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Arthroscopic Versus Open Debridement of Penetrating Knee Joint Injuries

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Arthroscopic Versus Open Debridement of Penetrating Knee Joint Injuries ARTHROSCOPIC VERSUS OPEN DEBRIDEMENT OF PENETRATING KNEE JOINT INJURIES John R. Raskind, M.D.* Richard A. Marder, M.D. ABSTRACT included in this study. The group treated with arthroscopic Arthroscopic debridement of penetrating knee joint debridement consisted of seven motor vehicle "dash- injuries has become a common treatment method. A board" injuries, five motorcycle/moped/bicycle injuries and comparative study was undertaken to compare this two low velocity gun shot wounds. The mean wound size method with open joint debridement. Fourteen penetrat- in this group was 3.8 centimeters (cms) (range one to ing knee joint injuries (fourteen patients) were treated by twelve cms) and the mean patient age was 26.6 (range arthroscopic examination and debridement and were com- nine to fifty-twelve years). The open debridement group pared to sixteen penetrating knee joint injuries (fifteen consisted of eight motor vehicle "dashboard" injuries, five patients) treated by open debridement. There were no motorcycle/moped injuries, one low velocity gunshot resultant infections or operative complications in either wound, one weed-trimmer laceration, and one power-saw group. Of note, the arthroscopic debridement group had a laceration. The mean wound size in this group was 4.6 cms shorter postoperative hospital stay [mean of 1.6 days (range one to twelve cms) and the mean patient age was compared to a mean of 2.6 days in the open debridement 26.9 years (range fifteen to forty-three years). group (p < 0.02)], a significant incidence of additional Diagnosis was based upon examination of the wound, intra-articular injuries detected (p < 0.01), less postoper- AP, lateral, and notch radiographic views of the knee, and ative pain, and a superior cosmetic result. We conclude a saline-methylene blue arthrogram performed in the that arthroscopic debridement of penetrating knee joint emergency room. The finding of a visible or palpablp injuries is a safe and effective method of treatment, laceration extending into the joint, air in the joint on providing additional diagnostic information while minimiz- radiographs, or fluid extravasation during saline- ing morbidity and reducing hospital stay. methylene blue arthrogram was considered as confirma- tion of knee joint penetration. All patients received irriga- INTRODUCTION tion of the soft tissue wound in the emergency room, Penetrating knee joint injuries are the most common application of a sterile betadine soaked dressing, intrave- open joint injuries seen in a busy trauma center today5. nous cefazolin, and tetanus prophylaxis. Surgical debride- The joint contamination from these injuries can result in ment was subsequently performed on an urgent basis septic arthritis and lead to joint destruction unless ade- within eight hours, with the treatment method determined quate and prompt surgical debridement is performed2. by surgeon preference. Additional damage to articular cartilage, menisci, and ligaments may result from direct or indirect trauma at the Surgical Procedure time of knee joint penetration. Traditional treatment has consisted of open surgical Arthroscopic examination and debridement was per- debridement and primary or delayed closure. With the formed using standard superomedial inflow and anterolat- development of arthroscopic surgery, many surgeons eral viewing portals. An additional anteromedial portal was have adapted this method of treatment for selected open utilized as necessary for probing and debridement. Open joint injuries. A study was undertaken to compare these debridement was performed by extending the traumatic two methods of treatment. wound into a limited medial or lateral parapatellar arthro- tomy (depending upon location of traumatic wound). Both MATERIALS AND METHODS arthroscopic and open treatment groups underwent exam- ination of knee stability under anesthesia and irrigation of During a two year period, thirty consecutive penetrat- the joint with six liters of sterile saline. In both groups, a ing knee joint injuries in twenty-nine patients were iden- 1/4 inch suction drain was inserted into- the joint and tified and treated. Injuries with associated fractures re- brought out through a separate stab incision. Traumatic quiring internal fixation or cast immobilization were not skin wounds were left open. Postoperatively, all patients received intravenous cefazolin every eight hours until the *From the Department of Orthopaedic Surgery, University of drain was removed at twenty-four to forty-eight hours California, Davis, School of Medicine, Sacramento, California (dependent upon drain output). Local wound care was Volume 13 121 J. R. Raskind, R. A. Marder begun at the time of drain removal and full weight bearing Patzakis et al,5 reported a prospective study in which with early active motion was instituted. 129 open knee joint injuries were treated with intravenous antibiotics, open arthrotomy, and closed suction irrigation. RESULTS In this series, a high proportion of the cases resulted from A retrospective review of all study patient's medical gunshot wounds or co-existed with open fractures extend- records was performed. No acute or subacute infection ing into the knee joint. With their closed suction irrigation requiring additional treatment occurred in either treatment system, a fourteen percent wound contamination rate was group and there were no operative complications. At noted. The authors concluded that arthrotomy followed by surgical debridement, eleven out of fourteen (79%) arthro- primary closure of the joint without a drain was the scopically debrided knees had additional intra-articular treatment of choice. abnormalities detected; whereas in the group treated by Gunshot wounds to the knee, although a minority of the open debridement, only two out of sixteen (13%) knees patients in our study (ten percent), represent a special were noted to have additional intra-articular abnormalities case. A bullet which traverses the joint may contaminate (Table 1). This observed difference between groups was the wound directly or from clothing fragments and skin flora. Autosterilization of low velocity bullets has not been statistically significant (p < 0.01) by independent t-test. 8 The mean postoperative inpatient stay for the arthro- shown to occur . Other problems occur when retained scopic group was 1.6 days (range one to two days), intra-articular lead fragments become solublized3, leading compared to 2.6 days (range one to four days) for the open to chronic synovitis, hypertrophic arthritis, or even sys- group (p <0.02 by independent t-test). At the initial temic lead poisoning6. Meticulous debridement is there- postoperative visit five knees treated by arthroscopic fore mandatory with gunshot wounds to the knee, and may debridement had full range of motion as compared to none be carried out by either open arthrotomy' or in the open debridement group. This difference, however, arthroscopically4 7. was not statistically significant. SUMMARY AND CONCLUSIONS DISCUSSION Penetrating knee joint injuries require early debride- Although penetrating wounds to the knee joint are the ment to prevent the development of joint infection and its most common open joint injury, sparse literature exists sequelae. In our series, surgical debridement (open or concerning management of these injuries. Those reports arthroscopic) with joint closure over a suction drain in which are available advocate conflicting treatment meth- conjunction with twenty-four to forty-eight hours of intra- ods. venous antibiotics resulted in no joint infections. With Based upon his World War II experience, Hampton2 arthroscopic debridement the hospital stay was reduced, a recommended early aggressive surgical treatment of open higher incidence of associated intra-articular abnormalities joint wounds, but stated that simple penetrating wounds was detected, postoperative pain was reduced, and cos- with little or no articular damage should be treated mesis was improved. nonoperatively. For those which are debrided surgically, Arthroscopic debridement of penetrating joint injuries is he urged thorough immobilization as an essential deterrent therefore a safe and effective treatment method of treat- to infection. ment. It allows for a more complete examination of the knee with the potential to detect and treat associated injuries which may not be evident with open debridement. Table 1 ADDITIONAL INTRA-ARTICULAR ABNORMALITIES DETECTED Arthroscopic Open Articular Injury 5 2 Chondromalacia 2 0 Partial Anterior Cruciate Ligament tear 2 0 Meniscal tear 2 0 11 2 122 The Iowa Orthopaedic Journal Arthroscopic Versus Open Debridement ofPenetrating Knee Joint Injuries BIBLIOGRAPHY 5 Patzakis, Door, et al.: The Early Management of Open ' Ashby, M.E.: Low-Velocity Gunshot Wounds Involv- Joint Injuries. J. Bone and Joint Surg., 57-A(8), 1975. ing the Knee Joint: Surgical Management, J. Bone and 6- Slavin, R.E., et al.: Lead Arthritis and Lead Poisoning Joint Surg., 56-A(5):1047-1053, 1974. Following Bullet Wounds: A Clinicopathologic, Ultrastruc- 2- Hampton, O.P.: Wounds ofJoints. SCNA, 38(6):1517- tural, and Microanalytic Study of Two Cases. Human 1528, 1958. Pathology, 19(2):223-235, 1988. 3- Leonard, M.H.: The Solution of Lead by Synovial 7- White, R.R.: Arthroscopic Bullet Retrieval. J. Fluid. CORR, 64:225-261, 1969. Trauma, 27(4):455-456, 1987. 4- Parisien, J.S. and Esformes, I.: The Role of Arthros- 8- Wolf, A.W., et al.: Autosterilization in Low-Velocity copy in the Management of Low-Velocity Gunshot Bullets. J. Trauma 18(1):63, 1978. Wounds of the Knee Joint. CORR, 185:207-213, 1984. Volume 13 123.
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