Knee Problems ?
Sam Rajaratnam
Consultant Orthopaedic
Surgeon
Eastbourne DGH,
Horder Centre,
Esperance Hospital, Eastbourne
Questions & Dilemmas
•
Physiotherapy or Orthopaedic Surgeon ?
•
MRI or Xray ? Which views ?
•
Operate or Not ?
•
Total Knee replacement or Partial ?
•
Can we afford it ??
•
Which hospital ? Fracture/Knee injury clinic/
Elective setting
Physio vs Surgeon
•
Not mutually exclusive
•
We work in teams
•
Physio – good for
weak muscles/extra
articular problems/
secondary stiffness
•
Surgeon – can deal
with intra-articular
pathology
Serious
Curable
•
Arthritis
•
Instability
•
Cartilage tears
•
Intra-articular
pain
Things that may be
treated conservatively
•
Chondromalacia patellae
•
Tendinosis
•
Bakers cysts
X-Ray or MRI
•
Xrays – Much more useful for Osteoarthritis
(probably avoid Primary care MRI’s)
•
MRI - useful for Meniscal tears or ligament injuries
MRI - Meniscal tears
Meniscal Repair vs
Resection
Meniscal Repair
Xrays Much better for arthritis
(Antero-medial wear –
Most common pattern (60 %) . Very Painful
)
Isolated patello-femoral
wear
Pain on walking up
& down stairs
No problem walking
on flat ground
Patella can “lock”
or “catch”
Knee giving way
Lateral Osteoarthritis
Knee Gives way
“Knock Knee”
Deformity can
progress rapidly
Often required total
knee replacement
(remember – disease of
flexor surface)
TKR’s vs Partials
Computerised Jigs
Rapid recovery
programme
Young arthritis –
options available
Cartilage surface
defects
•
MRI Poor at
diagnosing these
•
Look for articular
surface tenderness &
effusion
3. Diagnose Acute
Ligament Injuries
•
MCL
•
ACL
•
PCL
•
MPFL
Reminder - Acutely
injured knee
•
Intra-articular injuries present
with pain and swelling
•
Extra-articular ligament
injuries present with pain
MCL Injury
Tenderness, stress testing
Grade I
Local tenderness+slight or no laxity
Grade 2
Local tenderness+laxity with
endpoint.
Grade 3
Complete rupture
No endpoint.
Curable - if braced
early
ACL
History
• running (high velocity)
CLINICAL FINDINGS
• Swelling is haemarthrosis
• change of speed and
direction
• Restricted range of motion usually due to
ACL stump or muscular spasm
• “snap” or “pop”
almost never meniscal tear locking joint in
acute primary injury
• pain
LIGAMENT EXAMINATION
• immediate swelling (<4hours)
• unable to play on
• LACHMAN
• PIVOT SHIFT
• ANTERIOR DRAWER TESTS
ACL testing
Arthroscopic View
• Torn ACL
• POST
RECONSTRUCTION
Day Surgical Arthroscopic Hamstring ACL Accelerated Rehabilitation
Key Changes
• Pre ACL Rehab
• Patient education
• Improved technique
• Ice cold saline infusion
• Advanced Local Blockade
• Physiotherapy services
Key to good results
Early reconstruction
before meniscal damage
has occurred
P.C.L
Multi-ligament injury
4. Patella Dislocation - MPFL
Traumatic
•
May heal
•
May require
MPFL Repair
Spontaneous
•
Bad bony
alignment
•
Soft Tissue laxity
MPFL Rupture
Cartilage Repair
• Suitable for 15 – 55 year old
• Discrete area of chondral damage
• Stable knee (no ligament instability)
• Medial femoral condylar defects , Trochlea groove,
Patella
• Various techniques available
MACI & ACI
Osteochondral grafting
Microfracture
Chondro-tissue
Can Britain afford it ?
•
Probably not………….but as secondary care
clinicians, the decision is easy
•
Treat the patient in front of you as best you can…..
Thank you –
Any Questions ?
Sam Rajaratnam
Consultant Orthopaedic Surgeon
Eastbourne DGH
Horder Centre,
Esperance Hospital, Eastbourne