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Open knee joint injuries: an evidence-based approach to management.

The knee joint is the most common lower extremity joint to sustain an openjoint injury ranging from 51% to 91% of lower extremity openjoint injuries. (1) This is in contrast to the ankle and hip, which are reported to sustain 1.5% to 10% and 1% to 7% of lower extremity open joint injuries, respectively. (1) The frequency with which this joint is injured has resulted in nearly 100 years of peer-reviewed literature documenting the morbidity of open knee joint injuries, with most of the early literature arising from World War I. However, despite this long-time frame during which this injury has been studied, there are very few prospective or retrospective studies and no randomized controlled studies from which to draw evidenced-based conclusions regarding the optimal management strategy. The purpose of this paper is to provide current, evidenced-based data on the best methods to manage this potentially devastating injury.

Anatomy

Snell provided what appears to be the first radiographic depiction of the joint capsule. (2) The knee joint capsule extends superiorly approximately 3 cm to 4 cm proximal to the superior pole of the patella, posteriorly to the level of the physeal scars on the distal femur and to the articular surface of the tibial plateau, and anteriorly the joint capsule lies directly under the patellar tendon and is confluent with the undersurface of the surrounding medial and lateral retinaculum (Fig. 1). The undersurface of the joint capsule is lined by synovium, which in certain cases of puncture wounds to the knee can become inflamed causing a synovitis that mimics a septic knee. (3)

Epidemiology

Three large studies have reported on the epidemiology of open knee joint injuries. Patzakis and coworkers was the first to report on the "modern" management of open joint injuries in 1975. (4) They reported on 140 open joint injuries of which 129 (92%) were open knee joint injuries. Patients had a mean age of 25 years (range: 4 to 68 years). The mechanisms of injury for all joints were gunshot wounds (GSWs) (32%), motor vehicle accidents (MVAs) (22%), motorcycle accidents (MCAs) (20%), falls (12%), stab wounds (7%), and foreign bodies (6%). They reported 86 fractures (61.4%) and 3 (2.3%) knee infections; however, they did not report on amputations or vascular injuries.

[FIGURE 1 OMITTED]

Collins and Temple reported on 54 open joint injuries of which 32 (64%) were open knee joint injuries. (1) The mean age was 32 years (range: 18 to 45 years). The mechanisms of injury for all joints were MVCs (46%), GSWs (31%), falls (19%), MCAs (13%), and stab wounds (7%). Of their open knee joint injuries, they reported 8 (24%) associated periarticular fractures, 4 (11.8%) infections, 3 (9%) vascular injuries, and 1 (2.9%) amputation.

More recently, our group has reported on our experience treating open knee joint injuries. (5-7) We retrospectively reviewed 78 patients with periarticular knee wounds suspicious for an open joint injury who presented to a level I trauma center emergency department (ED) (Table 1). The mean age of our cohort was 30 years (range: 4 to 80 years), and there were 59 males and 18 females. The mechanism of injury was GSWs (32%), falls (21%), MVAs (17%), sharp objects (15%), MCAs (9%), and other (6%). The mean wound size was 4.0 cm [+ or -] 4.5 cm (range: 1 cm to 25 cm), and the wounds were located anteriorly (50%), medially (26%), laterally (22%), and posteriorly (3%). We found 40 (51%) knees with open joints (traumatic arthrotomies), 21 (27%) knees with associated periarticular fractures, and 0 infections at mean follow-up of 280.9 days [+ or -] 476.8 days. We had one (1.3%) patient with a vascular injury which ultimately necessitated an above the knee amputation.

We separately evaluated the 40 knees with traumatic arthrotomies (Table 2). Patients in this cohort had a mean age of 27 years (range: 8 to 75 years), and there were 35 males and 4 females. The mechanism of injury was GSW (43%), MVA (20%), MCA (13%), falls (5%), sharp objects (5%), and other (3%). Twenty-one (53%) of patients had an associated periarticular fracture. The infection rate was 0%, and there was one (2.5%) patient with a vascular injury, which ultimately necessitate an above the knee amputation.

In our series, GSWs were the predominant mechanism of open joint injury. Dougherty and associates has looked specifically at the prevalence of GSWs to the lower extremity. (8) Over a 5-year period, their group recorded 526 GSWs to the lower extremity of which 50 (10%) involved the knee joint. They noted that the knee was the most commonly involved lower-extremity joint. Perry and colleagues reported on 64 knees with GSWs of which 36 (56%) had an open joint injury. (9) They noted that all patients with an open joint injury had either an intra-articular or periarticular fracture. Interestingly, 36% (23/64) of knees had a suspected vascular injury and underwent an arteriogram of which 26% (6/23) were positive. Eighty-five percent (5/6) of those knees with a vascular injury necessitated surgical repair.

We can conclude from the available data that open knee joint injuries are more common in young males and result predominantly from gunshot wounds, dashboard type blunt injuries from MVAs and MCAs, and from falls or lacerations by sharp objects. The mean periarticular wound size seen in the ED is approximately 4 cm, but can range to as small as 1 cm (most commonly seen in puncture or penetrating type wounds from bullets) to large lacerations with associated degloving soft-tissue injuries. Fractures are common in open knee joint injuries with an incidence ranging from 24% to 55%. The infection rate ranges from 0% to 11.8%, the vascular injury rate ranges from 0% to 9%, and the amputation rate ranges from 2.5% to 2.9%.

Diagnosis

Historical

In 1915, Hightower reported that the diagnosis of an open joint injury could be made by evaluating the periarticular wound for synovial fluid extravasation or with an XR showing a foreign body. (10) In 1962, Dr. Kilfoyle described that air in the joint, as viewed on an XR, was diagnostic of an open joint injury. (11) He also described the presence of fat-droplets in the blood extravasating from the open wound as diagnostic of an associated fracture. In 1976, Fordham and Turner described the use of arthrography to determine the presence of an open knee joint injury. (12) They reported a case-series of four patients in which they injected 15 cc to 30 cc of a radiopaque contrast agent into the knee joint. They then performed XRs of the knee to evaluate for extravasation of the dye outside of the joint. Complications of this technique included synovial irritation leading to transient joint effusions.

Current

The modern diagnostic approach to evaluation of open knee joint injuries not readily diagnosed on clinical examination or a plain radiograph is to perform the Saline Load Test (SLT). Patzakis and colleagues were the first to mention the use of the SLT in 1975 when they described "extravasation of saline from the joint into the wound during arthrocentesis." (4) From 1975 through 1996, the SLT was used with increasing frequency in the emergency department setting to diagnose open kneejoint injuries. It was not until 1996 that an evidence-based approach to examining the efficacy of the SLT was performed.

Voit and coworkers performed a prospective cohort study of 50 open joints injuries of which 40 were open knees. (13) Their purpose was to compare their clinical prediction of an arthrotomy based on clinical and radiographic criteria to the results of a 60 cc SLT. They assumed that the SLT had 100% sensitivity although this had never been proven.

Their results showed that their clinical prediction had a false-positive rate of 39% and a false-negative rate of 43%. Ultimately, they concluded that the SLT altered treatment for 40% of their patients, and that it was better than clinical judgment alone in diagnosing an open joint injury. The primary flaw of this study, however, is that they assumed that a 60 cc SLT had 100% sensitivity, which future studies would later prove to be false. Yet, based on this study, the 60 cc SLT became the standard of care for diagnosing traumatic arthrotomies in the absence of other clinically obvious signs of an arthrotomy.

From 2007 to 2009, three studies were published that challenged the sensitivity of a low-volume (50 cc to 60 cc) SLT to accurately diagnose small traumatic arthrotomies. Keese and coworkers injected the knees of 30 patients undergoing elective knee arthroscopy with a 50 cc SLT after creating a small arthrotomy (26.4 [mm.sup.2]) and found that 194 cc of saline was necessary to achieve 95% sensitivity. (14) At the standard volume of 50 cc, they achieved only 46% sensitivity. Tornetta created an arthrotomy (7.5 mm incision via an arthroscopy portal) in 80 knees undergoing elective arthroscopy and performed a 60 cc SLT. (15) The investigators evaluated for extravasation in a static position (no knee range-of-motion) and a dynamic position (knee taken through a full range-of-motion from extension to flexion). They showed that a 60 cc SLT had a static sensitivity of 36% and a dynamic sensitivity of 43%. Finally, Tejwani and associates performed a randomized control trial of 56 knees undergoing elective arthroscopy and performed a static SLT and found that a 155 cc SLT was necessary to achieve 95% sensitivity. (16) Interestingly, the investigators had four patients for whom fluid did not extravasate from the arthrotomy (false negative rate = 7%; 4/60); however, these patients were excluded from the study analysis.

In a recent clinical study, 50 patients with a periarticular knee wound suspicious for an open joint injury received a dynamic SLT. (5) If the SLT was positive, they were taken to the OR for evaluation of the joint capsule integrity and were diagnosed as either having or not having a traumatic arthrotomy. Patients with a negative SLT and no other evidence of a traumatic arthrotomy were discharged after local wound care in the ED. If they developed a septic knee, they were considered to have had a missed traumatic arthrotomy, and if they did not develop a septic knee, they were considered to have simply a periarticular wound that was equivalent to no traumatic arthrotomy.

Based on a cohort of 50 patients who underwent the SLT, the investigators recorded a mean wound size of 3.9 cm [+ or -] 4.3 cm and the mean saline load volume of 74.9 cc [+ or -] 28.2 cc. The mean follow-up time for all patients was 280.9 days [+ or -] 476.8 days. The investigators recorded a sensitivity of 94%, a specificity of 91%, and a 9% false positive rate for the SLT as administered in the ED setting.

In summary, the evidence-to-date indicates that the SLT is inadequate to diagnose traumatic arthrotomies (Table 3). Arthroscopy models have shown that a 155 cc to 194 cc SLT is necessary to achieve 95% sensitivity in very small traumatic arthrotomies. In general, an awake and alert patient will not tolerate such large volumes injected into the knee joint. In the actual ED setting, smaller SLT volumes are required to achieve similar sensitivity (likely due to larger arthrotomy sizes); however, there is a high-false positive rate (9%).

Computed Tomography Scan

Konda and coworkers were the first to describe the use computed tomography scan (CT scan) to routinely diagnose traumatic arthrotomies. (6) Based on the assumption that traumatic knee arthrotomies result in intra-articular air that is readily visible on CT scans (Fig. 2), the investigators evaluated a consecutive series of 63 knees with periarticular knee wounds suspicious for a traumatic arthrotomy that received a CT scan. If the CT scan was positive for intra-articular air, then patients were taken to the OR for formal inspection of the arthrotomy. If it was negative for air without any other sign of a traumatic arthrotomy, then the patients were discharged from the ED. The validity of the CT scan was then determined by reviewing patients at follow-up to ensure they had not developed a septic knee. This is the same model that was used when evaluating the SLT as discussed previously. A cohort of 37 patients also received a SLT, and the investigators compared the ability of CT scan versus the SLT to detect a traumatic arthrotomy.

The sensitivity and specificity of the CT scan to detect traumatic arthrotomies and rule-out periarticular wounds equivalent to no traumatic arthrotomy was 100%. Compared to the SLT, the sensitivity and specificity of the CT scan was 100% compared to 92% for the SLT. There was a significant difference in both sensitivity (p < 0.01) and specificity (p < 0.01) favoring the CT scan over the SLT.

An additional benefit of the CT scan is that it improves detection and treatment of open periarticular knee fractures. (7) From the original cohort of 78 patients with periarticular knee wounds, we identified 21 knees with associated open fractures of the knee. The investigators found a 27% incidence of open periarticular fractures in the setting of an open periarticular wound presenting to the ED. If a traumatic arthrotomy was present, there was a 51% incidence of an associated open periarticular fracture. Overall, gunshot wounds had a 48% (12/25) incidence of an open periarticular fracture compared to a 17% (9/54) for all other injury mechanisms combined (p < 0.01).

Using CT scan as the gold standard to detect fractures, the specificity and sensitivity of XR to detect a fracture was 98% and 65%, respectively. Ultimately, CT scan altered the fracture classification in 48% of patients when compared to XR. When compared, the results of fracture treatment based on XR versus CT scan found that CT scan altered treatment in 43% of patients.

[FIGURE 2 OMITTED]

In an effort to minimize radiation doses associated with the test, Konda and colleagues injected 10 cadaver knees with sequentially increasing amounts of intra-articular air and then evaluated the lowest radiation dose at which the inter-observer reliability was [greater than or equal to] 0.8 to detect each amount of air. (17) This radiation dose was defined as the Threshold Radiation Dose. A maximum mean radiation dose of 8.42 mSv was automatically calculated by the CT scanner using the standardized setting for scanning an adult knee. The radiation dose was lowered to 0.74 mSv, the lowest radiation dose allowable by the CT scanner and approximately 11 times lower than the starting dose. The investigators found perfect agreement (kappa = 1.0) between the attending radiologist and orthopaedic surgeon in the ability detect intra-articular air at the lowest radiation dose of 0.74 mSv at a volume of 0.1 cc intra-articular air. The effective radiation dose of 0.74 mSv is equivalent to a single posteroanterior and lateral chest radiograph. These results indicate that the use of CT scan to detect intra-articular air can be accomplished with significantly lower doses of radiation than is currently administered by standard knee CT scan protocols.

In summary, the diagnosis of open joint injuries has been described for over 100 years, and clinical indicators of an open joint, which includes a visible joint surface or intraarticular air or foreign body on plain radiographs, provide the most rapid and least morbid method of diagnosis. The SLT has been in use for over 35 years but with little data to support its use as a gold-standard diagnostic test. More recent data suggests the CT scan is more accurate than the SLT to diagnose open joint injuries. There should be a high level of suspicion for associated periarticular fractures in patients with periarticular knee wounds, and we have shown that CT scan improves diagnosis and treatment of these injuries. Finally, cadaver data suggests that a low-dose radiation protocol can be utilized to detect open joint injuries with accuracy.

Treatment

Open Irrigation and Debridement

The current treatment paradigm for open joint injuries has evolved little from that described by Patzakis and colleagues 35 years earlier. Early broad-spectrum intravenous antibiotics and tetanus shots are administered in the ED. After diagnosis of the open joint, a moist sterile saline gauze is placed in the arthrotomy to prevent desiccation of the wound, and the knee is immobilized in extension. The patient should be taken to the operating room for urgent debridement and irrigation with a large volume of fluid. A medial parapatellar approach to the knee joint is the workhorse of the knee. The wound is closed primarily over an intra-articular drain, which is discontinued after 24 to 48 hours. Postoperative intravenous antibiotics are generally continued for 24 to 48 hours after the last irrigation and debridement.

Arthroscopic Irrigation and Debridement

Arthroscopic treatment of open joint injuries is an alternative to open surgical approaches. Several small case series evaluating the effectiveness of this approach have been published. The most complete study to-date is by Raskind and Marder, published in 1993, which retrospectively compared 14 arthroscopic versus 15 open debridements of 29 open joint injuries. (18) The investigators reported that approximately 80% of knees treated with arthroscopic debridement had associated intra-articular pathology compared to only 13% of openly debrided knees. They concluded that arthroscopy was beneficial in aiding in the diagnosis of additional intraarticular pathology.

Tornetta and Hui published another thorough review in 1997 of 33 low-velocity GSWs to the knee treated with arthroscopic irrigation and debridement. (19) The investigators compared the results of their radiographic findings to their arthroscopic findings. Seven patients (21%) had no XR findings of intra-articular pathology; however, during arthroscopy, all seven patients demonstrated some intra-articular pathology. Seventy percent had a meniscal tear, and 70% had intraarticular debris defined as a bullet fragment, bone, or clothing. The investigators concluded that in low-velocity GSWs to the knee, plain radiographic diagnosis alone was insufficient to diagnose intra-articular pathology, and that arthroscopy aided in their diagnosis and treatment of these injuries. The patients in this series also had no infections at a minimum of 21 days of follow-up and the investigators concluded that arthroscopic debridement of wounds with minimal soft-tissue injury was adequate to prevent infection (Table 4).

A rare complication of arthroscopy is the development of compartment syndrome due to extravasation of the pressurized inflow fluid into the surrounding soft-tissue. Although none of the investigators previously discussed reported on compartment syndrome as a complication, there is literature to suggest that it is a concern in treatment of openjoint injuries. In 1982, Noyes and Spievak published a cadaver study in which they performed a knee arthroscopy on a cadaver with a capsular perforation and showed that after infusion of 900 cc of saline, the thigh compartment pressures reached 80 mmHg, which they considered a compartment syndrome. (20) In 1997, Belanger and Fadale reported on the development of calf compartment syndrome after an arthroscopically assisted ORIF of a tibial plateau fracture. (21) These studies highlight the theoretical risk of compartment syndrome in open knee joint injuries.

In summary, arthroscopic irrigation and debridement is most commonly indicated for low-energy GSWs but can also be used for low-energy wounds with minimal soft-tissue injury. Studies have shown that arthroscopic irrigation and debridement improves the diagnosis and treatment of intra-articular pathology compared to XRs. The risk of compartment syndrome should be weighed when performing arthroscopy in the setting of an intra-articular fracture or multiple or large capsular perforations.

Antibiotic Therapy

The antibiotic therapy regimen for open joint injuries is loosely based on the literature on antibiotic therapy for open fractures. Based on the Gustillo-Anderson Classification system, Type I and II open fractures receive 1 g of cefazolin every 8 hours. Type III fractures also receive an aminoglycoside (3 to 5 mg/kg/day) as multi-agent therapy has been shown to significantly decrease infection rates compared to single-agent therapy. If organic contamination is present, penicillin should be administered every 4 hours. (22)

Only a handful of studies have reported the antibiotic regimen administered to their cohort of open joint injuries. The results show array of antibiotic regimens (Table 5). All studies reported at least 24 hours of IV antibiotics with most studies extending antibiotic use 48 to 72 hours. Only Collins and Temple and our group reported on the use of oral antibiotics after completion of intravenous antibiotics. (1,6)

Parker and Schmid reported on the antibiotic penetration of several different antibiotics into 75 patients with a septic knee. (23) They showed that serum antibiotics levels closely mimicked synovial fluid levels. In 1978, Shurman and coworkers showed in a rabbit model that synovial fluid antibiotic concentrations equaled serum antibiotic concentrations within 1 hour of antibiotic administration, and this effect was achieved regardless of how long the knee joint had been infected. (24)

Management Algorithm

Based on current evidence for diagnose and treatment of open joint injuries, the latest recommendation called for a stepwise algorithm for management of this injury. The first goal of management is to "save the limb" by performing a vascular assessment and treating the vascular injury appropriately. The second goal is to prevent joint infection by assessing for capsular violation. Finally, the third goal is to identify periarticular fractures via imaging and determine the method of treatment.

Step 1: Vascular Assessment

The first step to evaluation of an open joint injury remains evaluation of the vascular status of the patient. If a patient presents with an ischemic limb, it is necessary to coordinate with trauma team whether or not the patient is going directly to the operating room or if the patient is going to the CT scanner first for imaging of other injuries, such as imaging of the spine or abdomen and pelvis. If the answer is "CT scanner first," then a CT scan of the knee should be performed simultaneously to assess for an open joint via the presence of intra-articular air and for a fracture. If the answer is "operating room first," then an intraoperative SLT should be performed to assess for an openjoint. In the event that there is high suspicion for a vascular injury based on physical exam findings and the patient is going to undergo a CT angiogram to further assess the vascular status, then the CT scan of the knee should be used to simultaneously assess for both an open joint injury and fracture. If, however, there is no concern for vascular injury based on physical exam, then the work-up should proceed to assessment for an open joint injury and fracture (Fig. 3).

[FIGURE 3 OMITTED]

Step 2: Open Joint and Fracture Assessment

In the assessment of an open joint injury and fracture, both the clinical exam and plain XRs should be evaluated first because 41% of the time these two modalities demonstrate a grossly visible joint, intra-articular air, or a foreign body, all of which confirm the presence of an open joint. (6) In the scenario that clinical exam and XR confirm an open joint without a fracture, the work-up is complete, and the patient can proceed to the operating room for irrigation and debridement of the joint. If clinical exam and XR confirm and an open joint and a fracture, then a CT scan should be obtained to further assess the fracture pattern.

If there is no open joint on clinical exam and XR but a fracture is identified, then a CT scan should be obtained to better assess the fracture pattern while simultaneously assessing for intra-articular air to rule-out an open joint. In this scenario, regardless of the presence of an open joint on physical exam, if there is air on the CT scan, the patient should be taken to the operating room urgently for irrigation and debridement of the open fracture.

[FIGURE 4 OMITTED]

If the clinical exam and XR do not have any evidence for an open joint or fracture, the data supports the use of CT scan as the first choice diagnostic test as it is more sensitive and specific than the SLT. If the CT scan is positive, then the patient will go to the operating room for irrigation and debridement of the joint. If the CT scan is negative, local wound care and primary closure of the wound is performed at the bedside.

[FIGURE 5 OMITTED]

Step 3: Irrigation and Debridement (Open versus Arthroscopic)

If a fracture is present, open irrigation and debridement should be performed for the reason of obtaining adequate debridement of both the fracture and the joint and to minimize the risk of compartment syndrome (from arthroscopic fluid extravasation). If there is no fracture and the injury is a small laceration, GSW, or puncture wound with minimal soft-tissue injury, then arthroscopic irrigation and debridement is appropriate. If it is a high-energy wound or large laceration with significant contamination or moderate to severe soft-tissue injury, then open irrigation and debridement is appropriate (Fig. 5).

Conclusion

The knee is the most common lower extremity joint to sustain an open injury. Diagnosis and treatment of this injury is an orthopaedic urgency. Diagnosis starts with clinical exam and plain radiographs. Further diagnostic work-up includes using a CT scan (first choice) or SLT based on the clinical scenario. Treatment involves either open or arthroscopic irrigation and debridement and is dictated by the presence of a fracture, mechanism of injury, and amount of soft-tissue injury and contamination. Pre- and postoperative antibiotic therapy follows the guidelines for treatment of open fractures. Following the stepwise algorithm for management of open knee joint injuries presented here will help the treating surgeon minimize complications and achieve excellent outcomes.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

Caption: Figure 1 Illustration depicting the early radiographs of the knee joint after injection with radiopaque dye. (Reproduced from Snell FR. The knee-joint capsule: a radiographic study. Br Med J. 1918 Jun 29;1(3000)717-8, with permission from BMJ Publishing Group Ltd.)

Caption: Figure 2 Computed Tomography scan of knee with periarticular wound showing intra-articular air diagnostic of traumatic arthrotomy; bone window (A) and lung window (B).

Caption: Figure 3 Step 1: Vascular assessment. ABI = ankle-brachial index; abd = abdomen; CT = computed tomography scan; Fx = fracture; SLT = saline load test; OR = operating room.

Caption: Figure 4 Step 2: Open joint and fracture. XR = plain radiograph; Fx = fracture; CT = computed tomography scan; SLT = saline load test; OR = operating room; I&D = irrigation and debridement.

Caption: Figure 5 Step 3: Irrigation and debridement (open versus arthroscopic). OR = operating room; Fx = fracture; GSW = gunshot wound; I&D = irrigation and debridement.

References

(1.) Collins DN, Temple SD. Open joint injuries. Classification and treatment. Clin Orthop Relat Res. 1989 Jun;(243):48-56.

(2.) Snell FR. The Knee-joint Capsule: A Radiographic Study. Br Med J. 1918 Jun 29;1(3000):717-8.

(3.) O'Connor CR, Reginato AJ, DeLong WG Jr. Foreign body reactions simulating acute septic arthritis. J Rheumatol. 1988 Oct;15(10):1568-71.

(4.) Patzakis MJ, Dorr LD, Ivler D, et al. The early management of open joint injuries. A prospective study of one hundred and forty patients. J Bone Joint Surg Am. 1975 Dec;57(8):106570.

(5.) Konda SR, Howard D, Davidovitch RI, Egol KA. The saline load test of the knee redefined: a test to detect traumatic arthrotomies and rule out periarticular wounds not requiring surgical intervention. J Orthop Trauma. 2013 Sep;27(9):491-7.

(6.) Konda SR, Davidovitch RI, Egol KA. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. J Orthop Trauma. 2013 Sep;27(9):498-504.

(7.) Konda SR, Howard D, Davidovitch RI, Egol KA. The role of computed tomography in the assessment of open periarticular fractures associated with deep knee wounds. J Orthop Trauma. 2013 Sep;27(9):509-14.

(8.) Dougherty PJ, Vaidya R, Silverton CD, et al. Joint and long-bone gunshot injuries. J Bone Joint Surg Am. 2009 Apr;91(4):980-97.

(9.) Perry DJ, Sanders DP, Nyirenda CD, Lezine-Hanna JT. Gunshot wounds to the knee. Orthop Clin North Am. 1995 Jan;26(1):155-63.

(10.) Hightower CC. Looking back: punctured wounds of the knee-joint in 1915. J Miss State Med Assoc. 2002 Jul;43(7):225-6.

(11.) Kilfoyle RM, Dolphin JA, Mc CJ. Wounds into the knee joint. Carney Hosp J. 1962 Jun;4:31-8.

(12.) Fordham SD, TurnerAF. Arthrography in penetrating injuries. JACEP. 1976 Apr;5(4):265-7.

(13.) Voit GA, Irvine G, Beals RK. Saline load test for penetration of periarticular lacerations. J Bone Joint Surg Br. 1996 Sep;78(5):732-3.

(14.) Keese GR, Boody AR, Wongworawat MD, Jobe CM. The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. J Orthop Trauma. 2007 Aug;21(7):442-3.

(15.) Tornetta P 3rd, Boes MT, Schepsis AA, et al. How effective is a saline arthrogram for wounds around the knee? Clin Orthop Relat Res. 2008 Feb;466(2):432-5.

(16.) Nord RM, Quach T, Walsh M, et al. Detection of traumatic arthrotomy of the knee using the saline solution load test. J Bone Joint Surg Am. 2009 Jan;91(1):66-70.

(17.) Konda SR, Howard DO, Gyftopoulos S, et al. Computed Tomography Scan to Detect Intra-articular Air in the Knee Joint: A Cadaver Study to Define a Low Radiation Dose Imaging Protocol. J Orthop Trauma. 2013 Sep;27(9):505-8.

(18.) Raskind JR, Marder RA. Arthroscopic versus open debridement of penetrating knee joint injuries. Iowa Orthop J. 1993;13:121-3.

(19.) Tornetta P 3rd, Hui RC. Intraarticular findings after gunshot wounds through the knee. J Orthop Trauma. 1997 Aug;11(6):422-4.

(20.) Noyes FR, Spievack ES. Extraarticular fluid dissection in tissues during arthroscopy. A report of clinical cases and a study of intraarticular and thigh pressures in cadavers. Am J Sports Med. 1982 Nov-Dec;10(6):346-51.

(21.) Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. Case report and review of the literature. Arthroscopy. 1997 Oct;13(5):646-51.

(22.) Olsen SA, Willis MD. Initial Management of Open Fractures. In: Bucholz RW, Heckman JD, Court-Brown CC (eds). Rockwood and Green s Fractures in Adults (6th ed). Philadelphia: Lippincott Williams & Wilkins, 2006, p. 398.

(23.) Parker RH, Schmid FR. Antibacterial activity of synovial fluid during therapy of septic arthritis. Arthritis Rheum. 1971 Jan-Feb;14(1):96-104.

(24.) Schurman DJ, Hirshman HP, Nagel DA. Antibiotic penetration of synovial fluid in infected and normal knee joints. Clin Orthop Relat Res. 1978 Oct;(136):304-10.

(25.) Parisien JS, Esformes I. The role of arthroscopy in the management of low-velocity gunshot wounds of the knee joint. Clin Orthop Relat Res. 1984 May;(185):207-13.

(26.) Berg EE, Ciullo JV. Arthroscopic debridement after intraarticular low-velocity gunshot wounds. Arthroscopy 1993;9(5):576-9.

(27.) Oladipo JO, Creevy W, Remis R. Arthroscopic management of intra-articular low-velocity gunshot wounds of the knee. Am J Knee Surg. 1999 Fall;12(4):229-32.

Sanjit R. Konda, M.D., Roy I. Davidovitch, M.D., and Kenneth A. Egol, M.D., are in the Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York.

Correspondence: Sanjit R. Konda, M.D., 301 East 17th Street, Suite 1400, New York, New York 10003; Sanjit.Konda@nyumc.org.

Konda SR, Davidovitch RI, Egol, KA. Open knee joint injuries: an evidence-based approach to management. Bull Hosp Jt Dis. 2014;72(1):61-9.
Table 1 All Patients Presenting to the ED with a
Periarticular Knee Wound from 2008 to 2011

Total                   78

Mean Age (yrs)          29.7 (range: 4 to 80)
Sex (M/F)               59/18
Mechanism of Injury     25 GSW
                        16 Falls
                        13 MVAs
                        12 Sharp objects
                        7 MCAs
                        5 Other
Wound Location          Anterior: 39
                        Lateral: 17
                        Medial: 20
                        Posterior: 2
Mean Wound Size (cm):   4.0 [+ or -] 4.5 (range: 1-25)
Open Joint              40 (51.3%)
Fractures               21 (26.6%)
Infection Rate          0%
Vascular Injury         1 (1.3%)
Amputations             1 (1.3%)

Table 2 Confirmed Open Joint Injuries from 2008 to
2011

Total#                 40
Mean Age (yrs)         27.4 [+ or -] 14.2 (range: 8 to 75)
Sex (M/F)              35/4
Mechanism of Injury    GSW: 17
                       Fall: 4
                       MVA: 8
                       Sharp Object: 4
                       MCA: 5
                       Other: 2
Wound Location         Anterior: 19
                       Medial: 9
                       Lateral: 10
                       Posterior: 2
Mean Wound Size (cm)   3.7 [+ or -] 4.4 (range: 1 to 20)
Fractures              21
Infection Rate         0%
Vascular Injury        1 (2.5%)
Amputations            1 (2.5%)

Table 3 Summary Saline Load Test Evidence-Based Data

                                              SLT
                              Arthrotomy     volume    Static or
Study                  Year   model           (cc)      Dynamic

Voit et al. (13)       1995   ER               60         --

Keese et al. (14)      2007   Arthroscopy     194       Static

Tornetta et al. (15)   2008   Arthroscopy      60       Dynamic

Nord et al. (16)       2009   Arthroscopy     155       Static

Konda et al. (5)       2013   ER              74.9      Dynamic
                                            [+ or -]
                                              28.2

                       Sn/Sp   FP/FN
Study                   (%)     (%)

Voit et al. (13)        -/-     -/-

Keese et al. (14)      95/-     -/-

Tornetta et al. (15)   43/-     -/-

Nord et al. (16)       95/-     -/6

Konda et al. (5)       94/91    9/0

Study                  Comments

Voit et al. (13)       SLT better than clinical judgment along;
                       wrongly assumed SLT had 100% Sn

Keese et al. (14)      Investigators recommend not to use
                       SLT alone to diagnose small traumatic
                       arthrotomies of the knee

Tornetta et al. (15)   60 cc SLT has poor Sn to detect small
                       traumatic arthrotomies

Nord et al. (16)       Inferomedial portal requires less SLT
                       volume; high false-negative rate

Konda et al. (5)       High false-positive rate; large SLT
                       volumes poorly tolerated

ER = emergency room; SLT = Saline Load Test; Sn = sensitivity;
Sp = specificity; FP = false-positive; FN = false negative.

Table 4 Studies Evaluating Arthroscopic Irrigation and
Debridement of Open Joint Injuries in the Civilian Population

Year   Study                        # Patients

1984   Parisien and Esformes (25)       8
1993   Berg and Ciullo (26)             2
1993   Raskind and Marder (18)          29
1997   Tornetta and Hui (19)            33
1999   Oladipo et al. (27)              13

                             Infection
Year   Mechanism of Injury   Rate (%)

1984   Low-velocity GSWs         0
1993   Low-velocity GSWs         0
1993   Variable MOI              0
1997   Low-velocity GSWs         0
1999   Low-velocity GSWs         0

GSW = gunshot wound; MOI = mechanism of injury.

Table 5 Length of Antibiotic Therapy for Open Joint
Injuries in Studies Evaluating More Than 30 Patients

                      Number                                  Infection
Year   Study         of Knees   Antibiotic Protocol             Rate

1976   Patzakis et     129      IV antibiotics minimum 10       2.3%
       al. (4)                  days

1989   Collins and      34      -OR Cx: IV antibiotics          11.8%
       Temple (1)*              until 72 hours after last
                                I&D +OR Cx: IV or PO
                                antibiotics for 10 to 14
                                days

1993   Raskind and      30      IV antibiotics for 24 to 48      0%
       Marder (18)              hours until drain
                                discontinued

1997   Tornetta et      33      IV antibiotics for 1 to 5        0%
       al. (19)                 days

2013   Konda et         40      + arthrotomy: IV                 0%
       al. (5,6)                antibiotics until 48 hours
                                after last I&D + 5 days PO
                                Abx

                        38      Periarticular wound              0%
                                equivalent to no
                                arthrotomy: 1 dose IV
                                antibiotics in ER + 5
                                to 7 days PO antibiotics

IV = intravenous; * note, the investigators performed
intraoperative cultures of the knee joint during the initial
irrigation and debridement; -OR Cx = negative operating room
culture; +OR Cx = positive operating room culture; I&D =
irrigation and debridement; PO = oral.
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Author:Konda, Sanjit R.; Davidovitch, Roy I.; Egol, Kenneth A.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Jan 1, 2014
Words:5850
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