the knee consultation made easy for gp doctors (nuffield/ newcastle)

Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle

www.oasir.co.uk

Knee Surgeon, Nuffield Hospital, Newcastle upon Tyne

THE KNEE CONSULTATION MADE EASYGP TALK AT NEWCASTLE NUFFIELD HOSPITAL

Prof Deiary Kader

Arthroplasty Primary TKR Revision TKR Uni Knee Patellofemoral

Open Surgery Osteotomy (HTO) Chondroplasty Patella

Stabilisation

Arthroscopy Meniscal Excision Meniscal Repair Microfracture ACL reconstruction Revision ACL PCL reconstruction Multiple Ligament

Recon

Prof Deiary Kader

1. Arthritis2. Meniscus 3. Ligament (ACL, PCL, MCL)4. Patellofemoral5. Red Flag

◦ Fracture◦ Infection◦ Tumour

Prof Deiary Kader

HistoryPain Duration Onset Type

Give wayStair problemsTrauma

ExaminationTendernessOsteophytesEffusionDrawer test

5 Min Knee Consultation

Prof Deiary Kader

1Red Flags

2OA

3Meniscus

4Ligaments

5Patella

History Rest painTumorTrauma FractureFeverInfection

Dull painToothache

Sharp painLocking

Giveway StairsRising from a chair

Examination

General tenderness

Fixed flexionosteophytes

Tender joint lineEffusion

Drawer testLachman

Grinding

Short Knee Consultation

Prof Deiary Kader

Pain Duration

2-4 wksConservative

Onset Rest (Red Flag)

Mechanical(OA or Instability)

Type Dull(OA)

Sharp(Meniscal tear)

Give way 1-Ligaments 2-Patella Instability

Stairs Patellofemoral dysfunction

Short Knee Consultation

Prof Deiary Kader

1. Arthritis2. Meniscus 3. Ligament (ACL, PCL, MCL)4. Patellofemoral5. Red Flag

◦ Fracture◦ Infection◦ Tumour

Prof Deiary Kader

Prof Deiary Kader

OA Nonoperative treatment

Weight loss Exercise Patient education Analgesia, (NSAIDs) Bracing rarely

Intra-articular (IA) injections. Cochrane reviews

Steroids (better than placebo but not longer than 4wks

HA more prolonged effect than steriods

Microfracture

Operative treatment

Chondral Damage treated with Microfracture

Prof Deiary Kader

Autologous Cartilage Implantation

Prof Deiary Kader

Open or close wedge Osteotomy

Prof Deiary Kader

When to offer joint replacement

The pain should be significant and disabling. Night pain is particularly distressing

Prof Deiary Kader

MENISCAL RESECTION & REPAIR

Prof Deiary Kader

History Meniscal Injury Acute event Delayed swelling Effusion….. Swelling after exercise Pain Catching Locking

Prof Deiary Kader

Meniscal Tear Management :-

Excision 60% of people over 65yrs have

incidental tears

Repair

Transplant

Replacement

Prof Deiary Kader

Prof Deiary Kader

Prof Deiary KaderPOSTGRADORTH Deiary Kader

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Prof Deiary Kader

Menx Allograft Indications

Physiologically young and active Symptomatic (in the future ??prophylactically) Neutral alignment Normal stability No more than grade II-III Cartilage damage Understand the risk of disease transmission Post operative compliance & expectation No knee abuser and Not in BMI >35

Prof Deiary Kader

ACL InjuriesFRCS(Tr&Orth) Revision Course

Prof Deiary Kader

Valgus + ER

POP

Prof Deiary Kader

Non-Operative Treatment

Activity modification (swimming, bicycling, jogging on flat ground)

Muscle Training (Hamstrings strength)

Proprioceptive Training

Bracing (reduce anterior drawer)

Prof Deiary Kader

Surgical Treatment

Indications:

Subjective instability (non-coper)

In children and adolescents

Multiligament injury

Prof Deiary Kader

Intra-articular ACL Reconstruction

Prof Deiary Kader

HamstringBTB

Grafts / Fixations

Quads

Prof Deiary Kader

ANTEROLATERAL LIGAMENT

ALL

Prof Deiary Kader

OPEN ALL Recon

Prof Deiary Kader

MCL

Prof Deiary Kader

Medial Collateral Ligament Exam

Opening @ 30o only

Isolated MCL Injury Opening @ 0o

Injury to Posteromedial Capsule

Usually with ACL +/or PCL injury

Prof Deiary Kader

TreatmentAcute isolated MCL tear

I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks

II Hinged brace, WBAA, 2-3weeks

III Hinged brace 30-90/ Surgical 3-4 wks

Operative treatment depend on site and patient

Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch therefore needs Augmentation with semitendinosis

Combined injury ACL and MCL→Reconstruction ACL and non-operative treatment MCL I-II but surgical for III  

MCL

Prof Deiary Kader

Posterior Cruciate Ligament

Prof Deiary Kader

Prof Deiary Kader

35

PCL Reconstruction

Prof Deiary Kader

PATELLA CLINIC Evidence based intervention

History and outcome measuresLysholm ,Oxford, Kujala ScoresClinical examinationImaging

Prof Deiary Kader

Instability can be easier to treat

Pain primary or secondary

Prof Deiary Kader

Patellar Dislocation

Re-dislocation rate

First Time 17-20%

Second Time 44%-71%

High dissatisfaction following conservative Rx

Prof Deiary Kader

Med Epicondyle

Add Tubercle

Patella

MPFL

Prof Deiary Kader

Prof Deiary Kader

Bony Tunnel

Prof Deiary Kader

1.4 cm

Patella alta

Prof Deiary Kader

Prof Deiary Kader

Prof Deiary Kader

Prof Deiary Kader

Kurdistan/Iraq

Thank you