Observations on Tuberculous Knee-

Joint Disease in Childhood.

By Royal Whitman, M.D., M.R.C.S.

Assistant Surgeoii^tcT Out-Patients, Hospi-tal for Ruptured and Crippled,

New York.

Reprinted fromThe Archives of Pediatrics,

May, 1892.

New York :

M. J. Rooney, Printer and Stationer,1329 Broadway.

OBSERVATIONS ON TUBERCULOUS KNEE-JOINT DISEASE IN CHILDHOOD.

ROYAL WHITMAN, M.D., M.R.C.S.,Assistant Surgeon to Out-Patients, Hospital for Ruptured and Crippled, New York.

It is a well-established fact that the great majority ofchronic joint affections in childhood are tuberculous incharacter, and that the bacillus coming from without isnot primarily, or with rare exception only, deposited in thejoint. Koenig in sixty-seven autopsies on individualsaffected by tuberculosis of bones and joints, found infifty-three instances older foci of disease which might beconsidered the seat ofthe original infection. The autopsiesreported by Northrup, Bollinger, and others, have shownthat this primary infection is in most instances of thebronchial or mesenteric glands where it may lie dormantin persons of apparently perfect health. Ziemssen incalling attention to the fact that tuberculous disease sooften follows measles says, “the infection of measles hasnot excited tuberculosis, but has only made the latenttuberculosis manifest.” Krause has proved that it is pos-sible in previously inoculated animals to produce localtuberculous disease by spraining joints.

It seems fair to assume thenthat the sequence of events ina tuberculous joint disease, may be somewhat as follows;By inheritance the patient may be in a vulnerable con-dition ; whether or not inheritance has a more direct bear-ing than this we are at present unable to determine. Thebacillus coming from without finds lodgment probablyin the bronchial or other lymphatic glands and a state oflatent tuberculosis is established. Later a congestion, theresult of injury to a joint, forms a favorable nidus for thedeposition and growth of the bacilli, and the resultingjoint affection is thus a local manifestation of a disease oflonger standing. While it is not probable that these in-ferences are strictly true in all cases, the theory is clinicallycorrect, for it emphasizes the importance of general

WHITMAN : Tuberculous Knee- Joint Disease , etc.2

therapeutic, as well as local treatment, of nourishingfood, and above all of open air and exercise, asopposed to long confinement in bed. It shows alsowhy early excision of a diseased joint, as urged bythose who exaggerate the local malignancy of the tubercu-lous processes in childhood, may not entirely remove thedisease or its predisposition to recur. On the other hand,the presence of a painful joint with long-continued sup-puration, from its depressing influence on the health of thepatient may make an operation for the removal of thelocal affection imperative, although we may not hope toentirely eliminate all the foci of disease from the body.It is well known also that the age of the patient has amost important bearing on prognosis and treatment. It isnot at all infrequent to see children suffering from severallocal manifestations of tuberculosis who are in goodphysical condition, while in the adult, disease of a singlejoint may call for early and radical operation.

It must therefore be borne in mind that these remarksrefer to disease of childhood only. In knee-joint diseasewe know that the tuberculous process is at first usuallyconfined to the epiphysis, femur or tibia, that its growth isfavored by the congestion of traumatism. During thefirst stage certain sympathetic changes take place in thejoint itselftending to impair its usefulness, and later we mayexpect a breaking through into the joint with more or lessdiffuse tuberculous disease there, unless we are able tocheck the progress of the primary affection. If then wemight accurately determine the position of the limiteddisease in the epiphysis, we might hope to remove it; prac-tically this is not often possible without the destructionof much bone on which the future growth of the limbdepends.

We are therefore restricted to what may be termedsymptomatic treatment :

To provide when possible the best environment for thepatient.

To remove pain and the apprehension of pain.

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To furnish an apparatus which will allow the patient un-restricted exercise in the open air.

To remedy and prevent deformity.If pain is not relieved, temporary confinement in bed

for rest extension and local treatment is indicated. .

If observation shows that the disease is extra-articularit may be removed, abscesses may be aspirated and iodo-form-emulsion injected.

The tension of acute articular inflammation may be re-lieved by free incisions. The distension of the knee-jointby pus or the pus-like product of tuberculous inflamma-tion should not be permitted, because of the danger tothe cartilage which rapidly disintegrates under these con-ditions, exposing the healthly bone to the invasion ofdisease. If the disease is progressive the joint may befreely opened and all tuberculous soft parts removed, in-cluding those in the bone itself, partial and complete ex-cision being reserved as last resorts and as distinctly life-saving operations by which we sacrifice the usefulness ofthe limb to present necessity.

Under proper treatment radical excisions are rarely in-dicated. The record of 300 final results in knee-joint dis-ease collected by Gibney, after efficient treatment, im-proper treatment, and neglect, show that the death-rateimmediate or remote is less than ten per cent. ; and evenunder these adverse circumstances that the ultimate con-dition of the joint as to usefulness and functional abilityis surprisingly good. We are therefore encouraged tohope that early diagnosis and efficient treatment willgreatly improve on these results. The plea for early ex-cision, that we may thus entirely remove a malignantdisease, is invalidated by the probable presence of thebacillus elsewhere in the body, or in other words, theremay be a constitutional predisposition to disease whichcannot be removed by any operation. Life is endangeredrather by the violence of the local affection or from theeffects of long-continued suppuration, than by the merelocal tuberculosis per se.

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Even the modern operation of partial excision presup-poses a stiff leg and complete atrophy of all the muscleswhich should move the joint, thus diminishing the bloodsupply of the limb on which the growth of the bone de-pends, while complete excision subjects the patient to anamount of shortening, which in latter life may make theleg a useless appendage. It would seem, therefore, that onthe latter ground alone excision of the joint, except as anecessity should be limited to late adolescence and adultlife, when the whole question assumes quite another aspect.

The fact that early excisions are so often performedemphasizes the importance of special institutions for thetreatment of chronic joint affections, where the naturalhistory of the disease, its duration, complications andeffects on the limb and life of the patient is known, andwhere facilities for its proper treatment are provided.

Perhaps the strongest argument of the general surgeon,who is more familiar with neglected or advanced cases, orwith the acute phases of the disease which brings the childto the hospital than with final results, is that by excisionof the joint we may remove local disease and deformityand obviate the necessity of mechanical support and after-treatment. This is not borne out by facts. Hoffa investi-gated 135 cases of knee-joint excision, and in thirty-threeper cent, found a recurrence of deformity, and in manylocal disease also, which accords perfectly with our experi-ence here.

As the question of time and expense of apparatus isso often brought forward by those who would substituteexcision for conservative treatment, it is well that weshould know exactly how much time and how much ex-pense is entailed upon the poor at this institution. Asto time, a visit once in two or three weeks, for from oneto three years, and an expense of from five to ten dollarsa year for apparatus, which is furnished free of charge tothose who are unable to pay.

It cannot be too strongly urged that knee-joint disease,properly treated, is not a painful or depressing affection.These children attend school and are more often endan-

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gered by the violence of their play, than precluded fromexercise by pain or deformity. That the ultimate resultsof treatment are favored by early diagnosis is clear.What are the elements of early diagnosis of knee-jointdisease in children ?

First, chronicity ; as children recover so quickly fromany simple injury or disease the mere fact that a child hashad something the matter with the knee for several weeks,is in itself a very suspicious symptom.

In the earliest stage then, possibly after an injury, we mayexpect slight pain at night after violent exercise, a littlestiffness or limp sometimes noticed only in the morning.On examination, a slight limitation of motion particu-larly in extension, that is the ham strings are somewhatcontracted, there may be a slight enlargement and alittle increase in the temperature ofthe joint, tenderness onpressure often over the internal condyle and occasionallya subacute synovitis may be the prominent symptom.

The continued observation of joint affections in child-hood and infancy impresses one with the importanceof watchfulness. Any chronic affection no matter howslight, which shows a tendency to deformity or to limit-ation of normal motion, demands protection, no matterwhat the ultimate diagnosis may be.

By treatment in the earliest stage we may hope to checkthe progress of the disease ; to entirely prevent deformity ;

to preserve motion ; to prevent and modify the sequelaeof the disease, abscess, long-continued suppuration, andits effects. The essentials of proper treatment are :

i. To overcome deformity and place the limb in astraight line. The growth is so rapid in early childhood,especially under the stimulus of an inflammatory processthatpermanent distortion may quickly follow on continuedfaulty position.

2. To fix the joint by plaster-of-Paris, extension orotherwise.

3. To apply a brace which shall entirely prevent thefunctional use of the limb and insure protection from trau-matism.

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By protection and fixation we guard against the lia-bility to active or passive congestion which favors theincrease of local disease, and while we may not alwaysexpect to confine it to the epiphysis we may hope to checkthe rapidity of its progress until the sympathetic inflam-mation in the joint has shut off a healthy portion byconnective tissue, so that the subsequent tuberculousprocess may be limited in extent. In this way we explainthe nearly perfect motion which may ultimately be pre-served even after involvement and suppuration of the jointitself.

The apparatus which in out-patient practice at least,best fulfils the necessary conditions is what is known asthe Thomas knee-brace. It consists of a padded ringsurrounding the upper part of the thigh on which thetuberosity of the ischium rests, and the lateral rods ter-minating in a foot-piece three inches below the foot, onwhich the patient walks, with the aid of a high shoe orpatten on the sound side, we are thus able to dispensewith crutches which are very unsatisfactory for childrenwho cannot be closely watched. Complications are thentreated as they arise in the manner already indicated.

In the more advanced cases, when deformity is wellmarked, the patients are admitted to the hospital and theposition is corrected and abscesses or suppurating sinusestreated as a preliminary measure. Protective treatmentis then continued until there is no longer evidence of dis-ease, and until there is no further tendency to recurrenceof deformity. Time is of no particular importance com-pared with ultimate results, which we hope and expect toattain.

Several clinical cases may now be presented to illustratesome of the points touched upon.

I.—Early diagnosis of knee-joint disease in infancy ; per-sistent treatment and cure.

A well-developed infant of six months was brought tothe hospital on October 8, 1890, with a history of stiffness ofthe left knee of one week’s duration. There was no knowncause, no pain or discomfort. The watchful mother had

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noticed that the child did not extend the leg, and wishedto have the symptom explained. Examination showedthe joint absolutely normal in appearance ; no heat; noincrease in size ; no atrophy of the leg ; there was slightlimitation of flexion, and extension was impossible beyond160 degrees ; within this limit motion was painless. Asthe child did not walk, various short braces with andwithout extension were applied with the aim of over-coming the flexion, but were inefficient. Two monthslatter a very light Thomas brace with extension wasapplied which quickly overcame the deformity. Completerest and protection was kept up for one year, when thebrace was removed tentatively at night, and finally dis-carded.

Now at the age of two years the condition of the jointis normal in every way and motion is unrestricted. Meas-urements, however, show the affected limb to be three-quarters of an inch longer than its fellow, which provesthat there was an irritative process about the epiphysisof the femur, and confirms the original diagnosis.

ll.—Early diagnosis of knee-joint disease confirmed byanother tuberculous focus in the spine.

A child of three years was brought to the hospital onAugust 14, 1891, with an indefinite history of slight pain inthe knee on fatigue. Examination showed a slight thicken-ing of capsule ; slight creaking in the joint when moved,and limitation of extension at 1750 . No enlargement; noheat; no pain on motion ; three-quarters ofan inch atrophyof the thigh. Thomas brace, with extension, was applied.On November 27, an irregularity of the spine was dis-covered in the lumbar region with all the accompanyingsymptoms of Pott’s disease ; the symptoms in the knee-joint being quiescent; no pain or spasm or local indicationof disease. It seems probable that here we are dealingwith two primary foci of disease, that in the knee havingbeen first apparent, rather than with a transference fromthe affected knee to the spine.

111.—Early diagnosis of knee-joint disease confirmed byneglect.

An infant of eleven months was brought to the hospitalon April n, 1890, with a history of slight pain and stiff-ness in the right knee oftwo weeks’ duration, following in-jury. Examination showed slight limitation of motion andpain on complete extension of the leg, a little enlarge-

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ment of the knee and apparent tenderness on pressureover the internal condyle. There were several hard nodulesin the subcutaneous tissue of the right leg. Plaster band-ages were applied for several months. It may be notedhere that plaster bandages or any simple support of thisnature is unsatisfactory and inefficient even in infancy.In August the child had convulsions followed by righthemiplegia, and was transferred to a neurological clinic.In November the knee was said to be well. In January,1891, she was again brought to the hospital the hemiplegiahaving entirely disappeared. The leg was fixed at an angleof 1350

; there was marked enlargement and thickening oftheknee, withpain on attempted motion. A Thomas brace,with extension, was applied combined with firm bandagingand compression of the knee which rapidly brought theleg down to a straight line. This appliance has beencontinued for one year. The legs are now equal in length ;

the knees equal in size ; a slight thickening of the tissuebelow the patella being the only sign of disease. Thesubcutaneous tuberculous nodules have disappeared, leav-ing depressed scars. The brace will be worn for severalmonths, it will thenbe removed at night. If no syihptomsfollow the voluntary motion at the knee the child will beallowed to walk about a little in the morning and at night.Finally, all support will be removed under careful andcontinued observation.

IV.— Tuberculous knee disease with constitutional symp-toms ; arthrectomy; recurrence under neglect; sitbsidenceof disease under protection.

An Italian child eighteen months old was brought tothe hospital in August, 1890. The knee-joint was uniformlyswollen, infiltrated and fluctuating, and the child wasevidently suffering from severe constitutional disturbance.As the age limit would not permit her admission to thisinstitution she was sent to the New York Hospital. Dr.Bull made two long lateral incisions on either side of thejoint and all the soft parts were thoroughly removed. Thedisease was tuberculous in character. The wounds healedreadily, and she was discharged some months later, thejoint being freely movable in all directions, very loose andflail-like from the destruction of ligaments and other sup-porting structures. The parents failed to report for severalmonths, and when the child was again seen there wasrecurrence of the deformity. The leg was flexed at about1600

, and could not be extended to a straight line ; twosinuses had formed on either side of the joint.

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A Thomas knee-brace, with extension, quickly broughtthe leg into good position ; under protection the sinusesclosed and the disease ceased to progress. After oneyear a simple lateral support was applied and the childallowed to walk on the leg. Now there is no evidence ofdisease or deformity. The leg can be voluntarily ex-tended and flexed through an arc of 20°, the joint has be-come firm. The diseased leg is one inch longer than itsfellow, and the prospect of a useful limb with no sub-sequent shortening seems very good.

V.—Radical excision; recurrence of disease and de-formity ; subsequent osteotomy ; great shortening.

The patient’s knee-joint was excised at the age of four,two years later he came to this hospital presenting the fol-lowing condition : His leg was fixed in a position of flexion,with marked outward bowing and inward rotation of thetibia, several sinuses were still open and discharging. Hewas admitted to the hospital, osteotomies were performedand the leg brought to a straight line. Under treatment thesinuses closed, and he was discharged wearing a brace. Inspite of persistent treatment deformity tends to recur, andat the age of eight years he has an actual shortening of fourinches in the length of the leg. This disproportion inlength will be progressive, and in later years may makethe leg useless as a supporting member. This case ispresented only to illustrate what we may expect fromearly and complete excision in regard to cessation ofgrowth, and to show that this operation, as in this caseperformed by a skillful surgeon, may not remove the dis-ease or prevent subsequent deformity.

Vl.—Partial excision ; recurrence of disease; progress-ive deformity.

A child of seven was brought to the hospital February25, 1892, with the following history: Disease of the knee-joint at the age of three ; no treatment ; progressive de-formity. One-and-a-half years ago he was admitted to ahospital and the operation of excision performed ; thewounds closed and he was discharged four months later.In two months there was local recurrence, for which hewas readmitted. Again discharged cured, and againadmitted on three subsequent occasions at short intervals,for recurrence. He now presents the following condition:Firm union ; numerous scars of sinuses and operationwounds; one inch actual shortening of the leg ; marked

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knock-knee ; paralysis of the anterior muscles of the legand foot, with contraction of the tendo-Achillis. Thiscase shows the importance of protective treatment afterexcision. It is probable that these recurrences, and cer-tainly the knock-knee, might have been prevented by theuse of a proper brace while the leg was in a vulnerablecondition. The paralysis is probably due to division oftheexternal popliteal nerve during the operation. The childwill be admitted to the hospital where an osteotomy willbe performed for the relief of the knock-knee, the footbrought up to a right angle and supported. Protectivetreatment will then be continued until there is no furthertendency to recurrence of deformity.

VII.—The ordinary course of knee-joint disease whenuntreated.

A boy of nine is brought here on crutches. History; Aninjury to the right knee two years ago followed by pain,stiffness and deformity. Treatment: Anti-rheumaticremedies, liniments, etc. Progressive enlargement of thejoint, and finally suppuration. Three months in bed in ageneral hospital where the abscesses were opened. An at-tack of measles, and one month at North Brother’s Island ;

progressive deformity and emaciation ; removal; crutches,and exercise in the open air, followed by improvement ingeneral condition. Examination : Leg fixed at an angleof 135° ; general enlargement of theright knee, with tend-erness on pressure ; patella immovable ; two closed sinuseson the outer and one on the inner aspect discharging;outward and backward displacement of the tibia; thediseased femur is one inch longer than its fellow. Thepatient will be admitted to the hospital; the position will,as far as possible, be corrected. A close-fitting plasterbandage and a Thomas brace will then be applied, andby persistent treatment the patient may be assured a use-ful limb.

In conclusion, it may be stated that scientific conserva-tive treatment can be easily and effectually carried out,even among the poorest classes. One has only to com-pare the almost uniformly good results thus attained withthe rigid, short, atrophied and often deformed limbs seenin later years as the result of early excision, to decide thatthis operation, performed on young children simply be-cause the disease is tuberculous in character, or on the plea

that apparatus may thus be dispensed with, is unjustifiable.The principles of conservative treatment in brief are : Torapidly and completely overcome deformity; to hold thelimb at perfect rest, protected from traumatism, and thelimb in a straight line until a proper cure is established;complications to be treated on modern surgical princi-ples. Under these conditions the occasion for excision oramputation must be rare indeed.

Whitman : Tuberculous Knee-Joint Disease , etc.