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Knee Update Mark Clatworthy Orthopaedic Surgeon Knee Specialist.

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Presentation on theme: "Knee Update Mark Clatworthy Orthopaedic Surgeon Knee Specialist."— Presentation transcript:

1 Knee Update Mark Clatworthy Orthopaedic Surgeon Knee Specialist

2 Overview  How to diagnose a meniscal tear and ACL rupture  What x rays of the knee should I take?  Treatment options for early OA of the knee  Knee Arthroplasty update

3 ACL Injury   History taking key to diagnosis   Acutely injured knees are painful and swollen making the examination difficult   The diagnosis normally lies in the history

4 ACL Injury   Mechanism of injury Normally a side stepping or pivoting manoeuver or an awkward landing Often a non contact injury The posterolateral knee subluxes   Patient will feel a pop and the knee gave way

5 ACL Rupture  Patient usually presents with a haemarthrosis  Knee may fell unstable with any twisting activity  Difficulty weightbearing due to bone bruising  The knee subluxes posterolaterally thus this area is usually tender

6 ACL Rupture  Patients often present with a fixed flexion deformity. Initially this is due to bone bruising.  A bucket handle tear typically occurs only with multiple giving way episodes

7 Examination Findings  Must examine both knees. Large variation laxity  Fixed flexion deformity, reduced flexion

8 ACL Examination  Lachmann - anterior translation tibia

9 ACL Examination  Lachmann – Big leg, small hands

10 ACL Examination Anterior drawer decreased by posterior horn of the menisci – less positive than Lachmann

11 ACL Examination   Pivot shift test- reproduces the sensation of giving way. Lateral compartment subluxes

12 Exclude PCL Injury  Drop back seen with knee at 90°  Compare with other side

13 PCL Examination  Posterior drawer

14 Meniscal Tear  Mechanism of Injury Typically a twisting injury on a loaded knee Often sudden pain Knee swells – variable time frame Mechanical symptoms – catching, locking

15 Examination Findin gs   Effusion   Springy block to extension if bucket handle   Point joint line tenderness   Pain on meniscal grinding   Pain on loading and twisting the knee

16 Effusion Tense effusion is easily seen, Moderate effusion – patella tap Mild effusion - patella sweep

17 Meniscal Grind Test

18 Locked knee  Physical block  In young patient needs urgent meniscal repair  Don’t send to physiotherapist Urgent referral to orthopaedic surgeon We will see the patient that week

19 What X Ray’s Should I take  Weight bearing AP  45º weight bearing PA  Lateral  Skyline  AP Pelvis if unsure about hip

20 Weight bearing X Rays  Weight bearing X rays are critical

21 45° Weightbearing PA

22 Skyline patella

23 Treatment Options for Early OA Knee  Non surgical treatment  Arthroscopy  High Tibial Osteotomy

24 Non Surgical Treatment  Analgesics & Anti – inflammatories  Glucosamine & Chondrotin Sulphate – variable response  Intra-articular steroid – short term benefit – Cochrane 1 week Accelerates cartilage degeneration  Viscosupplementation – controversial  Knee Sleeve  Exercise – low impact – exercycle If the knee is painful and swollen. Stop it  Physiotherapy – maximize muscle strengthening  Orthotics

25 Early OA and Arthroscopy  Arthroscopic debridement and lavage has unpredictable results thus is not indicated  If a symptomatic meniscal tear with pain and mechanical symptoms worthwhile however must caution the patient that the knee will not be normal due to OA

26 Proposed ACC Guidelines  Clear history of injury  Signs and symptoms of a meniscal tear  Less than 50% joint loss on weight bearing X rays  Full thickness chondral lesions on MRI excluded

27 High Tibial Osteotomy  Indicated for younger patient with varus knee with medial compartment OA

28 High Tibial Osteotomy  Two hour operation, 2-3 days in hospital  Six weeks on crutches with a brace  Three – six month recovery  Knee better - not normal  VAS pain 7.1  2.6 at 5 years  Sydney study – 84% survival at 15 years  186 cases last 12 years – 4 converted to TKA

29 Total Knee Arthroplasty  Perception in the community  Only lasts 10 years  Very painful operation and the knee will continue to be painful  Doesn’t work that well.  Knee will be stiff

30 TKA Survival  National registries New Zealand 96% at 10 years Australia 92% at 8 years Swedish 95% at 10 years Norwegian 88% at 12 year s  Expert Designer Series 92% at 16 years 93% at 15 years 87% at 18 years  > 60 years > 90% implant will last life time

31 Survival – Age at TKA

32 Activity level & Pain  Younger patient more active thus higher failure rate  TKA is designed for every day activity Walking, golf, tramping, groomed skiing, doubles tennis  TKA is not designed for impact loading activities – running, jumping, dancing, singles tennis  The knee will be painful, swollen, warm and stiff for up to 6 months. Must take pain medication  TKJR will get rid of most but not necessarily all of the pain. VAS pain – 6.8  1.0 – 60% no pain

33 Improving Outcome  Computer Guided TKA  Enables the surgeon to:  Ensure accurate alignment – enhancing implant survival  Balance the ligaments to ensure good kinematics  Customize the TKA to patients anatomy & ligamentous laxity  Mobile Bearing TKA  RCT showed better knee function  Less wear in lab

34 NZ Joint Registry Oxford 6 months Score3738.340.3 Poor12.4%10.0%0% Fair16.3%12.4%6.8% Good35.4%37.5%30.3% Excellent35.9%40.1%62.8%

35 Oxford Score Significance  Statistically significant relationship between 6 month Oxford score and revision rate  Every 1 unit decrease in Oxford score increases the revision rate at 2 years by 10.4%  A patient with a score 36  ROC (Receiver operating characteristic) analysis demonstrates 31

36 Oxford Score & Revision Rate Poor Fair Good Excellent

37 NZ Joint Registry Oxford 6 months Score3738.340.3 Poor12.4%10.0%0% Fair16.3%12.4%6.8% Good35.4%37.5%30.3% Excellent35.9%40.1%62.8%

38 Range of Motion - Stiffness Pre-OperativePost-Operative Overall110°118° <90°+45° 90° - 125°+6° >125°-11°

39 Complications  Infection - Hot, painful, swollen, stiff knee - Wound may be oozing - Patient will often report a sudden increase in pain and decrease in movement - If in doubt refer back to operative surgeon - Don’t start antibiotics unless you are sure it is a superficial stitch abscess  DVT - Hot, tense painful calf - If in doubt refer for ultrasound

40 Websites  www.aucklandboneandjoint.co.nz www.aucklandboneandjoint.co.nz Tonight’s talks available on website  www.markclatworthy.co.nz www.markclatworthy.co.nz All my information sheets, pre and post op instructions, surgical videos and comprehensive information on knee conditions and treatment


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