THE CLASSIC: Surgical Treatment of Fresh Injuries to the Major Ligaments of the Knee

Abstract

Dr. O'Donoghue was born in Storm Lake, Iowa, in 1901. He was educated in the local schools before going to the University of Iowa where he obtained a B.S. degree (1923) and a medical degree (1926). After a year of surgical residency at the University of Iowa, he moved to the University of Oklahoma where he completed his orthopedic training in 1932. Following this, he entered the private practice of orthopedic surgery in Oklahoma City, and at the same time, served as the Chairman of the Department of Orthopaedic and Fracture Surgery at the University of Oklahoma. He retired in 1984. During the 50 years in which he was actively practicing and teaching, Dr. O'Donoghue had an enormous influence on the development of sports medicine in the United States and throughout the world. He traveled and lectured extensively and authored an important book on the treatment of sports injuries. His work on injuries of the knee was particularly important. He was active in numerous medical societies and civic organizations. Through his personality and his surgical skill, he has left an enduring legacy to those who treat athletic injuries. Leonard F. Peltier, M.D., Ph.D. For many years the author has had the privilege of attending to the major injuries of a large number of athletes, not only of college, but also of high-school age. None are so pleasant to treat and so eager to get back to the fray as these students. It is a problem to keep them from recovering too soon for their own good. One is forced then to seek methods which aim at obtaining the maximum recovery in the minimum time. The degree of recovery must always be paramount, but the rapidity of the cure cannot be ignored. Only one goal is permissible in the care of the young athlete,-namely, complete recovery; for, in the majority of cases of severe injury, especially to the knee, if the recovery is not complete, the patient is no longer an athlete. These principles apply to all major injuries. One particular injury which apparently has not received excellent, or even very good, treatment throughout the years is that injury caused primarily by abduction and external rotation of the tibia on the femur, with that unhappy triad (1) rupture of the medial collateral ligament, (2) damage to the medial meniscus, and (3) rupture of the anterior cruciate ligament. While there are many other types of injury to the knee and to other joints common in athletes, this paper deals entirely with this injury in its various degrees. In a rather careful review of the recent literature, one is impressed by the great number of articles directed toward management of meniscus injury. Relatively few have written in any detail concerning major ligament injury, a notable exception being the report to this Academy in 1943 by Abbott, Saunders, Bost, and Anderson. Brantigan and Voshell in their meticulous description of the function of the various structures of the knee have pointed out many valuable concepts in regard to the inter-relation of the various joint structures. However, their work has been widely misunderstood and often misquoted because of too casual interpretation of their conclusions. While it is true that both the anterior cruciate and the medial collateral ligaments prevent abduction-external rotation of the tibia and, with either intact, this motion may be checked, obviously, with both intact, the strength of the check is greater. If two of the five stabilizing factors of the knee are disrupted and one is repaired, improvement is noted; but, if both are repaired, the chance of improving stability and strength is greatly enhanced. Then, too, the greatest stability is in complete extension, in which position several stabilizing elements may be impaired without appreciable increase of motion. The athlete, however, must have stability in moderate flexion, where stability requires that all the structures be efficient. The time to diagnose an injury to the knee is at the time of injury. How often have we seen the athlete hobble from the field, be checked by the trainer or physician, and be put to bed with ice caps on the knee to await a more convenient time for a more leisurely examination! Far too often that examination is not made until weeks later, when manifest instability and disability demand that something be done. In too many instances the golden opportunity has passed, and reconstruction instead of repair must be undertaken with a resulting loss of time, increase in the extent of surgery, and impairment of the chances for that complete success which so frequently follows prompt, early, meticulous repair of every damaged structure. Immediately after injury, a careful examination can be done with an ease not possible later, since muscle spasm has not supervened, initial local shock has dulled the pain, and swelling and hemarthrosis have not yet developed. At this time careful, tender examination will reveal with surprising accuracy: (1) the degree of lateral instability, which is a valuable guide to the extent of the damage to the medial collateral ligament; (2) the exact area of tenderness, which serves to indicate the location of the tear or tears; (3) the positive drawer sign, which relates to the integrity of the anterior cruciate ligament; and (4) the restriction of extension which, if present early, before muscle spasm, is an almost infallible sign of meniscus damage. Careful attention to these four findings will often permit diagnosis of a serious ligament injury, even in that patient who has walked from the field with an apparently minor disability. While later, hemarthrosis, local swelling, and pain may be significant in indicating the severity of the injury, they are not especially diagnostic as to the type of the injury. Granted that one cannot always see these patients early, a determined effort to have them sent in early will yield excellent cooperation on the part of the team physician or trainer. This is particularly true if the orthopaedist sets a good example by prompt attention, even at some inconvenience to himself. The habit of seeing Saturday's injuries on Monday is not conducive to early diagnosis and prompt definitive treatment. An early decision as to treatment must be made immediately after examination. Surgery should not be reserved for those cases in which conservative treatment has failed. Modern asepsis, improved anaesthesia, and chemotherapy have minimized the hazards of surgical procedures to the degree that, in a well-run hospital with a competent surgical team, open surgery on a joint injury can take its place alongside non-surgical methods. The selection of treatment, in the absence of complicating factors, hinges on a decision as to what method will give the most complete recovery in the shortest time. The shorter the period of interference with normal joint mechanics, the more rapid and complete will be the recovery. The knee which demonstrates a serious or complete rupture of the medial collateral ligament, a fracture of the medial meniscus, or a tear in the cruciate ligament, or any combination of these, should have early and careful repair not of one or two, but of all damaged structures. Both superficial and deep layers of the collateral ligament must be replaced and repaired, the damaged or displaced meniscus must be removed, and the cruciate ligament must be repaired or plicated. Repair of the cruciate ligament should not be omitted because it “adds to the severity of the operation”, or “may not be essential”. By early exposure, one can clearly define all the damage and repair it all; only by complete repair of all structures will these injuries show maximum recovery. Complete recovery must be the goal in every case. In some instances, an apparently perfect result will follow incomplete repair. In other instances, imperfect results may follow apparently complete repair. However, by striving for complete repair in all cases, the proportion of normal results becomes higher. Some authors have described brilliant results from non-surgical treatment of major ligament injuries. Their follow-up seems to indicate good stable knees. It is, however, difficult for the author to reconcile these results with his own observations. His findings in various cases have shown the medial collateral ligament with its torn end lying within the joint; the semitendinosus, as well as the sartorious tendon end lying free and retracted; the collateral ligament avulsed from the tibia and retracted as far as one and one-half to two inches; the superficial layer of the ligament avulsed from the tibia and the deep layer from the femur, and vice versa; the meniscus entirely loose except for its attachment at the two ends; or the ligament folded up and lying under the cartilage. However, it has been impossible to determine accurately before surgery just which of these situations was present. How can one determine in advance which case will give a satisfactory result by simple plaster fixation? If one waits to see, at best he has lost the optimum time for surgery; at worst, he has precluded the possibility of success by surgery. Routine x-rays of these injuries will be non-productive, unless certain precautions are taken. A single flat antero-posterior roentgenogram should be followed by one made with the leg slightly flexed and forcibly abducted. If done early, this readily shows the “opening up” of the medial joint space. If not conclusive, the opposite limb should be x-rayed. After the patient is asleep, study of the range of abduction of both legs may be instructive. However, the lateral “rocking” of the leg is usually so definite clinically that, if the roentgenograms are positive, so will be the clinical check of motion. PATHOLOGICAL ANATOMY Most anatomical descriptions of the medial ligament of the knee are somewhat obscure and inaccurate from a functional point of view. Since this has been accurately pointed out by others-notably, Brantigan and Voshell; Abbott, Saunders, Bost, and Anderson-it needs no detailed description here. However, these latter descriptions seem needlessly complicated in consideration of early repair of the ligament. The important thing to remember is that there are two distinct layers of the medial collateral ligament. The superficial long fibers arise from the region of the epicondyle of the femur to attach well down on the tibia, some one and one-half to two inches below the rim of the tibial condyle. The upper portion of this ligament blends with the vaginal fascia of the thigh and the muscle fascia of the lower thigh. The deep layer consists of short, thick fibers passing in several directions and in several groupings, but basically connecting the rim of the femoral condyle to the upper rim of the tibia. While these two layers may seem intimately blended, that they are essentially separate is indicated by the fact that they almost invariably tear at different levels. In considering repair, it is essential to inspect both layers, since a major tear in the deep layer may well be, in fact usually is, screened by the superficial layer. By far the most common location of the tear in the superficial layer is at its tibial insertion and may often consist in an apparent slipping or stripping of the fibers from the tibia. The upper attachment is infrequently torn since, as has been previously noted, it has a connection to the muscle fascia of the thigh and so has a certain amount of elasticity. It is necessary to separate this layer from the tibia and to retract it upward to expose the deep layer, which may be torn from the femur, or from the tibia, or between the two. Often a single case may show the deep ligament torn from the tibia in front, and torn from its femoral attachment in its posterior portion, or vice versa, with a tear through the ligament in the central portion. It is the deep layer which includes the attachment of the meniscus. Thus, the meniscus will remain with the tibia, if the femoral attachment is torn, and may be wholly undamaged. However, if the central part of the ligament is torn or if the tibial attachment is pulled away, the meniscus is usually displaced and often ruptured. The importance, surgically, of these facts is that the surgeon must be sure that he has found and repaired each tear, and not be satisfied with a superficial repair. The meniscus must be carefully analyzed as to the integrity of its attachment, both anteriorly and posteriorly. The anatomy of the cruciate ligament has been ably described by Brantigan and Voshell, Palmer, and others. There is some difference of opinion as to the exact function of this ligament. Obviously, to retain this function, whatever it is, the ligament must be carefully inspected and, if damaged, must be repaired. The most consistent positive finding in injury to this ligament is the positive “drawer sign.” If this is present, as compared with the opposite knee, it must be assumed that the ligament is stretched or torn, and it must be plicated or repaired. While no new operative procedures are presented here, a few words as to the technique of repair may serve to clarify the intent of repair. Access to the area is obtained through a flat lazy-S incision, beginning well above the femoral epicondyle anteromedially, and crossing the anteromedial aspect of the joint to end about three inches below the tibial rim along its anteromedial surface. This gives access to the entire medial aspect of the knee. The superficial layer of the ligament is revealed and inspected. The site of damage will be indicated by ecchymosis and hematoma within the fibers, usually at its tibial attachment. This may be demonstrated also by rocking the tibia on the femur. The tear is defined, by sharp dissection if necessary, and the superficial layer is retracted to expose the deep layer. This layer must be inspected entirely across the line of the joint from front to back, and again rocking the tibia may give a clue as to the site of the tear. This tear is readily seen, if the operation is done before healing occurs. Frequently, the ligament will be torn in an irregular fashion,- that is, from the femur in front, across the joint, to the tibial attachment behind, or vice versa. It is advisable at this stage to enter the knee by an incision through the capsule along the medial parapatellar line. Through this incision, the medial meniscus is exposed; and decision as to its removal is made and carried out. The anterior cruciate ligament is inspected. If torn from the tibia, two drill holes are passed from the anteromedial surface of the tibia into the area of the anterior spine. A suitable ligature (No. 3 twisted silk or No. 10 cotton) is passed through one hole into the joint. It is recovered in the joint and placed in a needle and woven through the loose end of the ligament. It is removed from the needle and passed out of the knee through the second drill hole by means of a suitable ligature carrier. When this suture is tightened, the ligament is snugged up into its bed. If the ligament is redundant but not torn, it can be shortened by a similar procedure after some scarification. If the femoral attachment is torn away, a similar repair is made with two drill holes, in this instance passing the ligature from the lateral epicondylar ridge (through a small lateral incision) into the intercondylar notch. None of these procedures is formidable; and, with proper tools, should add no more than ten or fifteen minutes to the operative time. After the placing of these sutures, they are not tied until the medial ligament repair is completed, and the wounds are ready to close. The immediate repair of the deep layer of the collateral ligament may be by various methods. If there is a direct tear in the ligament with two well defined margins, simple suture will suffice, with imbrication if feasible. If the ligament is avulsed from bone, the best method of repair consists of a series of three or four superficial drill holes at the attachment, about three-quarters of an inch apart. Suitable suture is passed through the ligament ends, into one drill hole, out of an adjacent drill hole, and back through the ligament. When all of these have been placed, the knee is positioned at about 150 to degrees and all ligatures are tied. As a rule, the superficial layer can be repaired by simple suture to its bed. If not, a similar procedure may be carried out by drill holes at this level. General imbrication of the ligament by suture may be done to obtain maximum tightness. While these procedures may seem somewhat formidable, the experienced surgeon may readily accomplish repair well within the safe margin of tourniquet time (sixty to seventy-five minutes). If not, the tourniquet may be released after the deep ligament repair has progressed well. Fixation is best obtained by heavy posterior and lateral stirrup plaster splints, extending from the toes to high on the thigh, with the knee in extension of about 150 degrees. The exact time of fixation must vary somewhat according to circumstances. It has been the author's practice in recent years to immobilize in plaster for about four weeks; and to follow this with a so-called cotton cast, or some similar type of dressing, for another two weeks, during which time weight-bearing is permitted. Following removal of the protective splinting, six weeks after operation, an elastic bandage may or may not be used depending upon the effusion within the joint; and the usual measures for rehabilitation following knee surgery are instituted. Quadriceps-setting exercises and exercises designed to maintain the tone of the muscles about the hip and knee may be instituted after the first few days. COMMENT The cases illustrated, if carefully studied, are self-explanatory. Nearly perfect results were obtained in most patients who were seen early, if the diagnosis was accurate and an adequate operation was performed promptly. The second (right) knee in Cases 2 and 3, and the second (left) knee in Cases 4 and 5 illustrate, in the same patients, the different results from complete and incomplete repair. Cases 18 and 19 illustrate technical failure at operation, although proper decision for treatment was made. Cases 21 and 22, selected from many “non-athlete” cases, illustrate well the effect of poor rehabilitation, which is often true in compensation cases and in many women. Rehabilitation cannot be delayed for any reason. Case 13 was the only case presenting any degree of postoperative infection including the many cases done within the past twelve months and not reported here. No surgical case of this type in athletes, seen at this office during the period 1938-1948, has been omitted from this report. No attempt has been made to report non-surgical cases which were in the majority, especially in the early years; in many of these, reconstruction was later necessary. The sharp increase in patients operated upon in 1946, 1947, and 1948 continued in 1949, with fewer non-surgical The for surgery becomes more definite with improvement in the management of injuries to can be by early diagnosis and prompt definitive treatment. is this than in the surgical management of serious injury to the medial collateral ligament, anterior cruciate ligament, and medial meniscus of the knee.