Management of Chronic Knee Pain: Leading Edge Therapies

Demetris Delos, MD Orthopaedic Knee and Shoulder Surgery

February 7, 2017

Outline

• Basic Anatomy • Meniscus Injuries • Ligament Injuries • Cartilage Injuries • The Problem of Arthritis and Knee pain

– Nonoperative Solutions – Surgical Solutions – My approach

Knee Anatomy

• Knee – Femur (thigh bone) – Tibia (shin bone) – Patella (kneecap)

• Cartilage – Smooth surface lining the

ends of bones contacting one another

• Meniscus – C-shaped structures between

femur and tibia • Arthritis

– Loss of cartilage on both sides of the joint

Meniscus Tears

• 2 menisci per knee – Inner (medial) and outer

(lateral)

• Shock absorber of knee – Absorbs and distributes

forces

• Prone to tearing with age and activity

Treatment of Meniscus Injuries

• Rehabilitation • NSAIDs • Injections • Surgery

– Arthroscopic knee surgery to either trim a torn piece or repair it with stitches

– In extreme cases, meniscal transplantation can be considered

Ligament Injuries

• MCL most common • ACL most operated • Chronic injury to one

(or more) of the ligaments can lead to – Degenerative changes – Altered gait and

mechanics

Treatment of Ligament Sprains

• Most are Grade I (minimal tear), or Grade II (partial tear) and are treated successfully nonoperatively

• MCL sprain almost always nonop

• Grade 3 tears of ACL usually treated with surgery in patients who participate in cutting/pivoting activities – Graft

Cartilage Injuries

• Focal, isolated tears of cartilage

• Commonly associated with ligament injuries (ACL)

• Presentation – Pain – Swelling – Mechanical symptoms

Treatment of Cartilage Injuries

• Nonoperative – Rehab – NSAIDS – Injections – Bracing

• Operative – Microfracture – Cartilage Transplantation

• Auto • Donor

ARTHRITIS

Scope of the Problem

• Knee arthritis is VERY common – >9million Americans – 9.6% men, 18% women

>60 yo • The number of older

adults is increasing – Older individuals are more

active and WANT TO STAY THAT WAY

• Younger adults with OA are also looking for surgical options

Symptoms

• Pain • Swelling • Increasing Stiffness

CONSERVATIVE TREATMENT

The Basics

• Activity Modification • Weight Loss • Bracing/Orthotics

– Unloader braces • Use in pts w unicompartment dz, passively correctable

– Foot orthotics • Lateral wedge orthotic for varus knee

• Anti-inflammatories – Serious GI side effects in 2-4% of chronic users

• Physical Therapy – Exercise can reduce pain and improve function in pts w early OA

• Other treatments – Acupuncture etc

SURGERY

Arthroscopy

• Debridement – Useful in patient with

mechanical symptoms • Locking, catching, clicking • Loose bodies

• Limited efficacy

Arthroscopy - Rehab

• Weight bearing as tolerated • No restrictions on motion • Cleared for activities in 4-6 weeks

Osteotomy

• Goal: to realign mechanical axis so load is transferred to healthier part of knee from diseased part

• For patients w OA primarily in one compartment of knee

Osteotomy (Realignment Surgery)

• Advantages: – Retain native knee joint – Patient can return to all

activities, without limitation

• Disadvantages – Can’t be performed in

patients with diffuse arthritis

– Hardware often prominent and may require removal

Rehab

• Crutches for at least 6 weeks • CPM and range of motion from outset • Strengthening immediately after surgery • Return to sports at ~6 months once bone

heals

Unicondylar/Unicompartmental Knee Replacement

• Replacing one of the three compartments of knee (medial, lateral, PF)

• Advantages – Easier recovery than

osteotomy or TKR – Immediate weightbearing – Retain ligaments of knee

(ACL) • Disadvantages

– Technically challenging – Less predictable than TKR

Rehab

• Immediate full weightbearing • Gait training • Strengthening and range of motion without

limitation • Home exercise program • Return to activities in 2-3 months

– Recommend low impact activities (skiing, doubles tennis, biking)

Conclusions

• Isolated meniscal injuries can be treated nonoperatively or with meniscectomy vs repair

– In extreme cases, meniscal transplant • Isolated ligament injuries often

treated nonoperatively – ACL treated with surgery in active

individuals who participate in cutting sports

• Isolated cartilage injuries can be treated with observation or surgery

• Diffuse cartilage wear=arthritis – Treatment needs to be tailored to age,

expectations and activity levels • Younger, high impact – Arthroscopic

debridement, Osteotomy • Middle aged, medium impact –

Arthroscopic debridement versus Osteotomy versus Uni

• Elderly, low-medium impact – Arthroscopy versus Uni versus TKR

THANK YOU FOR YOUR TIME AND ATTENTION!