180ft. 
 
 '^ FtcfwrUul in Medical Times and Gaxetfce, London, En^., March 18, I8tl5. 
 

 and vice v«!rsa, it is just ns rare to meet with a case rc'f|uirinr,' the 
 free removal oi' the ends of the bones, and not callinj^ for the removal 
 of the synovial structures. To-day complete excision of the knee-joint 
 is a novelty, that is, opening the joint, sawing off the ends, and co- 
 asting the parts as in tlie days of Professor Geo. Fenwick, of McGill, 
 whose name is handed down as one of the most celebrated surgeons 
 Canada has pro<luced. Why these changes or modifications as to treat- 
 ment of sucli cases ? First, the more accurate recognition of the vast 
 importance of early and vigorous ti<'atment of tuberculous disease, has 
 arrested much, whicli formerly progressed to complete destruction of 
 the ends of Itoth thi; tibia and femur; and on the other hand, when 
 operation is decided upon, it is at a '*tage when disease of tlie bones 
 can be removed without complete excision of the ends, although the 
 bone tissue is conserved as much as possible, the removal t»f the 
 synovial tissue is now particulaily free. In fact, Treves st»xtes it is 
 not an unconnnon procedure t«i dis.sect out the entire synovial mem- 
 brane, wliether visil»ly affected or not. In general terms, in a case of 
 tuberculous joint, the first principle is to removt? all ti.ssues in which 
 we believe the bacilli are depo.sited and to spare all structures, except 
 the synovial membrane, not charged with the tubercle bacillus. It 
 niu.st be admitted that this is after all, a complex problem, not only in 
 theory, but also in practice. In adults exsection is truly the shortest 
 and safest way of eliminating the tedious mcjrbid process and substi- 
 tuting anchylosis for a comparatively useless joint. To adult cases, 
 orthopadic tieutment is rarely applicable, v'lilr in children, mechani- 
 cal and general treatment frequently are attended with the nu)st 
 practical results. In the child, the growth of the thigh and tibia, 
 depends so nnich on the epiphy.ses adjoining the knee, that exsec- 
 tion is liable to be followed by very consideral)le shortening, and 
 consequently is to Ik* avoided as much as juj-ssible. The anti.septic treat- 
 ment in such operations, as defined by CJer.-^ter, requires no comment 
 To be truly progressive is to be truly antiseptic in treatment, the 
 results of which certainly mark the present as a progres.sive era in 
 surgery. In the older operations on the knee-joint, in which an 
 absolutely t tiff knee was the object in view, it was not looked upon 
 as' important, whether the ligamentum patella; was divided or not, in 
 such, a case the action of the exten.sor muscles not beinar c'^nsidere<l. 
 More recent operations, however, tend to the preservation intact of the 
 liganjentum patella, in order to preserve, as far as possible, ."-ome 
 of the movements. Treves reconnnends that if the patellar ligament 
 has been divided, it should be stitched together again with silk, which 
 rtnnuins buried He considers it better not to include the can« . « '" 
 
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 the joint in the .stitches whicli unite the skin wound, as the skin is 
 liable to l>e dmg*,'e(l in and the edjjfes displaced, thus interfering with 
 primary union. It is also important that the edges of the capsule and 
 the fibrous expansion of the muscle should not be united, as any 
 effu.sion into the joint cavity after the operation would thus not be 
 pent up, but escape hito the areolar tissue around and become more 
 rapidly absorbed, and should even any ])us be formed, it would he 
 more easily evacuated. Sayre, in his recent work on " Joint Diseases," 
 states a.s his opinion that ex.section of the knee-joint is attended with 
 considerable danger, and in many instances you may justly hesitate 
 before resorting t<t the operation. Mr. Bryant, in a lecture at (iuy's 
 Ho.spita], published in the Lancet, " On the least sacrifice of parts as 
 a principle in operative surgery," states: " I trust that this .series of 
 '■ cases is enough to demonstrate with sufficient clearne.ss, the value of 
 " the practice 1 am now inculcating, and to show that in a large 
 " number of cases of di.sease of the joints, a cure may l)e secured by a 
 " simple incision into the affected joint and the removal of tlie necrosed 
 " lK)ne. The .series includes examples of di.sease of the shoulder and 
 " elbow, hip, knee and ankle and great toe joints, and I do not think 
 " I should be far wrong if I were to express my belief that in many 
 " ca.ses, if not in all, many surgeons, more particularly those who are 
 " adviwates for excision, would have excised the joints, and .some few, 
 " would have amputated. In the treatment I am now advctcating, the 
 " surgical proceedings are simple and are attended with a minimum 
 " of danger. The success of the practice I have recorded was great" 
 The opinion of Mr. Br\'ant is one founded on large practical exper- 
 ience and is c(!rtainly worthy of the fullest consideration, when such 
 trying cases present for surgical interference and treatment