Knee Problems ?

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Knee Problems ?

• Sam Rajaratnam
• Consultant Orthopaedic Surgeon
• Eastbourne DGH,
• Horder Centre,
• Esperance Hospital, Eastbourne

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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

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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

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Serious
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Curable

• Arthritis
• Instability
• Cartilage tears
• Intra-articular pain

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Things that may be treated conservatively

• Chondromalacia patellae
• Tendinosis
• Bakers cysts

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X-Ray or MRI

• Xrays Much more useful for Osteoarthritis
  (probably avoid Primary care MRIs)
• MRI - useful for Meniscal tears or ligament
  injuries

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MRI - Meniscal tears
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Meniscal Repair vs Resection
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Meniscal Repair
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Xrays Much better for arthritis(Antero-medial
wear Most common pattern (60 ) . Very Painful)
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Isolated patello-femoral wear

• Pain on walking up down stairs
• No problem walking on flat ground
• Patella can lock or catch
• Knee giving way

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Lateral Osteoarthritis

• Knee Gives way
• Knock Knee
• Deformity can progress rapidly
• Often required total knee replacement
• (remember disease of flexor surface)

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TKRs vs Partials
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Computerised Jigs
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Rapid recovery programme
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Young arthritis options available
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Cartilage surface defects

• MRI Poor at diagnosing these
• Look for articular surface tenderness effusion

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3. Diagnose Acute Ligament Injuries

• MCL
• ACL
• PCL
• MPFL

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Reminder - Acutely injured knee

• Intra-articular injuries present with pain and
  swelling
• Extra-articular ligament injuries present with
  pain

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MCL Injury

• Tenderness, stress testing
• Grade I
• Local tendernessslight or no laxity
• Grade 2
• Local tendernesslaxity with endpoint.
• Grade 3
• Complete rupture
• No endpoint.

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Curable - if braced early
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ACL

• History
• running (high velocity)
• change of speed and direction
• snap or pop
• pain
• immediate swelling (lt4hours)
• 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

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ACL testing
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Arthroscopic View

• Torn ACL

• POST RECONSTRUCTION

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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

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P.C.L
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Multi-ligament injury
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4. Patella Dislocation - MPFL

• Traumatic
• May heal
• May require MPFL Repair
• Spontaneous
• Bad bony alignment
• Soft Tissue laxity

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MPFL Rupture
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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

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MACI ACI
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Osteochondral grafting
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Microfracture
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Chondro-tissue
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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..

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Thank you Any Questions ?

• Sam Rajaratnam
• Consultant Orthopaedic Surgeon
• Eastbourne DGH
• Horder Centre,
• Esperance Hospital, Eastbourne