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BILATERAL RUPTURE OF EXTENSOR TENDONS OF THE KNEE
205 ritis on 55 occasions. On 10 occasions there was no relief of pain, and this happened most often when the pain was associated with peri-articular soft-tissue lesions. On 45 occasions there was partial or complete relief of pain, usually within an hour, lasting 5-210 days in different patients. Thanks
are
due to Boots Pure
Drug
Co. Ltd. for
a
supply
of
T.E.A.B.
BILATERAL RUPTURE OF EXTENSOR TENDONS OF THE KNEE G. P. MITCHELL ANDREW FOWLER F.R.C.S.E. M.C., M.B. Aberd., F.R.C.S.E. T.D., M.B. Aberd., LATE REGISTRAR
SURGEON
ABERDEEN ROYAL INFIRMARY
(1931) states that rupture of the ligamentum is the least common injury of the knee extensor mechanism. We have not found any published reference in the last twenty years to a bilateral rupture of the ligamentum patellae such as occurred in the following Platt
patellae
case.
Case l.-A boy,
admitted to Aberdeen Royal aged 13, Infirmary on July 7, 1948, with pain and loss of power of extension in both knees. His story was that he was running in a race in a rough field when his left foot seemed to catch He felt a sudden pain in his left knee as on a’tuft of grass. he was tripped up, and on falling he felt a similar pain in the right knee. Subsequently he collapsed on the ground and could not rise. On examination he was very well built and of medium height, with a moderate degree of shock. Both knees were grossly swollen but not unduly tender. There was a palpable gap in continuity at the lower margin of each patella, with some crepitus on the right side. The patient could not voluntarily contract either quadriceps. The diagnosis of bilateral rupture of the ligamentum patellae was confirmed was
by radiography (see figure). Operation (July 12, 1948).-Right knee (A. F.), left knee (G. P. M.). Under general anaesthesia (Dr. J. Bain), transverse infrapatellar incisions were made without the use of a tourniquet. The upper attachment of the ligamentum patellae in either knee was found to have been completely avulsed. In the right leg there was a tear extending into the capsule and continuing as far as the collateral ligaments, and three small flakes of bone remained attached to the torn ligament. On the left side the Iigament was lying deep to the patella. Blood-clot was evacuated, and the joints were washed out with saline solution. Three sutures of no. 6 chromic catgut were inserted through drill holes in each patella and through each ligamentum patellae. The holes were drilled in the long axis of the patella from midway on the superficial surface to the inferior pole. In addition, in the right leg, the lateral
were united with interrupted sutures of no. 6 catgut. Padded plaster-of-paris was applied from groins to toes with the knees in full extension. Postoperative Progress.-Three days after operation, in view of the boy’s extreme pallor, his blood was examined and he was found to have a microcytic hypochromic anaemia, with a hsemoglobin level of 38%. The patient was given-ferri et ammon. cit. gr. 30 t.i.d. The haemoglobin was 42% on the seventh postoperative day, 66% in the third week, and 84% in the fourth week. Progress was otherwise uncomplicated. A month after operation the plasters were " bivalved " and the sutures removed. Active non-weight-bearing movements were instituted, back splints being worn at night, and on Aug. 20 weight-bearing was begun. On Aug. 31 extension in both knees was limited by 10° and there was 45° of flexion ; the patient was walking well. Seven weeks after operation he was discharged, to continue quadriceps drill and active movement. On Feb. 15, 1949, seven months after the operation, when he was last seen, he was carrying out full normal activities, including playing games. The range of flexion in both knees was now 135°, though active extension was still limited by 10° ; passive extension was full.
tears
BILATERAL RUPTURE OF
QUADRICEPS TENDON quadriceps tendons is much less rare. cases have been reported in the last
of both
Rupture following twenty years : The
Meyerding (1935) reported the case of a man, aged 62, who fell while trying to show a small girl how to skip. As his feet, landed on the ground after the first jump, he lost his balance, and in an attempt to prevent himself falling lie jerked himself up suddenly. At this moment there were a loud snap and sudden pain in the right knee. As he fell again, there was a similar snap in the left knee. Meyerding cited two further cases : in a man aged 60 (Frey 1928) ; and in a man aged 6T (Sonnenschein 1927), but the latter case was diagnosed on. clinical grounds only, the patient refusing operation. James’s (1938) case was in a Covent Garden porter, aged 66, who fell down stairs and ruptured one quadriceps tendon. and then, hopping down a few more steps, ruptured the’ other. Lloyd (1948) reported the case of a man, aged 77, who caught his heel and slipped down stairs, rupturing both quadriceps tendons. We report two
cases
of bilateral
suprapatellar rupture.
Case 2.-A man, aged 70, was seen nine months after falling down stairs in semi-darkness. Since then he had been unable to descend any incline and had great difficulty in rising from
sitting position. At operation, in the right leg there was only a central tear, but in the left leg there was a complete tear with a 3-inch gap, the tear extending into the lateral expansions. A fascial graft from the iliotibial band was used in the repair. ImmobiHsation in plaster-of-paris for three weeks, followed by the usual graduated exercises, gave a good result. Case 3.-A man, aged 75, while dismounting from his bicycle by allowing the bicycle to fall sideways and taking the weight on his right leg, felt something give way in the region of his right knee and collapsed. With great difficulty he struggled about half a mile, and when he stepped on to his doorstep his left leg gave way in a like manner. Operation confirmed bilateral avulsion of the quadriceps tendons close to the upper margins of the patellse, with tears extending into the capsules in both legs. A striking feature was that the upper margins of the patellae were completely denuded. Repair was effected with fascial strips from the iliotibial bands. The grafts were not completely detached at the lower ends and were threaded through transverse drill holes in the patellae from lateral to medial sides and subsequently through the avulsed tendons. No. 6 catgut sutures were used to repair the capsule and reinforce the fascial a
graft. DISCUSSION
Right Rupture
of
Left
ligamentum patellae
in both legs.
The commonest injury of the extensor apparatus of the’ knee-joint is the transverse fracture of the patella. Carlucci (1934) gives the ratio of fracture of the patella. to rupture of the quadriceps as 318 : 4, and Lloyd (1948)) as 80 : 1. Under the age of 50 the quadriceps tendon, appears to be stronger than the patella. Brooke (1937a cited cases of fractured patella in patients aged 23-56,
206
35.
Over the age of 50 ruptured the average age being quadriceps is a more common injury, presumably owing to degenerative changes in the tendon. In the 7 bilateral cases mentioned the average age was 68. It is difficult to find any particular age-group for the infrapatellar rupture, but Cochrane (1940) reported a case in a woman aged 65, who slipped while stepping off a tramcar, and another in a man aged 34, who slipped while lifting a heavy cask. Both these tears took place in the actual substance of the tendon and were repaired by fascial suture. Some aspects of case 1 are interesting. The boy’s age, 13 years, does not seem to be associated with any special liability to injuries of the extensor mechanism of the knee, though osteochondritis of the tibial tubercle (Osgood Schlatter’s disease) is common at that age. The boy had the remarkably low hemoglobin level of 38% but this was a postoperative estimation, and there had been gross hsemarthrosis. There was no indication in the boy’s home conditions to suggest that malnutrition might explain the anaemia. When last seen he was very fit and
well coloured. In the suprapatellar rupture the typical history is of a stumble on the stairs in the dark or of a slip while lifting a heavy weight, the tear being due to degenerative changes in the tendon and a sudden violent contraction of the quadriceps against the resistance of the bodyweight in an effort to regain the upright posture. To accomplish this, the quadriceps will only contract when the tibia is fixed, and the maximum force will be exerted towards the angle of flexion as the knee-joint gives way under the body-weight. In case 1 this common factor was unlikely to have been present, since the first rupture took place while the boy was running, and the second as he fell, presumably in a forward direction from the momentum
gained.
Brooke (1937b), citing Lickey, pointed out that, when the tibia is moved, the fulcrum in the extended position is on the lower facets of the patellar surface, close to the lower end of the patella. In the position of full flexion it is nearer the upper end. Therefore in the position of extension the force acts to a much greater advantage than in the flexed position. When the tibia is fixed the conditions are reversed ; the force is now most effective in the flexed and least effective in the extended position. With- the tibia movable, extension of the knee-joint .produces the action of kicking, in which the greatest momentum is required at the moment of impact. With the tibia fixed, extension of the knee-joint will lift a considerable portion of the body-weight, and in this case the greatest amount of force is necessary at the beginning of the act, with a diminution of force and velocity at the end to avoid overbalancing. In an attempt to elucidate the cause of bilateral infrapatellar rupture in case 1, it might be surmised from the history that the angle of the knee-joint at the moment of rupture of the left infrapatellar tendon was that of a runner about to place the advancing foot on the ground —i.e., approaching full extension. It was at this point, when the boy’s left foot was obstructed by an irregularity of the turf,, that the rupture in the left leg took place. The runner must now fall freely forwards or try to regain his balance by attempting to advance the right leg. Since the right leg would be obstructed by the ground, ’and since the body was inclining forward at the same time, the angle of the right knee-joint would be approaching extension, and presumably the rupture of the right tendon took place at this moment. It appears from the histories cited that in suprapatellar rupture the tibia is fixed and the rupture occurs in an effort to regain the upright posture, the angle of the being towards that of flexion. In the infrapatellar rupture reported here it seems that the ’
knee-joint
the angle of the knee-joint was towards extension. It must be noted, however, that in one of Cochrane’s (1940) cases the history was that of a slip while lifting a heavy weight.
rupture took place when
consulting orthopaedic 2.
We are indebted to Mr. A. Mitchell, surgeon, North East Region, for permission to cite
case
REFERENCES
Brooke, R. (1937a) Proc. R. Soc. Med. 30, 203. (1937b) Brit. J. Surg. 24, 733. Carlucci, G. A. (1934) J. Bone Jt Surg. 16, 456. Cochrane, W. A. (1940) Lancet, ii, 583. Frey, S. (1928) Dtsch. Z. Chir. 209, 284. James, K. L. (1938) Brit. med. J. ii, 1369. Lloyd, E. I. (1948) Brit. J. Surg. 36, 94. Meyerding, H. W. (1935) Surg. Clin. N. Amer. 15, 1207. Platt, H. (1931) Brit. med. J. i, 611. Sonnenschein, H. D. (1927) Med. J. Rec. 125, 316. —
THE FLORA OF 100 BRONCHIAL SECRETIONS WITH PARTICULAR REFERENCE TO ANAEROBIC COCCI
J. G. BENSTEAD M.A., M.B. Camb., M.B. Leeds LECTURER IN PATHOLOGY, UNIVERSITY OF LEEDS
THE advent of the
bronchoscope
has made it
to examine secretions from bronchial
mucosa
possible uncon-
taminated by mouth flora. In the early years of this century observations on pulmonary flora were made on material aspirated from lung abscesses or obtained from sinuses. There are numerous observations of this character, and the flora of empyemata and lung abscesses are too well known to require recapitulation here. Weinberg et al. (1937) cite many instances of the isolation of anaerobic cocci from these sources. The types of organism occurring on bronchial mucosa, either itself diseased or associated with diseased lung parenchyma, One object, therefore, are not so widely appreciated. of the present survey was to find out whether anaerobic cocci or clostridia are present in the bronchial tree. The investigation was made on 100 unselected specimens of bronchial secretion sent for bacteriological examination in 1946 by the staff of the thoracic surgical department in the General Infirmary at Leeds after routine bronchoscopy ; 95 cases fell into seven main categories of disease, whereas 5 patients had rare or undiagnosed conditions (table i). METHOD
Secretions were obtained by the technique of Allison et al. (1943) and were received in sterile tubes sealed with a bung. Loopfuls of material were spread on the surfaces of duplicate horse blood-agar and heated horse blood-agar plates, and mms stained by Gram’s method were prepared for direct examination. One pair of plates was incubated aerobically at 37°C and examined on the first and third days. The duplicate plates were incubated in a McIntosh and Fildes jar in a hydrogen atmosphere to which was added a percenbage of carbon dioxide generated from acid and a small pellet of chalk in a test-tube placed in the jar. The jar was incubated at 37.°C, and cultures were examined on the third or fourth day. Further examinations of anaerobic strains were made by the standard methods.
. It will be seen in table r that the aerobes isolated from the 100 cases were mainly cocci. Excluding tubercle bacilli, 89 of the 122 aerobic strains cultured were cocci, and 64 of these were streptococci ; 2 strains of streptococci were of true mucoid type as described by Pilot (1934) and first noted by Schottmuller (1903). Of the 17 strains of Strep. pneumonitt isolated, 4 were type in. Strep. pneumonia was isolated from 17. secretions, but the complete absence of this coccus from the secretions. of patients with delayed pneumonic resolution suggests AEROBES
.
,
are
due to Boots Pure
Drug
Co. Ltd. for
a
supply
of
T.E.A.B.
BILATERAL RUPTURE OF EXTENSOR TENDONS OF THE KNEE G. P. MITCHELL ANDREW FOWLER F.R.C.S.E. M.C., M.B. Aberd., F.R.C.S.E. T.D., M.B. Aberd., LATE REGISTRAR
SURGEON
ABERDEEN ROYAL INFIRMARY
(1931) states that rupture of the ligamentum is the least common injury of the knee extensor mechanism. We have not found any published reference in the last twenty years to a bilateral rupture of the ligamentum patellae such as occurred in the following Platt
patellae
case.
Case l.-A boy,
admitted to Aberdeen Royal aged 13, Infirmary on July 7, 1948, with pain and loss of power of extension in both knees. His story was that he was running in a race in a rough field when his left foot seemed to catch He felt a sudden pain in his left knee as on a’tuft of grass. he was tripped up, and on falling he felt a similar pain in the right knee. Subsequently he collapsed on the ground and could not rise. On examination he was very well built and of medium height, with a moderate degree of shock. Both knees were grossly swollen but not unduly tender. There was a palpable gap in continuity at the lower margin of each patella, with some crepitus on the right side. The patient could not voluntarily contract either quadriceps. The diagnosis of bilateral rupture of the ligamentum patellae was confirmed was
by radiography (see figure). Operation (July 12, 1948).-Right knee (A. F.), left knee (G. P. M.). Under general anaesthesia (Dr. J. Bain), transverse infrapatellar incisions were made without the use of a tourniquet. The upper attachment of the ligamentum patellae in either knee was found to have been completely avulsed. In the right leg there was a tear extending into the capsule and continuing as far as the collateral ligaments, and three small flakes of bone remained attached to the torn ligament. On the left side the Iigament was lying deep to the patella. Blood-clot was evacuated, and the joints were washed out with saline solution. Three sutures of no. 6 chromic catgut were inserted through drill holes in each patella and through each ligamentum patellae. The holes were drilled in the long axis of the patella from midway on the superficial surface to the inferior pole. In addition, in the right leg, the lateral
were united with interrupted sutures of no. 6 catgut. Padded plaster-of-paris was applied from groins to toes with the knees in full extension. Postoperative Progress.-Three days after operation, in view of the boy’s extreme pallor, his blood was examined and he was found to have a microcytic hypochromic anaemia, with a hsemoglobin level of 38%. The patient was given-ferri et ammon. cit. gr. 30 t.i.d. The haemoglobin was 42% on the seventh postoperative day, 66% in the third week, and 84% in the fourth week. Progress was otherwise uncomplicated. A month after operation the plasters were " bivalved " and the sutures removed. Active non-weight-bearing movements were instituted, back splints being worn at night, and on Aug. 20 weight-bearing was begun. On Aug. 31 extension in both knees was limited by 10° and there was 45° of flexion ; the patient was walking well. Seven weeks after operation he was discharged, to continue quadriceps drill and active movement. On Feb. 15, 1949, seven months after the operation, when he was last seen, he was carrying out full normal activities, including playing games. The range of flexion in both knees was now 135°, though active extension was still limited by 10° ; passive extension was full.
tears
BILATERAL RUPTURE OF
QUADRICEPS TENDON quadriceps tendons is much less rare. cases have been reported in the last
of both
Rupture following twenty years : The
Meyerding (1935) reported the case of a man, aged 62, who fell while trying to show a small girl how to skip. As his feet, landed on the ground after the first jump, he lost his balance, and in an attempt to prevent himself falling lie jerked himself up suddenly. At this moment there were a loud snap and sudden pain in the right knee. As he fell again, there was a similar snap in the left knee. Meyerding cited two further cases : in a man aged 60 (Frey 1928) ; and in a man aged 6T (Sonnenschein 1927), but the latter case was diagnosed on. clinical grounds only, the patient refusing operation. James’s (1938) case was in a Covent Garden porter, aged 66, who fell down stairs and ruptured one quadriceps tendon. and then, hopping down a few more steps, ruptured the’ other. Lloyd (1948) reported the case of a man, aged 77, who caught his heel and slipped down stairs, rupturing both quadriceps tendons. We report two
cases
of bilateral
suprapatellar rupture.
Case 2.-A man, aged 70, was seen nine months after falling down stairs in semi-darkness. Since then he had been unable to descend any incline and had great difficulty in rising from
sitting position. At operation, in the right leg there was only a central tear, but in the left leg there was a complete tear with a 3-inch gap, the tear extending into the lateral expansions. A fascial graft from the iliotibial band was used in the repair. ImmobiHsation in plaster-of-paris for three weeks, followed by the usual graduated exercises, gave a good result. Case 3.-A man, aged 75, while dismounting from his bicycle by allowing the bicycle to fall sideways and taking the weight on his right leg, felt something give way in the region of his right knee and collapsed. With great difficulty he struggled about half a mile, and when he stepped on to his doorstep his left leg gave way in a like manner. Operation confirmed bilateral avulsion of the quadriceps tendons close to the upper margins of the patellse, with tears extending into the capsules in both legs. A striking feature was that the upper margins of the patellae were completely denuded. Repair was effected with fascial strips from the iliotibial bands. The grafts were not completely detached at the lower ends and were threaded through transverse drill holes in the patellae from lateral to medial sides and subsequently through the avulsed tendons. No. 6 catgut sutures were used to repair the capsule and reinforce the fascial a
graft. DISCUSSION
Right Rupture
of
Left
ligamentum patellae
in both legs.
The commonest injury of the extensor apparatus of the’ knee-joint is the transverse fracture of the patella. Carlucci (1934) gives the ratio of fracture of the patella. to rupture of the quadriceps as 318 : 4, and Lloyd (1948)) as 80 : 1. Under the age of 50 the quadriceps tendon, appears to be stronger than the patella. Brooke (1937a cited cases of fractured patella in patients aged 23-56,
206
35.
Over the age of 50 ruptured the average age being quadriceps is a more common injury, presumably owing to degenerative changes in the tendon. In the 7 bilateral cases mentioned the average age was 68. It is difficult to find any particular age-group for the infrapatellar rupture, but Cochrane (1940) reported a case in a woman aged 65, who slipped while stepping off a tramcar, and another in a man aged 34, who slipped while lifting a heavy cask. Both these tears took place in the actual substance of the tendon and were repaired by fascial suture. Some aspects of case 1 are interesting. The boy’s age, 13 years, does not seem to be associated with any special liability to injuries of the extensor mechanism of the knee, though osteochondritis of the tibial tubercle (Osgood Schlatter’s disease) is common at that age. The boy had the remarkably low hemoglobin level of 38% but this was a postoperative estimation, and there had been gross hsemarthrosis. There was no indication in the boy’s home conditions to suggest that malnutrition might explain the anaemia. When last seen he was very fit and
well coloured. In the suprapatellar rupture the typical history is of a stumble on the stairs in the dark or of a slip while lifting a heavy weight, the tear being due to degenerative changes in the tendon and a sudden violent contraction of the quadriceps against the resistance of the bodyweight in an effort to regain the upright posture. To accomplish this, the quadriceps will only contract when the tibia is fixed, and the maximum force will be exerted towards the angle of flexion as the knee-joint gives way under the body-weight. In case 1 this common factor was unlikely to have been present, since the first rupture took place while the boy was running, and the second as he fell, presumably in a forward direction from the momentum
gained.
Brooke (1937b), citing Lickey, pointed out that, when the tibia is moved, the fulcrum in the extended position is on the lower facets of the patellar surface, close to the lower end of the patella. In the position of full flexion it is nearer the upper end. Therefore in the position of extension the force acts to a much greater advantage than in the flexed position. When the tibia is fixed the conditions are reversed ; the force is now most effective in the flexed and least effective in the extended position. With- the tibia movable, extension of the knee-joint .produces the action of kicking, in which the greatest momentum is required at the moment of impact. With the tibia fixed, extension of the knee-joint will lift a considerable portion of the body-weight, and in this case the greatest amount of force is necessary at the beginning of the act, with a diminution of force and velocity at the end to avoid overbalancing. In an attempt to elucidate the cause of bilateral infrapatellar rupture in case 1, it might be surmised from the history that the angle of the knee-joint at the moment of rupture of the left infrapatellar tendon was that of a runner about to place the advancing foot on the ground —i.e., approaching full extension. It was at this point, when the boy’s left foot was obstructed by an irregularity of the turf,, that the rupture in the left leg took place. The runner must now fall freely forwards or try to regain his balance by attempting to advance the right leg. Since the right leg would be obstructed by the ground, ’and since the body was inclining forward at the same time, the angle of the right knee-joint would be approaching extension, and presumably the rupture of the right tendon took place at this moment. It appears from the histories cited that in suprapatellar rupture the tibia is fixed and the rupture occurs in an effort to regain the upright posture, the angle of the being towards that of flexion. In the infrapatellar rupture reported here it seems that the ’
knee-joint
the angle of the knee-joint was towards extension. It must be noted, however, that in one of Cochrane’s (1940) cases the history was that of a slip while lifting a heavy weight.
rupture took place when
consulting orthopaedic 2.
We are indebted to Mr. A. Mitchell, surgeon, North East Region, for permission to cite
case
REFERENCES
Brooke, R. (1937a) Proc. R. Soc. Med. 30, 203. (1937b) Brit. J. Surg. 24, 733. Carlucci, G. A. (1934) J. Bone Jt Surg. 16, 456. Cochrane, W. A. (1940) Lancet, ii, 583. Frey, S. (1928) Dtsch. Z. Chir. 209, 284. James, K. L. (1938) Brit. med. J. ii, 1369. Lloyd, E. I. (1948) Brit. J. Surg. 36, 94. Meyerding, H. W. (1935) Surg. Clin. N. Amer. 15, 1207. Platt, H. (1931) Brit. med. J. i, 611. Sonnenschein, H. D. (1927) Med. J. Rec. 125, 316. —
THE FLORA OF 100 BRONCHIAL SECRETIONS WITH PARTICULAR REFERENCE TO ANAEROBIC COCCI
J. G. BENSTEAD M.A., M.B. Camb., M.B. Leeds LECTURER IN PATHOLOGY, UNIVERSITY OF LEEDS
THE advent of the
bronchoscope
has made it
to examine secretions from bronchial
mucosa
possible uncon-
taminated by mouth flora. In the early years of this century observations on pulmonary flora were made on material aspirated from lung abscesses or obtained from sinuses. There are numerous observations of this character, and the flora of empyemata and lung abscesses are too well known to require recapitulation here. Weinberg et al. (1937) cite many instances of the isolation of anaerobic cocci from these sources. The types of organism occurring on bronchial mucosa, either itself diseased or associated with diseased lung parenchyma, One object, therefore, are not so widely appreciated. of the present survey was to find out whether anaerobic cocci or clostridia are present in the bronchial tree. The investigation was made on 100 unselected specimens of bronchial secretion sent for bacteriological examination in 1946 by the staff of the thoracic surgical department in the General Infirmary at Leeds after routine bronchoscopy ; 95 cases fell into seven main categories of disease, whereas 5 patients had rare or undiagnosed conditions (table i). METHOD
Secretions were obtained by the technique of Allison et al. (1943) and were received in sterile tubes sealed with a bung. Loopfuls of material were spread on the surfaces of duplicate horse blood-agar and heated horse blood-agar plates, and mms stained by Gram’s method were prepared for direct examination. One pair of plates was incubated aerobically at 37°C and examined on the first and third days. The duplicate plates were incubated in a McIntosh and Fildes jar in a hydrogen atmosphere to which was added a percenbage of carbon dioxide generated from acid and a small pellet of chalk in a test-tube placed in the jar. The jar was incubated at 37.°C, and cultures were examined on the third or fourth day. Further examinations of anaerobic strains were made by the standard methods.
. It will be seen in table r that the aerobes isolated from the 100 cases were mainly cocci. Excluding tubercle bacilli, 89 of the 122 aerobic strains cultured were cocci, and 64 of these were streptococci ; 2 strains of streptococci were of true mucoid type as described by Pilot (1934) and first noted by Schottmuller (1903). Of the 17 strains of Strep. pneumonitt isolated, 4 were type in. Strep. pneumonia was isolated from 17. secretions, but the complete absence of this coccus from the secretions. of patients with delayed pneumonic resolution suggests AEROBES
.
,