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

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

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

Serious

Curable Arthritis Instability Cartilage tears Intra-articular pain

Things that may be treated conservatively Chondromalacia patellae Tendinosis Bakers cysts

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

MRI - Meniscal tears

Meniscal Repair vs Resection

Meniscal Repair

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

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

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

TKR’s vs Partials

Computerised Jigs

Rapid recovery programme

Young arthritis – options available

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

3. Diagnose Acute Ligament Injuries MCL ACL PCL MPFL

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

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.

Curable - if braced early

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

ACL testing

Arthroscopic View Torn ACL POST RECONSTRUCTION

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

P.C.L

Multi-ligament injury

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

MPFL Rupture

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

MACI & ACI

Osteochondral grafting

Microfracture

Chondro-tissue

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…..

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