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

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

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

Knee injury service Started November 2001 3 times weekly Improve access to treatment No prior history Definite traumatic event Conservative treatment Persisting disability Referral source A&E Physiotherapy Consultant GP

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

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

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

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

Treatment Physiotherapy Recovery pattern 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 Arthroscopy Recovery pattern Meniscal tears 2-3 weeks acute knee pain/ swelling Episodic knee pain Post-operative 2-4 weeks sedentary work 4-6 weeks manual work

Treatment Ligament reconstruction Recovery pattern ACL tears 2-3 weeks acute knee pain/ swelling Episodic knee instability Post-operative 4 weeks sedentary work 12 – 24 weeks manual work

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

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

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

Take home message Post traumatic knee pain should be referred early for a specialist opinion. Early MRI scanning is cost effective. In high risk occupations, look specifically at high risk patients (obese, female, family history).

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

Arthroscopy Early OA Pain relief in 65 - 80% 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 Low complication rate Minimally invasive Repeatable 10 262 arthroscopies 1.68%.* Minimally invasive Repeatable Well accepted ??Necessary!! *Small NC. Arthroscopy 1998;4:215-21.

Arthroscopy 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

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

Take home message Post traumatic knee pain should be referred early for a specialist opinion. Early MRI scanning is cost effective. In high risk occupations, look specifically at high risk patients (obese, female, family history). There is a narrow indication for arthroscopy in osteoarthritis.

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

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

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

Upper tibial osteotomy (HTO) Results

Upper tibial osteotomy (HTO) Results

Upper tibial osteotomy Obese patients perform poorly Coventry et al JBJS (Am), 1993;75:2, 196-201, ACL deficiency Holden et al JBJS (Am), 1988; 70:2, 977-982 Initial success is dependent on successful correction Approximately 40% need knee replacements within 10 years

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

Take home message Post traumatic knee pain should be referred early for a specialist opinion. Early MRI scanning is cost effective. In high risk occupations, look specifically at high risk patients (obese, female, family history). There is a narrow indication for arthroscopy in osteoarthritis. Recovery after HTO is prolonged. Young males are the ideal cadidates for HTO.

Total knee replacement

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

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

Total knee replacement Swedish Knee Arthroplasty Register 2011

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

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

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

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

Total knee replacement Pre-op 1 yr post-op 2 yrs post-op Little difficulty 3% 15% 20% Very difficult 82% 58% 56%

Take home message Post traumatic knee pain should be referred early for a specialist opinion. Early MRI scanning is cost effective. In high risk occupations, look specifically at high risk patients (obese, female, family history). There is a narrow indication for arthroscopy in osteoarthritis. Recovery after HTO is prolonged. Young males are the ideal cadidates for HTO. Total knee replacement is the treatment of choice for end stage OA knee. Heavy manual work is a problem after TKR.

Take home message Post traumatic knee pain should be referred early for a specialist opinion. Early MRI scanning is cost effective. In high risk occupations, look specifically at high risk patients (obese, female, family history). There is a narrow indication for arthroscopy in osteoarthritis. Recovery after HTO is prolonged. Young males are the ideal cadidates for HTO. Total knee replacement is the treatment of choice for end stage OA knee. Heavy manual work is a problem after TKR.