Common knee problems: Impact on employment
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Common knee problems:Impact on employment
Theophilus Asumu FRCS (Tr & Orth)Consultant Orthopaedic Surgeon
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Objectives
• Common conditions– Surgical relevance
• Treatment and prognosis for functional recovery
• Take home messages• Discussion
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Patient groups
• Knee injury– Fractures and multiligament
injury– Soft tissue injury
• Knee pain– Osteoarthritis
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Knee injury service
►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
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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, ScottInjury 1996: 27: 407-9
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►Sports related injury►Majority are non specific►Early diagnosis difficult►Respond to RICE, crutches,
physio►Resolve after 6 to 8 weeks
Acute knee injury
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►Young active patientFire fighters, police officers
►Full time employment
►Early management plan►Return to work
Acute knee injury
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►Meniscal tear►Ligament injuries– Anterior Cruciate Ligament– Medial Collateral Ligament
►Osteochondral fractures►Patella dislocation
Early MRI scan
Acute knee injury
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►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
Treatment
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►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
Treatment
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►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
Treatment
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1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.
Take home message
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Knee pain
OSTEOARTHRITIS
Disabling symptoms10% of over 55’s
Predisposing factorsAge > 50 yearsGeneticFemale sexKnee injuryObesityOccupational factors
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Knee pain
OSTEOARTHRITIS
Occupational factorsHeavy manual work
Farming, miningHeavy liftingKnee bendingKneeling/ squatting/ crawling
Affect both onset and progression
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1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients
(obese, female, family history).
Take home message
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Surgical treatment
Severity of diseaseExtent of diseaseSuccess rateMorbidity LongevitySubsequent total knee replacement
• More difficult• Outcome
ArthroscopyArthroplastyOsteotomy
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Early OAPain relief in 65 - 80%Lasts up to 1 yearSwift recovery
Day surgery – immediate FWBDrive - 10 daysOffice work - 2 weeksManual work 4 – 6 weeks
Subsequent TKR unaffected
Arthroscopy
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Low complication rate10 262 arthroscopies 1.68%.*
Minimally invasiveRepeatableWell accepted??Necessary!!
• *Small NC. Arthroscopy 1998;4:215-21.
Arthroscopy
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ArthroscopyA Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee
180 patientsArthroscopy vs placebo surgery24 month follow up
PainFunction
J. Bruce Moseley et alHouston Veterans Affairs Medical Center
NEJM 2002
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Early OAMechanical symptoms– Meniscectomy– Loose bodies
Normal limb alignmentModerate x-ray changes
Arthroscopy
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1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients
(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.
Take home message
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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
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Upper tibial osteotomy (HTO)
• Indications– Isolated medial oa– Localised medial pain– Pain on activity• No rest pain
– Well preserved ROM– Correctible varus deformity
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Upper tibial osteotomy (HTO)
• Achieve 8-12 degrees of valgus• WBA through lateral compartment
• Pre-op planning• Precise osteotomy• Stable internal fixation
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Upper tibial osteotomy (HTO)
• Results
01020304050607080
12 8 0-4 -4 -8Valgus angle
% clinicalsuccess
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Upper tibial osteotomy (HTO)
• Results
0102030405060708090
100
2 3 4 5 6 7 8 9 10 11Years since surgery
% clinicalsuccess
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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
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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
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1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients
(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.5. Recovery after HTO is prolonged.6. Young males are the ideal cadidates for HTO.
Take home message
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Total knee replacement
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Total knee replacement
Treatment of choice for end stage OA
Improved:Prosthesis InstrumentationUnderstanding of knee biomechanics
Surgical technique
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Total knee replacement
Excellent survivorship
Reproducible results
Trend to earlier surgery
Informed consent
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Total knee replacement
1 2 3 4 5 6 7 8 9 100
5
10
1519872000
Years since surgery
% r
evis
ed
Swedish Knee Arthroplasty Register 2011
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Total knee replacement
• DisallowedContact sports, jogging, running,
high impact aerobics, power lifting• Caution
Vigorous hiking, skiing, tennis, repetitive lifting > 50lbs, repetitive stairs
• PermittedWalking, swimming, golf, driving,
cycling, ballroom dancing
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Total knee replacement
RecoveryInpatient 4 daysMobile with elbow crutchesNo walking aids at 4 – 6 weeks85% of muscle strength at 3 monthsFull recovery 12 months
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Total knee replacement
FunctionROM 0 – 110 degreesSedentary work Impact activityProlonged standingHeavy manual jobs
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Total knee replacement
Return to workDriving 4 weeks
(no walking aids)
Sedentary work 6 weeksManual work 12 weeks
Phased returnAltered dutiesHeavy liftingRestraint
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Total knee replacement
Pre-op 1 yr post-op 2 yrs post-op
Little difficulty 3% 15% 20%
Very difficult 82% 58% 56%
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1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients
(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.5. Recovery after HTO is prolonged.6. Young males are the ideal cadidates for HTO.7. Total knee replacement is the treatment of choice for end
stage OA knee.8. Heavy manual work is a problem after TKR.
Take home message
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1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients
(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.5. Recovery after HTO is prolonged.6. Young males are the ideal cadidates for HTO.7. Total knee replacement is the treatment of choice for end
stage OA knee.8. Heavy manual work is a problem after TKR.
Take home message
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