JBJS Classics: Arthroscopy’s Revolutionary Role in Diagnosing Knee Injuries
OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.
Prior to the advent and subsequently ubiquitous use of MRI that most young surgeons are now accustomed to, it was difficult to determine the incidence of several common sports-related injuries. Frank Noyes’ 1980 classic JBJS manuscript, “Arthroscopy in Acute Traumatic Hemarthrosis of the Knee,” was one of the first articles to establish the clear relationship between hemarthrosis and significant intra-articular knee pathology. While the importance of the anterior cruciate ligament (ACL) had just come to light, Noyes’ landmark findings demonstrated the high incidence of ACL injury in association with acute traumatic hemarthrosis (ATH). Furthermore, he delineated arthroscopy’s critical role in accurately diagnosing other associated knee injuries.
This classic manuscript advocated for the use of arthroscopy as a diagnostic tool for the evaluation of ATH at a time when the consequences of a “knee sprain” with acute swelling were unclear. In patients who did not have obvious laxity, an existing acute rupture of the ACL was often left undiagnosed during initial clinical evaluations. Noyes’ innovation pushed the field to couple clinical examination with arthroscopy in cases of acute knee injuries, to allow for more accurate diagnosis. Following this paper’s publication, and well into the 1980s, research continued to confirm Noyes’ findings that one of the best uses of arthroscopy was for diagnosis of acute knee injuries.
This paper and another Noyes study were among the first to identify the high rate of serious knee injuries among patients with ATH. Noyes’ JBJS paper showed that 72% of knees with ATH were characterized by some degree of ACL injury. Moreover, in knees with complete ACL disruption, both the anterior drawer and flexion-rotation drawer tests proved to be more accurate diagnostically when performed with the patient under anesthesia than when the tests were performed in the clinic. Further, he also established that ACL tear, meniscus tear, and/or cartilage injury must be included in the differential diagnosis of an ATH.
Noyes’ group revolutionized the course of treatment and care for patients with ATH. While we generally no longer use knee arthroscopy as a diagnostic tool, because of this article, we routinely order MRI in the setting of ATH. Noyes’ piece remains timeless and well-deserving of the title of a “JBJS Classic.”
Robert G. Marx, MD, MSc, FRCSC
JBJS Deputy Editor
Naaman Mehta, BS
Stephen Thompson, MD, MEd, FRCSC
JBJS Deputy Editor
 Noyes FR, Paulos L, Mooar LA, Signer B. Knee Sprains and Acute Knee Hemarthrosis: Misdiagnosis of Anterior Cruciate Ligament Tears. Phys Ther. 60(12): 1596-1601, 1980.