Lister’s Kneecap

Our Human Remains Conservator tells us about a knee cap with a connection to Joseph Lister.

kneecap 1

I recently came across a patella in our collection which has been cut in half vertically to show a healed fracture that crosses the bone transversely. On both sides of the knee, wire can be seen passing through holes drilled into the bone and crossing the fracture area before being twisted to secure the ends. Fascinatingly, this patella refers to an article in The Lancet from November 1883 by Joseph Lister. Lister is most famous for pioneering antisepsis in surgery, but he also developed a number of surgical techniques, including the innovation of wiring a fractured kneecap back together.

The novelty of this technique came from the fact that it took a simple fracture – one where the bone was broken but the skin remained intact – and via surgery turned it into a type of compound fracture, where the skin is ruptured. Simple fractures were rarely life threatening in themselves, though problems in the healing process could cause pain and loss of function, often impacting severely on a person’s life. Because of the rupture in the skin, compound fractures could often be deadly: bacteria could enter the wound and cause fatal sepsis. This was the major problem with any kind of surgical intervention before Lister’s introduction of antisepsis, and in the first years after it was adopted mortality following surgery in his ward dropped from 45 to 15 per cent. This gave him the confidence to try a technique that would largely have been unthinkable before.

 

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Carbolic spray of the type designed by Joseph Lister to sterilise the surgical environment

It was not his first attempt at what would come to be known as ‘internal fixation’ – using metal devices implanted inside the body to stabilise a fracture and facilitate healing. Lister had already tried this on the elbow. The patient had received a blow from a policeman’s baton five months earlier and could not straighten his arm without help. Lister discovered that the olecranon – a hook like projection on the ulna of the lower arm which facilitates the bending of the elbow – was at a considerable distance from the rest of the bone. He drilled holes to loop the wire through and then twisted it to secure it in place. Seven weeks later he removed the wire and soon the patient was wielding a hammer in a Glasgow shipyard once more.

 

Lister improved the technique over the course of a two more cases of olecranon fracture: “the practice of cutting the wire short and hammering down the twist upon the bone…is in every respect an advantage. The hammering down of the twist renders it more secure than if it is left projecting , to be moved by every shifting of the dressing… The time of healing is greatly shortened; and the knowledge that the loop of wire securely holds the fragments in position allows the use of the joint to be commenced much earlier than when we have only the organic band of union to trust to.” He goes on to say “Ever since my first case of ununited fracture of the olecranon I was on the lookout for a fracture of the patella to treat on the same principle.”

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Joseph Lister, C.1890

The paper goes on to describe seven successful cases where Lister did just that: silver wire was introduced – antiseptically of course – to secure ununited fractures of the kneecap. A thirty-seven-year-old coal porter who had fallen while carrying bags of coal resulting in a fracture running horizontally across his patella was reported to be able to kick vigorously, and carry 220lb of coal some distance without the slightest limp following Lister’s surgery. A woman in her forties said her only post-operative trouble was an inability to kneel. A sixty-two-year-old man, who was healthy apart from being a heavy drinker, was operated on three days after his accident, and was then able to continue to work a stamp hammer all day long, and had no difference in the degree of movement between the two knees.

The first three cases all mention the wire being removed by surgery a few months after healing had taken place, with no signs of what had happened apart from a small scar. This is not mentioned in the later cases, so we can presume the kneecap in our collection is one of these as the wire is still present. Possibly it is from the heavy drinker, who had to be given opium to calm his delirium tremens shortly after the operation: mention is made of being able to fail a faint ridge on the patella through the skin after it had healed, and such a ridge can be seen here. We can see too the twist of wire that Lister describes being hammered down onto the patella.

Today internal fixation will use rods, plates and screws made of surgical steel or titanium, and is a routine orthopaedic surgery. I have a plate down my fibula and two pins in the tibia of my right leg following a fall in the snow many years ago. Another thing to thank Joseph Lister for.

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