Management of knee problems in General Practice

1. 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 EASY
GP TALK AT NEWCASTLE NUFFIELD HOSPITAL

2. 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

3. Prof Deiary Kader
1. Arthritis
2. Meniscus
3. Ligament (ACL, PCL, MCL)
4. Patellofemoral
5. Red Flag
◦ Fracture
◦ Infection
◦ Tumour

4. Prof Deiary Kader
History
Pain
 Duration
 Onset
 Type
Give way
Stair problems
Trauma
Examination
Tenderness
Osteophytes
Effusion
Drawer test
5 Min Knee Consultation

5. Prof Deiary Kader
1
Red Flags
2
OA
3
Meniscus
4
Ligaments
5
Patella
History Rest pain
Tumor
Trauma
Fracture
Fever
Infection
Dull pain
Toothache
Sharp pain
Locking
Giveway Stairs
Rising from
a chair
Examination General
tenderness
Fixed flexion
osteophytes
Tender joint
line
Effusion
Drawer test
Lachman
Grinding
Short Knee Consultation

6. Prof Deiary Kader
Pain Duration 2-4 wks
Conservative
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

7. Prof Deiary Kader
1. Arthritis
2. Meniscus
3. Ligament (ACL, PCL, MCL)
4. Patellofemoral
5. Red Flag
◦ Fracture
◦ Infection
◦ Tumour

8. Prof Deiary Kader

9. 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

10. Microfracture
Operative treatment
Chondral Damage treated
with Microfracture

11. Prof Deiary Kader
Autologous Cartilage Implantation

12. Prof Deiary Kader
Open or close
wedge Osteotomy

13. Prof Deiary Kader
When to offer joint replacement
The pain should be significant and disabling.
Night pain is particularly distressing

14. Prof Deiary Kader
MENISCAL RESECTION & REPAIR

15. Prof Deiary Kader
History Meniscal Injury
 Acute event
 Delayed swelling
 Effusion….. Swelling after exercise
 Pain
 Catching
 Locking

16. Prof Deiary Kader
Meniscal Tear
Management :-
 Excision
 60% of people over 65yrs have incidental tears
 Repair
 Transplant
 Replacement

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POSTGRADORTH Deiary Kader
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20. 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

21. Prof Deiary Kader
ACL Injuries
FRCS(Tr&Orth) Revision Course

22. Prof Deiary Kader
Valgus + ER
POP

23. Prof Deiary Kader
Non-Operative Treatment
 Activity modification
(swimming, bicycling,
jogging on flat ground)
 Muscle Training
(Hamstrings strength)
 Proprioceptive Training
 Bracing (reduce anterior
drawer)

24. Prof Deiary Kader
Surgical Treatment
Indications:
 Subjective instability (non-coper)
 In children and adolescents
 Multiligament injury

25. Prof Deiary Kader
Intra-articular ACL Reconstruction

26. Prof Deiary Kader
Hamstring
BTB
Grafts / Fixations
Quads

27. Prof Deiary Kader
ANTEROLATERAL LIGAMENT
ALL

28. Prof Deiary Kader
OPEN ALL Recon

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MCL

30. 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

31. Prof Deiary Kader
Treatment
Acute 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

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Posterior Cruciate Ligament

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PCL Reconstruction

36. Prof Deiary Kader
PATELLA CLINIC
Evidence based intervention
History and outcome measures
Lysholm ,Oxford, Kujala Scores
Clinical examination
Imaging

37. Prof Deiary Kader
Instability
can be easier to treat
Pain
primary or secondary

38. Prof Deiary Kader
Patellar Dislocation
 Re-dislocation rate
 First Time 17-20%
 Second Time 44%-71%
 High dissatisfaction following conservative Rx

39. Prof Deiary Kader
Med Epicondyle
Add Tubercle
Patella
MPFL

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Bony Tunnel

42. Prof Deiary Kader
1.4 cm
Patella alta

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46. Prof Deiary Kader
Kurdistan/Iraq
Thank you