Oh My Aching Knee. Oh My Aching Knee WHO AM I? 10/15/2012. Jan Pieter Hommen, MD Orthopedic Surgeon Sports Medicine Arthroscopy Joint Replacements

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1 Oh My Aching Knee Jan Pieter Hommen, MD Orthopedic Surgeon Sports Medicine Arthroscopy Joint Replacements Oh My Aching Knee Jan Pieter Hommen, MD Orthopedic Surgeon Sports Medicine Arthroscopy Joint Replacements WHO AM I? Private Practice Orthopedic Surgeon Baptist Hospital Office 101 East 1

2 WHO AM I? Born - Netherlands Grew up - Pittsburgh WHO AM I? Education: College Cornell University Medical School Cornell University Residency NYU-Hospital for Joint Diseases Fellowship Southern California Orthopedic Institute WHO AM I? FIU Clinical Assistant Professor Orthopedics 2

3 WHO AM I? Team Physician Professional Soccer College Athletics High School Athletics Outline GOALS: Knee Anatomy Knee Work Up Knee Pathology and Treatments When to Refer Knee Anatomy Compound Joint } 2 condyloid joints 1 sellar joint (patellofemoral) 3

4 Knee Anatomy Cartilage Ligaments Blood Supply Innervation Biomechanics Knee Anatomy Cartilage Different Types: Growth Plate Cartilage Fibrocartilage Elastic cartilage Fibroelastic Cartilage Articular Cartilage Knee Anatomy Cartilage Fibrocartilage Articular Cartilage 4

5 Knee Anatomy Fibrocartilage 40 50% Load in Extension 85% in Load in Flexion Knee Anatomy Blood Supply Innervation Knee Anatomy Anterior/Lateral/Medial L2-L4 L4 Femoral Nerve Posterior S1-S2 Sciatic Nerve 5

6 Knee Anatomy Biomechanics Joint Reactive Force Tibiofemoral 3x body weight walking 4x climbing Patellofemoral: 7 x squatting 2-3 x descending stairs Screw-Home Mechanism As knee Extends, the Tibia Externally rotates: Tightens collaterals Knee Anatomy Ligaments Cruciates PCL and ACL Collaterals Medial and Lateral Alignment Effusion Range of motion Range of motion Stability Gait Point of maximum tenderness 6

7 Alignment VARUS VALGUS Windswept Knee Alignment Patella Alignment 7

8 Patella Alignment Alignment Effusion Range of motion Stability Gait Point of maximum tenderness Effusion 8

9 Alignment Effusion Range of motion Stability Gait Point of maximum tenderness Range of Motion Alignment Effusion Range of motion Range of motion Stability Gait Point of maximum tenderness 9

10 Alignment Effusion Range of motion Stability Gait Point of maximum tenderness Alignment Effusion Range of motion Stability Gait Point of maximum tenderness Point of maximum tenderness 10

11 Rule out Referred Pain from Hip Specialty Tests Meniscus Thessaly McMurray Anterior Cruciate Ligament Lachman Pivot Shift Anterior Drawer Patella Q angle J sign Patella apprehension Patella Load Sensitivity Sensitivity & Specificity Probability of a positive test among patients with disease High sensitivity has lower false negatives Specificity Probability of a negative test among patients without disease High specificity has lower false positive 11

12 Meniscus Thessaly Test Sensitivity:» 89% medial meniscus» 90% lateral meniscus Specificity:» 97% medial meniscus» 96% lateral mensiscus Most Sensitive and Specific Meniscus McMurray Test Sensitivity:» 50% for pain» 16% if clunk or thud Specificity:» 98% for thud» 94% for pain Apley Meniscus Distraction & Compression Sensitivity:» 97% Specificity:» 87% Compression Distraction 12

13 ACL/PCL Anterior Drawer:» Sens: 41%» Spec: 95% Posterior Drawer: 90% 99% Anterior Drawer Posterior Drawer ACL Lachman» Sensitivity: 68 77%» Specificity: 50 94% Most Sensitive for Acute Injuries ACL Pivot Shift Test Anterior Drawer:» Sensitivity: 82%» Specificity: 98% Most Sensitive and Specific 13

14 Knee Adjunct Studies MRI Bone Scan X rays CT Knee Adjunct Studies X rays Generally 4 views: 1. A-P 2. Lateral 30 degree flexion 3. Sunrise degree weight bearing Knee Adjunct Studies X rays Generally 4 views: 1. A-P 2. Lateral 30 degree flexion 3. Sunrise degree weight bearing Rosenberg View 14

15 Knee Adjunct Studies X rays Knee Adjunct Studies X rays Knee Adjunct Studies X rays What to look for: Alignment Joint space Fractures Bone lesions 15

16 Knee Adjunct Studies X rays Alignment Joint space Fractures Bone lesions Knee Adjunct Studies X rays Alignment Joint space Fractures Bone lesions X rays Name That Injury Segund Fracture = ACL Tear 16

17 Knee Adjunct Studies X rays Alignment Joint space Fractures Bone or Soft Tissue lesions Chondrocalcinosis Knee Adjunct Studies MRI scan Open vs Closed MRI Scan Recommend: 1.5 Tesla scanner or higher Better for soft tissue than bone pathology CT scan Knee Adjunct Studies Fractures Loose body Mal-alignment of knee Better for bone than soft tissue pathology 17

18 Knee Adjunct Studies Ultrasound: Joint Effusion Meniscus Collateral Ligaments Cruciate Ligament Cyst Help guide Injection Bone Scan: Knee Adjunct Studies Rule out: Patellofemoral Arthritis Stress fracture Complex Regional Pain Syndrome Knee Pathologies Cartilage Tears Ligament Tears Fractures Avascular Necrosis Arthritis 18

19 Meniscus Tears Incidence: 61 per 100,000 One of most common causes for visits to orthopedist Meniscus Tear Meniscus Tears History Giving way Buckling Mechanical Exam X-rays MRI Meniscus Tear Meniscus Tears Treatment: Injections NSAIDs Therapy Surgery Bucket Handle Younger patient Locked knee Meniscus Tear 19

20 Meniscus Tears Treatment: Injections NSAIDs Therapy Surgery Bucket Handle Tear Younger patient Locked knee Repairable Tear Bucket Handle Tear Meniscus Tears Meniscus Repair Articular Cartilage Tears 20

21 Articular Cartilage Tears Microfracture Articular Cartilage Tears Cartilage Transplantation Articular Cartilage Tears Autologous Chondrocyte Implantation 21

22 Ligament Tears Ligament Tears Willis McGahee Ligament Tears Nearly 100,000 ACL reconstructions per year 22

23 Fractures Fractures Avascular Necrosis Incidence: Unkown Approx 10% of all cases Knee 23

24 Avascular Necrosis 2 Types: 1. SPONK 2. Secondary SPONK Secondary Avascular Necrosis CAUSES EtOH abuse Steroid use Sickle Cell Prior Trauma Infection Caissons Disease Medications Gaucher Disease After arthroscopy Avascular Necrosis Symptoms: Night time ti pain Weight bearing pain Stair climbing pain 24

25 Avascular Necrosis Microvascular Ischemia Normal Ischemic Avascular Necrosis Diagnosis: X rays MRI scan Bone scan Avascular Necrosis Treatment: Limit weight bearing NSAIDs Core Decompression Knee Replacement 25

26 Knee Arthritis 3 Main Types: 1. Osteoarthritis 2. Rheumatoid arthritis 3. Post traumatic arthritis Knee Arthritis Osteoarthritis: Most common Age related Progressive destruction Middle age and older Commonly affects one or two joints Knee Arthritis Post traumatic 26

27 Knee Arthritis Rheumatoid Arthritis 1.3 million (75% female) Progressive destruction Multiple joints, symmetric Inflammation of the lining of joint Body attacks own cartilage Juvenile Rheumatoid Arthritis (JRA) is particularly severe Arthritis Algorithm Nutrition & Weight Exercise & Physical Therapy Injections Neutriceuticals Medications WEIGHT LOSS Nutrition & Weight Weight plays key role in force on cartilage Some joints more than others Weight loss program is critical Nutritional causes or solutions for arthritis have not been proven 27

28 Exercise and Therapy Exercise & Physical Therapy Neutroceuticals Neutriceuticals Medications Nutrition & Weight Exercise & Physical Therapy Injections Neutriceuticals Medications 28

29 INJECTIONS Injections Corticosteroids INJECTIONS Injections Hyaluronic Acid INJECTIONS Which To Use Initially? Often Dictated by 3 rd Party Payor 29

30 INJECTIONS Hylan G F 20 Versus Cortisone Group 1: Hylan 3 injections Group 2: Cortisone with 2 nd at any time 6 Month Study No Difference Leopold et al J Bone Joint Surg. 2003;85A: INJECTIONS Effect Size Study 0.5 indicates Moderate Effect 0.58 Cortisone 0.60 HA Similar Zhang W et al. OARSI Osteoarthritis Cartilage. 2010;18(4): INJECTIONS Any Difference Between HA? Similar However higher molecular weight slightly better Reichenbach S, Blank S, Rutjes AW, et al. Arthritis Rheum. 2007;57(8): Berenbaum F, Grifka J, Cazzaniga S, et al. Ann Rheum Dis. 2012;doi: /annrheumdis

31 Failure Non-Surgical Treatments Neutriceuticals FAILED FAILED Exercise Medications FAILED SURGICAL OPTIONS Physical FAILEDTherapy Nutrition FAILED & Weight Surgical Options LIMITED Synovectomy Arthroscopy Osteotomy Cartilage Transfer CURATIVE Resection Fusion Selective Replacements Total Replacements Surgical Options LIMITED Osteotomy < 40 Male 31

32 Osteoarthritis Surgical Options CURATIVE Partial Replacements Surgical Options CURATIVE Total Replacements 32

33 Osteoarthritis Diagnosis: History: Gradual pain Possible acute on chronic Exam: Swollen Generalized pain Localized pain Osteoarthritis Diagnosis: X-rays: All patients with chronic knee pain or acute pain MRI scan: If x-rays normal or mild arthrosis Rule our occult fracture, AVN Aspiration: Rule out crystals or infection Osteoarthritis Treatment: My Personal Strategy NSAIDs: GI protection * Confirm with internist Physical Therapy: Very GENTLE- strengthening, ROM Weight Loss Program Aspiration/Injection: Cortisone Hyaluronic acid 33

34 Osteoarthritis Treatment: My Personal Strategy Surgery: If failed all of the above Total Knee Replacement Uni Knee Arthroscopy When to Refer Remember When to Refer Orthopedics is the practice of preventing and correcting musculoskeletal disorders We are NOT all about Cutting and Replacing 90% of my office is non-surgical treatment Don t be afraid to send 34

35 When to Refer What Can You Do? Primary Care MD - Gait Keeper Cost Containment Prelim diagnostic Work-up Try: NSAIDs Physical Therapy Weight Loss Injections Cane Thanks WEB: jph@drhommen.com CELL: