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Knee Update

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

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  1. Knee Update Mark ClatworthyOrthopaedic Surgeon Knee Specialist

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. Examination Findings • Must examine both knees. Large variation laxity • Fixed flexion deformity, reduced flexion

  8. ACL Examination • Lachmann - anterior translation tibia

  9. ACL Examination • Lachmann – Big leg, small hands

  10. ACL Examination Anterior drawer decreased by posterior horn of the menisci – less positive than Lachmann

  11. ACL Examination • Pivot shift test- reproduces the sensation of giving way. Lateral compartment subluxes

  12. Exclude PCL Injury • Drop back seen with knee at 90° • Compare withother side

  13. PCL Examination • Posterior drawer

  14. Meniscal Tear • Mechanism of InjuryTypically a twisting injury on a loaded knee Often sudden painKnee swells – variable time frame Mechanical symptoms – catching, locking

  15. 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

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

  17. Meniscal Grind Test

  18. 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

  19. What X Ray’s Should I take • Weight bearing AP • 45º weight bearing PA • Lateral • Skyline • AP Pelvis if unsure about hip

  20. Weight bearing X Rays • Weight bearing X rays are critical

  21. 45° Weightbearing PA

  22. Skyline patella

  23. Treatment Options for Early OA Knee • Non surgical treatment • Arthroscopy • High Tibial Osteotomy

  24. 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

  25. 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

  26. 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

  27. High Tibial Osteotomy • Indicated for younger patient with varus knee with medial compartment OA

  28. 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

  29. 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

  30. 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

  31. Survival – Age at TKA

  32. 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

  33. 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

  34. NZ Joint Registry Oxford 6 months

  35. 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

  36. Oxford Score & Revision Rate Poor Fair Good Excellent

  37. NZ Joint Registry Oxford 6 months

  38. Range of Motion - Stiffness

  39. 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

  40. 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

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