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 Grade 2 Grade 3 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