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  1. Common knee problems:Impact on employment Theophilus Asumu FRCS (Tr & Orth) Consultant Orthopaedic Surgeon

  2. Objectives • Common conditions • Surgical relevance • Treatment and prognosis for functional recovery • Take home messages • Discussion

  3. Patient groups • Knee injury • Fractures and multiligament injury • Soft tissue injury • Knee pain • Osteoarthritis

  4. Started November 2001 3 times weekly Improve access to treatment No prior history Definite traumatic event Conservative treatment Persisting disability Referral source A&E Physiotherapy Consultant GP Knee injury service

  5. Acute knee injury *117 patients • 9.8% diagnosed by presenting physician • 1 month: 32 cases diagnosed • Average time to diagnosis = 21 month • 30% missed by ortho surgeon *Bollen, Scott Injury 1996: 27: 407-9

  6. Acute knee injury • Sports related injury • Majority are non specific • Early diagnosis difficult • Respond to RICE, crutches, physio • Resolve after 6 to 8 weeks

  7. Young active patient Fire fighters, police officers Full time employment Early management plan Return to work Acute knee injury

  8. Acute knee injury • Meniscal tear • Ligament injuries • Anterior Cruciate Ligament • Medial Collateral Ligament • Osteochondral fractures • Patella dislocation Early MRI scan

  9. Treatment • Physiotherapy • Medial Collateral Ligament injury • Non-specific muscle/tendon/ligament sprains • Recovery pattern • 2-3 weeks acute knee pain/ swelling • Progressive improvement • Full recovery • 6 weeks

  10. Treatment • Arthroscopy • Meniscal tears • Recovery pattern • 2-3 weeks acute knee pain/ swelling • Episodic knee pain • Post-operative • 2-4 weeks sedentary work • 4-6 weeks manual work

  11. Treatment • Ligament reconstruction • ACL tears • Recovery pattern • 2-3 weeks acute knee pain/ swelling • Episodic knee instability • Post-operative • 4 weeks sedentary work • 12 – 24 weeks manual work

  12. Take home message • Post traumatic knee pain should be referred early for a specialist opinion. • Early MRI scanning is cost effective.

  13. Knee pain OSTEOARTHRITIS • Disabling symptoms • 10% of over 55’s • Predisposing factors • Age > 50 years • Genetic • Female sex • Knee injury • Obesity • Occupational factors

  14. Knee pain OSTEOARTHRITIS • Occupational factors • Heavy manual work • Farming, mining • Heavy lifting • Knee bending • Kneeling/ squatting/ crawling • Affect both onset and progression

  15. Take home message • Post traumatic knee pain should be referred early for a specialist opinion. • Early MRI scanning is cost effective. • In high risk occupations, look specifically at high risk patients (obese, female, family history).

  16. Surgical treatment Severity of disease Extent of disease Success rate Morbidity Longevity Subsequent total knee replacement • More difficult • Outcome • Arthroscopy • Arthroplasty • Osteotomy

  17. Arthroscopy Early OA Pain relief in 65 - 80% Lasts up to 1 year Swift recovery Day surgery – immediate FWB Drive - 10 days Office work - 2 weeks Manual work 4 – 6 weeks Subsequent TKR unaffected

  18. Arthroscopy Low complication rate 10 262 arthroscopies 1.68%.* Minimally invasive Repeatable Well accepted ??Necessary!! • *Small NC. Arthroscopy 1998;4:215-21.

  19. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee 180 patients Arthroscopy vs placebo surgery 24 month follow up Pain Function J. Bruce Moseley et al Houston Veterans Affairs Medical Center NEJM 2002 Arthroscopy

  20. Arthroscopy Early OA Mechanical symptoms • Meniscectomy • Loose bodies Normal limb alignment Moderate x-ray changes

  21. Take home message • Post traumatic knee pain should be referred early for a specialist opinion. • Early MRI scanning is cost effective. • In high risk occupations, look specifically at high risk patients (obese, female, family history). • There is a narrow indication for arthroscopy in osteoarthritis.

  22. Upper tibial osteotomy (HTO) • Developed by Jackson 1950’s • Popularised by Coventry • Coventry et al JBJS (Am). 1973;55 :23-48 • Medial OA • Varus to valgus • Unload diseased compartment • Victim of knee replacement

  23. Upper tibial osteotomy (HTO) • Indications • Isolated medial oa • Localised medial pain • Pain on activity • No rest pain • Well preserved ROM • Correctible varus deformity

  24. Upper tibial osteotomy (HTO) • Achieve 8-12 degrees of valgus • WBA through lateral compartment • Pre-op planning • Precise osteotomy • Stable internal fixation

  25. Upper tibial osteotomy (HTO) • Results

  26. Upper tibial osteotomy (HTO) • Results

  27. Upper tibial osteotomy • Obese patients perform poorly • Coventry et al JBJS (Am), 1993;75:2, 196-201, • ACL deficiency • Holden et al JBJS (Am), 1988; 70:2, 977-982 • Initial success is dependent on successful correction • Approximately 40% need knee replacements within 10 years

  28. Upper tibial osteotomy (HTO) • Good initial success rate • Allows manual work • Fails over time • Worsening results recently • High morbidity Fracture healing • Long recovery period • PWB for 6 weeks • Full recovery 12 months

  29. Take home message • Post traumatic knee pain should be referred early for a specialist opinion. • Early MRI scanning is cost effective. • In high risk occupations, look specifically at high risk patients (obese, female, family history). • There is a narrow indication for arthroscopy in osteoarthritis. • Recovery after HTO is prolonged. • Young males are the ideal cadidates for HTO.

  30. Total knee replacement

  31. Total knee replacement Treatment of choice for end stage OA Improved: Prosthesis Instrumentation Understanding of knee biomechanics Surgical technique

  32. Total knee replacement Excellent survivorship Reproducible results Trend to earlier surgery Informed consent

  33. Total knee replacement Swedish Knee Arthroplasty Register 2011

  34. Total knee replacement • Disallowed Contact sports, jogging, running, high impact aerobics, power lifting • Caution Vigorous hiking, skiing, tennis, repetitive lifting > 50lbs, repetitive stairs • Permitted Walking, swimming, golf, driving, cycling, ballroom dancing

  35. Total knee replacement Recovery Inpatient 4 days Mobile with elbow crutches No walking aids at 4 – 6 weeks 85% of muscle strength at 3 months Full recovery 12 months

  36. Total knee replacement Function ROM 0 – 110 degrees Sedentary work Impact activity Prolonged standing Heavy manual jobs

  37. Total knee replacement Return to work Driving 4 weeks (no walking aids) Sedentary work 6 weeks Manual work 12 weeks Phased return Altered duties Heavy lifting Restraint

  38. Total knee replacement

  39. Take home message • Post traumatic knee pain should be referred early for a specialist opinion. • Early MRI scanning is cost effective. • In high risk occupations, look specifically at high risk patients (obese, female, family history). • There is a narrow indication for arthroscopy in osteoarthritis. • Recovery after HTO is prolonged. • Young males are the ideal cadidates for HTO. • Total knee replacement is the treatment of choice for end stage OA knee. • Heavy manual work is a problem after TKR.

  40. Take home message • Post traumatic knee pain should be referred early for a specialist opinion. • Early MRI scanning is cost effective. • In high risk occupations, look specifically at high risk patients (obese, female, family history). • There is a narrow indication for arthroscopy in osteoarthritis. • Recovery after HTO is prolonged. • Young males are the ideal cadidates for HTO. • Total knee replacement is the treatment of choice for end stage OA knee. • Heavy manual work is a problem after TKR.