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10/15/2012
1
Oh – My Aching Knee
Orthopedic Surgeon
Jan Pieter Hommen, MDOrthopedic Surgeon
Sports MedicineArthroscopy
Joint Replacements
Oh – My Aching Knee
Orthopedic Surgeon
Jan Pieter Hommen, MD
Orthopedic SurgeonSports Medicine
ArthroscopyJoint Replacements
Private Practice Orthopedic Surgeon
Baptist Hospital Office 101 East
WHO AM I?
10/15/2012
2
Born - Netherlands
WHO AM I?
Born Netherlands
Grew up - Pittsburgh
Education:
College – Cornell University
WHO AM I?
Medical School – Cornell University
Residency – NYU-Hospital for Joint Diseases
Fellowship – Southern California Orthopedic Institute
FIU Clinical Assistant Professor
WHO AM I?
Orthopedics
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Team Physician
WHO AM I?
Professional Soccer
College Athletics
High School Athletics
Outline
GOALS:
• Knee Anatomy
• Knee Examination
• Knee Work Up
• Knee Pathology and Treatments
• When to Refer
Knee Anatomy
Compound Joint2 condyloid joints
1 sellar joint (patellofemoral)}
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Knee Anatomy
• Cartilage
• Ligaments
• Blood Supply
• Innervation
• Biomechanics
Knee Anatomy
Different Types:
Cartilage
Different Types:– Growth Plate Cartilage
– Fibrocartilage
– Elastic cartilage
– Fibroelastic Cartilage
– Articular Cartilage
Knee Anatomy
Cartilage
Fibrocartilage
Articular Cartilage
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Knee Anatomy
Fibrocartilage 40‐50% Load in Extension85% in Load in Flexion
Knee Anatomy
Blood Supply
Knee Anatomy
Innervation
– Anterior/Lateral/Medial• L2 L4 Femoral Nerve• L2-L4 Femoral Nerve
– Posterior• S1-S2 Sciatic Nerve
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Knee Anatomy
Biomechanics• Joint Reactive Force
• Tibiofemoral• 3x body weight walking• 4x climbing• 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
Knee Examination
• Alignment
• Effusion
• Range of motionRange of motion
• Stability
• Gait
• Point of maximum tenderness
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Knee Examination
Alignment
VARUS VALGUS
Alignment
Windswept Knee
Knee Examination
Patella Alignment
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Knee Examination
Patella Alignment
Knee Examination
• Alignment
• Effusion
• Range of motionRange of motion
• Stability
• Gait
• Point of maximum tenderness
Knee Examination
Effusion
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Knee Examination
• Alignment
• Effusion
• Range of motionRange of motion
• Stability
• Gait
• Point of maximum tenderness
Knee Examination
Range of Motion
Knee Examination
• Alignment
• Effusion
• Range of motionRange of motion
• Stability
• Gait
• Point of maximum tenderness
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Knee Examination
• Alignment
• Effusion
• Range of motionRange of motion
• Stability
• Gait
• Point of maximum tenderness
Knee Examination
• Alignment
• Effusion
• Range of motionRange of motion
• Stability
• Gait
• Point of maximum tenderness
Knee Examination
Point of maximum tenderness
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Knee Examination
Rule out Referred Pain from Hip
Knee Examination
– Meniscus
• Thessaly
• Anterior Drawer
Specialty Tests
• McMurray
– Anterior Cruciate Ligament
• Lachman
• Pivot Shift
– Patella –• Q angle
• J sign
• Patella apprehension
• Patella Load
Knee Examination
Sensitivity –
• Probability of a positive test among patients with disease
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
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Knee Examination
– Sensitivity: » 89% medial meniscus
Meniscus Thessaly Test
» 89% medial meniscus
» 90% lateral meniscus
– Specificity: » 97% medial meniscus
» 96% lateral mensiscus
Most Sensitive and Specific
Knee Examination
– Sensitivity: » 50% for pain
Meniscus McMurray Test
» 50% for pain» 16% if clunk or
thud
– Specificity: » 98% for thud» 94% for pain
Knee Examination
Apley Meniscus Distraction & Compression
– Sensitivity: » 97%
– Specificity: » 87%
Compression Distraction
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Knee Examination
– Anterior Drawer:
S
ACL/PCL
» Sens: 41%
» Spec: 95%
– Posterior Drawer: • 90%
• 99%
Anterior Drawer Posterior Drawer
Knee Examination
» Sensitivity:• 68 77%
ACL Lachman
• 68‐77%
» Specificity: • 50‐94%
Most Sensitive for Acute Injuries
Knee Examination
– Anterior Drawer:
S iti it
ACL Pivot Shift Test
» Sensitivity:• 82%
» Specificity: • 98%
Most Sensitive and Specific
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Knee Adjunct Studies
X‐rays
MRI
CT
Bone Scan
Knee Adjunct Studies
Generally 4 views: 1. A-P
X‐rays
2. Lateral 30 degree flexion
3. Sunrise
4. 45 degree weight bearing
Knee Adjunct Studies
Generally 4 views: 1. A-P
X‐rays
2. Lateral 30 degree flexion
3. Sunrise
4. 45 degree weight bearing
Rosenberg View
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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
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Knee Adjunct Studies
X‐rays
• Alignment
• Joint space• Joint space
• Fractures
• Bone lesions
Knee Adjunct Studies
X‐rays
• Alignment
• Joint space• Joint space
• Fractures
• Bone lesions
Name That Injury
X‐rays
Segund Fracture=
ACL Tear
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Knee Adjunct Studies
X‐rays
• Alignment
• Joint space• Joint space
• Fractures
• Bone or Soft Tissue lesions
Chondrocalcinosis
Knee Adjunct Studies
MRI scan
Open vs Closed MRI Scan– Open vs Closed MRI Scan• Recommend:
– 1.5 Tesla scanner or higher
– Better for soft tissue than bone pathology
Knee Adjunct Studies
CT scan
– Fractures
– Loose body
– Mal-alignment of knee
– Better for bone than soft tissue pathology
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Knee Adjunct Studies
Ultrasound:– Joint Effusion
– Meniscus
– Collateral Ligaments
– Cruciate Ligament
– Cyst
– Help guide Injection
Knee Adjunct Studies
Bone Scan:
Rule out:
– Patellofemoral Arthritis
– Stress fracture
– Complex Regional Pain Syndrome
Knee Pathologies
• Cartilage Tears
• Ligament Tears
• Fractures
• Avascular Necrosis
• Arthritis
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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
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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
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Articular Cartilage Tears
Microfracture
Articular Cartilage Tears
Cartilage Transplantation
Articular Cartilage Tears
Autologous Chondrocyte Implantation
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Ligament Tears
Ligament Tears
Willis McGahee
Ligament Tears
Nearly 100,000 ACL reconstructions per year
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Fractures
Fractures
Avascular Necrosis
Incidence: • Unkown
f ll• Approx 10% of all cases ‐ Knee
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Avascular Necrosis
2 Types:
1. SPONK2 S d2. Secondary
SPONK Secondary
Avascular Necrosis
• EtOH abuse• Steroid use
CAUSES
• Sickle Cell• Prior Trauma• Infection• Caissons Disease• Medications• Gaucher Disease• After arthroscopy
Avascular Necrosis
Symptoms:
Ni ht ti i• Night‐time pain• Weight bearing pain• Stair climbing pain
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Avascular Necrosis
Microvascular Ischemia
Normal
Ischemic
Avascular Necrosis
Diagnosis:• X‐raysX rays• MRI scan• Bone scan
Avascular Necrosis
Treatment:• Limit weight bearing• NSAIDs• Core Decompression• Knee Replacement
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Knee Arthritis
3 Main Types:
1. Osteoarthritis2. Rheumatoid arthritis3. Post‐traumatic arthritis
Knee Arthritis
Osteoarthritis:
•Most common
•Age related•Age‐related
•Progressive destruction
•Middle age and older
•Commonly affects one or two joints
Knee Arthritis
Post‐traumatic
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Knee ArthritisRheumatoid 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
Nutrition &
Weight
Exercise &
Physical Therapy
Arthritis Algorithm
Injections
Neutriceuticals
Medications
Nutrition &
Weight
WEIGHT LOSS
•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
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Exercise &
Physical Therapy
Exercise and Therapy
Neutroceuticals
Neutriceuticals
Nutrition &
Weight
Exercise &
Physical Therapy
Medications
Injections
Neutriceuticals
Medications
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INJECTIONS
Injections
Corticosteroids
INJECTIONS
Injections
Hyaluronic Acid
INJECTIONS
Which To Use Initially?
Often Dictated by 3rd Party Payor
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INJECTIONS
Leopold et al J Bone Joint Surg. 2003;85A:1197‐1203.
Hylan G‐F 20 Versus Cortisone Group 1: Hylan 3 injections
Group 2: Cortisone with 2nd at any time6 Month StudyNo Difference
INJECTIONS
Zhang W et al. OARSI Osteoarthritis Cartilage. 2010;18(4):476‐499.
Effect Size Study0.5 indicates Moderate Effect
0.58 Cortisone0.60 HASimilar
INJECTIONS
Reichenbach S, Blank S, Rutjes AW, et al. Arthritis Rheum. 2007;57(8):1410‐1418Berenbaum F, Grifka J, Cazzaniga S, et al. Ann Rheum Dis. 2012;doi:10.1136/annrheumdis‐2011‐200972.
Any Difference Between HA?
SimilarHowever – higher molecular weight slightly better
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Failure Non-Surgical Treatments
Medications
Exercise
NeutriceuticalsFAILED
FAILED
FAILED
Physical Therapy
Nutrition & Weight
SURGICAL OPTIONS
FAILED
FAILED
Surgical Options
CURATIVE
• Resection
• Fusion
LIMITED
• Synovectomy• Fusion
• Selective Replacements
• Total Replacements
• Arthroscopy
• Osteotomy
• Cartilage Transfer
Surgical Options
LIMITED
• Osteotomy– < 40
– Male
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Osteoarthritis
Surgical Options
CURATIVE
• Partial Replacements
Surgical Options
CURATIVE
• Total Replacements
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Osteoarthritis
• Diagnosis:
– History:• Gradual pain
• Possible acute on chronicPossible acute on chronic
– Exam: • Swollen
• Generalized pain
• Localized pain
Osteoarthritis
• Diagnosis:
– X-rays:• All patients with chronic knee pain or acute pain
– MRI scan: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
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Osteoarthritis
• Treatment: My Personal Strategy
– Surgery:• If failed all of the above
• Total Knee Replacement
• Uni
• Knee Arthroscopy
When to Refer
When to Refer
Remember –
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
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When to Refer
• Primary Care MD - Gait Keeper• Cost Containment• Prelim diagnostic Work-up
What Can You Do?
Prelim diagnostic Work up• Try:
• NSAIDs• Physical Therapy• Weight Loss• Injections• Cane
Thanks
WEB: www.drhommen.com
EMAIL: [email protected]
CELL: 305.907.4505