History

CHAPTER VIII

Wounds of Joints

HISTORICAL NOTE

Pool, who wrote the section on wounds of the joints in the history of the United States Medical Department in World War I,²stated that the evolution of the management of these injuries by Allied medical officers fell into three well-defined stages:

1. Débridement; drainage; irrigation with antiseptic solutions; immobilizations. 2. Débridement; Carrel-Dakin treatment of the joint; immobilization. 3. Débridement; lavage of the joint with Dakin`s solution or ether; joint suture, with drainage of the joint for about 24 hours; immobilization; passive movements and massage in 8 to 10 days.

According to Pool, the poor results accomplished in joint injuries in the early years of World War I could be attributed to –

* * * an undervaluation, on the part of surgeons, of the resistance to infection which the synovial membrane of a joint offers, a failure to comprehend the proper operative procedures, and the universal employment of prolonged immobilization.

Certainly a realization of the importance of the three chief features that characterized the final program; namely, debridement, complete closure of the joint, and early motion, developed slowly. In the early years of the war, surgeons hesitated to close a wounded joint for fear of enclosing a potential septic process. Drainage tubes were therefore used freely. In November 1917, however, the Interallied Surgical Conference, when it met in its third session,³concluded that “complete closing of joint wounds is universally approved.” Early in the war, repeated efforts were made to obtain chemical sterilization of the joint cavity by the use of various antiseptic methods and solutions, including, somewhat later, the Carrel-Dakin method. Eventually, there was general agreement that sterilization could not be achieved by these methods and that drainage tubes not only failed to drain the joint but also caused considerable harm by trauma to the intra-articular structures and by inviting secondary infection. Drainage of the compounding wound was, of course, an entirely different matter.

¹ The data in this chapter on wounds of the knee joint were collected by Maj. Herbert W. Harris, MC, and Capt. Edwin L. Mollin, MC, 17th General Hospital: Maj. Howard B. Shorbe, MC, 70th General Hospital; and Lt. Col. George A. Duncan, MC, and Maj. Benjamin W. Rawles, MC, 45th General Hospital. The data on wounds of the hip joint were collected by Maj. Spencer A. Collom, Jr., MC, 300th General Hospital.
² Pool, Eugene H.: Wounds of Joints. In the Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 317-341.
³ Conclusions of the Interallied Surgical Conference, 3d session. In The Medical Bulletin, War Medicine, 1917-18, vol. t, pp. 77-78.

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Finally, immobilization for long periods was the rule in the early days of the war. Willems, whose work was done chiefly at La Panne in Belgium, provided the principal exception to this position.⁴ He contended that early, active motion was essential in all penetrating wounds of the joint and particularly in wounds of the knee joint, regardless of whether or not infection was present. He considered early motion, in fact, as especially essential in infected wounds of the knee joint, his contention being that by motion purulent exudate was “squeezed” out of the recesses of the joint, without the traumatizing effect of drainage tubes, while continued motion prevented ankylosis and favored full functional restoration. Some of his results were brilliant. Pool mentioned the Willems method approvingly but supplied no supporting data. In spite of the results Willems was ableto achieve, his concepts spread very slowly, and the general opinion continued to be that early active motion was even more impractical when suppurative arthritis was present than it was in uncomplicated penetrating wounds of the knee joint. The theory was generally accepted, however, that motion should be begun reasonably early, which usually meant within 10 days of injury.

Resection of joints that were the site of suppurative arthritis following penetrating wounds had been practiced in all recorded wars preceding World War I, including the War of the Rebellion. In World War I, the French used this method extensively. It was sometimes employed as a primary prophylactic procedure, to eliminate the risks of infection and subsequent generalized sepsis and to avoid the necessity for amputation. In other instances, it was used as a secondary procedure in joint wounds complicated by suppurative arthritis. The high death rate and the high amputation rate reported for wounds of the major joints in all previous wars and in the early phases of World War I furnished ample rationale for this practice, particularly in severely comminuted fractures extending into the joint. The operation, however, found little favor with either British or American surgeons in World War I, though Pool stated that it had a limited application, to be determined by individual indications, in cases of suppurative arthritis not progressing satisfactorily under more conservative methods of management.

The civilian experience with wounds of the joints between World War I and World War II is in no sense comparable to military experiences. Neither in number nor severity do civilian wounds compare with battle-incurred wounds. Furthermore, the suppurative arthritis observed in civilian practice is usually bloodborne, in contrast to the predominantly traumatic etiology of the variety observed after battle-incurred wounds.

In peacetime practice, suppurative arthritis continued to be treated between the wars by parapatellar drainage or, less often, by posterior drainage, combined with immobilization of the part by splints or by plaster casts. The Willems method of early mobilization, which some surgeons continued to use after World War I, gradually lost favor and was eventually discarded

⁴ See footnote 2, p. 211.

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entirely. Occasional surgeons practiced aspiration of the joint. Others advocated a small arthrotomy incision and lavage of the cavity followed by complete closure. Sulfonamide therapy, which was introduced shortly before World War II began, was thought to be beneficial.

Both Jolly ⁵ and Trueta,⁶ on the basis of their separate experiences in the Spanish Civil War, had concluded that the best method of management of war wounds of the joints seen in forward hospitals was (1) adequate debridement and removal of foreign bodies, (2) thorough lavage of the joint cavity, (3) suture of the synovial membrane or the capsule, and (4) immobilization of the part either in plaster or in a standard splint. There were differences of opinion as to how long immobilization should be continued in fixed hospitals, but there was general agreement that either passive or active motion should be instituted after the danger of suppurative arthritis had passed and as soon as the state of the soft-tissue wound permitted it. Joint injuries that were essentially compound fractures of the bones entering into the articulation were immobilized in the position least undesirable from the standpoint of future function, it being accepted that in such cases some residual limitation of motion was inevitable. Operation was not regarded as necessary in instances of perforating bullet wounds; in these cases it was assumed that bone damage was minimal.

In World War II, just as in World War I, joint resection was rather extensively practiced by French surgeons, who employed it, as in the earlier war, to forestall amputation due to infection in severely damaged joints, as well as in suppurative arthritis. Russian and German surgeons also employed resection of the joint, but the British seldom resorted to it.

GENERAL CONSIDERATIONS

It is surprising, in view of the extreme seriousness of wounds of the joints in military surgery, how few directions for their management were provided for United States Army medical officers. Technical manual Guides to Therapy for Medical Officers (TM 8-210), published 20 March 1942, merely stated that wounds of the joints should be treated as compound fractures. The item was even less useful than it might have been because the text was not. indexed. Orthopedic Subjects,⁷ one of the Military Surgical Manuals published by the Subcommittee on Orthopedic Surgery of the Committee on Surgery, Division of Medical Sciences, National Research Council, contains less than half a page on the subject:

If the wound involves a joint, this should be opened widely at the time of the incision of the skin and fascia and the joint should be thoroughly explored. Loose fragments of

⁵ Jolly, D. W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941.
⁶ Trueta, J.: Treatment of War Wounds and Fractures With Special Reference to the Closed Method as Used in the War in Spain. New York: Paul B. Hoeber, Inc.
⁷ Orthopedic Subjects. Prepared and edited by the Subcommittee on Orthopedic Surgery of the Committee on Surgery of the Division of Medical Sciences of the National Research Council. Military Surgical Manuals, Philadelphia & London: W. B. Saunders Co., 1942.

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bone and any foreign material present in the joint should be removed. Any soiled bone exposed in the wound should be excised. The joint may or may not be irrigated with physiologic salt solution, depending on the choice of the surgeon. In most instances it is possible to clean the joint adequately without irrigation. The wound should then be dried, the joint cavity should be sprinkled liberally with one of the sulfonamide drugs and the wound should be treated as has been described in the case of fractures not involving joints. The vaseline gauze packing should extend down to the joint cavity. In most instances the synovial membrane can be closed with fine catgut. In wounds which are not very recent, or which are in questionable condition, the joint should be left open. As a rule, no attempt should be made to suture the capsule or ligaments exposed in the wound and severed. The joint should be immobilized in a plaster-of-paris cast as described previously.

An accurate record of wounds of the various joints does not exist for World War II. This is chiefly because compound fractures adjacent to and involving the joints were so often present concurrently. When this happened, the injuries were likely to be recorded as fractures rather than as wounds of the joints. Certain corrections, of course, can be read into certain statistics. Thus a compound fracture of the femoral condyles necessarily involved the structures of the knee joint, just as a compound fracture of the head of the humerus necessarily involved the structures of the shoulder joint. These adjustments, however, were not possible when the level of the fracture was not stated, as it frequently was not, and in these circumstances the record of joint involvement was permanently lost.

There was never any question as to the potential seriousness of all wounds of the joints in World War II. Any damage, no matter how slight, had to be regarded as prejudicial, in some degree, to future function. The injuries varied from small penetrating depressions which carried the articular cartilage into the underlying cancellous bone to extensive compound comminuted fractures of the bone ends making up the joint. Often the damage amounted to complete destruction of all articular structures. Even if the damage was slight, suppurative arthritis was a possibility in every wound of a joint. At the best, its development invited ankylosis. At the worst, it endangered the survival of the extremity and sometimes the survival of the patient. Every injury of a joint had to be managed with the possibility of these consequences in mind.

Since the overwhelming majority of wounds of the joint were compound fractures of the bones entering into the articulation, the management of these wounds by United States Army surgeons in World War II, as might have been expected, went through the same process of evolution as has been described for the management of compound fractures. Since wounds of the knee joint are far and away the most important of these injuries, the development of a standard policy of management chiefly concerned them and can be most conveniently and logically described in connection with them. The management of wounds of the hip joint also introduced certain special considerations which are briefly described in a separate section.

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WOUNDS OF THE KNEE JOINT

Since the knee joint and the hip joint are the major weight-bearing joints of the body, any injury to either joint is serious. A penetrating wound produced by a missile usually results in intra-articular damage. The trauma is usually sufficient to affect future function to some degree, and each wound is a potential instance of suppurative arthritis. Once suppurative arthritis is established, the infectious process often endangers both life and limb, and fusion of the joint is often the best that can be hoped for.

Frankau, who wrote the section on gunshot wounds of the joints in the official British history of World War I, ⁸ confirmed these generalizations. In the first months of the war, he said, the results were “lamentable.” The amputation rate for wounds of the knee joint not complicated by fractures was 60 percent. It rose to at least 80 percent when a concurrent fracture was present. The case fatality rate was always high, though, as methods of management improved, it fell to 8 percent. The amputation rate was also reduced; it fell from 25 percent in 1916 to 7 percent in 1917.

In view of the results in World War I, one can understand the point of view expressed in Buxton`s ⁹ report on 273 wounds of the knee joint treated in one fixed hospital during the second and third Libyan campaigns in World War II; namely, that an incidence of 34.8 percent for suppurative arthritis, an amputation rate of 4.4 percent, and a death rate of 1.8 percent could well be regarded as “excellent.” Buxton attributed these results to the small size of the causative missiles in this series, as well as to the feasibility of early operation and the availability of systemic sulfonamide therapy. When, however, such results as these are fairly regarded as “excellent,” it is easy to see why wounds of the knee joint should be classified among the most serious of all battle injuries.

The majority of wounds of the knee joint in World War II were caused by high-explosive shell fragments, including artillery and mortar shells, grenades, mines, and boobytraps. These missiles were responsible for 222 of the 271 wounds of the knee joint observed at the 45th General Hospital in the Mediterranean theater. Forty-two of the remaining forty-nine injuries were caused by bullet wounds, six were noncombat injuries which had occurred in traffic accidents, and one injury was incurred in an airplane crash.

Early Plans of Management (Before February 1944)

In the early months of United States participation in World War II, wounds of the knee joint were managed as the judgment and experience of tile individual medical officer dictated, rather than by theaterwide policies. In

⁸ Frankau, C. F. S.: Gunshot Wounds of the Joints. In History of the Great War Based on Official Documents. Medical Services Surgery of the War, London: His Majesty`s Stationery Office, 1922, vol. II, pp. 297-325.
⁹Buxton,St. J. D.: Gunshot Wounds of the Knee Joint. Lancet 1:681-684, 20 May1944.

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the best treated cases, the plan of management included prompt, thorough debridement; through lavage of the joint cavity; the introduction of sulfonamide powder into the cavity; closure of the synovial membrane or capsule; and immobilization, usually in a long leg plaster cast. If initial surgery had been greatly delayed or if frank infection was present when the patient was first seen, closure of the synovial membrane was usually omitted, in an attempt to provide drainage. If the joint was severely damaged, the wound was usually extended and left open for drainage, but at this period in the war extensive intra-articular debridement was not performed. Primary resection as practiced by the French in this type of injury was not carried out, even when the joint had been destroyed. Although this program of management was extremely conservative, few secondary amputations seem to have been necessary.

Even in the early days of United States participation in World War II, the importance and desirability of complete closure of the joint were fully established, though the practice was not extended to infected cases. Once the joint was closed, the intra-articular cartilage was protected, the hazard of secondary intra-articular infection was obviated, and better subsequent function could be hoped for. It was also thought, though no direct proof existed, that closure of the joint permitted the presumptive bactericidal properties of the synovial fluid to act more effectively.

When the casualty reached a fixed hospital, the plaster was removed; the wound was dressed and again left open for drainage; and immobilization, usually by plaster, was reinstituted. It was not until the principles of reparative surgery had become firmly established that it became customary to suture the wounds of the soft part at the second operation, sometime between the 5th and 10th days after wounding, as surgical limitations permitted.

The duration of immobilization varied with the extent of bone damage. When it was not extensive, passive and active motion was instituted as promptly as it was thought to be safe in the special case. The Willems principle of immediate motion was almost never used. The feeling was that the advantages of a few days of additional immobilization and rest for the part would expedite wound healing and that the advantages of prompt wound healing would outweigh any advantages likely to be derived from early forced active motion.

Complications were infrequent when damage to the joint was minimal or even moderate, especially in joints without cartilaginous or bony damage. Even in these favorable cases, however, it was noted at the general hospitals that, when closure of the synovial membrane had been omitted, healing was frequently slow and there was more impairment of joint function than might have been predicted from the degree of initial damage. In other cases of minimal or moderate damage, prolonged infection, with slow destruction of the joint, sometimes occurred. In such cases, though the joint was doomed, open drainage usually prevented the development of toxemia and systemic sepsis. Precise figures are not available, but it was recognized that cases of

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this sort were not infrequent, both in overseas hospitals and in hospitals in the United States.

On the whole, joints operated upon early and thoroughly, with closure of the synovial membrane and institution of immobilization, were usually free from infection (fig. 70). The term “early,” however, was relative. The time lag from wounding to initial surgery usually exceeded 12 hours. In one typical series of 384 wounds of the knee joint, it averaged 16.5 hours. When operation was done so long after wounding, forward-area surgeons in the early months of the war, fearful of the consequences of infection in a closed joint, frequently assumed that infection might already be present and therefore left the joint open for drainage. Observations at the hospitals in the rear showed that patients who were treated in this way sometimes did well but that in many cases infection was prolonged and the joint was completely destroyed. These could not be regarded as satisfactory results, even though few amputations were necessary and loss of life was negligible.

The Formative Stages in Development of Standard Concepts of Management (March-April 1944)

In the early spring of 1944, there was a sharp rise in the incidence of suppurative arthritis following wounds of the knee joint treated in several of the general hospitals in the Naples area. It was possible to trace the cause, at least in part, to a wave of surgical conservatism among forward-area surgeons at the Anzio beachhead. Part of this conservatism was apparently deliberate. Part of it was to be explained by the extremely difficult combat conditions under which forward surgeons were then working. Whatever the explanation, the results were the same. In many instances, surgical exposure of the joint was inadequate, intra-articular debridement was incomplete, and infection in the joint was the consequence.

The increased incidence of suppurative arthritis in the group of casualties just described focused particular attention upon wounds of the knee joint and their possible complications. Shortly afterward, as part of the early formative stages of the program for the adjuvant use of penicillin in the management of battle wounds, a number of wounds of the knee joint with potential infection or early established infection were studied in several general hospitals in the Naples area. All the wounds had been sustained from a few days to a few weeks earlier. Observations made on these 35 cases brought out the following facts:

1. No infection had occurred in cases which had been treated by complete initial surgery, closure of the synovial membrane or capsule, and adequate immobilization.

2. Suppurative arthritis of varying degrees of severity, with prolonged drainage and slow destruction of the articular surfaces, was observed in several cases in which intra-articular damage at wounding had been only minimal to moderate but in which excisional surgery had been inadequate and in which

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FIGURE70. – Staged management of wound of left knee joint. A and B. Anteroposterior and lateral roentgenograms made in evacuation hospital before initial surgery, showing damage to lateral condyle of tibia. At initial surgery, the knee joint was opened medially and laterally and thorough debridement was performed. The synovial membrane and capsule were closed, penicillin solution was instilled into the joint, and immobilization was provided by a single hip spica. C and D. Anteroposterior and lateral roentgenograms made its fixed hospital 6 days later. The hip spica used as transportation splinting is still its place. Aspiration of the joint at this time showed no evidence of infection. The soft-part wounds were therefore sutured, and immobilization was continued. E. Appearance of healed wounds 2 weeks after reparative surgery. Because the wounds healed promptly, active and passive motion could be instituted promptly. F. Range of flexion and extension (90° ) 5 weeks after wounding. The application of the principles of staged surgical management to this injury prevented wound infection and produced a highly satisfactory functional result.

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the joints had been left open for drainage. The reaction closely resembled that observed in joints destroyed by the missile.

3. Compound comminuted injuries of the patella were particularly likely to be followed by infection.

4. In each of 15 cases complicated by infection of varying degrees of severity, unexcised, devitalized, traumatized intra-articular cartilage was present.

Nineteen patients with wounds of the knee joint (all then available) were managed by an aggressive regimen of surgery, blood transfusions, and penicillin at the 21st, 23d, and 45th General Hospitals in the medical center at Naples and at the 17th General Hospital several miles away, as follows:

1. Blood transfusions were given in amounts sufficient to maintain the hematocrit level at 40 or over.

2. Penicillin was given intramuscularly in doses of 25,000 to 50,000 units every 3 hours. Systemic administration was supplemented by local installations into the knee joint in amounts of 5,000 units percubic centimeter of physiologic salt solution. Systemic administration was always continued until all danger of continuing infection was past and, as a rule, until the wounds were healed.

3. Surgically, these 19 cases were managed as follows:

In eight cases, in which there was roentgenologic evidence of intra-articular trauma, the knee joint was explored. There was no definite evidence of infection in any of these cases, but exposure at initial wound surgery had not been complete and exploration was undertaken to be certain that debridement had been adequate. In four cases, it had been. In the other four cases, potential foci of infection, in the form of devitalized areas of articular cartilage, were excised (fig. 71). The joint cavity was then thoroughly irrigated, the joint was closed, and penicillin was instilled into the cavity. Suppurative arthritis did not ensue in any of these eight cases, and in each case joint function was no more greatly affected than it had already been by the trauma of the original wound.

In six wounds, in which definite, established suppurative arthritis was present but in which joint destruction had not yet occurred, the knee joint was widely exposed. The joint was cleansed on all devitalized tissue, debris, and foreign material, after which blood clot and purulent exudate were removed by thorough irrigation. The synovial membrane was sutured, and, finally, penicillin was instilled into the joint cavity. For the next week, at intervals of 24 to 48 hours, aspiration, irrigation, and reinstallation of penicillin were carried out. Attempts at aspiration were usually fruitless because remarkably little fluid accumulated between treatments. Infection was controlled in all six cases, and, again, the ultimate function of the joint was limited only by the damage caused by the missile at the time of wounding (figs. 72, 73, and 74).

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FIGURE71. – Staged management of penetrating wound of right knee joint associated with comminuted fracture of lower third of femur. A. Wounds of knee and lower third of thigh observed in operating room just before reparative surgery. The small size of the wound of the knee joint makes it clear that intra-articular surgery has not been adequate. B. Extensively damaged medial condyle of femur seen on adequate exposure of joint. All devitalized articular cartilage was removed through this wide arthrotomy incision. The incision was extended proximally, and the comminuted fracture of the femur was fixed with multiple screws. C. Steps of reparative surgery. The aggressive surgical attack on this injury, which had been inadequately treated at initial wound surgery, undoubtedly forestalled suppurative arthritis and was followed by prompt wound healing. The femur united firmly and in perfect condition.

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In two cases, in which subacute infectious processes had been present for several weeks, the knee joint was reopened. A comminuted fracture of the patella was present in one of these cases. In the other, purulent exudate was dripping into the joint cavity from an infected fracture of the lower third of the femur. In both cases, necrosis of the articular cartilage had been caused by the infection and was not the direct consequence of wounding. All necrotic areas were curetted, and the edges of the cartilage left in situ were trimmed free of loose tags. The menisci, which were devitalized and friable, were also removed. The patella was resected in the first of the cases. After the cavity had been thoroughly irrigated, the synovial membrane was closed, and the aspiration-instillation regimen just described was instituted, beginning with the instillation of penicillin solution on the operating table. Results in both these cases were good. Infection was promptly controlled, and satisfactory healing followed delayed wound closure. The desirable program of postoperative mobilization was hampered in both cases by the complicating femoral fractures, but each of these patients had 10° to 20° of motion when he was transferred to the Zone of Interior, as well as at a later examination.

In the three remaining cases, infection which endangered the limb was eradicated by resection of the knee joint (figs. 75, 76, and 77). In one of these cases, which was associated with a contralateral amputation in the upper third of the thigh, sepsis was severe enough to endanger the patient`s life. It had resulted from infection of a compound fracture of the medial tibial condyle, in which the line of fracture extended into the joint. The injury had looked relatively innocent but was poorly debrided. All three cases were treated by excision of the infected, necrotic bone and cartilage; resection of the joint; and staged procedures directed at wound healing. The infection was controlled, the wounds healed satisfactorily, and bony fusion was progressing when the patients were evacuated from the theater.

4. The joint was immobilized after operation by a single plaster spica or a Tobruk splint. Movement was permitted when healing was progressing satisfactorily and it was thought that all danger of a flareup of infection was past.

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FIGURE72. – Management of early established suppurative arthritis superimposed on multiple penetrating wounds of left knee. For reasons which are not clear, possibly because of the multiplicity of the penetrating wounds, this knee joint was not explored and debrided at initial surgery. A. Anteroposterior and lateral roentgenograms made in fixed hospital 10 days after wounding. B. Appearance of knee on same date. Note the bulging of the knee and the multiple wounds, from all of which pus oozed. C. Medial arthrotomy incision through which several areas of damaged articular cartilage were excised, together with several metallic foreign bodies embedded in the condyles of the femur and the partially devitalized medial meniscus. Areas of devitalized articular cartilage and the friable lateral meniscus were removed through a lateral arthrotomy incision. After thorough irrigation of pus and exudate, the synovial membrane was sutured in each incisions, and the joint was filled with penicillin. A hip spica was applied for immobilization. The synovial fluid was aspirated, and the joint was irrigated and filled with penicillin daily during the next 5 days, through a window in the cast. Systemic and local signs of infection rapidly subsided. Skin closure of each wound was carried out 12 days after the arthrotomy incisions were made. All signs of infection disappeared, and the wounds healed promptly. When the patient was evacuated to the Zone of Interior 5 ½ weeks after wounding, the range of motion was 30° from full extension. He was furnished with a removable splint for use at night, to maintain full extensions of the leg at the knee as a precaution against flexion contracture.

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Standard Plans of Management (After May 1944)

In the first months of the Mediterranean theater, as already noted, there was no theaterwide policy for wounds of the knee joint; each surgeon managed them in the light of his individual experience and training. As might have been expected, however, the differences between methods were more in details than in the basic pattern, which was generally as has just been described. The results accomplished during this early period seemed susceptible of improvement, particularly in the cases in which infection was present. That results could be improved was evident in the 19 injuries of the knee joint in which penicillin was tested in the Mediterranean theater and which were observed at about the time the reparative-surgery program for wounds of the soft tissues was becoming theaterwide. It was natural that this plan should be extended to wounds of the knee joint and that it should eventually become the standard plan of management for all wounds in this area, whether penetrating or perforating and whether or not they were complicated by infection. At the end of World War II, the surgical management of wounds of the knee joint had for all practical purposes come back to the concept enunciated by Pool in World War I;¹⁰ that is, thorough debridement and immediate closure of the joint wound. The contribution of World War II was the extension of this program to the infected knee joint.

Initial wound surgery. – Wounds of the knee joint, which were priority-two injuries, were treated at initial wound surgery by the same regimen as all other wounds, with such modifications as the location and character of the injury required. It was essential, for instance, to perform the operation on an operating table which could be broken at the knee; satisfactory exposure was otherwise difficult. Circumferential draping was used. A tourniquet was often applied to secure a dry surgical field.

The incision and its extent were determined by the necessities of the special case. A separate arthrotomy incision was frequently better than approach through the battle wound. It was essential that the excisional procedure should include the removal of all foreign bodies, including loose bone chips; damaged menisci, and loose, fragmented and devitalized cartilage. Defects in the condyles were trimmed evenly. It was usually the wisest plan to excise a comminuted patella.

After thorough irrigation of the joint cavity, the synovial membrane, with the capsule, if possible, was sutured, and penicillin solution was instilled into the cavity. When loss of soft tissue precluded suture of the membrane or capsule, flaps of fascia or skin were rotated to secure the desired coverage. The joint was left open only when the extent of the damage made return of any joint. function obviously impossible. In cases of this kind, it was always best to excise the remaining cartilage, which, since it was poorly nourished, avascular,

¹⁰ Sec footnote2, p. 211.

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FIGURE73 – Management of early established suppurative arthritis following wound of knee joint and comminuted fracture of patella. Ten hours after injury, wound was opened and a foreign body removed; joint was irrigated, capsule closed, penicillin instilled into joint and given systemically; immobilization by long leg cast. Initial debridement had been incomplete. Signs and symptoms of suppuration developed and persisted after patient was admitted to fixed hospital a week later, in spite of continuation of penicillin. A. Swollen joint, granulating wound, and draining pus, 15 days after wounding. B. Medial arthrotomy incision, with inflamed synovial membrane and partially necrotic cartilage of comminuted patella visualized. Bit of cloth shown on gauze sponge was removed from joint, together with coagulated fibrinous exudate quadriceps pouch. Severely comminuted fragments (Continued on opposite page.)

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of patella were excised. C. Fragments of patella, some fibrinous exudate, and bit of cloth removed from joint. D. Instillation of penicillin into joint, through arthrotomy incision, after closure of synovial membrane and capsule. Old wound, which had broken open as result of infection, was excised; capsule was closed. E. Wounds, after suture, through window in cast, 6 days later. F. Degree of active extension and flexion of leg at knee3 weeks later. Quadriceps power is sufficient to extend knee. Hand supports foot for photograph. Wounds healed promptly.

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FIGURE74. – Management of suppurative arthritis superimposed on moderately severe high-explosive shell fragment wound of left knee. At initial surgery 7 hours later, the knee joint was opened, and a foreign body embedded in the articular surface of the medial femoral condyle was removed. The joint capsule was sutured after irrigation of the cavity, and penicillin was instilled. In the fixed hospital 5 days later, local and systemic signs of suppurative arthritis were observed. The joint was aspirated and irrigated on two occasions, and penicillin solution was instilled into it. Four days later the temperature was 101°F.; the knee was swollen, boggy, and tender, and a sero purulent discharge exuded; maggots were crawling in the wound. A. Exposure of joint through proximal extension of old wound. Note intense hyperemia of synovial membrane and edge of damaged articular cartilage. Maggots were present in the joint cavity, which was thoroughly cleansed by irrigation. A piece of woolen cloth was removed, together with the devitalized area of articular cartilage, about an inch in diameter, which lay beneath it and which had been depressed into the condylar defect. The defect was trimmed evenly. The medial meniscus, although dull in appearance, was not friable and was left in situ. The synovial membrane and capsule were closed, and the joint was filled with penicillin. Immobilization was accomplished by a Tobruk splint. B. Appearance of region of joint 3 weeks later. The operative wound is healed, but there is an unhealed area of partial loss of skin over the patella. This loss occurred at wounding. For 2 days after operation, synovial fluid had been aspirated through a window in the cast, the joint cavity irrigated, and penicillin instilled. Wound closure was possible 5 days after operation, by which time all signs of infection had subsided. It was necessary, however, to leave a small gap in the center unclosed, to avoid excessive tension on the skin margins of the lateral surgical incision. Immobilization was discontinued 2 weeks later; meantime, quadriceps exercises had been instituted. Six weeks after the operation for suppurative arthritis, the patient was evacuated to the Zone of Interior with removable splinting for use at night as a precaution against flexion contracture. At this time the range of active motion was only 10°to 15° C. Anteroposterior roentgenogram made a year after wounding, showing extent of damage to medial condyle of femur. D. Range of active motion in knee a year later. Complete extension is possible but is not shown in this photograph.

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and traumatized, was a potential focus of infection. The remaining joint injury was then really only a compound fracture.

The same principles of exposure and debridement were employed in indirect injuries of the joint produced by fractures extending into the joint, to insure that no debris, loose fragments of bone, or blood clots were left in the cavity.

Immobilization was accomplished by a single hip spica or a Tobruk splint, with the knee in 10° to 15° flexion. Systemic penicillin therapy and the aspiration-instillation regimen of joint management were instituted and were continued as long as indications existed. Postoperative instillation was carried out with a large needle, through a window in the cast.

Reparative wound surgery. – Reparative surgery was undertaken at the general hospital 4 to 6 days after wounding. At this time, the cavity was again aspirated and irrigated, and penicillin was reinstilled, but the joint was not reopened unless there was reasonable doubt concerning the adequacy of initial wound surgery. If there was doubt, exploration was undertaken, as a precaution against the development of suppurative arthritis, and such additional excisional surgery as proved necessary was performed (fig. 71). The joint was well irrigated before it was closed, and skin closure was effected by the usual technique.

If for any reason reparative surgery could not be performed promptly after the patient`s arrival at the general hospital, the aspiration-instillation routine was carried out until operation could be performed.

Immobilization was continued for 10 to 14 days after delayed primary suture. Then active mobilization of the joint was instituted, usually with the patient in balanced suspension in an Army half-ring leg splint, with Pierson attachment. Motion was progressively increased from the position of full extension, to avoid flexion contracture.

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FIGURE75. – Management of suppurative arthritis of right knee joint, superimposed on damage resulting from severe perforating wounds. Injury included compound comminuted supracondylar and condylar fractures of femur and patella, with laceration of patellar tendon. Resection of joint. At initial surgery, it was recognized that the joint had been partially destroyed, and the comminuted patella was excised. In an endeavor to stabilize the condylar fragments as much as possible, a Steinmann pin was passed through them and brought out through the medial and lateral wounds, though the use of skeletal fixation in forward areas was not a recommended policy. When the patient was received at the general hospital on the 11th day after wounding, the joint and fracture site were bathed in purulent exudate. Efforts to control the suppurative process were not successful. A. Anteroposterior and lateral roentgenograms made just before reparative surgery. B. Appearance of knee just before reparative surgery, 3 weeks after wounding. C. Exposure of joint. The degree of destruction is such that restoration of function is obviously impossible. The Steinmann pin was removed, and the fracture site in the lower end of the femur was reduced and fixed by 2 screws. The almost totally destroyed condyles of the femur and the proximal end of the tibia were then excised. An external skeletal-fixation apparatus was applied to the extremity to maintain apposition of the femur and tibia. The operative wound was partly closed, so as to cover all exposed bone, and rubber-tissue drains to the dead space were inserted. A single hip spica was applied, incorporating the external skeletal-fixation apparatus. D. Articular surfaces of resected femur and tibia. Note destruction of articular cartilage. E. Anteroposterior and oblique roentgenograms of resected knee joint in plaster cast. Note wire suture used to help maintain apposition of fragments. Nine days after resection, the wounds were clean, but the edges were not suitable for suture. The wound margins were trimmed back to healthy tissue, and old granulation tissue was excised. Five days later, at a third operative procedure, a small protruding portion of the external condyle was chiseled away, and the wounds were closed. Wound healing was obtained except for a persistent small sinus to the region of the internally fixed fracture. This man was evacuated to the Zone of Interior 6 weeks after operative resection of the infected knee joint. When he was observed several months later by the consultant in orthopedic surgery for the Mediterranean theater, the fracture had united, and the knee joint was fused. The wounds were well healed except for the small sinus just mentioned. When the fixation screws and sequestrum to which the sinus led were removed, prompt healing occurred. In this case, a knee joint hopelessly destroyed by the initial injury and superimposed suppurative arthritis was managed by early resection, and the optimal result which could be expected for such an injury was achieved within a minimum period of time. Internal fixation of the fracture of the distal end of the femur was an essential part of the surgery; for technical reasons, stabilization of the fracture was necessary before resection could be performed. External skeletal fixation, while useful in maintaining stability during the staged surgical procedure, was insufficient in itself for adequate immobilization, so after each operation the apparatus was incorporated in a single hip spica.

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FIGURE76. – Management of severe suppurative arthritis superimposed on moderately severe damage to articular cartilage of left knee joint. Compound comminuted fracture of middle third of right femur. Resection of left knee joint. At initial surgery, high-explosive shell fragments were removed from the joint, which was irrigated and closed. Penicillin solution was instilled, and penicillin was given systemically. A hip spica was used for immobilization. At the fixed hospital, the right femur was placed in skeletal traction after the compounding wounds were closed. Aspirations, irrigations, and reinstallation of penicillin, the correct routine for the management of such wounds in a fixed hospital, were not instituted, and an infectious process developed and continued until the patient was extremely ill and the knee joint was grossly infected. A. Anteroposterior and lateral roentgenograms before initial surgery. Size and location of foreign bodies indicate considerable trauma to the articular cartilage. B. Anteroposterior and lateral roentgenograms 2 months after wounding, showing ravages of infectious process in joint. After proper preoperative preparation, the knee joint was resected. The resected surfaces were stabilized in reduction by the use of external skeletal-fixation apparatus, over which a single hip spica was applied. All wounds were left open for drainage but were closed 2 weeks later. C. Anteroposterior and lateral roentgenograms of resected knee joint, showing incomplete bony fusion about 2 months later. The bone destruction by the infectious process in this instance amounted to 3 inches and can be attributed not only to incomplete initial surgery but to failure to institute the proper regimen promptly in the fixed hospital when infection became evident. Re-arthrotomy should have been done at once. D. Healed wound several months later in the Zone of Interior.

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Management of infected knee joints. – The signs and symptoms of impending or established infection within the joint were chiefly pain, swelling, fever, and malaise. In the occasional case, if the manifestations were slight and if it appeared that initial wound surgery had been adequate, the aspiration-instillation routine with penicillin solution was carried out for a day or two, in the hope of aborting the infection. If the attempt was unsuccessful, no further time was lost. The joint was opened widely, was thoroughly cleansed of dead tissue and blood clot, was completely closed, and was filled with penicillin before it was immobilized (figs. 72, 73, and 74). Only when hope of a functioning joint had been entirely abandoned was the arthrotomy wound left open for drainage. The edges of the skin wound were freshened at this time, but closure was delayed until 5 or 6days later. The usual postoperative regimen, including instillations of penicillin solution, was instituted.

Resection of the knee joint. – Resection (figs. 75, 76, and 77) was limited to joints hopelessly destroyed either by the initial trauma or by infection. If it was performed on the indication of joint destruction, it was preferably carried out at the evacuation hospital, with the objective of preventing chronic infection and promoting wound healing. Resection for infection was occasionally necessary in a forward hospital, but the necessity for it on this indication more often became evident in fixed hospitals. The amount of bone excised at operation and the resultant shortening of the limb were predetermined by the extent of bone loss and the degree of destruction inherent in the trauma or the infectious process. Because of the shortening which resulted from the operation, the resected surfaces were designed to conform in extension rather than in slight flexion.

Results of the Reparative-Surgery Program

The reparative-surgery program for wounds of the knee joint had its first theaterwide application in May 1944, with the beginning of the Cassino Rome campaign. Its results were immediately apparent. The incidence of wound infection in wounds of the knee joint dropped sharply. If infection was already present when patients were received in general hospitals, appropriate surgery and intensive postoperative care almost always controlled the process. A functioning joint, limited only by the damage done at wounding, was the usual result. Chronic infection seldom occurred except in joints hopelessly destroyed by trauma. For all practical purposes, the chief problem of wounds of the knee joint had been solved. The surveys described below furnished data to substantiate these conclusions.

Disposition-board proceedings. – An examination of disposition-board proceedings for 1944, on file in the Office of the Surgeon, Mediterranean Theater of Operations, showed that in none of the 1,073 amputations performed for all causes had the operation been required for infection or sepsis following a properly managed wound of the knee joint (fig. 71).

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FIGURE 77. – Management of long-standing suppurative arthritis of right knee joint superimposed on penetrating wound which damaged proximal end of tibia. Radical resection of joint. The left lower extremity had been amputated traumatically in the middle third of the thigh by the same shell explosion that caused the injury to the right knee. Forty hours after injury, the traumatic amputation was completed by the open circular method and other wounds were debrided, but little was done to the penetrating wound compounding the injury of the knee joint. After the patient was admitted to the fixed hospital 14 days later, signs and symptoms of sepsis were constant, there being no response to bilateral parapatellar incisions, penicillin therapy, blood transfusions, and immobilization. Pus extended up the fascial planes of the thigh, and incision and drainage were necessary. A. Anteroposterior and lateral roentgenograms 10 weeks after injury, showing complete destruction of right knee joint. At this time, the patient was quite toxic, temperature elevations to 102° and 103° F. occurred daily, and amputation was seriously considered as a lifesaving measure. B. Interior of knee joint after exposure at operation 76 days after wounding through longitudinal incision extended proximally to drain another abscess in the thigh. The patella, which has been excised, is held beside the destroyed femoral condyle for demonstration purposes. All articular surfaces in the joint were found totally destroyed by the septic process. The healthy ends of the femur and tibia left after excision were held in approximation by a suture of stainless-steel wire placed anteriorly. Old wound edges were excised, but closure was not done. A hip spica provided postoperative immobilization. C. Resected joint. Shortening was of no consequence in this case because the opposite leg was already amputated. D. Dead, infected bone and cartilage excised from joint.

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FIGURE 77 –Continued. E. Partial closure of medial wound, with drainage, 6 days after first operation, after evident control of septic process. F. Closure of lateral wound at same operation. Drainage of abscess of calf. The depths of each wound were thoroughly irrigated before suture. G and H. Healed medial arid lateral wounds 6 weeks later. Healing was entirely satisfactory, except for occasional small granulating areas. There were no sinus tracks. Local and systemic sepsis had been eliminated, and the patient was rapidly gaining weight and strength. A new hip spica was applied for transfer of the patient to the Zone of Interior .

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In 271 wounds of the knee joint studied from the same disposition-board proceedings, the cases were divided into those treated before the final drive for Cassino and Rome, which began 11 May 1944, and those treated after that date.

In the 73 cases which made up the earlier group and which were treated by the original techniques, the incidence of infection in general hospitals was 27.4 percent. In the 198 cases treated after the reparative program had become effective, the incidence of infection was 5.4 percent.

In the earlier group, the infectious process continued in 8.2 percent of the cases until the joint had been completely destroyed, while in another 8.2 percent of the infected cases the end result was not known. There were only 4 instances (2 percent) of complete joint destruction in the later series, and in 3 of these the recommended regimen for the management of early infection had not been instituted. In the remaining case, damage at wounding had been so severe that resection of the knee joint was necessary.

General hospitals. – Reports from individual hospitals showed that when initial wound surgery had been adequate, results in wounds of the knee joint were greatly improved.

At the 17th General Hospital, 194 wounds of the knee joint were analyzed, in 128 of which initial surgery had been adequate and in 66 of which it had not been.

In 119 of the 128 cases in which initial surgery had been adequate, there was no evidence of infection when the patients were received in the fixed hospital, and closure of the wounds of the soft parts could be proceeded with at once.

In 4 of the other 9 cases, in all of which infection was present, the process was controlled without surgery by the aspiration-instillation routine with penicillin solution. In two cases, secondary arthrotomy was performed, with excision of intra-articular devitalized tissue, and in another case incision and drainage controlled the infection. In these seven cases, a functioning knee joint was obtained. In the two remaining cases, bone damage had been extreme. Resection of the knee joint was necessary in one case and amputation of the limb in the other, primarily because of trauma.

In the 66 cases at the 17th General Hospital in which initial wound surgery had apparently not been complete, 16 joints were found to be infected when the wounds were exposed. In eight eases, infection was controlled satisfactorily by arthrotomy and secondary debridement. In another case, in which bone damage was severe, prolonged drainage was instituted through the open wound, without expectation that satisfactory function would ultimately be obtained. In the other seven cases, in all of which bone damage was extreme, resection of the joint was necessary in five cases and amputation in the other two. The results in the five resections were as satisfactory as this procedure permits.

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The 70th General Hospital received 45 patients with wounds of the knee joint after the Po Valley campaign, at the end of the fighting in Italy. Reparative surgery was rendered on an average of 7.7 days after wounding. In eight of these cases, arthrotomy was performed for exploratory purposes and to complete intra-articular debridement, on the indication of impending infection. Recovery was uneventful in all. In the only two cases in the whole group in which infection became established, the process spread from infected fractures adjacent to the joint, a supracondylar fracture of the femur in one instance and a fracture of the upper tibia in the other.

Resection of the knee joint. – It is known that 31 resections of the knee joint (figs. 75, 76, and 77) were performed in the Mediterranean Theater of Operations by United States Army surgeons; 24 of the operations were on United States Army personnel.

Two of these operations were performed at initial wound surgery on the indication of extensive trauma.

In six operations, all on French colonial soldiers and all at the 9th Evacuation Hospital, which was then serving as a fixed hospital, initial wound surgery had not been adequate, and severe suppurative arthritis had followed relatively minor injuries caused by penetrating wounds. In each of these cases, it was thought that the infection present seriously endangered the vitality of the limb.

In 3 other resections, the indication was also severe suppurative arthritis, superimposed in 1 case on minimal intra-articular damage and in 2 cases on moderate damage.

In the remaining 20 cases, the indication for resection was traumatic destruction of the joint, with impending or early established infection.
The results in these 31 cases were satisfactory within the limitations of resection of the knee joint. There were no deaths. Rapid improvement invariably followed the operation. Most of the patients were evacuated to the United States with well-healed wounds, and nine are known to have had clinically stable limbs before they left the theater. In every case, it had been possible, without special difficulty, to achieve apposition of the bony structures in the position of function. The shortening of the limb, which varied from 1 to 3 inches and which averaged 1 ½ inches, was dictated by the bone loss from trauma or infection.

In a follow up survey of various procedures conducted in the Zone of Interior early in 1945, it was possible either to examine or to secure accurate information about eight patients who had been subjected to resection of the knee joint overseas. In seven cases, the indication for the resection was traumatic destruction of the joint, followed by infection. In the eighth case, the original damage was moderate, but the joint had been destroyed by infection.

In this case, as well as in six others, the wounds were healed. In the remaining case, there was a sinus to a condylar fracture just above the joint.

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Fusion was satisfactory in six cases, including the case in which the joint had been destroyed by infection; one of these patients was at a convalescent hospital and ready for a Certificate of Disability discharge. In another case, fusion seemed to be occurring, but only 3 months had elapsed since operation. In the remaining case, in which there was no evidence of fusion, it was thought that bone grafting would be required.

The results in this small group of cases further confirmed the impression that resection of the knee joint has a definite, but fortunately limited, application in the management of severely traumatized and infected wounds of the knee joint encountered in military surgery.

WOUNDS OF THE HIP JOINT

Wounds of the hip joint (figs. 78, 79, and 80) presented even more difficult problems in military surgery than wounds of the knee joint. Because they affected one of the two major weight-bearing joints of the body, they were always serious, even when the injury was not extensive. The immediate case fatality rate was high, probably not because of the injury to the hip joint but because of associated injuries to overlying and adjacent major blood vessels. Later deaths were the result of associated intra-abdominal wounds, particularly wounds of the rectum or the urinary bladder. Such combinations of injuries were frequent, and their management taxed the ingenuity of forward- and rear-area surgeons alike.

The management of wounds of the hip joint produced the least satisfactory results obtained its skeletal injuries in World War II. For this, there were a number of reasons: (1) The damage at wounding was often sufficient to destroy the joint and in itself was often enough to cause ankylosis. (2) Infection was frequent. If the articulating surfaces of the femur and acetabulum had been damaged, as they had been in many cases, drainage was likely to be prolonged, and there was often evidence of systemic absorption and toxemia. (3) The high incidence of suppurative arthritis observed in general hospitals in cases in which trauma had been slight or moderate suggested that initial wound surgery had frequently not been adequate. In some of these cases, the joint was completely destroyed by the infectious process. (4) The principles of excisional surgery were the same for the hip joint as for all other joints, and their application to wounds in this area was equally necessary.

On the other hand, the hip joint is not readily accessible, and adequate debridement required wide exposure and precise anatomic orientation. Initial wound surgery, in short, was a procedure of magnitude, with which the average forward surgeon had usually had a limited experience if he had had any at all. The availability of a consultant in orthopedic surgery to the army surgeon (p. 5) might have contributed to the improvement of initial wound surgery in compound fractures of the hip joint and to a consequent improvement in the end results of these complicated injuries.

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FIGURE78. – Management of suppurative arthritis superimposed on high-explosive shell fragment injury of hip joint. Initial surgery in this patient was inadequate; the hip joint was not opened, and the foreign body was not removed. Suppurative arthritis ensued, not controlled by removal of the foreign body 10 days later, without thorough intra-articular debridement. A. Anteroposterior roentgenogram of pelvis and hip joint in evacuation hospital showing high-explosive shell fragment lying in articular cartilage of head of femur. B. Anteroposterior roentgenogram of pelvis and hip joint 4 weeks later, showing hip joint totally destroyed from infection.

Survey of Cases, January 1945

The results achieved in the treatment of wounds of the hip joint in the Mediterranean theater were recognized as so unsatisfactory that, in January 1945, a survey was undertaken, on orders of the theater surgeon and at the request of the consultant in orthopedic surgery, to collect precise data concerning them. At this time, 15 casualties with injuries of the hip joint were hospitalized in the general hospitals of the Naples base area, the ratio being 1 to 250 patients then hospitalized for all battle-incurred injuries. In addition, a search revealed 24 previous admissions for this cause in which the hospital records contained data sufficiently detailed for analysis. The material for the survey thus consisted of 39 cases.

No case was accepted for this analysis unless there was roentgenologic evidence of trauma to bone or cartilage, on the reasonable assumption that a missile which penetrated the hip joint would inevitably produce some skeletal damage. A joint was classified as infected (1) if there was roentgenologic evi-

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FIGURE79. – Management of suppurative arthritis superimposed on high-explosive penetrating wound of left buttock, hip joint, and neck of femur. Life-endangering thoracic injury permitted only minimal debridement of wound of buttock in initial surgery. Arthrotomy of hip joint was omitted. Suppurative arthritis could not be controlled, even after removal of intra-articular foreign body a week after wounding. No effort was made at this time to cleanse joint of debris or to insure good posterior drainage. A. Anteroposterior roentgenogram showing foreign body overlying neck of femur. A lateral view demonstrated that missile had perforated femoral neck and come to rest anteriorly. B. Anteroposterior view of left hip joint, showing total destruction by infection 6 weeks after wounding. Patient was transported to ZI in hip spica before infection was controlled.

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FIGURE80. - Management of suppurative arthritis of right hip joint, following damage to neck and head of femur by high-velocity missile. A. Anteroposterior roentgenogram of pelvis and hips made in evacuation hospital, showing fracture of neck of femur and retained foreign body. At initial wound surgery, the wound of entry was debrided, after which the joint was explored and the bullet and some loose bone fragments were removed. A hip spica was applied as transportation splinting. In the fixed hospital, the extremity was placed in balanced-suspension skeletal traction. Infection was persistent, and wound healing was not obtained. B. Anteroposterior roentgenogram made infixed hospital 5 weeks after wounding, showing dead femoral head and destruction of hip joint by infectious process. Soon after this film was made, the joint was opened through a posterior approach, and all dead bone was removed. The joint cavity was thoroughly irrigated, and the operative wound was sutured. A drain was inserted down to the old hip-joint cavity. Immobilization was obtained by a hip spica which extended to the knee on the opposite side. C. Dead head of the femur, which was removed along with other fragments of bone and cartilage. D. Healed wound, 3 weeks after surgery on infected hip joint. The drain was removed 5 days after this operation, and healing occurred promptly. All signs of systemic toxemia also disappeared promptly.

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dence of progressive destruction, (2) if the patient presented the manifestations of toxemia, or (3) if there had been prolonged drainage from the joint. An unhealed compounding wound was not regarded, in itself, as evidence of joint infection.

It is unfortunate that little precise information could be secured concerning the initial wound surgery performed in these 39 cases. In 13 cases, in which no infection had occurred, it could be ascertained that foreign bodies had been removed in several instances and that the joint capsule had been closed in two instances. In most of the 39 cases, however, including 26 cases of undoubted infection by the criteria just stated, the location and extent of the wounds suggested that exposure sufficient to permit adequate excision of devitalized tissue had seldom been accomplished.

Certain observations made in this survey seemed highly significant. They are as follows:

1. All six patients with concurrent intra-abdominal injuries also had infections of the hip joint. The origin of the infections seemed obvious; it was assumed to have resulted from cross-infection from the associated injuries, its most of which the intestines were involved.

2. Eighteen of the 19 patients with damage to the articular cartilage, 17 of the 21 with involvement of multiple components of the hip joint, and 15 of the 19 with severe comminution had infections of the hip joint. These data, especially in the light of the similar data available for wounds of the knee joint (p. 219), clearly pointed to traumatized, devitalized, poorly nourished, unexcised articular cartilage as the focus of infection.

3. The time lag from wounding to initial wound surgery, while prolonged, was substantially the same, on the average, in both the infected and the uninfected group of cases (16 versus 17 hours). The time lag from wounding to reparative surgery was, however, considerably longer in the infected group, 12 days compared with 7 days in the uninfected group.

4. It was known that penicillin had been given in 22 of the26 infected cases and in 12 of the 13 uninfected cases.

5. In the 13 cases in which no infection was present, surgery in general hospitals had consisted only of wound closure.

6. In 10 of the 26 infected cases, no additional surgery was performed in the general hospitals. The procedures performed in the other cases, after infection was evident and in an attempt to accomplish wound healing, included additional debridement (3 cases); additional drainage (3 cases); sequestrectomy (4 cases); excision of the head of the femur (2 cases); removal of foreign bodies and drainage, exploration of a sinus, and skins grafting (1 case each); and closure of the wound (1 case). In spite of these additional operations, wound healing was accomplished in only 2 of the 26 infected cases.

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Early Plans of Management

Before the development of the program of reparative surgery, in the spring of 1944, patients with wounds of the hip joint, after initial wound surgery in a forward hospital, were transported to general hospitals in double hip spicas, extending only to the knee on the intact side. Transportation was usually possible within 5 to 6 days unless concurrent wounds required that the holding period be extended to 10 or 15 days, or even longer. Since established infection of the hip joint may become evident within 5 to6 days, some wounds were infected before the patients ever left forward hospitals.

After the patients reached the general hospital, the transportation spica was removed, the wound was dressed, and another spica was applied to hold the joint in a few degrees of abduction and external rotation and in about 300 flexion. Should ankylosis occur, this was the most desirable positions. In occasional cases, skin traction or skeletal traction was used for a few weeks before the spica was reapplied. If suppurative arthritis developed, it was usually managed by open drainage, after which the patient was put up in plaster immobilization or in skeletal traction.

Later Plans of Management

The results of the survey undertaken in January 1945 confirmed the impression that the unsatisfactory results secured in wounds of the hip joint in the Mediterranean theater were chiefly caused by an inadequate approach to the problem. Confirmatory evidence was secured later in the year, when the theater consultant in orthopedic surgery was able to question the chiefs of various orthopedic sections in the hospitals in the Zone of Interior visited for another purpose (p.189). Formal data were not compiled, but the unanimous opinions was expressed that, in the great majority of cases, infection of the hip joint was the result of retention of dead tissue and that it could not be controlled until this tissue had been removed by direct surgical attack.

Early in 1945, an ideal regimen was worked out for wounds of the hip joint, based on aggressive surgery, adjunct chemotherapy, and liberal blood replacement. It was to include the following:

1. Adequate exposure of the articulation, which, as already mentioned, was frequently a difficult technical procedure.

2. As complete debridement as possible, followed by immobilizations of the extremity.

3. Transportation to a general hospital as rapidly as possible.

4. Reparative operation as soon as preoperative preparation could be completed. If there were no evidences of infection, the operation was to be limited to closure of the wound.

5. If signs of infections became evident in the forward hospital, radical secondary surgery was to be performed, as in wounds of the knee joint (p.231).

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Wide exposure and thorough redebridement were recommended, with, if necessary, dislocation of the hip to secure adequate exposure. Since the operation was not an emergency, the services of an orthopedic surgeon qualified to undertake such extensive surgery were to be obtained. They were practically always available in the same or at some nearby hospital.

6. If infection became evident after the patient reached the general hospital, the same sort of aggressive surgery was recommended. Here, qualified orthopedic surgeons were always available. Removal of devitalized bone and cartilage and of foreign material was to be carried out, as at initial wound surgery. Sometimes the removal of the dead and fractured femoral head would constitute, in effect, a resection of the joint. Elective resection for suppurative arthritis, as practiced by continental surgeons, is not known to have been performed by United States medical officers.

It was realized that the proposed regimens represented a radical solution of the problem of wounds of the hip joint. It was also realized that the excision of devitalized bone and cartilage, with dislocation of the hip, if necessary, to secure adequate exposure, might be followed by partial or complete restriction of joint function. On the other hand, it was felt that the hazard of secondary surgery, under the protections of penicillin and blood replacement, could not possibly exceed the risk of severe infection of the joint, which might destroy life as well as limb.

In the isolated cases in which this plan was followed, the results were as good as could have been expected under the circumstances, which were frankly disadvantageous. The program had, however, no theaterwide application. Almost as soon as it had been set up, the German armies in Italy capitulated, and fighting ended. In the light of the knowledge available at the end of the war, this program was felt to be the best plan possible for the management of wounds of the hip joints its future conflicts.

WOUNDS OF THE SMALLER JOINTS

In the great majority of wounds of the shoulder, elbow, wrist, and ankle joints, the policy of closing the synovial membrane or capsule, which eventually became theater policy, could not be practiced at initial wound surgery because of the extensive loss of soft parts and the bony destruction which had occurred at the time of wounding. Whenever it was possible, closure was effected after thorough excisional surgery had been carried out and the joint cavity had been irrigated. Transportation splinting was in accordance with the practices outlined for wounds in the special areas affected.

Primary resection of the smaller joints was seldom if ever performed as a deliberate procedure at initial wound surgery. In many instances, however, what was in effect a traumatic resection had already occurred when the articulating components were blown away at wounding. This frequently happened at the elbow joint and happened less often at the shoulder and wrist joints.

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As the importance of complete excisional surgery became more and more clearly understood, debridement of the badly damaged joint, in the occasional case, at least, amounted to resection.

The management of wounds of the smaller joints in general hospitals was essentially the same as the management of compound fractures in the special region affected. Early in the war, the plaster was removed; the wound was dressed and left open; and immobilization was again instituted, usually by plaster of paris. Later, when the principles of reparative surgery had become established, it became the practice, as in all other soft-tissue wounds, to suture the wound of the soft tissue over the joint if possible, preferably between the 5th and 10th days after wounding. The closure was more often closure over a compound fracture extending into and involving a joint than closure over a joint injury.

The old Willems method of early active motion was almost never employed in wounds of the shoulder, wrist, elbow, and ankle joints, though immobilization was discontinued just as soon as it was considered surgically sound from the standpoints of wound healing and fracture healing. This was usually between the second and third weeks after wounding, unless a fracture made further immobilization necessary.
Suppurative arthritis was seldom a complication of penetrating wounds of the smaller joints of the upper extremity unless intra-articular damage had been considerable. In the ankle, suppurative arthritis was frequently superimposed on the original wound if destruction of the articulating portions of the joint had been extensive. The infection was usually treated by open drainage and immobilization by plaster in the position of election. The best that could be hoped for in most cases was spontaneous or surgical fusion of the joint.

Secondary resection was seldom done as an elective procedure for suppurative arthritis of the shoulder, wrist, and ankle joints. In most of the cases in which it was performed, it was, in effect, little more than delayed excisional surgery. At the 21st General Hospital, in which it was employed in a number of cases on the indication of severe infection, it was thought that the operation probably had a limited field of usefulness in suppurative arthritis of the elbow joint superimposed on severe trauma.