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

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

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

4. 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

5. 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

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

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

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

9. 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

10. 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

11. 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

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

13. 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

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

15. 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).

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

17. 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

18. Arthroscopy Low complication rate Minimally invasive Repeatable
arthroscopies 1.68%.*
Minimally invasive
Repeatable
Well accepted
??Necessary!!
*Small NC. Arthroscopy 1998;4:

19. 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

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

21. 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.

22. 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

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

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

25. Upper tibial osteotomy (HTO)
Results

26. Upper tibial osteotomy (HTO)
Results

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

28. 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

29. 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.

30. Total knee replacement

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

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

33. Total knee replacement
Swedish Knee Arthroplasty Register 2011

34. 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

35. 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

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

37. Total knee replacement
Return to work
Driving weeks
(no walking aids)
Sedentary work 6 weeks
Manual work weeks
Phased return
Altered duties
Heavy lifting
Restraint

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

39. 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.

40. 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.