FOREIGN BODIES IN THE KNEE-JOINT.

BY SIR GEORGE PORTER, M.Ch., UNIV. DUB., Honoris Causa;

Fellow and ex-President, Royal College of Surgeons in Ireland;

Surgeon-in-Ordinary to Her Majesty the Queen in Ireland;

Senior Surgeon to the Meath Hospital.

[Read in the Surgical Section, February 8, 1884.]

THE subject of foreign bodies, or loose cartilages, situated in the

knee-joint, is one of great interest to the practical surgeon—first,

as regards their presence in an articulation which, with reference

to size and utility in locomotion, is the most important in the body;

and secondly, owing to the excruciating pain and oft-recurring

attacks of inflammation their presence so frequently produces by

getting locked between the articulating surfaces of the bones, ren-

dering the life of the patient most miserable, and preventing his

usual avocations, or his indulging in any form of active exercise.

With respect to the formation of these loose cartilages several

theories have been advanced, and although they have not been

noticed by any of the very ancient writers, their presence is by no

means uncommon in the different ranks of life. Ambrose Paré

was the first who drew attention to the subject. Ile stated "thatthat

a hard, polished, white body, of the size of an almond, was dis-charged from the knee-joint of a patient in the year 1558," in

which he made an incision for the purpose of removing therefrom

a collection of fluid The next surgeon who wrote concerning

these bodies was Pechlin, in the year 1691, who published the fulldetails of another case in which a cartilaginous body was success-

fully extracted from the knee-joint. Later on we find Dr. A.

Monro, in 1726, dissecting the knee-joint of a woman who had

been executed, and in the course of his dissections discovering a

Foreign Bodies in the Knee joint. 181

cartilaginous body of the shape and size of a small bean. Ten

years later, in 1736, Mr. Simpson cut out of the knee-joint a

similar substance, which at the time of the operation he believed

was only underneath the skin. From that period until now their

presence and consequent effects seem to have been pretty well

understood, and have been mentioned and described by nearly every

surgical writer. The articulations in which these formations occur

are—the wrist, elbow, shoulder, temporo-maxillary, knee and ankle.

They are met with, however, most frequently in the knee, and

the severe set of symptoms which they produce during loco-

motion render their consideration interesting. These movable

bodies are of two lincls--first, those described as round or flat con-

cretions, which are supposed to consist of fibrin ; secondly, those

which are irregular in shape, often nodulated, and formed ofossifying cartilage. They vary in number, size, and colour. Onemay be found in a joint, or many. Malgaigne found sixty in the

elbow-joint, and Dr. Berry, of Kentucky, removed thirty-eight

from the knee of a male negro. Their size varies from that of a

millet-seed to that of a walnut. Their colour is sometimes white

or whitish grey ; others are of a faint yellow tint. As regards

mobility, they may be completely isolated and moving freely about

the joint in every direction, or they may be attached by a slight

band of fibrinous exudation or lymph to some point of the synovialmembrane.

The loose cartilages belonging to the first or fibrinous varietyare supposed to originate in different ways—viz., they may be

formed out of the masses of fibrin which float about in the exuda-

tion and effusion that accompany an attack of synovitis ; or they

may arise in the synovial fluid, which has been changed in its con-

stitution by inflammation; or again, they may arise by the concen-

tration of fibrin around a mass of coagulated blood which has found

its way into the joint by the rupture of a small vessel, the resultof an accident.

Those bodies of the second variety mentioned are organised, andcan be referred to one of four distinct sources.

Firstly, in the apices of the synovial fringes cartilage cells are

182 Foreign Bodies in the Knee joint.

known occasionally to exist, which, under the stimulus of infam

-matory action, undergo active proliferation and organisation, thus

forming a cartilaginous nodule, which ossifies in the centre, and by

the movement of the joint becomes completely detached from the

fringe of the synovial membrane it originally sprang from, and

thus falls loose into the cavity of the joint and floats about in every

direction.

Secondly, one or more of the edges of the synovial membrane

may become pinched or squeezed between the articulating surfaces

of the bones, giving rise to local and inflammatory infiltration, and

thickening of small portions of the membrane. In due course these

become crushed off or detached from their connexion with the rest

of the synovial sac, and drop freely into the joint.

Thirdly, these bodies may arise outside the synovial sac in the

periosteum or sub-synovial connective tissue as osteophytes, and in

time, by excessive movement, may be forced into the cavity of the

articulation.

Fourthly, they may arise, as Mr. Teale has suggested, as the

result of fragmentary exfoliations, or separations, of small portions

of the cartilages composing the joint itself.

The late Mr. Adams, of Dublin, considered their presence was

due to an osteo-arthritic origin. The symptoms attending the pre-

sence of these bodies are so well known that it is hardly necessary

to mention them. Suffice it to say—the patient, when walking or

in some movement of the joint, is suddenly seized with a most

violent pain, and is unable to move the joint in any direction. The

pain at times is so great that he becomes sick and faint, and

is compelled to grasp the nearest object to prevent himself from

falling. When the position of the limb is changed the cartilage

slips from between the articulating surfaces, the pain instantly sub-

sides, and the function of the joint is immediately restored. These

attacks of pain occur as often as the body gets between the bones,

and according to the amount of exertion the patient has been

subjected to. The frequency of the attacks would also depend on

whether the foreign body was entirely free, or its range of mobility

limited in its extent by a small attached pedicle, or band of lymph.

By SIR GEORGE PORTER. 183

It is most likely that during some movement slight inflammation

may set in, causing the pouring out of lymph which makes the

body become adherent to some part of the synovial membrane, in a

situation that would not interfere with motion ; or else it may

fall into some little pocket or recess formed by the folds of the

synovial membrane, in which it becomes temporarily fixed. This

accounts for the absence of pain, inconvenience, and disappearance

of the body for intervals of weeks, and the return of the symptoms

would prove that it has again been detached or dislodged.

The treatment for these loose cartilages, or foreign bodies of any

kind finding their way into the knee-joint, may be divided into the

palliative and the radical. The former consists in the wearing of a

well-fitting laced knee-cap, or other mechanical appliance for the

purpose of fixing permanently the body in a situation that will not

interfere with the free motion of the joint. Some patients are

quite satisfied with this form of treatment.

Cases, however, will occur, owing to constant attacks of pain and

inflammation, when it becomes necessary to recommend the removal

of the foreign body. In adopting the radical treatment the surgeon

has the choice of two operations :

1. The direct incision.

2. The indirect or subcutaneous incision, as practised by Syme

and Goyrand.

As two remarkable cases of foreign bodies in the knee-joint have

very recently come under my observation, I will briefly give the

history, progress, and successful result of the direct method of

operation, as performed under the spray, and other antiseptic pre-

cautions ;

Removal of a Loose Cartilage from the Knee-joint.

CASE I.----J. IÍ., aged twenty-six, a private in the nth DragoonGuards, stationed at York, was admitted into the Meath. Hospitalon January 7th, 1884, suffering from a loose cartilage in his leftknee-joint.

History. He stated that in July, 1883, whilst riding throughthe streets of York, his horse became restive and backed againsta passing cab. IIis knee was squeezed. After this accident he

184 Foreign Bodies in the Knee joint.

was confined to the Military Hospital at York for a fortnight, andalthough he suffered much pain he did not observe the small bodymoving about in his knee-joint until September, 1883, when Dr.Riordan, of the Army Medical Department, detected it. For weekshe felt no inconvenience from its presence, being able to walkabout and attend to his military duties. At other times he wasseized with a most violent pain in his knee rendering him unableto stand, walk, or move the joint in any direction.

He was now invalided from the service by a medical board, andmy friend, Dr. Riordan, gave him a letter to me asking that heshould be admitted to the Meath Hospital, where he was taken inon January 7th, 1884.

State on admission. —His left knee-joint being carefully examined,a loose cartilage was discovered moving about in several directions.Sometimes it was difficult to ascertain its exact position. The man,however, by different movements of his joint, could always manageto find it.

Operation, On January 17th, 1884, ether having been admi-nistered, I operated by the direct method under the carbolic spray,assisted by my colleagues, Messrs. Smyly, Ormsby, and Hepburn.The cartilage was found to be extremely movable, and very difficultto fix in any one given position. It was secured after severalattempts by means of a needle at the outer and lower border ofthe patella. The needle was passed through the integument, andmade to penetrate the body. An incision about two inches longwas carried directly over the cartilage. A quantity of synovialfluid escaped through this incision. The cartilage was thenextracted, and the edges of the wound brought together by meansof two silver wire sutures, and dressed with full antiseptic pre-cautions. The joint was also fixed by means of a well-paddedposterior splint, and the patient removed to his bed.

After-treatment.---He suffered very little pain or uneasiness thenight of the day of the operation. His pulse and temperature werenormal and remained so throughout his entire convalescence.

First dressing. The wound was dressed under the ,spray on the25th, eight days after the operation, and it was found aseptic; noappearance of pus ; its edges lying in perfect apposition. Thesutures were removed, and it was covered with carbolic gauze.

Second dressing on 29th January, 1884, when it was found to becompletely healed. Dressings were then discontinued, and merelya bandage applied. Four days later he was able to walk about

By SIR GEORGE PORTER. 185

the ward. He has now obtained almost complete use of his joint,and is most anxious to re-enter the service.

A Bullet removed from the Knee joint after a lodgment of ThirteenYears.

CASE II.--Whilst Mr. R. T. aged forty-five years, one of themost eminent gun-makers in this city, was holding a Derringerpistol, which he was about to discharge, it suddenly went off, andthe ball struck him and entered about two inches above his leftpatella. This occurrence happened thirteen years ago. He bledvery little at the time, and was seen in about half an hour afterthe accident by the late Mr. John Hamilton, who did not deemit prudent to explore the wound, but placed his limb in a fixedposition, and applied a cold lotion.

The next day considerable inflammation was present in the knee-joint, and in two days afterwards a slight discharge of pus flowedfrom the wound, which was supposed, at the time, to have taken adownward course. He was confined to bed for upwards of threemonths, and had a slow convalescence for three months longerbefore he was able to resume his usual avocations. From thistime to about seven years after the accident he remained well;then, whilst stepping off a car, the bullet suddenly came to thesurface below the patella, but before he could obtain any surgicalassistance it had disappeared again.

In the early part of December, 1883, his knee-joint becameswollen and uncomfortable, but not very painful ; and on theevening of the 24th of December last I received a note fromhis brother stating that the ball had come to the surface, andrequesting me to see him at once. I saw him in about twentyminutes, bringing with me the necessary instruments and antisepticdressings. I found that the ball had made its way to the inside ofthe patella, and was almost under the skin. Having fixed it withthe thumb and fore-finger of my left hand, I cut down and exposedits surface. I attempted to seize it with a forceps, but the instru-ment slipped twice. I then passed beneath a small steel scoop,and thus extracted it with ease. The joint being opened, a largequantity of synovial fluid escaped at the moment the ball wasremoved. I, however, closed the wound immediately with a stripof salicylic plaster and applied the usual antiseptic dressings.

I need not weary you with the daily notes of this case, but maystate that it was treated throughout antiseptically. In ten days the

186 Foreign Bodies in the .Knee joint.

wound was healed, and the patient was allowed to sit up, and inthree weeks from the operation he was walking about his room.

These two cases I considered might be received with interest by

the Academy, and I think are additional proofs (if such were re-

quired) of the great advantages of antiseptic surgery. In my

student days a wound of the knee-joint, with escape of synovia,

was often followed by amputation or death. Now, without fear,

we cut into a knee-joint under the carbolic spray, thus stamping

on " Listerism " the verdict of almost universal success.