4. Common myths
All knee injuries have meniscal tear
All knee pain in adults is due to OA
Knee problems do not have curative treatment
All knee problems require surgery
5. Prevalence of Knee Pain
(Croft et al, 1998)
7,500
• Knee pain, some disability & X-ray OA
12,500
• Knee pain with some disability
25,000
• 4 weeks of knee pain in past year
• Knee pain, severe disability & X-ray OA 2,000
100,000
• Subjects aged 55 years+
2%
6. Knee pain can be caused by pain referred from the
hip and spine
Easy to differentiate as knee motion rarely
aggravates referred pain
If examination of knee is normal. Test hip and ankle
to identify referred pain
INTRINSIC V/S EXTRINSIC
7. Intra-articular
• Structural defect or an inflammatory process
• Patient experiences discomfort within knee
• Often chronic effusion & diffuse tenderness
Peri-articular
•Pain localize d to a specific area around the knee
•Specific examination maneuvers
(direct palpation, valgus or varus stress) to elicit a focal
pain at the involved structure
Intra-articular v/s Peri-articular
8. Intra-articular Knee Pain:
Inflammatory v/s Structural
Structural (e.g. Meniscal tear, ACL tear)
Pain is usually provoked by activity and is
absent at rest
Inflammatory (e.g Arthritis, Synovitis)
Pain with activity AND at rest
Often presents with joint effusion and fluid
analysis is needed by aspiration of the effusion
9. Focused History (Questions)
Mechanism of Injury –
helps predict injured structure
Contact or noncontact injury?*
If contact, what part of the knee was
contacted?
Anterior blow?
Valgus force?
Varus force?
Was foot of affected knee planted
on the ground?**
9
10. Focused History Questions3
Injury-Associated Events*
Pop heard or felt?
Swelling after injury (immediate vs delayed)
Catching / Locking
Buckling / Instability (“giving way”)
10
11. Focused History Questions5
Aggravating Factors
Activities, changing positions, stairs, kneeling
Relieving Factors/treatments tried
Ice, medications, crutches
History of previous knee injury or surgery
11
12. Chronic Onset (Questions I ask)
How long?
What were you doing when pain first noticed
Prior injuries
Pain all the time or come and go
Swelling
Mechanical symptoms
What makes it better / worse (Theatre sign)
Treatments? (Rehab, bracing, meds)
13. Physical Exam - General
Develop a standard routine
Alleviate the patient's fears
GENERAL STEPS
Inspection
Palpation
Range of motion
Strength testing
Special tests
13
15. Value of MRI?
When should an MRI be done?
When knowledge of location of injury might
influence treatment
When additional injury is suspected
Instability at full extension should increase suspicion of cruciate
injury
Mazzocca, A.D., et al., Valgus medial collateral ligament rupture
causes concomitant loading and damage of the anterior cruciate
ligament.
J Knee Surg, 2003. 16(3): p. 148-51.
22. ACL INJURY
Signs and Sx
- Hear or feel a pop
- Rapid effusion
- Buckling of the knee
- Guarding will occur quickly
so special tests need to be
done within 5 minutes of
injury
24. Septic arthritis
More common in immune
compromised
Abrupt onset of pain
Warm, swollen, and
exquisitely tender
MINIMAL motion causes
INTENSE pain
Arthrocentesis
-WBC > 50,000/mm3
- Gram stain – Staph, Strep,
Gonorrhea
Blood – Elevated WBC, ESR,
CRP
25. Crystal induced inflammatory
arthropathy
Gout – Sodium urate
crystals precipitate and
cause inflammatory
response
Pseudogout – Calcium
pyrophosphate
PE – Red, warm, swollen,
tender
Arthrocentesis
WBC – 2,000 to 75,000 per
mm3
Protein – high (>32g/dL)
Glucose – 75% of serum
26. Popliteal cyst (Baker’s cyst)
Mild to moderate pain in
popliteal area
The most common synovial
cyst
Usually a response to preceding
trauma
Posteromedial aspect at the
level of the
gastrocnemiosemimembranous
bursa
Palpable fullness
posteromedially
McMurray test may be positive
27. Patellofemoral syndrome
(Chondromalacia)
The most common diagnosis
in outpatients presenting with
knee pain
Anterior pain - mild to
moderate severity
“Theater sign”
Poorly localized “Circle sign”
“Knee giving way”
29. Osteoarthritis is the most common form of
arthritis
Rheumatoid arthritis
Post-traumatic
arthritis
Inflammatory
arthritis
Septic arthritis
All result in loss of joint
cartilage
30. The Knee and Osteoarthritis
Most common joint affected
by osteoarthritis
Large weight-bearing joint
Complex motion pattern
Common site of injury
31. Osteoarthritis
Aggravated by weight
bearing and relieved by
rest
No systemic symptoms,
morning stiffness
Episodes of acute synovitis
PE reveals decreased
ROM, crepitus, mild joint
effusion, possibly palpable
osteophytes
35. The Issue
80% of people over 70 years suffer from
Knee Osteoarthritis (OA)
80% of patients with Knee OA have some degree of
limitation of movement, and 25% cannot perform their
daily activities
Patients with Knee OA experience decrease in quality of life
37. Facts
RA affects 1% of adult Indian population
Affect females 4-5 times more (30-40yrs)
Autoimmune systemic disorder
Characterized by joint erosion and destruction
RA follows a chronic course and results in shorter life
span (10-15 yrs)
38. Why is this problem more prevalent
in India?
Squatting / Ground sitting habits
Climbing stairs
Indian Toilets
Obesity
Complicated patients
Heredity
Can we prevent Osteoarthritis?
39. Paracetamol
the drug of choice
lower incidence of side effects
Aspirin and Other NSAIDs
if patients do not respond to paracetamol
gastrointestinal complications
Cox-2 Inhibitors
low incidences of side effects, well tolerated
Nutraceticals: Glucosamine/Chondroitin
Drugs
40. Side effects of NSAIDs
GI Toxicity
Renal toxicity
Cardiac events
Strokes
41. Hyaluronic Acid
Viscosupplementation – Long-term experience in
veterinary use
Maintain correct enzyme balance, preventing
excessive cartilage breakdown
Actions
restores lubrication and shock absorbing properties
anti-inflammatory
normalisation of hyaluron synthesis
Intra-articular Injection
42. The Orthopaedic Specialist
When conservative
treatments no longer resolve
activity limiting pain caused
by osteoarthritis then . . .
Surgical and reconstructive
treatments may be
appropriate
43. Surgical Options for Knee Arthritis
Arthroscopy
debridement,
meniscectomy,
chondroplasty
Osteotomy
bone re-alignment
Arthroplasty
joint replacement
44. Arthroscopic Debridement
“clean out” or “scrape bone”
Somewhat unpredictable
results
50 to 66 percent get relief
for some period of time
Best for patients with
mechanical symptoms
(catching, locking and
giving out)
45. Knee Osteotomy
Re-align weight-bearing axis through “good” cartilage
Most popular before success of
contemporary knee
replacement
Useful for patients too young,
heavy or active for knee
implants
Early results acceptable,
questionable durability
46. End-Stage Osteoarthritis
Knee Replacement
“Gold Standard of Care”
Uni-compartmental Knee Replacement
“Uni,” “partial replacement” or UKR
Tri-compartmental Knee Replacement
“total replacement” or TKR
48. Total Joint Replacement
(Myths)
TKR is not a successful operation
PM’s operation was not successful
It is an expensive operation
Body may not accept it
Change in life style necessary
Life of artificial joints is short
One may not be able to walk again!
49. Present & Past TKRs
PAST PRESENT
Operating time 4-6 hours 1 hour
Recovery time 3-6 months 1 month
Blood transfusion 3-4 units 1unit
Pain Moderate to severe Minimal
Range of motion 90 degrees 120-145 degrees
Permitted ADL Major restrictions Mostly allowed
Incision length 20-25 cms 10 cms
Hospital stay 15-20 days 4-5 days
Life span 8-10 years 20-25 years
50. Newer Joint Replacements
Artificial components are made of stronger, more
durable materials & more customized designs
Can be implanted using MIS
Recovery time is shorter
Outcomes are vastly improved
