Can Ultrasound Identify Traumatic Knee Arthrotomy in a Cadaveric Model? (2023)

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  • Abstract
  • Introduction
  • Section snippets
  • References (7)
  • Cited by (1)
  • Recommended articles (6)

The Journal of Emergency Medicine

Volume 57, Issue 3,

September 2019

, Pages 362-366

Author links open overlay panelMatthewKongkatongMD∗ChristopherThomMD, RDMS†JamesMoakMD, RDMS†

(Video) Approach to a septic joint by Dr. Abdul Ghani

Abstract

Background

Traumatic arthrotomy of the knee (TAK) involves the violation of the knee capsule. TAK differs from simple lacerations because it requires operative management to prevent resultant septic arthritis. The diagnostic test of choice in the emergency department is the saline load test (SLT). SLT sensitivity ranges from 34% to 99%, depending on volume used. Computed tomography (CT) is a possible alternative, using intra-articular air as a diagnostic marker. Ultrasound can identify air in various tissues, given its highly echogenic nature.

Objective

We sought to determine the sensitivity and specificity of ultrasound for detecting intra-articular air in cadaveric knee joints.

Methods

Soft embalmed cadavers were utilized. The knees were block randomized to having 1mL of air injected into the joint or sham skin injection. Two blinded, expert operators scanned the knees with a high-frequency linear transducer. The sensitivity and specificity were calculated.

Results

Twenty knees were included. Knees that had any prior dissection were excluded from analysis. Ten knees were randomized for air injection. The pooled sensitivity was 0.65 (95% confidence interval [CI] 0.41–0.85) with a specificity of 0.75 (95% CI 0.48–0.93). Mean time taken was 143s.

Conclusions

Ultrasound may have utility in evaluation of TAK. There were limitations. Some knees had effusions with echogenic material present, which could have led to false-positive results. It is also unknown how much air is typical of TAK. One milliliter was used based on previous work with CT. The use of ultrasound for diagnosis of TAK warrants further study.

Introduction

Traumatic arthrotomy involves violation of the capsule of a joint. Traumatic arthrotomies most commonly occur in the knee joint. Fractures are associated with traumatic arthrotomy of the knee (TAK) between 24% and 61% of the time (1). TAK should be on the differential for soft tissue injuries around the knee because it can result in septic arthritis. Definitive management of traumatic arthrotomy includes i.v. antibiotics and operative irrigation and debridement (2). Injection of saline into the joint space, known as the saline load test (SLT), is the standard approach for diagnosing TAK. The reported sensitivity of the SLT for TAK ranges from 34% to 99%, with larger volumes (eg, 150–200mL) yielding better sensitivity (3). Unfortunately, the SLT can be painful for the patient and time-consuming for the clinician; moreover, this procedure risks iatrogenic infection of a joint space that may not have been violated by the incident trauma.

Recently, computed tomography (CT) has been proposed as an alternative to the SLT for identifying TAK. In a cohort series of 62 patients, Konda etal. demonstrated that CT was able to diagnose TAK with 100% sensitivity and specificity based on the presence of intra-articular air (4). While the diagnostic performance of CT appears promising, this modality has the disadvantages of cost, ionizing radiation, and removal of the patient from the treatment area. The ideal test for identifying TAK would be cost effective, time efficient, highly sensitive, and low risk for the patient. Point-of-care ultrasonography meets all of these criteria. Air within the fluid-filled tissues has a characteristic appearance of a hyperechoic signal with “dirty shadowing” posteriorly. One can also commonly see reverberation artifact (5). Because ultrasound can detect gas–fluid interfaces in soft tissue and the finding of intra-articular air has been shown to be diagnostic of TAK, we sought to determine the sensitivity and specificity of a point-of-care ultrasound examination of the knee joint for intra-articular air.

Section snippets

Materials and Methods

We utilized the knee joints of soft embalmed cadavers for this study. Because no living human subjects were scanned, the study was exempt from Institutional Review Board review. The knees were excluded from analysis if the knee or the soft tissue surrounding the knee had been violated by dissection or by other procedures evident by skin incisions. The knees were randomized to intra-articular injection of 1mL of air using a 19-gauge needle or to sham skin puncture with 19-gauge needle. An

Results

Twenty knees were screened for inclusion in the study, two were excluded due to prior dissection. A total of 10 knees were randomized to have air injected into the joint space. Each knee was scanned by the two operators, yielding 36 data points. Effusions with echogenic material were noted in 9 of the 36 knee scans analyzed (for an example, see Video 1). The appearance of the echogenic material (Figure1) in these knees differed from those of true-positive knees in that the echogenic material

Discussion

Traumatic knee arthrotomy injuries require operative debridement and irrigation to prevent resultant septic arthritis. Standard diagnosis of TAK involves utilizing the SLT to evaluate for extravasation of any saline from a laceration adjacent to or overlying the structures of the knee. However, this procedure is invasive and has varying reported degrees of diagnostic sensitivity (3). Ultrasonography is capable of demonstrating fracture, tendon injury, as well as air within the tissues, the

Conclusions

This study describes a novel protocol to use non-invasive bedside ultrasound to evaluate for intra-articular air as a proxy for traumatic arthrotomy. To our knowledge, this is the first study to investigate this. The sensitivity and specificity of ultrasound in this study does not support its use as a screening test for TAK at this time. However, additional study into the accuracy of this modality for TAK is warranted.

Article Summary

1. Why is this topic important?

Traumatic arthrotomy of the knee, like other traumatic joint arthrotomies,

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Acknowledgments

The authors would like to acknowledge Dana Sikon, CTBS, FSL and David Moyer, DC for providing the cadavers used in this study.

References (7)

  • O. Bonnefoy et al.Acute knee trauma: role of ultrasound

    Clin Imaging

    (2007)

  • D. Lee et al.Ultrasound of the knee

    Eur J Ultrasound

    (2001)

  • S. Buttar et al.Air and its sonographic appearance: understanding the artifacts

    J Emerg Med

    (2017)

There are more references available in the full text version of this article.

Cited by (1)

  • Traumatic arthrotomy (TA) is a rare but serious condition associated with a high morbidity and mortality that can be mitigated with prompt diagnosis and appropriate management.

    This review highlights the pearls and pitfalls of the emergency department (ED) evaluation of TA, including diagnostic procedures, imaging, and management based on current evidence.

    Traumatic arthrotomy occurs when the joint capsule is disrupted during a penetrating injury. This exposes the intra-articular contents to contamination and poses a serious risk for development of septic arthritis. All periarticular injuries should prompt evaluation for TA, as missing this diagnosis can lead to significant morbidity and possibly mortality. ED evaluation options include plain radiographs, computerized tomography, and the saline load test. Each of these diagnostic modalities has unique limitations, and as such it is difficult to determine optimal practice or a standard of care. This is further complicated by the limited number of studies evaluating joints other than the knee. ED management includes orthopedic surgery consultation, wound care including irrigation, tetanus prophylaxis, and antibiotic administration.

    An understanding of an evidenced-based approach to TA can assist emergency clinicians in diagnosing and managing this challenging clinical presentation.

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FAQs

How is Traumatic arthrotomy diagnosed? ›

The SLT has been considered the test of choice for evaluation of traumatic arthrotomy for more than 40 years. This test involves inserting a needle into the joint space away from the traumatic wound. Sterile saline is then injected, and the wound is observed for fluid extravasation.

What is traumatic arthrotomy of knee joint? ›

Traumatic arthrotomy is defined as a soft tissue injury over a joint that penetrates the joint space. Violation of the joint capsule exposes the sterile intra-articular space to the environment which can result in a deep infection and sepsis.

What is saline load test? ›

The saline load test (SLT) is the most common nonsurgical diagnostic test for traumatic arthrotomies of the knee joint. 13. It is defined as an injection of sterile saline into a joint with a periarticular wound where a traumatic arthrotomy is suspected.

What is a joint challenge? ›

First described in the orthopedic literature in 1978, this test involves challenging the knee joint by injecting a significant amount of sterile saline into the joint space and observing for extrusion of saline from the wound(s).

What is an open knee injury? ›

Type I open joint injuries are single penetrations without extensive soft-tissue damage, permitting uncomplicated joint and wound closure. Type II injuries are single or multiple penetrations with extensive soft-tissue disruptions (flaps, avulsions, degloving), often requiring secondary operations to attain closure.

How do you do a saline load test? ›

Saline is slowly injected into the joint space until the capsule distends and fluid leeks out the wound, proving for a positive test. Saline is then aspirated back from the knee to remove the pressure. Positive tests will result in a patient being taken to the operating room for wash out and repair.

What is the difference between arthrotomy and arthroscopy? ›

Surgery. Although arthrotomy alone can be performed to evaluate and treat the contaminated joint space, arthroscopy allows more complete evaluation of the septic joint. Whether arthrotomy or arthroscopy is used, osteochondral fragments and areas of osteomyelitis should be removed and/or debrided.

What is it called when you have a laceration penetrate the joint space? ›

Traumatic Arthrotomy (forums.mtbr.com) Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment.

What happens if you hurt your knee cap? ›

There may be damage to the soft tissues, such as a patellar tendon tear, or a fracture to the bone. Symptoms may include pain, swelling, or a feeling of instability or that the joint is locked. Some types of injuries can be treated with bracing and rehabilitation exercises, but others may need surgery.

What is the CPT code for therapeutic infusion of saline solution? ›

99.9% of the time we see saline solution (aka: NSS, 0.9%NS) infused into a patient it is for hydration, and the correct code for the infusion is 96360 (+96361).

How long does a knee laceration take to heal? ›

How long does it take to recover? A minor skinned knee may take one to two weeks to fully heal. The wound is considered fully healed and no longer susceptible to infection once it's closed and any scabbing has fallen off naturally. The area may continue to look pink or pale for several weeks longer.

What is traumatic arthropathy? ›

What is traumatic arthropathy? Traumatic arthropathy is due to an injury to the joint that caused bleeding, swelling and/or distension of the joint. The injury results in joint disease due to the formation of adhesions between the tissue covering the articular cartilage and fibrous ankylosis.

What is the code for knee laceration? ›

2022 ICD-10-CM Diagnosis Code S81. 019A: Laceration without foreign body, unspecified knee, initial encounter.

What are 3 common knee injuries? ›

Some of the more common knee injuries include:
  • ACL injury. An ACL injury is a tear of the anterior cruciate ligament (ACL) — one of four ligaments that connect your shinbone to your thighbone. ...
  • Fractures. ...
  • Torn meniscus. ...
  • Knee bursitis. ...
  • Patellar tendinitis.
11 May 2021

How is knee injury diagnosed? ›

Diagnosis of knee injuries

X-rays show bone fractures or degenerative joint disease. Ultrasound produces images of the soft tissues in your knee. CT scans create more detailed pictures to find subtle fractures. MRI uses radio waves and a powerful magnet to view soft tissues like ligaments, tendons, and cartilage.

What is the most common knee injury? ›

ACL injuries are one of the most common types of knee injuries and account for about 40 percent of all sports-related injuries. An ACL injury can range from a small tear in the ligament to a severe injury –when the ligament completely tears or becomes separated from the bone itself.

How do you do a saline suppression test? ›

During the test

A small plastic tube called a cannula will be inserted into a vein in your arm or hand and a blood sample will be taken. This allows your nurse to take your blood samples directly, without further use of needles. You will then receive an infusion of saline that will last for four hours.

Is arthrotomy an open procedure? ›

Arthrotomy is a surgical procedure that employs an open technique in which incisions are made into the joint and the loose body is removed.

How long does an arthrotomy take? ›

Arthrotomy. Arthrotomy, also known as Arthroplasty, is an open joint procedure (an incision is made a few inches long over the joint so your doctor can operate on the joint itself) done under general anesthesia in the hospital. The surgery may last between one to two hours.

Is arthrotomy a major surgery? ›

It's a minor surgery and is done on an outpatient basis, which means you can go home the same day. Your doctor may recommend it if you have inflammation in a joint, have injured a joint, or have damaged a joint over time. You can have arthroscopy on any joint.

What is the knee joint capsule? ›

The articular capsule of the knee joint (commonly referred to as the capsular ligament) is the wide and lax joint capsule of the knee. It is thin in front and at the side, and contains the patella, ligaments, menisci, and bursae of the knee.

What is septic arthritis? ›

Septic arthritis is a painful infection in a joint that can come from germs that travel through your bloodstream from another part of your body. Septic arthritis can also occur when a penetrating injury, such as an animal bite or trauma, delivers germs directly into the joint.

What is intra articular fracture? ›

An intraarticular fracture is a fracture that crosses a joint surface. Such fractures also involve some cartilage damage. Fractures to joints are more complicated to treat and heal than simple fractures, as multiple bones are involved. Bone fragments inside the damaged joint may impede healing time and efficacy.

What happens if you hit your knee to hard? ›

A knee contusion or bruise is a common injury if you fall on a hard surface. The impact can cause a blood vessel or capillary in the skin or muscle underneath to leak blood into the surrounding area, creating the black and blue sign of a bruise.

How do you treat a knee cap injury? ›

Self-care measures for an injured knee include:
  1. Rest. Take a break from your normal activities to reduce repetitive strain on your knee, give the injury time to heal and help prevent further damage. ...
  2. Ice. Ice reduces both pain and inflammation. ...
  3. Heat. ...
  4. Compression. ...
  5. Elevation.
11 May 2021

How long does patellar tracking take to heal? ›

Recovery from a patellar tracking disorder can take weeks or months. Patients must work with their doctor to avoid movements that cause the condition, continue strengthening exercises even after pain subsides and lose weight.

What should be reported when an infusion is 15 minutes or less? ›

Time documentation is critical since separate codes exist for initial, sequential, and concurrent infusions. It is important to note that infusions of 15 minutes or less are reported using an IV push code.

What is code 96372 used for? ›

CPT® code 96372: Injection of drug/substance under skin or into muscle | American Medical Association.

When do you use 96368? ›

CPT® 96368, Under Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration)

Can you bend your knee after stitches? ›

The basic ideas are that knee bending and weight bearing must be limited for the first 6 weeks. We do not want you to bend your knee completely while the meniscus is healing. Bending the knee, even without your weight on it, can cause it to tear.

Can you walk with stitches in your knee? ›

General Advice. The area where you've gotten stitches will affect the types of activities you can do. Light activities like walking are usually fine when recovering, and shouldn't affect your wound healing. However, strenuous activities like heavy lifting should be avoided.

When Should knee stitches be removed? ›

Removing stitches

stitches over joints, such as your knees or elbows – you'll need to return after 10 to 14 days. stitches on other parts of your body – you'll need to return after 7 to 10 days.

How is post-traumatic arthritis diagnosed? ›

Your healthcare provider will diagnose post-traumatic arthritis with a physical exam and imaging tests. Your provider will move your joint, ask you about your symptoms and compare your joint and its range of motion (how far you can move part of your body) to what it was before your injury — if possible.

How is post-traumatic arthritis treated? ›

Conservative Post-Traumatic Arthritis Treatment

Conservative treatment measures include modifying one's activities and unloading the joint with cane, crutches or walker. Also, supplemental glucosamine, Tylenol, anti-inflammatories, pain medications may help.

Can a knee injury cause arthritis? ›

Knee injuries are a strong risk factor for knee osteoarthritis and may distinguish knees with accelerated knee osteoarthritis from common knee osteoarthritis progression or knees with no knee osteoarthritis.

What is considered a complex laceration? ›

Complex lacerations have jagged edges that extend into deeper layers of tissues and are accompanied by heavy bleeding. These lacerations may necessitate several hours of layered closure, but the aesthetic results can be spectacular with proper technique.

What is a complex laceration repair? ›

Complex. A complex wound repair code includes the repair of a wound requiring more than a layered closure (e.g., scar revision or debridement), extensive undermining, stents, or retention sutures. It may also include debridement and repair of complicated lacerations or avulsions.

What is the difference between 97605 and 97607? ›

Codes 97605 and 97606 are used for placement of a non-disposable wound vac device, while codes 97607 and 97608 are used if the wound vac is disposable.

What is the difference between arthrotomy and arthroscopy? ›

Surgery. Although arthrotomy alone can be performed to evaluate and treat the contaminated joint space, arthroscopy allows more complete evaluation of the septic joint. Whether arthrotomy or arthroscopy is used, osteochondral fragments and areas of osteomyelitis should be removed and/or debrided.

What is traumatic arthropathy? ›

What is traumatic arthropathy? Traumatic arthropathy is due to an injury to the joint that caused bleeding, swelling and/or distension of the joint. The injury results in joint disease due to the formation of adhesions between the tissue covering the articular cartilage and fibrous ankylosis.

Is arthrotomy an open procedure? ›

Arthrotomy is a surgical procedure that employs an open technique in which incisions are made into the joint and the loose body is removed.

How long does an arthrotomy take? ›

Arthrotomy. Arthrotomy, also known as Arthroplasty, is an open joint procedure (an incision is made a few inches long over the joint so your doctor can operate on the joint itself) done under general anesthesia in the hospital. The surgery may last between one to two hours.

Is arthrotomy a major surgery? ›

It's a minor surgery and is done on an outpatient basis, which means you can go home the same day. Your doctor may recommend it if you have inflammation in a joint, have injured a joint, or have damaged a joint over time. You can have arthroscopy on any joint.

How is post-traumatic arthritis diagnosed? ›

Your healthcare provider will diagnose post-traumatic arthritis with a physical exam and imaging tests. Your provider will move your joint, ask you about your symptoms and compare your joint and its range of motion (how far you can move part of your body) to what it was before your injury — if possible.

How do you get rid of post-traumatic arthritis? ›

Post-Traumatic Arthritis Treatment
  1. Corticosteroid injections.
  2. Exercise and physical therapy.
  3. Hyaluronic acid injections.
  4. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  5. Lifestyle changes, including weight loss.

How is post-traumatic arthritis treated? ›

Conservative Post-Traumatic Arthritis Treatment

Conservative treatment measures include modifying one's activities and unloading the joint with cane, crutches or walker. Also, supplemental glucosamine, Tylenol, anti-inflammatories, pain medications may help.

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