War Surgery and Medicine
WOUNDS OF THE KNEE JOINT
WOUNDS OF THE KNEE JOINT
WOUNDS of the knee joint have always been of considerable importance not only because of possible loss of function of the joint, but particularly because of the serious effects produced by infection often leading to the loss of the limb and sometimes to loss of life.
First World War
Infection of knee-joint wounds was common during the 1914–18 War, and many methods were adopted to combat it. Excision of the wound was carried out, and in a clean wound the synovial membrane was sutured and the skin wound left open and treated with antiseptic dressings. When sepsis developed the joint was opened and drained. This was normally done by lateral incisions at either side of the patella opening up the suprapatellar pouch. Posterior drainage was at times carried out, but it was recognised that it was not efficient. The whole of the front of the joint was also laid open by cutting across the patellar tendon and stitching the large flap, including the patella, on to the front of the thigh, at the same time bending the knee. This produced very marked damage to the joint and an almost certain stiff knee afterwards. With the institution of the Carrel-Dakin treatment, tubes were inserted into the joint and regular irrigation carried out through the two long lateral incisions. The joint was rested in a Thomas splint with some extension, whether clean or infected.
The Belgians instituted early ambulatory treatment associated with lateral drainage and claimed good results, but this treatment was not adopted by the British Army and was contrary to the accepted principles of the treatment of infection. BIPP was used both on the wound and as an emulsion injected into the joint. Irrigation of the joint by the Carrel-Dakin method was the most successful form of treatment of the infected joint, and undoubtedly saved many limbs.
Amputation, however, was necessary in a considerable proportion of the cases, especially in the earlier period of the war. Serious infection produced a profound toxaemia, and the infection commonly page 388 spread outside the joint into the tissues of the thigh and the popliteal space. If the limb was saved, ankylosis of the joint often followed. The knee-joint cases were a constant anxiety to the surgeon.
The treatment of wounds of the knee joint was essentially the same as that carried out during the First World War, namely, excision and suture of the synovial membrane. The perforating injuries with small puncture wounds were not operated on. Larger wounds were excised. In penetrating wounds with a retained foreign body the foreign body was removed if of large size and if it was handy at operation, or if located satisfactorily by X-ray. Bony injury was not explored except in the process of removal of a large foreign body, or as part of wound excision. In the latter part of the war the patella was completely excised in compound fractures into the joint. Small or unlocated foreign bodies were left alone at the primary operation, which was strictly conservative in type. Sulphonamides were applied to the wound and then given by mouth generally at four-hourly intervals for six to seven days. The limb was splinted in a Thomas splint to ensure essential rest. A posterior slab or gutter splint was at first utilised with the Thomas, and later the modified Tobruk splint was used with flexion of 10–15 degrees and moderate extension. Some surgeons used plaster splints, considering that immobilisation was of more importance than traction. Foreign bodies were removed from the joint after X-ray localisation, not earlier than six weeks after wounding and generally later. Many small foreign bodies in quiescent areas of the joint were left alone and gave rise to no trouble.
Following this treatment very little infection arose during the North African campaign, though when it did arise drainage was necessary and amputation sometimes had to be carried out. Posterior drainage was given up and lateral drainage relied on. In the latter part of the war the patient was nursed on his face to facilitate drainage, and this proved successful. Sulphathiazole in oil was injected into the joint at one period, but was thought to produce undue irritation. When penicillin was available it was instilled into the joint and also used as an irrigation as well as parenterally.
Delayed primary suture of knee wounds was carried out at the end of the war and penicillin given (from the time of wounding) to all knee cases. Little sepsis eventuated and penicillin generally controlled any infection satisfactorily. Early quadriceps exercises and gentle knee movements ensured satisfactory function of the page 389 joint in the great majority of the cases without serious bony injury or sepsis.
The results obtained in knee-joint wounds of the Second World War were markedly superior to those of the First World War. Conservative original operation, adequate rest to the joint by splintage, and the bacteriostatic effect of the sulphonamides and penicillin had abolished much of the previous anxiety in the treatment of knee wounds. The excision of the patella, when it was at all extensively fractured, had contributed also to the results. Amputation was still required if the patients showed signs of serious lack of resistance to infection and started going downhill. Cases of this kind, though fortunately much less common than in the First World War, still caused anxiety and demanded careful watching and good judgment in deciding the right moment for amputation. Loss of limb had to be accepted in order to save life.