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– 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

►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 patientFire 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

Acute knee injury

►Physiotherapy– 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– Meniscal tears

►Recovery pattern►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– ACL tears

►Recovery pattern►2-3 weeks acute knee pain/ swelling►Episodic knee instability►Post-operative►4 weeks sedentary work►12 – 24 weeks manual work

Treatment

1. Post traumatic knee pain should be referred early for a specialist opinion.

2. Early MRI scanning is cost effective.

Take home message

Knee pain

OSTEOARTHRITIS

Disabling symptoms10% of over 55’s

Predisposing factorsAge > 50 yearsGeneticFemale sexKnee injuryObesityOccupational factors

Knee pain

OSTEOARTHRITIS

Occupational factorsHeavy manual work

Farming, mining

Heavy liftingKnee bendingKneeling/ squatting/ crawling

Affect both onset and progression

1. Post traumatic knee pain should be referred early for a specialist opinion.

2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients

(obese, female, family history).

Take home message

Surgical treatment

Severity of diseaseExtent of diseaseSuccess rateMorbidity LongevitySubsequent total knee replacement

• More difficult• Outcome

ArthroscopyArthroplastyOsteotomy

Early OAPain relief in 65 - 80%Lasts up to 1 yearSwift recovery

Day surgery – immediate FWBDrive - 10 daysOffice work - 2 weeksManual work 4 – 6 weeks

Subsequent TKR unaffected

Arthroscopy

Low complication rate10 262 arthroscopies 1.68%.*

Minimally invasiveRepeatableWell accepted??Necessary!!

• *Small NC. Arthroscopy 1998;4:215-21.

Arthroscopy

Arthroscopy

A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

180 patientsArthroscopy vs placebo surgery24 month follow up

PainFunction

J. Bruce Moseley et alHouston Veterans Affairs Medical Center

NEJM 2002

Early OAMechanical symptoms– Meniscectomy– Loose bodies

Normal limb alignmentModerate x-ray changes

Arthroscopy

1. Post traumatic knee pain should be referred early for a specialist opinion.

2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients

(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.

Take home message

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

0

10

20

30

40

50

60

70

80

12 8 0-4 -4 -8

Valgus angle

% clinicalsuccess

Upper tibial osteotomy (HTO)

• Results

0102030405060708090

100

2 3 4 5 6 7 8 9 10 11

Years since surgery

% clinicalsuccess

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 morbidityFracture healing

Long recovery period PWB for 6 weeks Full recovery 12 months

1. Post traumatic knee pain should be referred early for a specialist opinion.

2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients

(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.5. Recovery after HTO is prolonged.6. Young males are the ideal cadidates for HTO.

Take home message

Total knee replacement

Total knee replacement

Treatment of choice for end stage OA

Improved:Prosthesis InstrumentationUnderstanding of knee biomechanics

Surgical technique

Total knee replacement

Excellent survivorship

Reproducible results

Trend to earlier surgery

Informed consent

Total knee replacement

1 2 3 4 5 6 7 8 9 100

5

10

151987

2000

Years since surgery

% r

evis

ed

Swedish Knee Arthroplasty Register 2011

Total knee replacement

• DisallowedContact sports, jogging, running,

high impact aerobics, power lifting

• CautionVigorous hiking, skiing, tennis,

repetitive lifting > 50lbs, repetitive stairs

• PermittedWalking, swimming, golf, driving,

cycling, ballroom dancing

Total knee replacement

RecoveryInpatient 4 daysMobile with elbow crutchesNo walking aids at 4 – 6 weeks85% of muscle strength at 3 monthsFull recovery 12 months

Total knee replacement

FunctionROM 0 – 110 degreesSedentary work Impact activityProlonged standingHeavy manual jobs

Total knee replacement

Return to workDriving 4 weeks

(no walking aids)

Sedentary work 6 weeksManual work 12 weeks

Phased returnAltered dutiesHeavy liftingRestraint

Total knee replacement

Pre-op 1 yr post-op 2 yrs post-op

Little difficulty 3% 15% 20%

Very difficult 82% 58% 56%

1. Post traumatic knee pain should be referred early for a specialist opinion.

2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients

(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.5. Recovery after HTO is prolonged.6. Young males are the ideal cadidates for HTO.7. Total knee replacement is the treatment of choice for end

stage OA knee.8. Heavy manual work is a problem after TKR.

Take home message

1. Post traumatic knee pain should be referred early for a specialist opinion.

2. Early MRI scanning is cost effective.3. In high risk occupations, look specifically at high risk patients

(obese, female, family history).4. There is a narrow indication for arthroscopy in osteoarthritis.5. Recovery after HTO is prolonged.6. Young males are the ideal cadidates for HTO.7. Total knee replacement is the treatment of choice for end

stage OA knee.8. Heavy manual work is a problem after TKR.

Take home message