A CASE OF ACTINOMYCOSIS TREATED BY IODIDE OF POTASSIUM

ColvinB.M Smith
1897 The Lancet  
734 has hardly differed from many others; but in the next step-namely, the treatment of the bones-it is quite different from any I have been able to find described. First, the articular surface of the patella is sawn off and, if necessary, its cancellous tissue is gouged. Then the trochlear surface of the femur is sawn off, leaving a flat surface upon which the upper part of the patella fits. The femur itself is next raised vertically by the assistant and the greater part of its articular
more » ... ces taken away by two saw cuts which begin at the convexity of the condyles at the edge of the articular cartilage. These saw cuts are carried obliquely into the intercondylar notch of the femur until they converge,. entering the notch at the edge of the articular cartilages and below the attachments of ' the crucial ligaments (vide Fig. 1 ). In making these cuts the lower part of the rather extensive attachment of the crucial ligament cannot always be saved, but as the upper attachments spread out a good deal the greater part can be saved. The antero-posterior plane of these cuts should be at right angles to the axis of the femur. By these saw cuts a deep notch is made in the femur, leaving some articular cartilage in the front and back of the condyles. This cartilage is either torn off or removed with a sharp spoon or gouge. The tibia is treated upon the same principles as the femur. With a narrow saw two oblique cuts are carried upwards from the epiphysial line to converge at the base of the spinous process (Fig. 2) . Here, again, the articular cartilages can be removed Showing section of femur. Showing section of tibia. without destroying the lower attachments of the crucial ligaments. This is quite feasible because these structures occupy but a small area of the upper surface of the tibia in front of and behind the spine ; indeed, the posterior is attached to the posterior surface of the tibia in the popliteal notch. This stage of the operation is easily accomplished without destroying the lower attachments of either the external or of the internal lateral ligaments, the latter being attached down the shaft of the tibia quite out of harm's way. The antero.posterior direction of the plane of these saw cuts is at right angles to the axis of the tibia; their obliquity should correspond to that of the sawn surfaces of the femur. The advantages which may be claimed for this method of sawing the femur and tibia are as follows. The original fitting of the tibia into the intercondylar notch is preserved and any lateral displacement of the tibia is still impossible. Further, the same wedging in of the tibia effectually prevents rotation of that bone upon its long axis, and, therefore, the foot falls neither inwards nor outwards. To these advantages may be added that large areas of sawn bone are brought in apposition, and this with the smallest removal of either epiphysis. The whole thickness of the femoral epipbysis is left at either side and the whole thickness of the tibial in the middle. If the knee be extended after the bones have been sawn, the benefit of preserving the ligaments becomes apparent. As the leg is extended they become tight and jam the wedge of the tibia into the notch in the femur. Here it is firmly fixed so long as extension is maintained. As I have pointed out, if the crucial ligaments can be preserved a further advantage is gained, because in extension the posterior prevents the tibia falling backwards and the anterior prevents its displacement forwards. The operation is finished by sewing together the ligamentum patellæ with buried silk sutures and by subsequently closing the wound. In one case the patella was fastened with ivory pegs to the femur and tibia, but lately this has been omitted. The patella seems to form very strong connexions without the pegging. The front of the tibia and the front of the femur were wired together in one case so as to prevent flexion. Afterwards the limb is kept for a month or six weeks on a Gant's splint. But after this operation the immobility which is so essential for success is much easier to preserve. Indeed, as the tibia cannot slide to either side or backwards and cannot rotate, we have only to guard against flexion. That movement is one of the easiest to prevent and has little tendency to occur if the patella has been preserved and its ligament sutured. When the limb comes_off the Gant splint it is put into a leather splint. A patten having been put cn the sound foot the patient goes about on crutches swirging the resected limb. I have hitherto advised that this treatment be continued for a year, but perhaps this time might be shortened. I have been unable to learn that any surgeon has performed a resection of the knee at all similar to that which has just been described. Mr. Trevesl1 remarks that " Dr. Fenwick of Montreal saws both femur and tibia in a curved line, so as to make them fit together more closely and accurately than they would do otherwise." The bones have been sawn in all kinds of ways 12-obliquely by Billroth, in a kind of zigzag by Albert, and the exact reverse of that which I have described by Sédillot. However, none of these methods seem to be based upon the principle of attempting to retain the original fitting of the bones and the action of the ligaments. The operation which has just been described has been done four times since 1889. A youth who was operated on in 1889 was earning his living three years afterwards and his father wrote: " He gets about freely and does not complain of it in any way ; it is filling out very nicely and straight." Mr. Mark Taylor, writing-about a youth operated upon in April, 1896, says that now "the leg is in very good position ; no pain or tenderness anywhere." The photographs which Mr. Taylor sent certainly bear out the statement as to the position of the limb and also show that it is exceedingly well developed. In a third case done nearly a year ago the patient has a good and straight limb, but I dcubt whether the union is yet bony. She had a septic sinus at the time of operation and the wound suppurated. The fourth case was, as I have already said, a comparative failure, because I did not thoroughly remove all the synovial membrane about the crucial ligaments and behind the condyles. This omission evidently needs to be particularly guarded against. So far this operation seems to me to have the advantage of treating the bones so as to make it much easier to keep their cut surfaces in contact and at rest ; no lateral movement or rotation is possible. Also, under favourable circumstances no falling backwards of the tibia can occur; next, the growth of the epiphyses is less interfered with ; and, finally, the ultimate result is a very solid synostosis, with hardly any tendency to flexion. To gain these advantages the patient runs no risks beyond those of the usual operation.
doi:10.1016/s0140-6736(00)48927-0 fatcat:s3rqeb6yqbebfdejg6rul3wer4