A Clinical Lecture ON A CASE OF DISPLACED CARTILAGE

1895 The Lancet  
SURGEON TO THE LONDON HOSPITAL. e GENTLEMEN,-The patient whom I bring before you is i a young woman twenty-one years of age whose knee-joint a you saw me open ten days ago for the purpose of removing t the anterior half of the internal semilanar cartilage. The f t wound is healed, and although there is a little swelling f around it and slight tenderness when it is pressed upon, t the movement of the joint is perfect. In a few days ( it will be as strong and secure as the other one. Three (
more » ... r one. Three ( years ago the patient met with an accident, slipping off I the kerbstone and falling with her knee twisted under c 1 her. Whether the internal cartilage was torn at the 1 time, or whether it was merely strained and then weakened a by subsequent inflammation, it is not possible to say t now, although the latter is the more probable. At any 1 rate, ever since she has been liable, at intervals that were I steadily growing shorter, to that peculiar form of injury ( known as internal derangement of the knee.joint. The knee, I so she told us, was to all appearance as strong and secure as 4 it ever had been. It could ba flexed and extended through 4 the normal range. She c)uld walk on it and rest her weight ; i upon it without discomfort. Bat if the foot was rotated outi wards ever so little when the 3int was partly flexed some-1 thing slipped from its position, shot forwards so that it pro-1 jected under the skin by the inner side of the patella, and locked the joint. Sitting upon a high chair with the foot off J the ground the patient could swing the limb back wards and fori wards as easily a she could the sound one ; but when her I weight rested upon it the joint was almost fixed in a position of partial flexion. This happened to her on several occasion, once whilst she was in hospital a few days before the operation, from sitting with her legs crossed, and each time it was followed by an attack of synovitis. There was no difficulty in reducing the displaced structure, although this does occasionally happen. Firm pressure over the projection while the knee-joint was alternately flexed and extended made the cartilage slip back into position at once ; but as the displacement kept happening more and more frequently, and as each time it happened it caused severe pain and was followed by a smart attack of s3 novitis, the patient not unnaturally wished something to be done. Tbis pecaliar accident has been well known for many years. It was first described by Hey, who gave it the title by which it is known at present-viz., internal derangement of tne knee-joint. Then Knott of Dablin published a further account of it from his own personal experience, and since then Allingham and others have continued to work at it and have thrown a good deal of fresh light upon it. It is caused either by the tearing or, as in the present instance, by the loosening of one of the semilunar cartilages from its attachment, so that it becomes displaced and is caught between the bones. The internal one, because its attachments are more rigid and less yielding, suffers more frequently than the external and the anterior end more often than the posterior ; but the posterior end may be torn, or the whole circumference may be separated and the cartilage curled up into the intercondyloid notch, or the cartilage may be Fplit in two. The symptoms vary in character and severity, according to the nature of the injury. They are most marked when the dif placed structure is caught and held between the bones. When it shoots forward, so that it lies quite out of the way or curls up in the notch, the pain and loss of power are not so great. Whatever the form, however, that the injury takes, it is always followed by an attack of s3novitis, and this in course of time, if frequently repeated, becomes chronic. The treatment of internal derangement of the knee is very simple in principle. The dislocation must be reduced as soon as possible, the limb kept at rest until the injury is repaired, only passive motion allowed, and cold and pressure applied to check the evasion. Then-and this is the point to which I wish to direct your attention-steps must be taken to prevent recurrf nee. If the cartilage has only been slightly torn or strained it may in time recover and be as strong as it was before. But if the injury passes these very narrow limits, or if the accident happens a second times breaking down the adhesions formed in the process of repairs such a result is not to be expected. The accident will occm again and again until either the cartilage is in some way made secure or the loosened part removed. For reasons that I will shortly give you I am myself strongly in favour of the latter course, the one that was adopted in the present instance. If the cartilage is to be retained it must be kept in position either by means of some mechanical appliance or by suturing it to the head of the tibia. Now the former of these is , almost impossible unless the patient consents to give up all the pleasures of active life. The simplest contrivance io , formed of a metal spring which passes horizontally across , the limb behind the knee, and terminates at either end in a : firm horseshoe-shaped pad. These pads rest upon the soft tissues in front of the knee and fit closely against the margin I tf the patella, one on each side. The idea is that the , cartilage can be prevented from shooting forwards by the pressure in front. But this is only of use in a limited number " of cases, for forward displacement is by no means the only kind that is met with ; and even in these cafes the degree 01 , pressure that can be applied is entirely insufficient. Another appliance is formed of two lateral metal bars, hinged opposite r the jint, and fastert d by means of leather straps above and 7below the patella. This aims at keeping the disc in place by ! limiting the movement of the joint itself, especially in the f direction of complete extension and rotation. But I need not , tell you that all these appliances are cumbersome, very diffic-alt of accurate adjustment, and only to be thought of in the i case of patients who are well to-do and are willing to lead t a life of ease and quiet. For the our g and active life-long -restraint such as this implies is intolerable. If the car--tilage is to be retained and fixation tried there can be -no doubt that the plan of securing it by sutures to the head i of the tibia as practised by Annanda]e is much to be pref ferred. I cannot, however, from my own experience entirely -recommend this. Fixation by suture is seldom a permanent rsuccess except in those rare instances in which the circum-1 ference of the cartilage is detached from the tibia, without , the ends being torn. Where a previously sound cartilage has given way, or where one of the ends has been wrenched from s off the bone, I am very sceptical as to whether it is possible p to make it secure by means like thip, and at the same time allow it to have its normal range of movement. Sutares and e adhesions cannot make it stronger than it was before it was e burt unless they fix it so that it is completely rigid ; and if it gave way before it wiil give way all the more easily a h second time if exposed to a similar sf rain. I have tried a. suturing en two occasions, and in both patients the accident i recurred. For this reason I am convinced that in all cases in 11 which the cartilage is torn away from the bone, or in which oalthough it may not be torn it is so stretched that it gets in .1 the way of the bones and is caught between them, the knee-)-joint should be opened freely and the whole of the loosened, ipart of the disc excised. The operation is cne that at the o present day, if proper precautions are taken aid the patient n is in a good state of health, can be performed with perfect It safety. This is the fifth occasion on which I have done it for a this purpose, and in none has the temperature risen to 100° F s It has the merit of being thorough; displacement cannot ocom e again. The risk is not greater than it is in fixing the cartilage s by means of sutures. I myself am of opinion that it is lCPf'5 d as there is less manipulation of the joint, and the knee after y the cartilage has been removed, and the wound is sound, ia das strong and as free in its range of action as it was before LO the cartilage was displaced. This last statement, I know, n has been disputed. The operation has been objected to, and r. is objected to, on the ground that it weakens the knee-joint 1t by depriving it of a structure that is especially adapted to 10 reduce the concussion caused by the sudden impact of the 1, feet against the ground in jumping down from a height-Ie Now I do not wish in any way to weaken your respect for 'y authority. There are many statements in physiology as well eas in other things incapable of proof, which 3ou are expected to receive and accept on faitb. But a little scepticism is 'y often judicious, and if you quietlyexamit:e this objection I s think you will agree with me that the respect which is due is to tradition is almost the only foundation that it has. I do re not believe that these cartilages are of any sensible use in U
doi:10.1016/s0140-6736(02)04458-6 fatcat:ongg5wlyg5delbtpu6s6uv45ga