FORCIBLE CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE 
WITH A REPORT OF CASES 
JOEL E. GOLDTHWAIT, M. D, of Boston [Reprinted from the Boston Medical and Surgical Journal of September 7, 1893.] 
FORCIBLE CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE, 
WITH A REPORT OF CASES.1 
JOEL E. GOLDTHWAIT, M. D., of Boston. 
In any inflammation about the knee-joint, in which 
there is muscular irritation, the leg flexes ; and if this 
condition be kept up for any length of time, the head 
of the tibia is drawn backwards, so that the normal 
relations of the articular surfaces are lost. The knee 
is flexed and the tibia subluxated backwards. 
In the first, the acute trouble would be increased; 
while in the latter, fracture of the bones, with lacera- 
tion of some of the soft structures would result. 
The third class, which really represents the inter- 
The cause of this double deformity lies in the direct 
insertion of the posterior thigh muscles, and in the 
method of application of the power of the Quadriceps 
group. 
At times rotation of the foot and leg outwards is 
seen in connection with these other deformities. This 
is probably due to the fact that the Biceps tendon is 
inserted far out upon the head of the fibula, and conse- 
quently has a longer lever upon which to act than the 
inner Ham-string group, which antagonizes the Biceps 
in rotating the leg. 
The treatment of these deformities by means of force 
suddenly applied is not new ; nevertheless, from a lim- 
ited experience, I am confident that the method has 
received too little attention, and that patients are al- 
lowed to go without operation and to remain cripples, 
or else more serious operations are performed than is 
necessary. This lethargy undoubtedly is due partly to 
an incomplete understanding of the operation, but still 
more because of the faulty apparatus for such use 
which we have had at our command. 
It is with the hope that by a free discussion here to- 
night we may arrive at a better understanding of the 
subject, that 1 present this paper, and offer the deduc- 
tions which I have made. 
Clinically, as these cases are seen, they group them- 
selves pretty definitely into three classes : 
(a) Those that are seen during the acute or sub- 
acute stages of the disease, in which the deformity is 
maintained entirely by muscular spasm. 
(b) Those in which there is complete bony anchy- 
losis, as the result of extensive osteo-arthritis. 
(c) Those in which the malposition is maintained 
by adhesions in or about the joint, as the result of old 
arthritic or peri-arthritic disease. 
The first two classes are dismissed entirely, as forci- 
ble straightening should not be considered in their 
treatment. In the first class simple continued exten- 
sion, with complete immobilization of the joint, will 
be found to be all that is necessary ; while, in the sec- 
ond class, some bone operation, such as excision or 
osteotomy, will be required. Forcible correction of 
the deformity in either of these groups would do harm. 
mediate position between the other two, includes all 
of those cases in which the malposition is maintained 
by fibrous adhesions, without regard to the original 
disease, whether tubercular or otherwise. If the ad- 
hesions be slight, they can be broken up with the 
hands, and the deformity corrected ; but if, as is usu- 
ally the case, the adhesions be firm, the correction is a 
Fig. i. 
1 Read before the Ortbopoedic Section of the New York Academy 
of Medicine in New York, May 19, 1893. 4 
CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE. 
very different matter, and mechanical appliances be- 
come necessary. 
after this the apparatus is applied, with the leg flexed. 
The posterior band, d, is then screwed forward; and 
after as much force has been applied as seems prudent, 
the leg is straightened as much as possible, by means 
of the long lever handle, the power being applied in- 
termittently. The apparatus is then taken off and the 
leg again manipulated with the hands, to still farther 
break up the adhesions; after which, with the appara- 
tus, the complete correction is attempted. In a mild 
case one application may be all that is required, while 
in others several applications (at one sitting) may be 
necessary before the position is entirely satisfactory. 
At times, when the apparatus is finally removed, the 
head of the tibia drops back and cannot be held in 
place, even though the leg be straight, because of the 
firm contraction of the Ham-string tendons. This may 
be overcome by division of the tendons, or what was 
better in one of the cases, the leg was put up slightly 
flexed, enough to relax the contracted parts, and the 
dressings allowed to go undisturbed for one week. At 
the end of that time the tendons had relaxed so much 
that the leg could easily be straightened, and the cor- 
rect apposition of the bones maintained. During the 
operation, the rotation of the leg, which is due to one 
condyle of the tibia slipping farther back than the 
other, can be corrected very easily, by simply rotating 
the apparatus so as to bring the greatest pressure upon 
the condyle that is posterior, if this last deformity 
be allowed to remain, it not only produces an awk- 
ward gait, from the turning out of the foot, but also, 
from the posterior position of the outer condyle of the 
tibia, a more or less marked knock-knee is produced. 
In a paper which was printed in the Boston Medical 
and Surgical Journal of December last, I described 
I'M. 11. 
an apparatus (Figs. I and IT) for use in the correction 
of such deformities. It is a modification of an appara- 
tus, devised several years before, by Dr. E. H. Brad- 
ford ; the modifications being made to make the ap- 
paratus adjustable, to make the application of the 
' Fig. 111. 
Fig. IV 
Fig. V. 
power more easy and more under control, and to have 
the counter-pressure so directed that no damage could 
be done to the femur. Its mechanical principles are 
simple, and its adjustment and use is not difficult. 
The operation, which is always performed with the 
patient anaesthetized, may be briefly described as fol- 
lows : First, the adhesions are broken up as much as 
possible with the hands only (this in some cases means 
a good deal, and in others practically nothing); and 
At times, however, the knock-knee is due to an 
elongation of one condyle, as a result of the disease, 
and a Macewen osteotomy may be necessary ; but it is 
best to wait a few weeks, at least, as in one of the 
cases in which this deformity was well marked, it en- 
tirely disappeared without operation, evidently being 
due to an old inflammatory deposit on the inner side, 
which was absorbed. 
The after-treatment is simple. A plaster-of-Paris 5 
CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE. 
bandage is applied at the time of the operation, and is 
not disturbed for one or two weeks; after which the 
patient is allowed to go about upon crutches, the knee 
being fixed with the plaster bandage, or, what is bet- 
ter, with a Thomas knee-splint. In a few weeks the 
apparatus is omitted at night, thus favoring the estab- 
lishment of motion in the joint; but while the patient 
is up and about, the splint or some protective appli- 
ance should be worn, for from six months to a year. 
The pain, which is surprisingly slight, can usually 
be controlled by the salicylates. Morphia, of course, 
is to be used if necessary. 
Case 11. A boy eight years of age. Six weeks 
before being seqn at the Boston City Hospital, in De- 
cember last, the patient received a wound of the knee- 
joint, in which the patella tendon was divided. The 
wound had been neglected, and as a result of the 
suppuration which followed, the joint structures were 
badly disorganized. When first seen, the tibia had 
slipped back, as the result of the absence of the ante- 
rior ligaments and tendon, so far that there was scarcely 
any articulation between the two bones. There was 
about twenty degrees of flexion. After waiting some 
time for his general condition to improve, the opera- 
tion was performed and the tibia drawn forward into 
place. The position was maintained by a plaster-of- 
Paris bandage. 
The result in this case is a useful leg, but with a 
stiff knee-joint. This, of course, was expected from 
the nature of the injury and the subsequent suppura- 
tion. 
Case 111. A girl fourteen years of age. In Jan- 
Fig. VI. 
Fjg. VII. 
Fig. VIII. 
The following four cases have been operated upon 
since the paper of last December was published; and 
in each case the apparatus, figured above, was used. 
Case I. A young woman, sixteen years of age. 
When thirteen months old, the right leg “ drew up,” 
and it has remained in that position ever since. 
Figure 111 represents the position of the leg at the 
time of entrance to the Massachusetts General Hospi- 
tal, in December, 1892, flexed to a right angle, with 
marked subluxation of the tibia, and with only a few 
degrees of motion in the joint. There was consider- 
able cicatricial tissue in the Popliteal space, but little 
or no bony thickening. 
She was operated upon, and the position corrected 
without much difficulty. In ten days she was up in a 
wheel chair, and was about on crutches a week or two 
later wearing a caliper splint. 
uary of this year the patient entered the Massachu- 
setts General Hospital, with the leg flexed about forty- 
five degrees (Fig- VI); the deformity having existed 
for twelve years. There were several degrees of flex- 
ion possible, but extension was restricted, as is shown 
above, and this limitation of motion was evidently due 
largely to the position of the patella, which was firmly 
adherent to the femur. 
With the correcting appliance the leg was straight- 
ened without difficulty ; and as the force was applied, 
the adhesions between the patella and the femur gave 
way, allowing free motion between these bones. 
The patient was up in a chair the second day after 
the operation, and a few days later was about on 
crutches. 
At present, about six months later, the leg is 
straight, as is shown in Fig. VII, and voluntary 7 mo- 
tion is possible to the position shown in Fig. VIII. 
Case IV. A woman twenty-one years of age. In 
December of last year the patient entered the Boston 
City Hospital, and gave the following history. Eleven 
years previous, she fell striking the right knee. This 
Her condition at the present time, six months later, 
is best understood from the accompanying cuts (Figs. 
IV and V), wdiich represent the leg straight, and also 
flexed to show the amount of voluntary motion that is 
possible; almost ninety degrees. 6 
CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE. 
was followed by an abscess which opened just below 
the patella, and from which there has been a slight 
discharge ever since. At the time of the appearance 
of the abscess the leg “ drew up,” and has remained in 
that position until now. At the time of entrance to 
the hospital, it was flexed to about a right angle, and 
subluxated as is shown in Fig. IX. There were only 
a very few degrees of motion possible. 
On December 21st, Dr. Bradford opened the sinus 
constant before the operation has entirely disap- 
peared. 
I am indebted to Dr. C. B. Porter for permission to 
see Cases I and 111, to Dr. M. F. Gavin for Case 11, 
and to Dr. E. H. Bradford for Case IV. 
Fig. IX. 
Fig. X. 
Fig. XI. 
below the patella, and removed with a curette, a large 
amount of dead bone from the head of the tibia. The 
cavity remaining was about the size of a small lemon. 
At this time, the correcting apparatus was applied, 
I wish, also, at this time, to give a later report of 
one of the cases of the December series. The patient 
was a girl sixteen years of age, in which the deformity 
had existed for eight years before the operation. It 
Pig. xii. 
and the leg partially straightened; but because of the 
danger of fracturing the tibia in its weakened condi- 
tion, the correction was not completed. 
Two months later the cavity in the tibia having 
filled up, the apparatus was again applied and the leg 
fully straightened. x 
is now a year since the leg was straightened, and all 
apparatus has been omitted for about two months. 
She walks well, there being enough motion in the joint 
to prevent the marked limp common with a stiff knee, 
and there are no uncomfortable symptoms. Fig. XII 
shows her condition before operation, Fig. XIII. the 
leg straight, and Fig. XIV the amount of voluntary 
free motion. 
At the present time the patient is walking about, 
wearing a Thomas caliper-splint, with the leg straight, 
as is shown in Fig. X, and with several degrees of 
voluntary motion (Fig. XI). The pain which had been 
In considering these cases, Case I seems to be 
worthy of special attention, and is of interest as a CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE. 
7 
physiological experiment as well as a surgical result. 
The fact that a joint can be put out of use for nearly 
fifteen years, and then restored to use with very nearly 
the normal amount of motion, is not only a matter of 
interest but of surprise. To be sure, the original dis- 
ease had been largely in the tissues about the joint, 
judging from the position of the cicatrices ; but even 
where there has been no joint injury or disease, as in 
fractures of the long bones —in which it is necessary 
to confine the adjacent joint for a long time —it has 
In calling attention to this treatment it is to be un- 
derstood that the original cause of the deformity is of 
little consequence, and that whether it be rheumatic, 
gonorrhoeal, or tubercular ; or whether the disease has 
been confined to the joint or to the structures about 
the joint, the deformity 
can be corrected as thor- 
oughly and without much 
more danger, in one case 
as in the other. In the 
tubercular cases a consid- 
erable interval, at least 
two years, should be al- 
lowed after the disap- 
pearance of all of the 
acute symptoms, before 
the correction be at- 
tempted, because of the 
danger of starting up the 
tubercular process. In 
the gonorrhoeal or rheu- 
matic cases the apparatus 
can be applied at any time 
where it is reasonable to 
suppose, from the dura- 
tion of the disease, that 
adhesions have formed. 
Usually in these cases the 
pain will cease with the 
restoration of motion. 
The dangers attending 
the use of the apparatus 
are very slight, if its 
principles are understood 
and ordinary precautions are used. 
In the acute cases, and in those in which there is 
bony anchylosis, its use is contraindicated, for reasons 
stated above. The danger of lacerating the vessels 
and nerve in the Popliteal space, from the application 
Fig. XXV. 
Fig. XIII. 
Fig. XV. 
always been supposed (except for Dr. Phelps’s exper- 
iments on dogs) that the functions of the joint would 
be seriously impaired, due to the formation of fibrous 
adhesions inside of the capsule. In this case, in one 
week from the time of the operation there was nearly 
normal voluntary motion without pain; at least strongly 
suggesting that no intra-articular changes had taken 
place. 
The results in the other cases need no special com- 
ment ; the illustrations represent their condition bet- 
ter than any verbal account. 
of so much force, is very slight. As was shown in the 
paper before referred to, the head of the fibula, and 
the inner condyle of the tibia act as buttresses; and 
upon these points the pressure is applied, while the 
vessels lie deep in the muscles entirely protected, as is 
shown in Fig. XY. In cases of extensive peri-artic- 
ular disease behind the joint, it would be better to 
straighten the leg gradually, gaining a little with each 
operation, rather than to correct it at one sitting; in 
which case the vessels might be lacerated, from being 
involved in the old cicatrix. This precaution should 8 
CORRECTION OF ANGULAR DEFORMITIES OF THE KNEE. 
also be taken in elderly persons in which atheromatous 
changes in the vessels are to be considered. 
leg, are very good. One case, in which the deformity 
had existed almost fifteen years, has nearly normal 
motion in the joint. One case is reported in which all 
apparatus has been omitted one year after operation. 
In none of the cases has any acute trouble resulted. 
7ihe operation and the use of the apparatus is not diffi- 
cult, and the dangers attending its use are compara- 
tively slight. 
A special apparatus is presented for the correction 
of the angular deformities of the knee in which there 
is fibrous anchylosis. Five cases are reported in all, 
of which the ultimate results, as to usefulness of the 
CONCLUSIONS.