10/15/2012

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Oh – My Aching Knee

Orthopedic Surgeon

Jan Pieter Hommen, MDOrthopedic Surgeon

Sports MedicineArthroscopy

Joint Replacements

Oh – My Aching Knee

Orthopedic Surgeon

Jan Pieter Hommen, MD

Orthopedic SurgeonSports Medicine

ArthroscopyJoint Replacements

Private Practice Orthopedic Surgeon

Baptist Hospital Office 101 East

WHO AM I?

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Born - Netherlands

WHO AM I?

Born Netherlands

Grew up - Pittsburgh

Education:

College – Cornell University

WHO AM I?

Medical School – Cornell University

Residency – NYU-Hospital for Joint Diseases

Fellowship – Southern California Orthopedic Institute

FIU Clinical Assistant Professor

WHO AM I?

Orthopedics

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Team Physician

WHO AM I?

Professional Soccer

College Athletics

High School Athletics

Outline

GOALS:

• Knee Anatomy

• Knee Examination

• Knee Work Up

• Knee Pathology and Treatments

• When to Refer

Knee Anatomy

Compound Joint2 condyloid joints 

1 sellar joint (patellofemoral)}

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Knee Anatomy

• Cartilage

• Ligaments

• Blood Supply

• Innervation

• Biomechanics

Knee Anatomy

Different Types:

Cartilage

Different Types:– Growth Plate Cartilage

– Fibrocartilage

– Elastic cartilage

– Fibroelastic Cartilage

– Articular Cartilage

Knee Anatomy

Cartilage

Fibrocartilage 

Articular Cartilage

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Knee Anatomy

Fibrocartilage 40‐50% Load in Extension85% in Load in Flexion

Knee Anatomy

Blood Supply

Knee Anatomy

Innervation

– Anterior/Lateral/Medial• L2 L4 Femoral Nerve• L2-L4 Femoral Nerve

– Posterior• S1-S2 Sciatic Nerve

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Knee Anatomy

Biomechanics• Joint Reactive Force

• Tibiofemoral• 3x body weight walking• 4x climbing• 4x climbing

• Patellofemoral: • 7 x squatting• 2-3 x descending stairs

• Screw-Home Mechanism• As knee Extends, the Tibia Externally rotates: Tightens

collaterals

Knee Anatomy

• Ligaments

– Cruciates• PCL and ACL

– Collaterals• Medial and Lateral

Knee Examination

• Alignment

• Effusion

• Range of motionRange of motion

• Stability

• Gait

• Point of maximum tenderness

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Knee Examination

Alignment

VARUS VALGUS

Alignment

Windswept Knee

Knee Examination

Patella Alignment

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Knee Examination

Patella Alignment

Knee Examination

• Alignment

• Effusion

• Range of motionRange of motion

• Stability

• Gait

• Point of maximum tenderness

Knee Examination

Effusion

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Knee Examination

• Alignment

• Effusion

• Range of motionRange of motion

• Stability

• Gait

• Point of maximum tenderness

Knee Examination

Range of Motion

Knee Examination

• Alignment

• Effusion

• Range of motionRange of motion

• Stability

• Gait

• Point of maximum tenderness

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Knee Examination

• Alignment

• Effusion

• Range of motionRange of motion

• Stability

• Gait

• Point of maximum tenderness

Knee Examination

• Alignment

• Effusion

• Range of motionRange of motion

• Stability

• Gait

• Point of maximum tenderness

Knee Examination

Point of maximum tenderness

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Knee Examination

Rule out Referred Pain from Hip

Knee Examination

– Meniscus

• Thessaly

• Anterior Drawer

Specialty Tests

• McMurray

– Anterior Cruciate Ligament

• Lachman

• Pivot Shift

– Patella –• Q angle

• J sign

• Patella apprehension

• Patella Load

Knee Examination

Sensitivity –

• Probability of a positive test among patients with disease

Sensitivity  & Specificity

• Probability of a positive test among patients with disease

• High sensitivity has lower false negatives

Specificity –

• Probability of a negative test among patients without disease

• High specificity has lower false positive

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Knee Examination

– Sensitivity: » 89% medial meniscus

Meniscus Thessaly Test

» 89% medial meniscus

» 90% lateral meniscus

– Specificity: » 97% medial meniscus

» 96% lateral mensiscus

Most Sensitive and Specific

Knee Examination

– Sensitivity: » 50% for pain

Meniscus McMurray Test

» 50% for pain» 16% if clunk or

thud

– Specificity: » 98% for thud» 94% for pain

Knee Examination

Apley Meniscus Distraction & Compression

– Sensitivity: » 97%

– Specificity: » 87%

Compression Distraction

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Knee Examination

– Anterior Drawer:

S

ACL/PCL

» Sens: 41%

» Spec: 95%

– Posterior Drawer: • 90% 

• 99%

Anterior Drawer Posterior Drawer

Knee Examination

» Sensitivity:• 68 77%

ACL Lachman

• 68‐77%

» Specificity: • 50‐94%

Most Sensitive for Acute Injuries

Knee Examination

– Anterior Drawer:

S iti it

ACL Pivot Shift Test

» Sensitivity:• 82%

» Specificity: • 98%

Most Sensitive and Specific

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Knee Adjunct Studies

X‐rays

MRI 

CT

Bone Scan

Knee Adjunct Studies

Generally 4 views: 1. A-P

X‐rays

2. Lateral 30 degree flexion

3. Sunrise

4. 45 degree weight bearing

Knee Adjunct Studies

Generally 4 views: 1. A-P

X‐rays

2. Lateral 30 degree flexion

3. Sunrise

4. 45 degree weight bearing

Rosenberg View

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Knee Adjunct Studies

X‐rays

Knee Adjunct Studies

X‐rays

Knee Adjunct Studies

X‐rays

What to look for:

• Alignment

• Joint space

• Fractures

• Bone lesions

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Knee Adjunct Studies

X‐rays

• Alignment

• Joint space• Joint space

• Fractures

• Bone lesions

Knee Adjunct Studies

X‐rays

• Alignment

• Joint space• Joint space

• Fractures

• Bone lesions

Name That Injury

X‐rays

Segund Fracture=

ACL Tear

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Knee Adjunct Studies

X‐rays

• Alignment

• Joint space• Joint space

• Fractures

• Bone or Soft Tissue lesions

Chondrocalcinosis

Knee Adjunct Studies

MRI scan

Open vs Closed MRI Scan– Open vs Closed MRI Scan• Recommend:

– 1.5 Tesla scanner or higher

– Better for soft tissue than bone pathology

Knee Adjunct Studies

CT scan

– Fractures

– Loose body

– Mal-alignment of knee

– Better for bone than soft tissue pathology

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Knee Adjunct Studies

Ultrasound:– Joint Effusion

– Meniscus

– Collateral Ligaments

– Cruciate Ligament

– Cyst

– Help guide Injection

Knee Adjunct Studies

Bone Scan:

Rule out:

– Patellofemoral Arthritis

– Stress fracture

– Complex Regional Pain Syndrome

Knee Pathologies

• Cartilage Tears

• Ligament Tears

• Fractures

• Avascular Necrosis

• Arthritis

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Meniscus Tears

• Incidence: – 61 per 100,000

– One of most common causes for visits to orthopedist

Meniscus Tear

Meniscus Tears

• History– Giving way

– Buckling

– Mechanical

• Exam

• X-rays

• MRI

Meniscus Tear

Meniscus Tears

Treatment:• Injections

• NSAIDs

• Therapy

• Surgery– Bucket Handle

– Younger patient

– Locked knee

Meniscus Tear

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Meniscus Tears

Treatment:• Injections

• NSAIDs

• Therapy

• Surgery– Bucket Handle Tear– Younger patient

– Locked knee

– Repairable Tear

Bucket Handle Tear

Meniscus Tears

Meniscus Repair

Articular Cartilage Tears

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Articular Cartilage Tears

Microfracture

Articular Cartilage Tears

Cartilage Transplantation

Articular Cartilage Tears

Autologous Chondrocyte Implantation

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Ligament Tears

Ligament Tears

Willis McGahee

Ligament Tears

Nearly 100,000 ACL reconstructions per year

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Fractures

Fractures

Avascular Necrosis

Incidence: • Unkown

f ll• Approx 10% of all cases ‐ Knee

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Avascular Necrosis

2 Types: 

1. SPONK2 S d2. Secondary

SPONK Secondary

Avascular Necrosis

• EtOH abuse• Steroid use

CAUSES

• Sickle Cell• Prior Trauma• Infection• Caissons Disease• Medications• Gaucher Disease• After arthroscopy

Avascular Necrosis

Symptoms:

Ni ht ti i• Night‐time pain• Weight bearing pain• Stair climbing pain

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Avascular Necrosis

Microvascular Ischemia

Normal

Ischemic

Avascular Necrosis

Diagnosis:• X‐raysX rays• MRI scan• Bone scan

Avascular Necrosis

Treatment:• Limit weight bearing• NSAIDs• Core Decompression• Knee Replacement

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Knee Arthritis

3 Main Types:

1. Osteoarthritis2. Rheumatoid arthritis3. Post‐traumatic arthritis

Knee Arthritis

Osteoarthritis:

•Most common

•Age related•Age‐related 

•Progressive destruction 

•Middle age and older

•Commonly affects one or two joints

Knee Arthritis

Post‐traumatic

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Knee ArthritisRheumatoid Arthritis

•1.3 million (75% female)

•Progressive destruction

•Multiple joints, symmetric

•Inflammation of the lining of joint

•Body attacks own cartilage

•Juvenile Rheumatoid Arthritis (JRA) is particularly severe  

Nutrition &

Weight

Exercise &

Physical Therapy

Arthritis Algorithm

Injections

Neutriceuticals

Medications

Nutrition &

Weight

WEIGHT LOSS

•Weight plays key role in force on cartilage

•Some joints more than others

•Weight‐loss program is critical

•Nutritional causes or solutions for arthritis have not been proven

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Exercise &

Physical Therapy

Exercise and Therapy

Neutroceuticals

Neutriceuticals

Nutrition &

Weight

Exercise &

Physical Therapy

Medications

Injections

Neutriceuticals

Medications

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INJECTIONS

Injections

Corticosteroids

INJECTIONS

Injections

Hyaluronic Acid

INJECTIONS

Which To Use Initially? 

Often Dictated by 3rd Party Payor

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INJECTIONS

Leopold et al J Bone Joint Surg. 2003;85A:1197‐1203.

Hylan G‐F 20 Versus Cortisone Group 1: Hylan 3 injections

Group 2: Cortisone with 2nd at any time6 Month StudyNo Difference

INJECTIONS

Zhang W et al. OARSI Osteoarthritis Cartilage. 2010;18(4):476‐499.

Effect Size Study0.5 indicates Moderate Effect

0.58 Cortisone0.60 HASimilar 

INJECTIONS

Reichenbach S, Blank S, Rutjes AW, et al. Arthritis Rheum. 2007;57(8):1410‐1418Berenbaum F, Grifka J, Cazzaniga S, et al. Ann Rheum Dis. 2012;doi:10.1136/annrheumdis‐2011‐200972.

Any Difference Between HA?

SimilarHowever – higher molecular weight slightly better

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Failure Non-Surgical Treatments

Medications

Exercise

NeutriceuticalsFAILED

FAILED

FAILED

Physical Therapy

Nutrition & Weight

SURGICAL OPTIONS

FAILED

FAILED

Surgical Options

CURATIVE

• Resection

• Fusion

LIMITED

• Synovectomy• Fusion

• Selective Replacements

• Total Replacements

• Arthroscopy

• Osteotomy

• Cartilage Transfer

Surgical Options

LIMITED

• Osteotomy– < 40

– Male

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Osteoarthritis

Surgical Options

CURATIVE

• Partial Replacements

Surgical Options

CURATIVE

• Total Replacements

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Osteoarthritis

• Diagnosis:

– History:• Gradual pain

• Possible acute on chronicPossible acute on chronic

– Exam: • Swollen

• Generalized pain

• Localized pain

Osteoarthritis

• Diagnosis:

– X-rays:• All patients with chronic knee pain or acute pain

– MRI scan:MRI scan: • If x-rays “normal” or mild arthrosis

• Rule our occult fracture, AVN

– Aspiration: • Rule out crystals or infection

Osteoarthritis

• Treatment: My Personal Strategy

– NSAIDs:• GI protection

• * Confirm with internist

– Physical Therapy: • Very GENTLE- strengthening, ROM

• Weight Loss Program

– Aspiration/Injection: • Cortisone

• Hyaluronic acid

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Osteoarthritis

• Treatment: My Personal Strategy

– Surgery:• If failed all of the above

• Total Knee Replacement

• Uni

• Knee Arthroscopy

When to Refer

When to Refer

Remember –

Orthopedics is the practice of preventing and correcting musculoskeletal disorders

• We are NOT all about Cutting and Replacing

• 90% of my office is non-surgical treatment

• Don’t be afraid to send

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When to Refer

• Primary Care MD - Gait Keeper• Cost Containment• Prelim diagnostic Work-up

What Can You Do?

Prelim diagnostic Work up• Try:

• NSAIDs• Physical Therapy• Weight Loss• Injections• Cane

Thanks

WEB: www.drhommen.com

EMAIL: jph@drhommen.com

CELL: 305.907.4505