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Common knee problems: Impact on employment Theophilus Asumu FRCS (Tr & Orth) Consultant Orthopaedic Surgeon.

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Presentation on theme: "Common knee problems: Impact on employment Theophilus Asumu FRCS (Tr & Orth) Consultant Orthopaedic Surgeon."— Presentation transcript:

1 Common knee problems: Impact on employment Theophilus Asumu FRCS (Tr & Orth) Consultant Orthopaedic Surgeon

2 Objectives Common conditions – Surgical relevance Treatment and prognosis for functional recovery Take home messages Discussion

3 Patient groups Knee injury – Fractures and multiligament injury – Soft tissue injury Knee pain – Osteoarthritis

4 Knee injury service Started November times weekly Improve access to treatment No prior history Definite traumatic event Conservative treatment Persisting disability Referral source – A&E – Physiotherapy – Consultant – GP

5 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

6 Sports related injury Majority are non specific Early diagnosis difficult Respond to RICE, crutches, physio Resolve after 6 to 8 weeks Acute knee injury

7 Young active patient Fire fighters, police officers Full time employment Early management plan Return to work Acute knee injury

8 Meniscal tear Ligament injuries – Anterior Cruciate Ligament – Medial Collateral Ligament Osteochondral fractures Patella dislocation Early MRI scan Acute knee injury

9 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

10 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

11 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

12 1.Post traumatic knee pain should be referred early for a specialist opinion. 2.Early MRI scanning is cost effective. Take home message

13 Knee pain OSTEOARTHRITIS Disabling symptoms 10% of over 55s Predisposing factors Age > 50 years Genetic Female sex Knee injury Obesity Occupational factors

14 Knee pain OSTEOARTHRITIS Occupational factors Heavy manual work Farming, mining Heavy lifting Knee bending Kneeling/ squatting/ crawling Affect both onset and progression

15 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

16 Surgical treatment Severity of disease Extent of disease Success rate Morbidity Longevity Subsequent total knee replacement More difficult Outcome Arthroscopy Arthroplasty Osteotomy

17 Early OA Pain relief in % Lasts up to 1 year Swift recovery Day surgery – immediate FWB Drive - 10 days Office work - 2 weeks Manual work 4 – 6 weeks Subsequent TKR unaffected Arthroscopy

18 Low complication rate arthroscopies 1.68%.* Minimally invasive Repeatable Well accepted ??Necessary!! * Small NC. Arthroscopy 1998;4: Arthroscopy

19 A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee 180 patients Arthroscopy vs placebo surgery 24 month follow up Pain Function J. Bruce Moseley et al Houston Veterans Affairs Medical Center NEJM 2002

20 Early OA Mechanical symptoms – Meniscectomy – Loose bodies Normal limb alignment Moderate x-ray changes Arthroscopy

21 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

22 Upper tibial osteotomy (HTO) Developed by Jackson 1950s Popularised by Coventry » Coventry et al JBJS (Am). 1973;55 :23-48 Medial OA Varus to valgus Unload diseased compartment Victim of knee replacement

23 Upper tibial osteotomy (HTO) Indications – Isolated medial oa – Localised medial pain – Pain on activity No rest pain – Well preserved ROM – Correctible varus deformity

24 Upper tibial osteotomy (HTO) Achieve 8-12 degrees of valgus WBA through lateral compartment Pre-op planning Precise osteotomy Stable internal fixation

25 Upper tibial osteotomy (HTO) Results

26 Upper tibial osteotomy (HTO) Results

27 Upper tibial osteotomy Obese patients perform poorly » Coventry et al JBJS (Am), 1993;75:2, , ACL deficiency » Holden et al JBJS (Am), 1988; 70:2, Initial success is dependent on successful correction Approximately 40% need knee replacements within 10 years

28 Upper tibial osteotomy (HTO) Good initial success rate Allows manual work Fails over time Worsening results recently High morbidity Fracture healing Long recovery period PWB for 6 weeks Full recovery 12 months

29 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

30 Total knee replacement

31 Treatment of choice for end stage OA Improved: Prosthesis Instrumentation Understanding of knee biomechanics Surgical technique

32 Total knee replacement Excellent survivorship Reproducible results Trend to earlier surgery Informed consent

33 Total knee replacement Swedish Knee Arthroplasty Register 2011

34 Total knee replacement Disallowed Contact sports, jogging, running, high impact aerobics, power lifting Caution Vigorous hiking, skiing, tennis, repetitive lifting > 50lbs, repetitive stairs Permitted Walking, swimming, golf, driving, cycling, ballroom dancing

35 Total knee replacement Recovery Inpatient 4 days Mobile with elbow crutches No walking aids at 4 – 6 weeks 85% of muscle strength at 3 months Full recovery 12 months

36 Total knee replacement Function ROM 0 – 110 degrees Sedentary work Impact activity Prolonged standing Heavy manual jobs

37 Total knee replacement Return to work Driving 4 weeks (no walking aids) Sedentary work 6 weeks Manual work 12 weeks Phased return Altered duties Heavy lifting Restraint

38 Total knee replacement Pre-op1 yr post-op2 yrs post-op Little difficulty3%15%20% Very difficult82%58%56%

39 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

40 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

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