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Acta orthop. scand. 48, 190-196, 1977
ARTHROSCOPY IN ACUTE INJURIES OF THE KNEE JOINT
J. GILLQUIST, G. HAGBERG & N. ORETORP
Department of General Surgery, University Hospital, Linkoping, Sweden.
Arthroscopy was performed during the acute phase of injury in 84 knees (79 patients). A satisfactory view of the joint was obtained in all cases, and no complications occurred. About two-thirds of the patients had injuries associated with violent rotation-abduction. In about one-third of the patients operation could be avoided. In cases with haemarthrosis, serious ligament injury was present i n nearly 50 per cent. Complete arthroscopy was associated with few diagnostic errors. Clinical examination often led to uncertain or incorrect diag- nosis even when performed under anaesthesia by experienced surgeons. In contrast, arthroscopy led to rapid diagnosis and treatment, thus shortening the period of disability. We recommend arthroscopy in acute knee injuries, bu t the examination must be performed by an experienced arthroscopist.
Key words: endoscopy; arthroscopy; knee injury; knee joint; haemarthrosis
Accepted 18.i.77
Early diagnosis of injuries of the knee joint is of great importance, in order to prevent disability (Liljedahl & Nord- strand 1969, Alm 1974). However, com- mon diagnostic methods often fail during the acute stage of a knee injury (Lilje- dahl et al. 1965). In recent years arthros- copy has been used with great success in diagnosis of non-acute cases of knee joint trauma or disease (Jackson & Abe 1972, Dandy & Jackson 1975, Casscells 1971, Wruhs 1970, Watanabe et al. 1968, Gallannaugh 1973, Alm et al. 1974, Gill- quist & Hagberg 1976). Jackson (1974) and O’Connor (1974) reported that arthroscopy might be of value in acute injuries. Some preliminary experiments with arthroscopy in the acute stage (Gill- quist ,& Hagberg 1976) led us to test the technique in a larger series of consecu-
tive patients over the past few years. This paper summarizes our experiences.
METHODS
Zndications f o r arthroscopy Patients admitted to the emergency department with acute knee injury d i t h haemarthrosis or acute locking with effusion were included. Lock- ing was defined as an extension defect with a n elastic resistance against forced extension. The diagnosis of haemarthrosis was made when swelling of the joint took place immediately after trauma and blood was aspirated from the joint. Patients were examined on admission im- mediately after aspiration of the distended joint. A preliminary diagnosis was made, and the patient was admitted to hospital. Straight X-ray films were always taken on admission.
Arthroscopy was carried out as soon as pos- sible after admission, usually within a few days, by an experienced arthroscopist, the joint being first examined under general anaesthesia by the
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ARTHROSCOPY IN ACUTE KNEE INJURIES 191
n
10 .'r 5 1
Figure I . Interval between accident and arthros- opy. In some patients treated initially at other hospitals arthroscopy was delayed.
surgeon. The procedure was always included in the normal operation list, so that immediate operation could be carried out if necessary.
Technique of arthroscopy Our technique has been described earlier (Gill-
quist & Hagberg 1976). No tourniquet was used. The 5 mm Storz arthroscope (Stille Werner, Sweden) is introduced into the suprapatellar bursa through the patellar tendon. Sterile water is flushed through the joint by an infusion pump (Sarns Model 5500, Stille Werner, Sweden). and allowed to escape through a special needle (arthroscopy cannula, Stille Werner, Sweden) inserted into the suprapatellar bursa. About 2000 ml is required. Hooks (Gillquist & Hagberg 1976) are used to test the menisci and the liga- ments. When indicated by the findings a t arthroscopy, arthrotomy is performed at the same session.
accident. In some cases the interval was longer as the patients had first been treated at other hospitals. These patients also fulfilled the criteria of haemarthrosis or locking.
RESULTS
Figure 2 shows the diagnosis arrived at during arthroscopy or arthrotomy. The anterior cruciate ligament was injured in 50 per cent of the injured knees. Com- bined injury of the anterior cruciate liga- ment, medial meniscus, and the medial collateral ligament was the commonest finding. In fact, combhed injuries were the rule. Acute locking of the joint was an unreliable sign of meniscus lesion. Out of 28 patients with a locked knee only 12 showed tears of the meniscus (10 medial and 2 lateral). Most others showed partial rupture of the medial col- lateral ligament.
Haemarthrosis Haemarthrosis was present in 69
arthroscopies (Table 1 ) . The commonest
menisci
PATIENTS
During the period 1972 to 1975, we performed 84 arthroscopies on 79 consecutive patients (66 men and 13 women) in the acute period after a knee injury. The age of the patients ranged between 15 and 60 years, and most ( 5 5 patients) were between 15 and 30. Soccer was a prominent cause of injury, and together with other sports accounted for 63 per cent of all cases.
Time of arthroscopy (Figure 1) Seventy per cent of the arthroscopies were
performed within the first 4 days after the
pl ica Im synov.
m m Figure 2, Diagram showing the combination o f injuries found at 84 arthroscopies. There were also three patients with rupture of the posterior cruciate iigament, two with dislocation o f the patella, seven with a chondral fracture, and one with a ruptured patellar tendon strip after re- construction of the anterior cruciate ligament. Two patients wi th rupture of the anterior cruciate ligament and lateral meniscus also showed partial rupture of the medial collateral ligament. Ten showed partial rupture of the anterior cruciafe Iigament. (For abbreviations, see text to Table 3.)
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192 J. GILLQUIST ET AL.
finding was rupture of the medial col- lateral ligament in combination with tearing of the anterior cruciate ligament. Rupture of the anterior cruciate ligameni was present in 64 per cent of the 69 cases with haemarthrosis. However, the rup- ture was partial and did not necessitate operation in 10 cases. Rupture of the medial collateral ligament was diagnosed by valgus instability, and at arthroscopy a wide medial recess or haemorrhage from the ruptured medial synovia was found. In some cases rupture of the deep portion of the ligament could be demon- strated. The arthroscopic findings do not permit differentiation of partial and total ruptures of the medial collateral ligament, however, and this was done by testing the valgus instability. In seven cases a rupture of the plica synovialis was found to be the sole source of the haemarthrosis, and this together with partial rupture of the medial collateral ligament was present in five cases. Rup- ture of the joint capsule was an uncom- mon cause of haemarthrosis.
Table 1 . Injuries in patients showing haem- arthrosis ( n = 69). In many cases the various
Figure 2 ) . injuries occurred in combination (see also
Type of injury Per cent n
Total rupture of
Partial rupture of
Total rupture of
Total or partial rupture
Rupture of a meniscus Osteochondral fracture Dislocation of the patella Rupture of the plica synovialis Rupture of the joint capsule Rupture of a strip from the
the anterior cruciate ligament
the anterior cruciate ligament
the posterior cruciate ligament
of the medial collateral ligament
patellar ligament (reconstruction of the anterior cruciate ligament)
31 45
10 14
2 3
41 59 16 23
7 10 2 3 7 10 3 4
1 -
Table 2 . Diagnosis at arthroscop~] or arthrotorn!] in 15 patients without haemarthrosis.
Diagnosis No. Rupture o f :
medial meniscus 7 lateral meniscus 3 medial collateral ligament 4 posterior cruciate ligament 1
Total 15
Cases wi th no haemarthrosis The diagnosis in these 15 cases is
shown in Table 2. The commonest lesion was ruptured meniscus. One patient showed rupture of the tibia1 insertion of the posterior cruciate ligament without haemarthrosis. There were no ruptures of the anterior cruciate ligament in this group.
Follow-up examinat ion In 30 patients arthroscopy was not fol-
lowed by operation. They were followed up for 1 year and most regained full activity. In two patients total rupture of the anterior cruciate ligament and par- tial rupture of the medial collateral liga- ment were not treated by operation. In one of them arthroscopy was performed under epidural anaesthesia and the pa- tient wished to postpone operation. The other was an obese, 40-year-old woman alcoholic, injured while drunk. Apart from the cruciate ligament injury she also had severe osteoarthrosis. Operation was not considered to be indicated. In both cases the knee joint was unstable, and the patients were disabled at the follow-up examination.
Diagnostic errors In five cases ( 9 per cent) there was
some lack of correlation between the arthroscopic picture and the findings at operation. In four of these a linear rup- ture of the posteromedial part of the medial meniscus was not diagnosed. One
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ARTHROSCOPY IN ACUTE KNEE INJURIES 193
Table 3. Number of patients with different diagnoses included in groups I -III .
Type of injury Group I Group Group I11
avoided zL$::te superfluous Operation Change Of Arthroscopy Total
acl (partial rupture) + mcl 4 5 1 10 - 2 2 acl + mm -
acl + Im 1 * 1 1 3 acl + mcl + mm - 2 4 6 acl + rncl + Im - 1 1 2 acl + mcl + mm + Im - 1 1 2 acl ( 3 with fracture) - 2 2 4 rncl (1 capsular rupture) 9 - 1 10 mm - 3 4 7
4 lm (1 with fracture) -
1 7 plica synovialis (+ 5 with mcl) 6 - 3 PCl
osteochondral fracture 4 1 2 7 capsular rupture 1 - 1 2
2 patellar dislocation 1 1 1 rupture of reconstructed -
- 4
3 - -
- - 1
anterior cruciate ligament
Total 26 31 27 a4
This patient showed partial rupture of the anterior cruciate ligament, a small rupture of the lateral meniscus, and severe osteoarthrosis. Operation was not performed. acl = the anterior cruciate ligament, rncl = medial collateral ligament, mm = medial meniscus, Im = lateral meniscus, pcl = posterior cruciate ligament.
rupture of the lateral meniscus was also overlooked. In these cases indication for operation had already been established by the arthroscopic demonstration of a ruptured anterior cruciate ligament.
Misinterpretation and technical errors This group comprises three patients
subjected to unnecessary operations. The first patient with a rupture of the plica lata was erroneously operated on with a diagnosis of rupture of the anterior cruciate ligament. In another patient with a fracture of the eminentia inter- condyloidea without dislocation a small rupture of the medial meniscus was diag- nosed at arthroscopy. During arthrotomy, however, the rupture was found to be insignificant.
The third patient had a linear rupture of the capsular attachment of the medial
meniscus diagnosed at arthroscopy. Dur- ing operation a rupture of the capsule was seen, but the meniscus was thought to be intact. However, the patient had to be subjected to reoperation after further trauma a few months later. He then showed a dislocated medial meniscus. The significance I of the arthroscopic finding had thus been underestimated during the first operation.
Diagnostic value of arthroscopy The diagnosis arrived at during ar-
throscopy was compared with the diag- nosis made after X-ray examination (mostly straight films) and clinical examination under anaesthesia by an ex- perienced surgeon. The patients were ar- ranged in three groups according to the diagnostic contribution made by arthros- copy in each case. Group I consists of
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194 J. GILLQUIST ET AL.
patients in whom operation could be avoided as a result of arthroscopy and Group I1 of patients in whom the sur- gical approach was changed. When the clinical examination was completely in accordance with the arthroscopic diag- nosis the arthroscopy was regarded as having been unnecessary (Group 111). Patients in whom diagnostic errors, mis- interpretations, and technical errors oc- curred were also referable to groups 11-111. Clinical examination at the emer- gency department gave correct findings in only 15 per cent of cases. Subsequent examination under anaesthesia gave cor- rect findings in only 32 per cent of the patients. In patients with ruptured men- iscus the diagnosis was correct in 63 per cent.
Group Z. Operation avoided (26 cases). In this group, clinical examination on ad- mission, examination under anaesthesia and straight X-ray failed to result in a conclusive diagnosis. In eight patients the knee was locked, simulating rupture of a meniscus. Other patients showed haemarthrosis and a suspected drawer sign forwards, or fractures were present possibly indicating rupture of the an- terior cruciate ligament. Four with par- tial rupture of the anterior cruciate and medial collateral ligaments were included (Table 3 ) .
Group ZZ. Change of surgical procedure (31 cases). In this group most patients showed marked haemarthrosis. Liga- ment injury was suspected but could not be confirmed. Seven of the 10 patients with a rupture of the lateral meniscus were in this group (Table 3 ) . It was often impossible to distinguish clinically between these patients and the patients of group I with haemarthrosis.
Group 111. Arthroscopy superfluous (27 cases). Here the clinical diagnosis was clear. Of 31 patients with total rup- ture of the anterior cruciate ligament, 17 were included in this group, as were also 11 out of 17 with ruptured medial
meniscus (Table 3 ) . Many of these pa- tients were referred to us for arthroscopy from other hospitals. An experienced surgeon established the diagnosis by clinical examination, and this was con- firmed by arthroscopy.
Complications No infections occurred. Bacterial cul-
tures of the irrigation fluid before and after arthroscopy were always negative. No adverse effects resulted from flushing with sterile water. In two patients slight pain at the site of introduction of the instrument disappeared after a few weeks. In no case was the field of view obstructed by haemorrhage in the joint even though fresh bleeding sometimes occurred during the procedure.
DISCUSSION
Arthroscopy of an acutely injured knee joint with haemarthrosis presents sev- eral difficulties. This is probably why some clinicians regard the condition as a contraindication to the procedure (Cass- cells 1971, Jackson & Abe 1972, Henche 1974, Glinz 1974). On the other hand, early diagnosis of an intra-articular in- jury has several advantages (Liljedahl & Nordstrand 1969, Gillquist et al. 1971, Alm 1974), and efforts to overcome the difficulties will be rewarded. However, the haemarthrosis necessitates irrigation of the joint. We have tested several means of doing this (Gillquist & Hagberg 1976). Our present technique using an infusion pump, arthroscopy cannula, and sterile water has proved entirely satis- factory.
Another problem was the new, un- familiar picture of an acute knee injury. It was sometimes difficult t o demon- strate rupture of the anterior cruciate ligament, as the tissue was so frag- mented. However, the absence of the
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ARTHROSCOPY IN ACUTE KNEE INJURIES 195
cruciate ligament at its normal site often led us to the diagnosis. Moreover, after some days arthroscopy becomes more difficult as the blood in the joint causes synavitis and the bulging synovia often tends to obstruct the field. Because of these problems, arthroscopy of an acute knee injury should only be undertaken by a surgeon with great experience of arthroscopy in non-acute cases.
The fact that haemarthrosis is a sign of serious injury is demonstrated by the present series. In 46 per cent of patients with haemarthrosis a lesion of the an- terior cruciate ligament was present in association with partial rupture of the medial collateral ligament and sometimes also with rupture of the meniscus (the “unhappy triad”, O’Donoghue 1950) . However, in 10 of these patients only a partial rupture of the anterior cruciate ligament was found. The “unhappy triad” leads to permanent disability if left untreated (Alm 1974), and treat- ment is more complex if delayed (O’Donoghue et al. 1966, Brostrom et al. 1968, Gillquist et al. 1971, Alm et al. 1974). If all our patients had been initi- ally treated by conservative means about two-thirds would have suffered from prolonged disability (Alm 1974). In pa- tients with haemarthrosis rupture of a meniscus was usually combined with lesions of the ligaments, whereas when no haemarthrosis was present a single rupture of a meniscus was the com- monest finding. Rupture of the joint capsule alone was an infrequent cause of haemarthrosis. The conclusion is there- fore that a patient with haemarthrosis should be regarded as having a serious ligament injury until this has been dis- proved.
Our series also demonstrates the in- sufficiency of clinical examination even when performed under anaesthesia by an experienced surgeon. In fact, even when we later judged the arthroscopy to have been superfluous many of the patients
could not have been safely distinguished from the other groups by clinical exam- ination alone, However, the clinical diag- nosis was always correct when marked instability was present. Thus in such cases arthroscopy seems unnecessary. This series includes some patients in whom more than one experienced sur- geon clinically diagnosed rupture of the medial meniscus that during arthroscopy proved to be rupture of the lateral one, calling for a completely different ap- proach. Smillie (1970) also drew atten- tion to this problem. Locking of the knee joint with extension defect was inter- preted at the clinical examination as being a sign of rupture of the meniscus. At arthroscopy, however, no injury of this kind could be found in more than half of the cases. In the present series very few meniscus ruptures were missed. Arthroscopy can in the majority of cases establish the state of a meniscus.
In seven cases arthroscopy also dis- closed a type of knee injury not previous- ly described, a rupture of the plica synovialis. In the first case the diagnosis was confirmed at operation. It might be argued that the introduction of the arthroscope through the patellar tendon might have caused the injury. The fact that the lesion has never been observed in any of our non-acute arthroscopies is evidence against this. The association with a partial rupture of the medial col- lateral ligament might indicate that the injury represents the initial stage of the rotational force resulting in the “un- happy triad”.
In conclusion, we have found arthros- copy to be a very safe, reliable, and use- ful diagnostic method in cases of acute knee trauma. About two-thirds of the patients underwent early, satisfactory re- pair owing to the early diagnosis. In one- third of the patients operation could be safely avoided. Only three patients were subjected to unsuccessful arthrotomy. No complications occurred.
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ACKNOWLEDGEMENT
This work was supported by grant no. 73:22 from The Research Council of the Swedish Sports Fcdcration.
REFERENCES
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Alm, A. & Gillquist, J. (1974) Reconstruction of the anterior cruciate ligament by using the medial third of the patellar ligament. Acta chir. scand. 140, 289-296.
Brostrom, L., Gillquist, J., Liljedahl, S.-0. & Lindvall, N. (1968) Behandling av invcterc- rad ruptur av framre korsbandet. Suenska LaIc.-Tidn. 65, 4479-4487.
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Gillquist, J. & Hagberg, G. (1976) A new modi- fication of the technique of arthroscopy of the knee joint. Acta chir. scand. 142, 123-130.
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Jackson, R. W. (1974) The role of arthroscopy in the management of the arthritic knee. Clin. Orfhop. 101, 28-35.
Liljedahl, S.-O., Lindvall, N. & Wetterfors, J. (1965) Early diagnosis and treatment of acute ruptures of the anterior cruciate liga- ment. J . Bone Jt Surg. 4’7-A, 1503-1513.
Liljedahl, S.-0. & Nordstrand, A. (1969) Injuries to the ligaments of the knee. Diagnosis and results of operation. Znjury 1, 17-24.
O’Connor, R. L. (1974) Arthroscopy in the diag- nosis and treatment of acute ligament in- juries of the knee. J. Bone J t Surg. 56-A, 333-337.
O’Donoghue, D. H. (1970) Treatment of injuries to athletes. W. B. Saunders, London.
O’Donoghue, D. H., Frank, G. R., Jack, S. C. & Kenyon, R. (1966) Repair of the anterior cruciate ligaments in dogs. J . Bone J t Surg. 48-A, 503-518.
O’Donoghue, D. H. (1950) Surgical treatment of fresh injuries to the major ligaments of the knee. 1. Bone Jt Surg. 32-A, 721-738.
Smillie, I. S. (1970) Injuries of the knee j o i n t . Livingstone, Edinburgh & London.
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Correspondence to : Jan Gillquist, M.D., Department of Surgery, University Hospital, S-581 85 Linkoping, Sweden.
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