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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


Overview
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
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


Effusion
Effusion

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


45 weightbearing pa
45° Weightbearing PA



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




Complications
Complications

  • 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


Websites
Websites

  • www.aucklandboneandjoint.co.nz

    Tonight’s talks available on website

  • www.markclatworthy.co.nz

    All my information sheets, pre and post op instructions, surgical videos and comprehensive information on knee conditions and treatment