The Knee Andrew Pearse Consultant Trauma and Orthopaedics

The Knee Andrew Pearse Consultant Trauma and Orthopaedics Worcestershire Acute Hospitals NHS Trust

Introduction • • • Brief anatomy and topography History & examination Osteoarthritis Investigations Referral Oxford Knee Score Primary Care Management

Anatomy • Complex hinge joint • Tibio-femoral articulation – Medial – Lateral Cruciates • Patello-femoral articulation • Function depends on interaction of – Articular and meniscal cartilages – Cruciate ligaments Primary Care Management

Knee Topography Quads tendon Suprapatellar pouch Patella Medial joint line Patellar tendon Tibial tuberosity Primary Care Management

History • Pain – Where? • Mechanical symptoms – Giving way – True locking • Anteriorly - PFJ • Medial or lateral • History of trauma – When? – Twisting • Walking – Contact / non-contact • At rest – Swelling • Immediate - haemarthrosis • At night • Stiffness • Swelling • Next day - effusion Primary Care Management

Examination • LOOK • FEEL • MOVE • Special tests - eg Lachman Primary Care Management

Examination • LOOK – – – – Get them to STAND UP & WALK Limp Use of a stick (same side) Effusion Varus (bow-legged) Valgus (knock-kneed) Fixed flexion deformity Muscle wasting - quads Primary Care Management

Examination • FEEL – Effusion – Joint line – medial and lateral – Patellar tendon • Patella insertion • Tibial tuberosity – Point tenderness Primary Care Management

Examination • MOVE – Rough ROM – Crepitus – Ligament instability – Tests like Mc. Murray’s are often inaccurate and not particularly helpful Primary Care Management

Osteoarthritis Of The Knee Primary Care Management

Knee OA – The Patient • History – Pain • ? waking at night – Limited walking distances • Up slopes / stairs • On the flat – Walking aids – Analgesic requirements – Groin pain (NB OA hip causes knee pain) Primary Care Management

Knee OA – The Patient • LOOK – Limp – Deformity – • varus or valgus • FEEL – Swelling – Tender joint line • MOVE – Limited ROM – Crepitus – Correctable deformity Primary Care Management

Management • XR knee – AP weight-bearing / lateral • Bloods – inflammatory markers • Review analgesia • Walking aids Primary Care Management

Clinical Knowledge Summary Non-drug treatment recommendations Braces? Physio? Weight loss? Use of walking aids? TENS? Yes – valgus braces Yes – exercises and taping – irrespective of age Yes for BMI > 28 Yes Primary Care Management

Clinical Knowledge Summary • Corticosteroid injections – Short-term (2 to 4 week) relief – No long term benefit over other treatments (e. g. physio) • Hyaluronase injections – Some mild benefit – NICE not recommended www. cks. library. nhs. uk Primary Care Management

Referral • According to CKS: “Refer if person’s joint symptoms have a substantial impact on their quality of life and are refractory to non -surgical treatment” • • Pain waking from sleep Ineffective analgesia DO THEY WANT SURGERY? Oxford knee score… Primary Care Management

Oxford Knee Score • • 12 -point questionnaire Patient-assessed Valid and reliable Score 0 -48 – 0 -19 severe OA – 20 -29 moderate to severe OA – 30 -39 mild to moderate OA – 40 -48 satisfactory joint function Primary Care Management

Oxford Knee Score • NHSW Commissioning policy: “… less than 30 has been identified as an indicator for possible surgery. . . this is only a guide…if considered clinically necessary onward referral with a score of more than 30 will be accepted” • Evidence for referral? • Previous use: – Derby (refer if OKS < 24 + other factors) – Avon • Lots of post-TKR evidence Primary Care Management

Summary • Anatomy • Examination – Look, feel, move • Osteoarthritis • Treatments • Oxford Knee Score Primary Care Management