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

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

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