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Knee Update. Mark Clatworthy Orthopaedic Surgeon Knee Specialist. Overview. How to diagnose a meniscal tear and ACL rupture What x rays of the knee should I take? Treatment options for early OA of the knee Knee Arthroplasty update. ACL Injury. History taking key to diagnosis

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knee update

Knee Update

Mark ClatworthyOrthopaedic Surgeon

Knee Specialist

  • How to diagnose a meniscal tear and ACL rupture
  • What x rays of the knee should I take?
  • Treatment options for early OA of the knee
  • Knee Arthroplasty update
acl injury
ACL Injury
  • History taking key to diagnosis
  • Acutely injured knees are painful and swollen making the examination difficult
  • The diagnosis normally lies in the history
acl injury1
ACL Injury
  • Mechanism of injuryNormally a side stepping or pivoting manoeuver or an awkward landingOften a non contact injuryThe posterolateral knee subluxes
  • Patient will feel a pop and the knee gave way
acl rupture
ACL Rupture
  • Patient usually presents with a haemarthrosis
  • Knee may fell unstable with any twisting activity
  • Difficulty weightbearing due to bone bruising
  • The knee subluxesposterolaterally thus this area is usually tender
acl rupture1
ACL Rupture
  • Patients often present with a fixed flexion deformity. Initially this is due to bone bruising.
  • A bucket handle tear typically occurs only with multiple giving way episodes
examination findings
Examination Findings
  • Must examine both knees. Large variation laxity
  • Fixed flexion deformity, reduced flexion
acl examination
ACL Examination
  • Lachmann - anterior translation tibia
acl examination1
ACL Examination
  • Lachmann – Big leg, small hands
acl examination2
ACL Examination

Anterior drawer decreased by posterior horn of the menisci – less positive than Lachmann

acl examination3
ACL Examination
  • Pivot shift test- reproduces the sensation of giving way. Lateral compartment subluxes
exclude pcl injury
Exclude PCL Injury
  • Drop back seen with knee at 90°
  • Compare withother side
pcl examination
PCL Examination
  • Posterior drawer
meniscal tear
Meniscal Tear
  • Mechanism of InjuryTypically a twisting injury on a loaded knee

Often sudden painKnee swells – variable time frame

Mechanical symptoms – catching, locking

examination findin gs
Examination Findings
  • Effusion
  • Springy block to extension if bucket handle
  • Point joint line tenderness
  • Pain on meniscal grinding
  • Pain on loading and twisting the knee

Tense effusion is easily seen, Moderate effusion – patella tapMild effusion - patella sweep

locked knee
Locked knee
  • Physical block
  • In young patient needs urgent meniscal repair
  • Don’t send to physiotherapistUrgent referral to orthopaedic surgeonWe will see the patient that week
what x ray s should i take
What X Ray’s Should I take
  • Weight bearing AP
  • 45º weight bearing PA
  • Lateral
  • Skyline
  • AP Pelvis if unsure about hip
weight bearing x rays
Weight bearing X Rays
  • Weight bearing X rays are critical
treatment options for early oa knee
Treatment Options for Early OA Knee
  • Non surgical treatment
  • Arthroscopy
  • High Tibial Osteotomy
non surgical treatment
Non Surgical Treatment
  • Analgesics & Anti – inflammatories
  • Glucosamine & ChondrotinSulphate – variable response
  • Intra-articular steroid – short term benefit – Cochrane 1 weekAccelerates cartilage degeneration
  • Viscosupplementation – controversial
  • Knee Sleeve
  • Exercise – low impact – exercycleIf the knee is painful and swollen. Stop it
  • Physiotherapy – maximize muscle strengthening
  • Orthotics
early oa and arthroscopy
Early OA and Arthroscopy
  • Arthroscopic debridement and lavage has unpredictable results thus is not indicated
  • If a symptomatic meniscal tear with pain and mechanical symptoms worthwhile however must caution the patient that the knee will not be normal due to OA
proposed acc guidelines
Proposed ACC Guidelines
  • Clear history of injury
  • Signs and symptoms of a meniscal tear
  • Less than 50% joint loss on weight bearing X rays
  • Full thickness chondral lesions on MRI excluded
high tibial osteotomy
High Tibial Osteotomy
  • Indicated for younger patient with varus knee with medial compartment OA
high tibial osteotomy1
High Tibial Osteotomy
  • Two hour operation, 2-3 days in hospital
  • Six weeks on crutches with a brace
  • Three – six month recovery
  • Knee better - not normal
  • VAS pain 7.1  2.6 at 5 years
  • Sydney study – 84% survival at 15 years
  • 186 cases last 12 years – 4 converted to TKA
total knee arthroplasty
Total Knee Arthroplasty
  • Perception in the community
    • Only lasts 10 years
    • Very painful operation and the knee will continue to be painful
    • Doesn’t work that well.
    • Knee will be stiff
tka survival
TKA Survival
  • National registriesNew Zealand 96% at 10 years Australia 92% at 8 years Swedish 95% at 10 years Norwegian 88% at 12 years
  • Expert Designer Series92% at 16 years 93% at 15 years 87% at 18 years
  • > 60 years > 90% implant will last life time
activity level pain
Activity level & Pain
  • Younger patient more active thus higher failure rate
  • TKA is designed for every day activityWalking, golf, tramping, groomed skiing, doubles tennis
  • TKA is not designed for impact loading activities – running, jumping, dancing, singles tennis
  • The knee will be painful, swollen, warm and stiff for up to 6 months. Must take pain medication
  • TKJR will get rid of most but not necessarily all of the pain. VAS pain – 6.8  1.0 – 60% no pain
improving outcome
Improving Outcome
  • Computer Guided TKA
    • Enables the surgeon to:
    • Ensure accurate alignment – enhancing implant survival
    • Balance the ligaments to ensure good kinematics
    • Customize the TKA to patients anatomy & ligamentous laxity
  • Mobile Bearing TKA
    • RCT showed better knee function
    • Less wear in lab
oxford score significance
Oxford Score Significance
  • Statistically significant relationship between 6 month Oxford score and revision rate
  • Every 1 unit decrease in Oxford score increases the revision rate at 2 years by 10.4%
  • A patient with a score <20 has a 30 times the revision rate of a patient with a score > 36
  • ROC (Receiver operating characteristic) analysis demonstrates < 31 has an 8 times greater risk of revision than a score > 31
oxford score revision rate
Oxford Score & Revision Rate

Poor Fair Good Excellent

  • Infection - Hot, painful, swollen, stiff knee - Wound may be oozing - Patient will often report a sudden increase in pain and decrease in movement - If in doubt refer back to operative surgeon - Don’t start antibiotics unless you are sure it is a superficial stitch abscess
  • DVT- Hot, tense painful calf- If in doubt refer for ultrasound

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