the knee consultation made easy for gp doctors (nuffield/ newcastle)
TRANSCRIPT
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Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle
www.oasir.co.uk
Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne
THE KNEE CONSULTATION MADE EASYGP TALK AT NEWCASTLE NUFFIELD HOSPITAL
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Prof Deiary Kader
Arthroplasty Primary TKR Revision TKR Uni Knee Patellofemoral
Open Surgery Osteotomy (HTO) Chondroplasty Patella
Stabilisation
Arthroscopy Meniscal Excision Meniscal Repair Microfracture ACL reconstruction Revision ACL PCL reconstruction Multiple Ligament
Recon
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Prof Deiary Kader
1. Arthritis2. Meniscus 3. Ligament (ACL, PCL, MCL)4. Patellofemoral5. Red Flag
◦ Fracture◦ Infection◦ Tumour
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Prof Deiary Kader
HistoryPain Duration Onset Type
Give wayStair problemsTrauma
ExaminationTendernessOsteophytesEffusionDrawer test
5 Min Knee Consultation
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Prof Deiary Kader
1Red Flags
2OA
3Meniscus
4Ligaments
5Patella
History Rest painTumorTrauma FractureFeverInfection
Dull painToothache
Sharp painLocking
Giveway StairsRising from a chair
Examination
General tenderness
Fixed flexionosteophytes
Tender joint lineEffusion
Drawer testLachman
Grinding
Short Knee Consultation
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Prof Deiary Kader
Pain Duration
2-4 wksConservative
Onset Rest (Red Flag)
Mechanical(OA or Instability)
Type Dull(OA)
Sharp(Meniscal tear)
Give way 1-Ligaments 2-Patella Instability
Stairs Patellofemoral dysfunction
Short Knee Consultation
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Prof Deiary Kader
1. Arthritis2. Meniscus 3. Ligament (ACL, PCL, MCL)4. Patellofemoral5. Red Flag
◦ Fracture◦ Infection◦ Tumour
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Prof Deiary Kader
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Prof Deiary Kader
OA Nonoperative treatment
Weight loss Exercise Patient education Analgesia, (NSAIDs) Bracing rarely
Intra-articular (IA) injections. Cochrane reviews
Steroids (better than placebo but not longer than 4wks
HA more prolonged effect than steriods
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Microfracture
Operative treatment
Chondral Damage treated with Microfracture
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Prof Deiary Kader
Autologous Cartilage Implantation
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Prof Deiary Kader
Open or close wedge Osteotomy
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Prof Deiary Kader
When to offer joint replacement
The pain should be significant and disabling. Night pain is particularly distressing
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Prof Deiary Kader
MENISCAL RESECTION & REPAIR
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Prof Deiary Kader
History Meniscal Injury Acute event Delayed swelling Effusion….. Swelling after exercise Pain Catching Locking
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Prof Deiary Kader
Meniscal Tear Management :-
Excision 60% of people over 65yrs have
incidental tears
Repair
Transplant
Replacement
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Prof Deiary Kader
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Prof Deiary Kader
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Prof Deiary KaderPOSTGRADORTH Deiary Kader
??????
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Prof Deiary Kader
Menx Allograft Indications
Physiologically young and active Symptomatic (in the future ??prophylactically) Neutral alignment Normal stability No more than grade II-III Cartilage damage Understand the risk of disease transmission Post operative compliance & expectation No knee abuser and Not in BMI >35
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Prof Deiary Kader
ACL InjuriesFRCS(Tr&Orth) Revision Course
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Prof Deiary Kader
Valgus + ER
POP
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Prof Deiary Kader
Non-Operative Treatment
Activity modification (swimming, bicycling, jogging on flat ground)
Muscle Training (Hamstrings strength)
Proprioceptive Training
Bracing (reduce anterior drawer)
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Prof Deiary Kader
Surgical Treatment
Indications:
Subjective instability (non-coper)
In children and adolescents
Multiligament injury
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Prof Deiary Kader
Intra-articular ACL Reconstruction
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Prof Deiary Kader
HamstringBTB
Grafts / Fixations
Quads
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Prof Deiary Kader
ANTEROLATERAL LIGAMENT
ALL
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Prof Deiary Kader
OPEN ALL Recon
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Prof Deiary Kader
MCL
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Prof Deiary Kader
Medial Collateral Ligament Exam
Opening @ 30o only
Isolated MCL Injury Opening @ 0o
Injury to Posteromedial Capsule
Usually with ACL +/or PCL injury
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Prof Deiary Kader
TreatmentAcute isolated MCL tear
I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks
II Hinged brace, WBAA, 2-3weeks
III Hinged brace 30-90/ Surgical 3-4 wks
Operative treatment depend on site and patient
Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch therefore needs Augmentation with semitendinosis
Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III
MCL
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Prof Deiary Kader
Posterior Cruciate Ligament
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Prof Deiary Kader
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Prof Deiary Kader
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35
PCL Reconstruction
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Prof Deiary Kader
PATELLA CLINIC Evidence based intervention
History and outcome measuresLysholm ,Oxford, Kujala ScoresClinical examinationImaging
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Prof Deiary Kader
Instability can be easier to treat
Pain primary or secondary
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Prof Deiary Kader
Patellar Dislocation
Re-dislocation rate
First Time 17-20%
Second Time 44%-71%
High dissatisfaction following conservative Rx
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Prof Deiary Kader
Med Epicondyle
Add Tubercle
Patella
MPFL
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Prof Deiary Kader
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Prof Deiary Kader
Bony Tunnel
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Prof Deiary Kader
1.4 cm
Patella alta
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Prof Deiary Kader
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Prof Deiary Kader
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Prof Deiary Kader
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Prof Deiary Kader
Kurdistan/Iraq
Thank you