common knee problems: impact on employment theophilus asumu frcs (tr & orth) consultant...
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Common knee problems:Impact on employment
Theophilus Asumu FRCS (Tr & Orth)Consultant Orthopaedic Surgeon
Objectives
• Common conditions– Surgical relevance
• Treatment and prognosis for functional recovery
• Take home messages• Discussion
Patient groups
• Knee injury– Fractures and multiligament
injury– Soft tissue injury
• Knee pain– Osteoarthritis
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
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, Scott
Injury 1996: 27: 407-9
►Sports related injury►Majority are non specific►Early diagnosis difficult►Respond to RICE, crutches,
physio►Resolve after 6 to 8 weeks
Acute knee injury
►Young active patientFire fighters, police officers
►Full time employment
►Early management plan►Return to work
Acute knee injury
►Meniscal tear►Ligament injuries– Anterior Cruciate Ligament– Medial Collateral Ligament
►Osteochondral fractures►Patella dislocation
Early MRI scan
Acute knee injury
►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
►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
►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
1. Post traumatic knee pain should be referred early for a specialist opinion.
2. Early MRI scanning is cost effective.
Take home message
Knee pain
OSTEOARTHRITIS
Disabling symptoms10% of over 55’s
Predisposing factorsAge > 50 yearsGeneticFemale sexKnee injuryObesityOccupational factors
Knee pain
OSTEOARTHRITIS
Occupational factorsHeavy manual work
Farming, mining
Heavy liftingKnee bendingKneeling/ squatting/ crawling
Affect both onset and progression
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
Surgical treatment
Severity of diseaseExtent of diseaseSuccess rateMorbidity LongevitySubsequent total knee replacement
• More difficult• Outcome
ArthroscopyArthroplastyOsteotomy
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
Low complication rate10 262 arthroscopies 1.68%.*
Minimally invasiveRepeatableWell accepted??Necessary!!
• *Small NC. Arthroscopy 1998;4:215-21.
Arthroscopy
Arthroscopy
A 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
Early OAMechanical symptoms– Meniscectomy– Loose bodies
Normal limb alignmentModerate x-ray changes
Arthroscopy
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
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
Upper tibial osteotomy (HTO)
• Indications– Isolated medial oa– Localised medial pain– Pain on activity• No rest pain
– Well preserved ROM– Correctible varus deformity
Upper tibial osteotomy (HTO)
• Achieve 8-12 degrees of valgus• WBA through lateral compartment
• Pre-op planning• Precise osteotomy• Stable internal fixation
Upper tibial osteotomy (HTO)
• Results
0
10
20
30
40
50
60
70
80
12 8 0-4 -4 -8
Valgus angle
% clinicalsuccess
Upper tibial osteotomy (HTO)
• Results
0102030405060708090
100
2 3 4 5 6 7 8 9 10 11
Years since surgery
% clinicalsuccess
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
Upper tibial osteotomy (HTO)
Good initial success rate Allows manual work Fails over time
Worsening results recently
High morbidityFracture healing
Long recovery period PWB for 6 weeks Full recovery 12 months
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
Total knee replacement
Total knee replacement
Treatment of choice for end stage OA
Improved:Prosthesis InstrumentationUnderstanding of knee biomechanics
Surgical technique
Total knee replacement
Excellent survivorship
Reproducible results
Trend to earlier surgery
Informed consent
Total knee replacement
1 2 3 4 5 6 7 8 9 100
5
10
151987
2000
Years since surgery
% r
evis
ed
Swedish Knee Arthroplasty Register 2011
Total knee replacement
• DisallowedContact sports, jogging, running,
high impact aerobics, power lifting
• CautionVigorous hiking, skiing, tennis,
repetitive lifting > 50lbs, repetitive stairs
• PermittedWalking, swimming, golf, driving,
cycling, ballroom dancing
Total knee replacement
RecoveryInpatient 4 daysMobile with elbow crutchesNo walking aids at 4 – 6 weeks85% of muscle strength at 3 monthsFull recovery 12 months
Total knee replacement
FunctionROM 0 – 110 degreesSedentary work Impact activityProlonged standingHeavy manual jobs
Total knee replacement
Return to workDriving 4 weeks
(no walking aids)
Sedentary work 6 weeksManual work 12 weeks
Phased returnAltered dutiesHeavy liftingRestraint
Total knee replacement
Pre-op 1 yr post-op 2 yrs post-op
Little difficulty 3% 15% 20%
Very difficult 82% 58% 56%
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
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