Knee Problems ?
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![Page 1: Knee Problems ?](https://reader036.fdocuments.us/reader036/viewer/2022081513/56813767550346895d9efb35/html5/thumbnails/1.jpg)
Knee Problems ?
Sam Rajaratnam
Consultant Orthopaedic Surgeon
Eastbourne DGH,
Horder Centre,
Esperance Hospital, Eastbourne
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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
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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
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Serious
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Curable
• Arthritis
• Instability
• Cartilage tears
• Intra-articular pain
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Things that may be treated conservatively
• Chondromalacia patellae
• Tendinosis
• Bakers cysts
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X-Ray or MRI
• Xrays – Much more useful for Osteoarthritis (probably avoid Primary care MRI’s)
• MRI - useful for Meniscal tears or ligament injuries
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MRI - Meniscal tears
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Meniscal Repair vs Resection
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Meniscal Repair
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Xrays Much better for arthritis
(Antero-medial wear –
Most common pattern (60 %) . Very Painful)
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Isolated patello-femoral wear
Pain on walking up & down stairs
No problem walking on flat ground
Patella can “lock” or “catch”
Knee giving way
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Lateral Osteoarthritis
Knee Gives way
“Knock Knee”
Deformity can progress rapidly
Often required total knee replacement
(remember – disease of flexor surface)
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TKR’s vs Partials
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Computerised Jigs
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Rapid recovery programme
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Young arthritis – options available
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Cartilage surface defects
• MRI Poor at diagnosing these
• Look for articular surface tenderness & effusion
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3. Diagnose Acute Ligament Injuries
• MCL
• ACL
• PCL
• MPFL
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Reminder - Acutely injured knee
• Intra-articular injuries present with pain and swelling
• Extra-articular ligament injuries present with pain
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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.
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Curable - if braced early
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ACLACL
History
• running (high velocity)
• change of speed and direction
• “snap” or “pop”
• pain
• immediate swelling (<4hours)
• unable to play on
CLINICAL FINDINGS• Swelling is haemarthrosis • Restricted range of motion usually due to
ACL stump or muscular spasm almost never meniscal tear locking joint in
acute primary injury
LIGAMENT EXAMINATION
• LACHMAN• PIVOT SHIFT• ANTERIOR DRAWER TESTS
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ACL testing
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Arthroscopic View
• Torn ACL
• POST RECONSTRUCTION
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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
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P.C.L
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Multi-ligament injury
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4. Patella Dislocation - MPFL
Traumatic• May heal
• May require MPFL Repair
Spontaneous• Bad bony
alignment
• Soft Tissue laxity
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MPFL Rupture
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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
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MACI & ACI
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Osteochondral grafting
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Microfracture
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Chondro-tissue
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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…..
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Thank you –
Any Questions ?
Sam Rajaratnam
Consultant Orthopaedic Surgeon
Eastbourne DGH
Horder Centre,
Esperance Hospital, Eastbourne