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Knee Problems ? Sam Rajaratnam Consultant Orthopaedic Surgeon Eastbourne DGH, Horder Centre, Esperance Hospital, Eastbourne.

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Presentation on theme: "Knee Problems ? Sam Rajaratnam Consultant Orthopaedic Surgeon Eastbourne DGH, Horder Centre, Esperance Hospital, Eastbourne."— Presentation transcript:

1 Knee Problems ? Sam Rajaratnam Consultant Orthopaedic Surgeon Eastbourne DGH, Horder Centre, Esperance Hospital, Eastbourne

2 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

3 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

4 Serious

5 Curable Arthritis Instability Cartilage tears Intra-articular pain

6 Things that may be treated conservatively Chondromalacia patellae Tendinosis Bakers cysts

7 X-Ray or MRI Xrays – Much more useful for Osteoarthritis (probably avoid Primary care MRI’s) MRI - useful for Meniscal tears or ligament injuries

8 MRI - Meniscal tears

9 Meniscal Repair vs Resection

10 Meniscal Repair

11 Xrays Much better for arthritis ( Antero-medial wear – Most common pattern (60 %). Very Painful )

12 Isolated patello-femoral wear Pain on walking up & down stairs No problem walking on flat ground Patella can “lock” or “catch” Knee giving way

13 Lateral Osteoarthritis Knee Gives way “Knock Knee” Deformity can progress rapidly Often required total knee replacement (remember – disease of flexor surface)

14 TKR’s vs Partials

15 Computerised Jigs

16 Rapid recovery programme

17 Young arthritis – options available

18 Cartilage surface defects MRI Poor at diagnosing these Look for articular surface tenderness & effusion

19 3. Diagnose Acute Ligament Injuries MCL ACL PCL MPFL

20 Reminder - Acutely injured knee Intra-articular injuries present with pain and swelling Extra-articular ligament injuries present with pain

21 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.

22 Curable - if braced early

23 ACL 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

24 ACL testing

25 Arthroscopic View Torn ACL POST RECONSTRUCTION

26 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

27 P.C.L

28 Multi-ligament injury

29 4. Patella Dislocation - MPFL Traumatic May heal May require MPFL Repair Spontaneous Bad bony alignment Soft Tissue laxity

30 MPFL Rupture

31 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

32 MACI & ACI

33 Osteochondral grafting

34 Microfracture

35 Chondro-tissue

36 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…..

37 Thank you – Any Questions ? Sam Rajaratnam Consultant Orthopaedic Surgeon Eastbourne DGH Horder Centre, Esperance Hospital, Eastbourne


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