War Surgery and Medicine
CHAPTER 18 — Knee-joint Injuries
INJURIES of the knee joint are of considerable importance to a New Zealand force because of the frequency of the occurrence of this injury in our national game of Rugby football. Accidental injuries were found to be extremely common in the army, and in these there was a high proportion of knee injuries.
First World War
In the First World War knee disabilities were common and were found very difficult to treat satisfactorily. Operation was not often carried out as results were not held to justify this treatment in the forces overseas. At the Convalescent Depot at Hornchurch particular attention was given to the rehabilitation of the chronic knee cases. Temporary plaster splinting associated with activity and strenuous physiotherapeutic measures were adopted, but with very little effect. It was found very difficult to render the men fit for further active service.
Between the wars orthopaedic surgery developed considerably, largely following the impetus given by the First World War. Operative treatment for the common semilunar cartilage injuries became the regular routine, and the results were generally satisfactory. Trained surgeons specialising in orthopaedic surgery were available for service in the Second World War.
At the beginning of the war there were grave doubts about the advisability of operating on knee-joint injuries overseas, but it seemed that in the younger fit men with no other disability such treatment merited a fair trial. Operative treatment was therefore authorised and encouraged in suitable cases. The cases for operation were carefully chosen, and the majority were operated on by the orthopaedic surgeon attached to the base hospital. Men approaching, and certainly those over, forty years of age were not as a rule deemed suitable for operative treatment. The presence of any osteoarthritis or other pathological condition of the joint which would prevent satisfactory recovery negatived operation. The test question was whether the treatment would result in making the page 382 man fit for full service or at least render him fit for full service at the Base. The qualifications of the man for any specialised base service were naturally of great importance and determined the issue. If a man could not be made a valuable member of the force then he was, from the military point of view, not worth the time and trouble necessitated by the operative treatment, and return to New Zealand, and probably to civil life, was indicated.
In the period before actual hostilities commenced in Greece there were many knee disabilities in the 2 NZEF. Football accounted for the majority, but there were also many recurrences of pre-war injuries. The increase in exercise during training, and in sports generally, naturally led to more trouble in long-standing disabilities, as well as to fresh injuries. Actions and training carried out often at night and on uneven ground accounted for a considerable number of the cases. They were treated first in their units and then referred to the base hospitals, either as outpatients or inpatients. The usual investigations, including X-rays, were undertaken, and consultations took place between the surgeon and the divisional surgical officer, and often with the consultant surgeon. Physiotherapy was utilised at first as a post-operative treatment, and later also before operation, as it was realised how essential muscular efficiency was in the treatment of these cases. The cases were then sent after operation to the Convalescent Depot for graduated physical exercise before returning to their units.
A brief résumé of the methods adopted will now be given.
Selection: As already stated, this depended on the estimate of the man's future efficiency in the forces and not on the pathological condition. Care was also necessary not to risk bad results because of the reaction that would be produced on other patients on whom operation was deemed advisable.
Diagnosis: The history, and by this is meant the man's own unprompted story, was of the utmost importance. In cartilage injuries there was usually a story of an abduction rotation strain, with severe pain and later swelling. Locking might occur, and this might suddenly unlock or require manipulation to reduce it. Repetition of these symptoms commonly followed, as the avascular cartilage did not undergo repair except when the lesion was at the periphery. On examination of the knee, tenderness was often noted over the site of the anterior attachment of the cartilage. Limitation of extension was often present. The knee was then manipulated, reconstituting the abduction and the rotation outwards, at the same time bending and then straightening the knee. A distinct click was felt, and often heard, and some indication of the site of the injury to the cartilage obtained by the position at page 383 which the click appeared. For external cartilage injury the knee was adducted and rotated inwards and then extended. With practice, confidence in this test increased, and manipulations other than those outlined might be found useful. X-rays normally showed nothing except some possible narrowing of the joint space, but it might show other pathology such as a loose body or arthritic changes.
Operation was performed to remove disability and to prevent secondary degenerative changes in the joint, resulting from repeated trauma. Before operation the limb was elevated and a tourniquet applied to prevent bleeding in the joint and to improve vision. Very careful preparation and operative asepsis, and the no-touch technique, was essential.
Simple incisions were almost universally employed, the larger incisions such as the splitting of the patella being reserved for cases where general exploration of the joint was required. As it was deemed advisable never to operate on these cases till the diagnosis had been fully confirmed and proved by physiotherapeutic tests, the larger incisions were very rarely used. A good light was necessary. A small blunt hook was valuable in elucidating the injury and a strong clamp was required to grasp the cartilage during removal, which was carried out by cutting along the rim with a short tenotomy knife or similar instrument. The excision of the whole cartilage was generally carried out, including the posterior horn, which was apt to give rise to further trouble if it was left behind. Often damage to this portion could not be seen till the cartilage was being removed. If the meniscus was cystic the whole cartilage was generally removed.
The synovial membrane was sutured by a continuous catgut stitch and the skin sutured. At the end of the operation a firm bandage was applied over a bulky dressing of gamgee or wool, and then the tourniquet removed. This prevented bleeding in the joint.
After-treatment: This consisted in rest to the joint, combined with immediate continued and persistent functional use of the quadriceps muscles. This gave a stable and strong joint with full movement in three to four weeks, when the patient was normally sent to a convalescent depot for graduated training till he was fit to return to his unit.
Throughout the war there were never more than twenty men graded down for knee disabilities at any one time.
A survey of the results of treatment in the 2 NZEF in Egypt was undertaken in 1942, all cases operated on up to that time, page 384 or those who had been reclassified as unfit for full duty, being included. The cases were checked carefully to assure that cases Grade I were actually posted as such. The results were:
|Ruptured Semilumar Cartilage|
|Patients operated on overseas||31||13|
|Doing full duty in Division||71 per cent||61·6 per cent|
|Doing base duties in MEF||16 per cent||15·4 per cent|
|Evacuated to New Zealand||13 per cent||23 per cent|
(Two cases operated on in New Zealand prior to the war, for ruptured internal cartilage, were employed on base duties, and two cases not operated on had been invalided to New Zealand.)
It seemed established that, in ruptured internal cartilages, with cases uncomplicated by:
injuries to other structures in the knee joint;
osteoarthritis or osteochondritis dessicans;
the operation of meniscectomy normally resulted in the men being fit for full duty; also the most common cause of failure to get a satisfactory result in an uncomplicated case was wasting of the quadriceps. This was a preventable cause, and quadriceps training both before and after operation was insisted upon.
The type of operation performed on ruptured external cartilages was generally carried out by a simple small joint incision. The larger arthrotomy sometimes done did not seem to militate against full recovery of the knee. The complete removal of the cartilage was aimed at. Post-operative treatment consisted either of retention in plaster for a fortnight or simple pressure bandage for twentyfour hours. Early quadriceps function was insisted upon.
There were seven cases, six of which had arthrotomy, three by a transpatellar incision. Loose bodies were removed in three cases and an internal meniscus in one. Of the six cases operated on, three became Grade I, two fit for base duties, and only one was evacuated to New Zealand. These results were surprising and gratifying and fully justified operation.
The following observation was made:'This tends to show that a fair degree of arthritis can be present in the knee joint without causing any marked disability, and emphasising the important distinction between pathological changes and function. It also proves that it is worth while to treat the cases surgically if any definite indications arise. Again it seems to discount the presence of any real disability in slight degrees of chronic osteoarthritis in joints generally, a common observation in civil life.'page 385
This review clinched the opinion in our force that the operative treatment of semilunar cartilage injury and also of osteochondritis dessicans was fully justified, if proper selection of cases was made and especially if the older men were excluded.
This remained our practice throughout the war, and a considerable number of men were operated on in the base hospitals by the orthopaedic surgeons. The results continued to justify the treatment. More and more emphasis was put on the importance of full efficiency of the quadriceps muscle as the most important factor in the control of the stability of the knee joint.
Lesions of the Internal Lateral Ligament
These may be:
Slight degrees of injury insufficient to cause any increased mobility in the knee and resulting only in bruising and tenderness at the insertion of the ligament, or
Severe trauma with increased mobility of the knee.
The treatment consisted under (a) in rest associated with adequate quadriceps exercises, and under (b) in the application of a plaster splint in extension for a minimum of six weeks, as well as the quadriceps exercises.
Lesions of the crucial ligament were also treated in plaster with quadriceps exercises. The severe internal lateral ligament and crucial ligament cases were automatically evacuated to New Zealand, operation being considered unjustifiable overseas.
Experience in Other Forces
In an article by Graham of the Australian Army Medical Corps on internal derangement of the knee in the Middle East, similar results were recorded. Out of 128 cases operated on, no fewer than 104 were rendered fit for service and 15 more fit for service at the Base. As much as possible of the meniscus was removed. No pad or bandage was used after operation. Football was found to be the chief causative factor.
A statistical survey covering 800 cases was carried out in the British Army in the United Kingdom in 1943, and football was shown to account for nearly 60 per cent of the cases.
Apart from locking, the most frequently observed signs of diagnostic value were local tenderness, persistent effusion, limitation of extension, and the results of manipulation. Early active use of the quadriceps in walking was the most important part of aftertreatment. Grouping post-operative cases with early transfer to a convalescent ward and resumption of light duties promoted early recovery.
Hospitalisation was prolonged both for conservative and for page 386 operative treatment and caused much wastage. Pain and locking were the main symptoms; tenderness at the joint line and wasting of the quadriceps the main signs. The results of sub-total meniscectomy were satisfactory. The review also confirmed our opinion of the results of severe injuries of the internal lateral and crucial ligaments and the uselessness of operative treatment of these injuries in the army.
Our experience during the war showed that the most important factor in the treatment of knee conditions was the preservation and development of the muscular control of the joint. Rest at the beginning for the injured tissues was also necessary, followed by the gradual resumption of voluntary joint movement. Passive movement was generally uncalled for and harmful. At a later stage, in a few specially selected cases, manipulation might be practised. When the cases were carefully selected, with the exclusion of the older men and of those suffering from other knee disabilities, operation for the removal of damaged semilunar cartilages, and also of loose bodies in cases of osteochondritis dessicans, was definitely successful in the large majority of the cases. Quadriceps exercises were essential both as a pre-operative and post-operative measure. Graduated training was necessary before a man resumed full military duty with the Division. Severe injuries to the internal lateral and crucial ligaments, on the other hand, demanded discharge from the army.
|Semilunar cartilage, internal and external||32|
|Cruciate and int. lateral ligament||2|
|Internal lateral ligament||9|
|External lateral ligament||1|
|ADMISSIONS TO HOSPITAL, 2 NZEF, 1941–45—|
|Joint involvement, knee||609|
|R. V. Graham||Aust and NZ Journal of Surgery, January 1942.|
|Statistical Report on Health of British Army, 1943–45.|