1 
DIVISION OF THE CRUCIAL LIGA- 
MENTS FOR THE RELIEF OF 
KNEE-JOINT ANKYLOSIS* 
other. This is a condition of affairs to which 
neighboring soft parts do not fail to accommo- 
date themselves, for it is a well-known fact that 
ligaments entering into the construction of a 
joint, will, if the bones are placed in an abnor- 
mal position, so adapt themselves to the new 
attitude, as to firmly hold the bones in their 
changed relations, justasthe ligaments formerly 
were expected to do in the normal. 
There is no good cause why the above line 
of thought should not apply to both extra and 
intra-articular ligaments, and fitting the train 
of reasoning to the knee, it occurred to me 
sometime since that the crucial ligaments had 
a good deal to do with the characteristic posi- 
tion which a knee having assumed, retains so 
sturdily after a severe attack of inflammation, 
and as both flexion and extension are limited, 
that division of these two ligaments would not 
only permit more motion, but also would ena- 
ble the tibia to glide forward to its proper re- 
lation with the femur. 
In November last, a case of knee-ankylosis 
fell into my hands, which I was unwilling to 
excise owing to the patient’s youth, and not 
being able to straighten without undue violence, 
I subjected to division of the crucial liga- 
ments. 
In deciding whether a distorted knee should 
be subjected to the above operation, it is ne- 
cessary first of all, that all inflammation of, 
and about the joint, should have long since 
passed away, otherwise the necessary manipu- 
lation may give rise to recurrence of the origi- 
nal trouble, disastrous suppurat on or what 
not. Furthermore, the patient should be. as 
a matter of course, in excellent health, with 
the functions of life well performed. The 
hamstring muscles, lateral ligament , and 
any opposing bands of fascia are then to be 
divided subcutaneously in the usual way. 
When the tenotomy punctures have healed, ex- 
tension under anaesthesia is made, and the ope- 
rator will be able to recognize that the failure of 
the joint to further straighten, is due to intra- 
articular bands. The amount of force which can 
be exerted to straighten the joint must depend 
upon the surgical acumen of the operator, and 
no rule in pounds can be laid down ; suffice it 
to say, that a point is reached beyond which the 
exercise of force will be prejudicial to the pa- 
tient’s welfare, and this point will, of course, be 
reached earlier in patients with whom the epiph- 
yseal cartilage still perists, than in those whose 
bones are completely ossified, for of course, an 
epiphysis might be wrenched off by too strong 
manipulation. Further forcible extension be- 
ing inexpedient and the deformity continuing, 
division of the crucial ligaments is indicated, 
and may be done as follows: The patient lies 
on the back, the affected limb is extended 
steadily, so as to render tense the anterior cru- 
BY L. M° LANE TIFFANY, M. D., 
Professor of Surgery, University of Maryland. 
(.Reprint from Maryland MedicalJournal.) 
In common with, I suspect, many other 
medical practitioners, I have experienced not 
infrequently, great difificultv in overcoming 
the deformity and ankylosis remaining after 
knee-joint inflammation has subsided, and any 
operative measure which, in proper cases, will 
lessen this difficulty, is worthy of mention. 
The procedure named in the title of this pa- 
per (division of crucial ligaments), has been 
made use of by me wi'h great and immediate 
benefit to my patient, benefit which, in view of 
the time which has elapsed since the operation, 
may be confidently expected to be permanent. 
It is not unusual after that variety of knee- 
joint inflammation which is denominated 
white-swelling has subsided, to find the artic- 
ulation left in a more or less ankylosed condi- 
and the head of the tibia resting more 
behind the femoral condyles than normal, 
while there is present at the same time rota- 
tion of the limb below the knee, so that the 
toes point outvard too strongly; the inner 
condyle of the femur also is over-prominent; 
from all of which it results that the function 
of the entire limb as a weight-bearing organ 
of progression, is seriously impaired. To re- 
store natural shape and usefulness, d'vision of 
tendons, of extra-articular bands of fascia, 
of ligaments, forcible extension under anaes- 
thesia of intra-articular bands and adhesions, 
shampooing, passive motion, etc., are called 
into requisition and with excellent effect. It 
is sometimes found however, that the above 
means fail to bring about the wished-for result, 
and that notwithstanding our efforts, the joint 
remains obstinately misshapen, and more or 
less stiff. The deformity of the knee under 
consideration, is far more apt to be met with in 
children than in adults, and after tendons with 
extra-articular bands have been severed, the 
question presents itse’f as to how much power 
it is proper to exert in order to forcibly rup- 
ture any intra-articular adhesions, the doubtful 
point being whether, the bone itself, the ad- 
hesions, or the epiphyseal joining will give 
way the soonest. It is customary to break up 
adhesions, and try to restore motion to a knee- 
joint not only after inflammatory action has 
subsided, but a long time after it has subsided, 
when therefore, of necessity, the articular sur- 
faces of the tibia and femur have become pretty 
well settled in their vicious relations to each 
* Read before the Baltimore Academy of Medicine 
January 15th, 1884. 2 
cial ligament ; the tenotome is entered to the 
inner side of the ligamentum patellae a quarter 
of an inch above the articular surface of the ti- 
bia and carried backwards and outwards, so 
as to pass between the tibial spine and the ex- 
ternal condyle of the femur below the ligament 
(ant. crucial). The flat of the blade is towards 
the tibia, the back of the blade towards the 
ligamentum patellae and the edge toward the 
spine after entering the joint. The knife is now 
to be carried from side to side across the joint, 
the edge being directed so as to pass over the 
spine and divide the anterior crucial just 
above its attachment to the tibia; the posterior 
crucial will probably also be divided, but as it 
lies farther from the skin-punctur» it is wise to 
turn the edge of the tenotome without with- 
drawal, pass it more deeply into the joint and 
carry it from the internal to the external con- 
dyle, retracing the path already travelled. 
The tenotomy wound is to be treated as usual. 
Before entering the knife, it iswell to draw up- 
wards the skin, that the opening may be val- 
vular, and air less likely to gain admission to 
the joint. If the operation has been successful 
the limb can be well extended ; the tibia is felt 
to glide forwards upon the condyles of the 
femur to the usual situation, the posterior 
projection of he id disappears and the ever- 
sion of the foot is lessened. A proper retent- 
ive apparatus (gypsum) is to be applied and the 
tibia held in its new position until all likelihood 
of inflammation be past, when passive motion, 
is to be commenced. 
Inasmuch as the affected limb, from long 
continued non-use is usually but illy devel- 
oped, friction, electricity, etc., can be used with 
advantage. Certain practical points in the op- 
eration described above present themselves 
and claim attention : one is, the depth to which 
the knife must be entered before attempting to 
cut the ligaments. This will, of course, de 
pend upon the size of the knee demanding 
treatment; the case related hereafter, required 
that the tenotome be entered if inches. Late- 
ly, when practicing the operation upon an 
adult male subject in the dissecting-room, I 
found that the cutting-edge of the knife had 
to be carried 2\ inches below the skin-surface 
before the crucial ligaments could be severed ; 
here, of course, the joint was healthy. It is wise, 
I think, that the tenotome should possess a 
blade about three inches long, of which not less 
than one inch should have a cutting-edge, the 
better to divide both ligaments at one time ; a 
long and slender point is not entirely free 
from chance of fracture in an ankylosed knee- 
joint, and it is well to have the end rounded, 
or chisel-shaped with the corners cut off, fur- 
nished however with a good terminal edge. 
Case.—A— W.—. ; female, aet. 11 years ;' 
seen Nov. 12, 1883. She desired to have her 
leg made useful. At two years of age she had an 
inflammation of the left knee, after which the 
joint remained permanently flexed to nearly a 
right angle, thus rendering walk ng on the 
limb impossible. She has always used a 
crutch. Examination shows leg flexed on 
thigh as stated, inner condvle of femur very 
prominent, the toes rotated outwards strongly, 
and the head of the tibia displaced backwards 
to a marked degree. The thigh showed a 
deeply depressed cicatrice, presumptively con- 
nected with the former knee disease. Both 
thigh and leg were less developed than upon 
the right side, owing perhaps to disuse, per- 
haps to inflammatory changes in the epiphy- 
seal cartilages. I divided tendons, fascia, etc., 
and put on a splint until the tenotomy punctures 
had healed. Extension to a certain point was 
then possible, but strong resistance was,beyond 
this, felt, and so it was inferred that the crucial 
ligaments required cutting. This was then at 
once done, after which the limb could be 
straightened, and the tibia head advanced to 
its proper position upon the femoral condyles. 
The puncture was covered with a piece of ab- 
sorbent cotton, the whole limb wrapped in cot- 
ton-wadding, and encased in a plaster-splint. 
No pain or constituiional disturbance ensued. 
Examination at the end of a week showed the 
puncture to be healed. At the end of three 
weeks, passive motion was commenced, and 
the patient is now gaining both strength and 
motion- The tibia has not returned to its 
former position behind the femur, the sole of 
the foot rests on the floor, and the limb bears 
weight.