Jasmine
Welcome to this evening's webinar - Advancements in Orthopaedics: Evidence Based ACL and Other Knee Injury Treatments and Surgical Management of Osteoarthritis in Younger Patients. My name is Jasmine, your RACGP representative for this evening. We are joined by our presenters, Associate Professor Sam Adie and Dr Michael Dan. Our facilitator for this evening is Dr Tim Senior. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work and pay our respects to Elders past, present and emerging. I myself am joining from Gadigal Land this evening in Sydney's Inner West. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening.
I would like to introduce you to our presenters for this evening. Associate Professor Sam Adie is an experienced orthopaedic surgeon specialising in hip and knee reconstruction surgery. Sam graduated with honours from the University of New South Wales. He has been published in the most prestigious medical journals and won multiple awards with competitive funding for his research where he leads a series of clinical trials to improve outcomes in joint replacement and orthopaedic trauma. Dr Michael Dan is an Australian trained lower limb orthopaedic specialist with further formal subspeciality training from the Lyon Knee School in France. Dr Dan provides the highest standard of contemporary care for complex knee and lower limb tendon problems, and his passion is helping his patients return to the highest level of function. He has a proven track record in cutting-edge research and is now part of the Macquarie Translational Orthopaedic Research Library. We are also joined by Tim who is our facilitator for this evening. Dr. Tim Senior is GP at Tharawal Aboriginal Corporation in Southwest Sydney. He is a medical advisory to the RACGP in Aboriginal and Torres Strait Islander health and is a clinical senior lecturer in General Practice and Indigenous Health at the University of Western Sydney. Welcome to all our speakers and I will now hand over to Tim who will go over the learning objectives.
Dr Tim Senior
Thank you very much. Good evening everyone. I am joining from Dharawal country tonight, the land where I live and work. These are our learning objectives for the evening, which is educational speak for what we hope to get out of the session. This is what we hope to get out of the evening. By the end of this online CPD activity, we should all be able to discuss the functional anatomy of the knee, different knee injuries and their severity for the patients. Apply an evidence-based approach to managing your patients with these knee injuries. Analyse the role of osteotomy and unicompartmental knee replacement in the treatment of unicompartmental arthritis and evaluate the influence of tibial slope on knee stability and finally assess the longevity and revision risk of total knee replacement based on patient age. I am going to hand over to Professor Adie to start us off. Thank you very much.
Associate Professor Sam Adie
Thanks so much, Tim. Good evening, everyone, and thanks for the introduction. I will be talking about the management of anterior cruciate ligament and other knee injuries and particularly focusing on the evidence on their management. Just a little bit more about me. I split my practice between Macquarie University Hospital and the new Orthopaedic Institute that was just built on level 5 of the hospital, which is a state-of-the-art centre, and also my public appointment at St George Public Hospital and the University of New South Wales where I do a lot of my academic work and supervise PhD students. When I am not doing all of that, these things keep me busy. These are my sons and when they are not occupying all of my free time, I try to get on the bike as much as possible. That usually means I am up at 4 o'clock in the morning because that seems to be the only time available that I can have to myself. I am sure a lot of you would share those sentiments. We have already discussed the learning objectives. I am not going to go through them in much detail, but the outline of the talk follows along from the objectives. I am going to be talking about the structure of the knee with particular reference to the functional anatomy of the knee as to what those structures actually do for the patient from a practical point of view, briefly talk about how to assess knee injuries, and then briefly talk about collateral ligament and PCL injuries. Then a little bit more detailed discussion on ACL injuries and the evidence for their management as well as meniscus injuries. Again, a little bit more of a detailed discussion on the evidence for their management. If we have time because time is a bit limited with the talk, I will be talking to you about the EPIK trial, which is the current big clinical trial that we are running.
Let us dive straight in. Everyone knows that the knee joint is a modified hinge joint between the bottom part of the femur and the top part of the tibial plateau, which are lined with a thick layer of cartilage. You can see just from the pictures that the knee itself does not really have any inherent bony stability because you have got essentially a convex surface articulating with a flat surface at the top of the tibia. The knee is one of those joints that really does rely on soft tissues or ligamentous stability. These are conferred by four major ligaments as well as a number of muscles and tendons that help stabilise it. Collateral ligaments, everyone has heard of those. They are the ones on the side that mostly confer coronal plane stability, so varus and valgus stability. The lateral collateral attaches to the lateral epicondyle and then gains attachment to the proximal fibula. The lateral collateral should not really be understood as a structure operating by itself because there is a whole bunch of other structures on the lateral side that are actually not depicted here, but it should be understood more in keeping with the so-called posterolateral corner where there is a bunch of other smaller ligaments, as well as larger muscles such as the biceps and ITB that confer stability on the posterolateral side of the the knee. Lateral collateral ligament injuries by themselves are actually quite rare. Whenever you see that, you have to think that there is a more serious injury to the posterolateral corner or possibly multiple ligament injuries to the knee and on the medial side, you have got the MCL which attaches to the medial epicondyle and the proximal medial surface of the tibia, and that mostly confers valgus stability to the knee. We will be talking a little bit more about it during our discussion on the injuries. Then you have got the cruciate ligaments which are intra-articular ligaments, the anterior cruciate ligament here you can see attaching to the anterior tibial spine, and the lateral part of of the notch. Then you have got the PCL which attaches to the medial part of the notch and more towards the back of the tibia. These confer a lot of anterior and posterior translation stability, but more importantly, they actually confer rotational or pivot stability to the knee, and the different bundles in those ligaments do that. Rotational stability is probably a more functionally important structure of those ligaments. You can get by if you have a little bit of anterior or posterior instability, but it is that pivotal twisting or changing direction type movement that the cruciate ligaments are mostly responsible for constraining that really is important for the function of the knee and the function of the patient because that is the thing that the patient is going to notice when the knee gives way. Enough on the structure of the knee. I will just move on.
The assessment of knee injuries. We know all about the history, examination and the tests, but the things that I just want to quickly point out here from the history is to get a sense of how much energy actually went into that injury. The mechanism, for example, whether it is a sporting injury, whether it is a fall from standing height and then we can ask them about swelling, bruising, stiffness and reduced range of motion. Mostly because the knee puffs up because it fills up with fluid and the patient cannot bend or move it and that is an indicator of how serious the injury is. Difficulty weight bearing, of course, and then you have got mechanical symptoms. These are things like clunking and clicking or even sometimes locking of the knee. It is important when you talk about locking or the patient says that it gets stuck in a certain position to clarify exactly what that means because different people have different understandings of what locking means, just ask them to put that into their own words because that is a very, very important symptom that may need surgery. It is important to get if it actually is occurring or whether it is something that the patient understands to be occurring, but may actually be another mechanical symptom like clicking or clunking, for example. It is important to get a sense of their level of function. As orthopaedic surgeons, our main role really apart from improving patient's quality of life from a pain point of view is actually restoring their function. You can imagine an older retired patient is going to be quite a different proposition to a young athletic type patient who presents with a knee injury. and of course, whether offering the various treatments, including surgery, are going to be appropriate for that type of patient in order to restore their function. For most people, I start by asking what they do for work and if it is a younger person, then I would also ask on top of that what sort of sport they do, how often they do it, what level they play. Whether they want to get back to that level or whether they have a keen interest in returning to sport. All of those things are really, really important for me to get a sense of how active and functional that patient's background is. Examination is actually quite difficult. Patients often present to you guys first. It is quite a fresh injury, first especially a couple of weeks. That is going to be quite difficult. I usually would not push it too hard. Just note that they have got swelling or an effusion and how much range of motion they have. They can be quite tender over the particular injured structure. Again, that is an important finding, and then stability when stressing the ligament and it is hard to talk about in a PowerPoint Zoom presentation. It has to be demonstrated, but essentially you can stress each ligament in a particular fashion to understand how badly injured it is and how unstable it is. We will talk a little bit about that when I talk about the different ligament injuries. Then tests, x-ray always. X-ray, it is surprising still how often they are not done, but when we are talking about soft tissue injuries, in particular MRI is essentially the gold standard.
Let us talk about the different injuries now. The medial collateral ligament. We talk about the medial side of the knee, mostly responsible for valgus stability. It is the most common knee ligament injury. About 40% of knee injuries involve the MCL in some way. Fortunately, most of the time it is avulsed from the femoral attachment, so it is avulsed from the medial epicondyle. I say fortunately because that injury has quite good healing potential and the vast majority of the time does not require any surgery. It just requires occasional splinting with a brace like a Zimmer splint or preferably like a ROM brace that allows them to have some movement but also confers some varus valgus stability. It has pretty good healing potential and they usually do heal to allowing the patient to have a good functional knee. If you examine patients with MCL injuries, there is always going to be a little bit of laxity, but what you want them to have is a bit of that functional stability and the vast majority do. You can grade them in terms of type 1, 2 and 3. That is what I was talking about. When you examine them, you stress that ligament and you see how much laxity there is. Usually the cut-offs are about 5 mm, so it is 5 and then 5 to 10. Then type 3 are more than 10 and do not really have that feeling of a strong endpoint when you stress it. Even type 3, I have written that usually the management is non-operative and people have a good prognosis with appropriate treatment. The only caveat to that is I will just point out that there is a type 3 subgroup called the Stener lesion, a type 3 lesion. These are the ones that are torn off the tibial side, and they are problematic because on the tibial side, they have poorer healing potential. That is essentially because other structures get stuck between the torn edge of the MCL, which you can see in this MRI slice here where the arrows are. Essentially, the pes anserinus or the hamstring tendons get stuck between the bone and the MCL. Usually the MCL is the deepest structure there. If you have got something in between that torn end of the ligament and the bone, it is unlikely to heal very well. That is one of the rare presentations that may need surgery, preferably acutely. Lateral collateral ligament injuries. Again, just a brief mention of these only to say that when you see an ACL injury, you should really look for more extensive injuries because it is quite rare to be injured on its own and it is more common when it is combined with multi-ligament knee injuries, ACL, PCL or the posterolateral corner, which I briefly talked about when I talked about the functional anatomy. You can see some of those structures here like the popliteus, fibular ligament or the tendon of the popliteus. That is an important injury to not miss only because a more extensive unstable posterolateral corner injury can have functional problems and affect the long-term prognosis of the patient, particularly if it causes rotational instability. That is something that is probably beyond the scope of this in terms of how to assess for that, but it is something that can definitely cause a functional and prognosis problem for the patient in terms of development of arthritis and further problems down the track. An important one to keep in mind. Whenever you see that term posterolateral corner or a significant injury to the posterolateral corner and most radiologists would pick up on it, you should watch out for it and probably refer that one early.
PCL injuries, again, I will only briefly discuss these only because they are quite good in terms of their prognosis. Most of them are managed non-operatively. We talked about the anatomy. The thing that I want you to know about the PCL is yes, it is responsible for that posterior translation stability. The posterior draw is the classic examination to test for how stable a PCL is, but sometimes you do get the rotational instability from PCL injuries as well. The only thing I would note about PCL's is, the higher their grade, the more alarm bells should be ringing because they are more associated with other ligament injuries. Most of the ones that would present to an office or a clinic environment would be grade 1 or grade 2. Again, there is that 5 mm cutoff. Grade 1 would be considered like sprains and grade 2 are about 5 to 10 mm of translation. When you start getting the more significant injuries, the only concern I have for those is that you need to look for something else going on. Again, that patient should have an MRI, if they have not had already just to look for other associated injuries, but even if it was a grade 3 isolated PCL, a lot of the time that can be managed non-operatively as well. I think with PCL's, I am not going to focus a lot on their management because traditionally they have really, really good outcomes with nonsurgical management. It is not really a controversial area that has needed the design and the conduct of a big clinical trial to work out what the best way is to manage them. There is no real high-level evidence and no clinical trials or RCTs about PCL injuries. Again, it is just because of our experiences that they do really, really well with non-operative treatment the vast majority of the time even in high level athletes. Surgery really does not confer much additional functional gain for those patients. For those two reasons, they are managed non-operatively most of the time. If there are any questions at that point just to have a bit of a breather, you can type them in the chat box, and I think Jasmine has covered that and I will try and get to them while Mike is talking. We will move on to ACL injuries. Here I want to focus a little bit about more of a deep diving to the evidence for their management. I alluded to the fact before that ACL injuries or ACLs are responsible for that anterior stability, but more importantly, it prevents that rotator instability of the tibia on the femur or pivot instability, and that is mostly because of the posterolateral bundle of the ACL, and that is the thing that is going to cause a functional problem for the patient rather than just that anterior translation. ACL injuries are very common. In the States about 400,000 reconstructions are done. We are not even talking about injuries, we are talking about the ones that are operated on. In Australia, there has been about 200,000 done in a 15-year period up to 2015, and the rates are really increasing. You can see by the figure on the right here that in certain subgroups of patients, particularly younger patients that are less than 25 years old, there has this massive rise in the number of injuries, particularly females. Females less than 25 years old have increased quite a bit over the last few years and this is only data from 2015 and they do cost a lot. It is about 150 million of direct costs, and again this is 2015 data. It is about almost ten years old right. They are probably getting if anything more common. The classic mechanism for an ACL injury, and this is what the patient will tell you. They will volunteer it even on their own. It is a non-contact pivot injury. Usually no other players around them, they are either going for the ball or changing direction and they have got their leg fixed on the ground, and the knee is typically slightly flexed, and then their body essentially rotates across the knee. They often hear something give like a snap and then swelling happens within a few minutes, if not an hour or two, and that is what happens when the ACL ruptures. It is the tibia that translates anteriorly, and you can see here the so-called kissing lesion on this MRI scan slice where the back part of the lateral tibial plateau violently rotates forward and then impacts the lateral condyle causing these like so-called kissing lesion or the bony oedema. Other injuries are common, most frequently the lateral meniscus. I would be surprised if you have an ACL without a lateral meniscus. These injuries are mostly minor and they do not really need anything, the lateral meniscus injuries are talking about and occasionally other ligaments like the MCL and the medial meniscus often gets damaged if the ACL is a little bit more subacute or chronic. I am not sure how we are going for time, but these are the key questions that I want to cover, and these are the questions that patients will ask you. Do I need to have surgery? Can I play sport again? How good is the ACL reconstruction and will it tear again if I do have surgery? What is the long-term outcome? and particularly do I get arthritis as a result of this injury? and then sometimes people ask if I do have surgery, what do you do for the surgery? So, I am not going to really talk about the intricacies of the surgery or the approach that I have for ACL reconstruction because that is not really a common question that patients have. I am just going to focus on the evidence for these questions. First of all, do I need to have surgery, and there are actually high-level clinical trials that address this question. In fact, three RCTs have been published on this topic and what they did is they randomised patients with ACL injuries acutely to either rehab with a physio or nonsurgical management with the option potentially of having a surgical reconstruction later or immediate surgical reconstruction, and that is the Ryman and the Froebel study. These were major trials published in big journals like The Lancet and and the New England Journal of Medicine, and essentially, they found very, very similar results. These trials were published in two different centres in Europe, two different countries. It is quite impressive that they actually found very, very similar results, and that tells you that these results actually ring true, and I have just really summarised them there. Okay. I am not going to go into much detail except to say that with more longer term outcomes a year or two down the track, there was very little difference between the nonsurgical group, the non-operative group and the operative reconstruction group at a year or two down the track, but what is important to note there is that those who were allocated to the nonsurgical group, ended up having surgery half the time, so 50% of those patients actually chose to have surgery for one reason or another down the track. The details about why those patients actually opted for surgery are a little bit vague, and there has been additional studies done afterwards to clarify who those patients are so that we can identify them maybe a little bit earlier. There are definitely the patients that have persistent stability issues, right, so patients who try to get back to work or play and they have ongoing instability of the knee, but there are a lot of patients who probably have already made up their mind perhaps, or were told by family or friends or whatever. We do not really know the details of of what actually happened to them, but the bottom line is that 50% of them actually ended up having surgery. That is what I tell patients when they see me that you can manage this injury really, really well without surgery if you wanted to, but there is a chance, well, 50% chance anyway that um, within a year that you will come back and you will opt to have the surgery so patients then can make up their own mind about what choice they want. There is another RCT that is really worth mentioning here, and this was recently published by Beard and Colleagues, and this is a randomised trial done in the UK, and this is not an acute ACL. This is people with an established ACL tear that are at least a couple of months down the track and also have established instability. For those patients who then come back and they have already had at least a couple of episodes of the knee giving way, can we then offer them non-operative treatment, and they were randomised to non-operative treatment or randomised to the other arm being surgery, and in that trial there was quite clear benefits to having a surgical reconstruction, so surgery actually worked better for those patients. Patients I guess, who present to you a little bit down the track who have already had a couple of instability episodes, surgery is favoured for those patients. That is a little bit different to the acute ACL injury who has just presented to you a couple of weeks after having their trauma. Can I play sport again? There have been quite a few observational studies on this. Summary is that most will have excellent function. 90% or more will return to near normal function based on patient reported outcomes, but what is interesting is not everyone returns to sport. We like to think of surgeons that we do a great job and people get back to what they love and want to do, but only 80% or so return to some kind of sport and only 60% of those actually return to their pre-injury level and even less at a competitive level, and fear of re-injury was the most commonly cited problem, rather than any functional problem of the knee. Will my ACL tear again? This is an interesting one. There have been a few studies here, observational studies that including this one, for example, that was done in really high level soccer players and that showed a very high re-injury rate, but what is interesting is that the contralateral knee has almost a similar rate to the ipsilateral knee or the one that got the ACL reconstruction. There is a similar rate of rupture to the contralateral uninjured knee, and other clinical trials also show that re-injury rates are about 5% or 10%. These are quite reliable statistics so that is what I tell patients that they probably have somewhere around a 5 to 10% chance if they do go back to their previous level of sport or function. but it is similar to the contralateral knee. What you can infer from that, I guess, is that the ACL reconstruction works quite well from I guess a stability point of view, and if they were to have an injury, they probably would have had that injury anyway because it is similar re-injury rates to the contralateral normal ACL that they have. Long term outcomes, will I get arthritis later? What are the problems. The evidence suggests that yes they do have ongoing problems with an ACL tear even if that ACL tear is isolated. These are observational more longer term study. There is a little bit of bias here to the studies that were included in this systematic review, but there is a suggestion that even with an isolated ACL, they have got four times the odds of developing arthritis and that odds actually increases quite significantly if they have an associated injury to the meniscus, and then if I do have surgery, what works best and I do not really want to dwell on this just in the interest of time just to say that there are quite a lot of graft options, surgeons will have different preferences based on what they think works best or mostly because of what they trained in. I will say that the things that tend to heal quicker are the things that come from the patient's own body, so autograft, taking tissue from the patient's own body, whether that is the patellar tendon or more commonly now hamstrings and quads tendon, I am doing much more quads tendon. and they tend to heal better and probably will result in better bedside stability, like if you examine them, but they do cause some morbidity to the patient, right? If you take something away, then they are probably going to notice that at least temporarily before they start rehabbing it. If you were to make a matrix like this, you will see that there has advantages and disadvantages, and donor site morbidity is always an issue if you take tissue from the patient, and the only thing that does not really do that is these allografts which are more commonly being used now especially because the method of preparation is actually I guess a much more advanced technique where they are not irradiated, which does not really damage that graft as much, but, Allografts do take longer to heal. They may have slightly higher retear retail rates as a result and they tend to be quite expensive. It is a big proposition to use them routinely for ACL surgery, and then I should mention this concept of the lateral tenodesis because I think a lot of patients should have this done in addition to the ACL reconstruction because of all of these randomised trials that are coming out, including this landmark one called the Stability Trial, which was done in Canada. Essentially what that is is taking a small part of the Iliotibial band, which is that big flat tendon on the lateral side of the knee and tenodesing it to the lateral side of the knee, and essentially what that does in my mind, it really just provides another point of stability so the knee does not rotate. If you have got two points of fixation, it is less likely to pivot and therefore less likely to be unstable when you are examining the patient and also unstable for re-injury, and that has been borne out by the evidence because it shows massive reductions in graft rupture, like there is a 70% reduction in graft ruptures, and we are talking about these are really active young athletic patients, but on a negative side, it does take them longer to recover because you are doing this extra lot of surgery that takes them about six months to get over and like catch up to the other group if they have not had it done. I always tell people that the short-term outcomes, it is more difficult, it is more painful and swollen and so on, but longer term they will get better outcomes in terms of the stability and the function conferred. Again, if there are any questions in the chat box and I think I might be running towards overtime.
Dr Tim Senior
We are over time now. We have had a few questions come through. We should hand over to Dr. Dan. Is there a take home message about meniscus injuries that you wanted to tell us?
Associate Professor Sam Adie
This is the take home message because I was not going to cover meniscus injuries in any, like, specific detail. All I want you to know is that there has a spectrum of injuries between that acute single event trauma in the younger athletic patient, and then the older, more chronic type presentation in that sedentary overweight patient, so completely different. The one on the right I would summarise the evidence to say that there is no good evidence to support surgical management for that more chronic degenerative meniscus tear. The picture on the right older patient and in the picture on the left is different. A lot of those can be managed non-operatively, but a lot of the time they need surgery, but the problem is there is a spectrum and there has a whole wide variation of patients that fit in between, and it is up to us to work out where that patient fits into that spectrum and whether they actually what the most appropriate management is for them, that is the take home message there, and most of them I would say would be managed non-operatively at least from the get go.
Dr Tim Senior
Thank you very much indeed. That was a quick race through there, really useful for GPs. I am going to hand straight over to Dr. Dan. We have had a few questions come through in the chat box as well, but thank you for your presentation and thank you, Dr. Dan for continuing.
Dr Michael Dan
Fantastic. Thanks, Sam. Good overview of knee anatomy, which helps with my talk. I am going to be talking about the surgical management of arthritis in the younger patient, and I will start with the disclosure. These knee x-rays are my own, and so you can see the lateral compartment arthritis with a few osteophytes and joint space narrowing and, I am yesterday's hero. I am a failed footballer who is very passionate about joint preservation because of my own subjective experience. The inability to repair a meniscus drove my outcomes, and that is what led me into orthopaedic surgery, and so I have learned over the years to manage my knee, and even with an x-ray looking like that, that is me from two years ago playing for my local junior football club, and a month ago, I managed to tick a life box off and run the city to surf in under an hour, and just recently there was Health Care Standards Commission, which came out with an article which was well publicised in the media, and it is this idea that surgery should not be entered into lightly, and it is that principle of patients need to learn to manage their knee, and there has particularly a lot of good things we can do non-surgically to help our patients manage or cope or learn to live with osteoarthritis. It does not necessarily need to be something that is solved, but for some patients there has no alternative, and in these patients, we can offer them a knee replacement, however, as Sam he did not get to any slides, but he was going to bring up, not all our patients are satisfied after a knee replacement. There has quoted 15% dissatisfaction rate. A lot of patients will feel it is not like a normal knee, and you saw that complex anatomy that Sam put up, and unfortunately, you know the knee replacement is a mechanical solution to this biological problem, and so in the interests of having beneficial wear properties, we need to simplify our knee replacement to have better wear characteristics. Patients often say it does not feel like a normal knee. I will skip over this, but my main approach to my patient with the knee arthritis is to try to align their expectations with what we are able to provide with our outcomes. There are certain things that I try to do surgically to optimise this, but again, they are up for debate. and just giving a case example this patient presented to me. It is pretty common and topical 84 but only had three months of significant knee pain not improving, and they said they do not want a knee replacement. The last thing I want to do is offer them a knee replacement. First thing I want to do is educate them about their disease process. A lot of times patients will come to me saying they have got a baker's cyst, they do not have a knee arthritis, and then I try to make sure that not all non-operative measures are implemented and then follow up with the outcomes. This patient went away not wanting a knee replacement, came back to me twice before they did undergo a knee replacement, and all I am trying to demonstrate here is that, objectively, we have been able to reduce her pain, not necessarily completely alleviate it and improve her function, and so with less pain, hopefully have better function. This is the kind of numbers that a lot of people throw around. If we look at the revision rate for knee replacement surgery for osteoarthritis, it is only an 8% incidence of needing a revision knee replacement. Those numbers sound fantastic, however, when we break it down into our younger age groups, the older patients, that revision rate goes down even less because they are approaching their expiry date and their knee replacement will live longer than they will. However, for our younger patients, that incidence of revision goes up, and so this is a graph I like to show my patients, and if you can Google lifetime revision risk, and this will come up so you can educate patients, but generally speaking, if we were to have it, this is the blue lines, the unicompartmental knee replacement, AND often it is utilised as a bridging solution in unicompartmental knee replacement in these younger patients. A revision in their lifetime is probably an expected outcome, however, for a total knee, if we are in our below 50s, in the men who are more physically active, generally speaking you have got a 1 in 4 chance of revision, and with each knee revision, the risk of complications increase and outcomes decrease. I think it is important to understand that. Ideally Sam started on the ACL, went through the ACL, and so this case study just gives an example of the ideal patient that I would like to be considered, and this is a 27-years old. She has previous had an ACL reconstruction four years ago, returned to sport and had a medial meniscectomy at the time of surgery, now starting to get medial compartment pain and you can see here her MRI. This is the sagittal plane of the medial compartment, and you can see the posterior cartilage relative to more anterior cartilage which is when the weight bearing, and you can see that cartilage thinning, and so for this patient, we can potentially offer a meniscal transplant to improve the biomechanics of the knee and reduce the issues associated with a meniscectomy this knee, however, that is a much rarer indication. The theme for today is I do not know if you have seen the remember the superannuation ads with compare the pair, same income, same lifetime contributions, different outcome. I am going to present three different patients today, all with similar looking x-rays and discuss different surgical outcomes to try to meet their expectations. This patient here, he is 47 years old. He ruptured his ACL eight years ago, and he started to develop medial side of knee pain, and as Sam was talking about in his talk, a lot of these patients can function really well, but then they can later on develop functional instability, and so this patient cannot step off ladders. He had previously been able to play rugby with a ruptured ACL, and he wants to continue having an active lifestyle and does not want a knee replacement, and this is his MRI showing that his self meniscectomy and his knee, we have got thinning of the articular cartilage on the medial side of the knee, and we can see here shortened ACL. You can see the ACLs are scarred down to the PCL and this is not his examination, but, as Sam alluded to, we can cope with anterior instability, but what patients cannot really tolerate and this clinically correlates with their subjective experience a lot of times is this pivot shift this rotational control, and then this is an AL scan which is a form of long leg alignment films. And you can see here this line shows that his weight bearing axis or his plumb line is going through the medial side of the knee. He is overloading that inside compartment of the knee, and then if you look at the knee from side on, it has got a slope to it, and if you imagine if you park your car on the hill versus parking it on the flat, the handbrake has to work a lot harder if it is parked on the hill compared to the flat, and so the same is true for the ACL in terms of slope, and this is what this is trying to demonstrate here that as this slope increases, this strain or stress on the ACL increases and this translation with axial weight bearing increases, that is the idea is if we can alter this slope, we can decrease the forces subjected to the ACL, and for this patient his issues are medial sided knee pain and instability, so the ACL reconstruction is very good at abolishing that laxity and with that hopefully has stability to his knee, however he would still have medial sided knee pain, and so for that we do an osteotomy which involves a saw to cut the bone. You leave the outer cortex intact and then you can hinge it open to change his weight bearing line of the knee from the medial side to the centre or slightly through the outside of the knee, and with technology nowadays, we can try to change that slope that I talked about as well to minimise the stress on the ACL.
Looking at my next patient, my next income protection it is a similar story, 43-year-old, very heavy man works in a manual job in the mines. He is now at the point where he is coaching his son's football team. He had a rugby injury and had a PCL injury that Sam talked about, roughly eight years ago, and so he has gone on to develop a consequence of that with the medial sided arthritis of the knee, and he cannot run 10 to 20 metres without bringing on his pain, and he has got some instability going downhill. As Sam already talked about, the patients generally do very well from a functional point of view with regards to their PCL injuries, and you can see here he has an intact ACL, but he has got no PCL, and then again, this long leg alignment film shows that his weight is going through the inside of his knee and then his slope rather than being high is less, and so the reverse is true. He has now got this negative translation whereas the other patient had a positive translation with their ACL injury. By doing the osteotomy, we can realign the coronal alignment, change this plumb line to go through the outer compartment, the healthy part of the knee, and we can also increase his slope to functionally compensate for the lack of the PCL, and so then my last patient again medial compartment osteoarthritis, and this is a 53-year-old female. She is not as physically active. She has got medial sided knee pain in particular and walking and when standing for prolonged periods and she has had a meniscectomy 15 years ago. She has got the changes associated, the Fairbank changes associated that with squaring of her tibial and femoral condyles. She has got this sclerosis and she is starting to develop some osteophytes, and again, all her pain is on the medial side of the knee, and you can see here she has an intact ACL and intact PCL, AND for unicompartmental knees, we at least need a PCL. Traditionally you need an ACL, but that is a relative indication, and you can see here she has got a healthy lateral compartment of the knee with the white articular cartilage, good triangular meniscus here on the lateral compartment of the knee, whereas you can see the meniscectomised residual meniscus here and we have got complete loss of the articular cartilage, and so for her, I would offer her a unicompartmental knee replacement, and as a general rule because you preserve your ACL and your PCL, you have got more normal knee kinematics with better patellofemoral function. Patients have less morbidity, so there has a quicker return to function and less mortality, but of the understanding that she will likely need a revision to a total knee at some stage in her life. I just wanted to finish with this slide. This is the idea about managing the knee, and this is orthopaedic surgeon Scott Dye in America, and he had some interesting principles and he actually arthroscoped his own knee with just with local anaesthetic into the portals, and he got another surgeon to go around and poke each of the structures and for which were pain generators, and you can see that our what is attached to our synovium is largely painful, whereas, articular cartilage is a neural. The inside inner part of our meniscus is largely a neural, and that is why, where it attaches to the synovium or the joint capsule is largely innervated, and so that is a good reflection on when we are thinking about what is driving the pain in our knee and how we can learn to manage our knee for the forces associated with it and provide this envelope of function that he talks about. So that is my talk.
Dr Tim Senior
Wonderful. Thank you very much. That was really good. We have got time for questions. We have had quite a few come through. I think one of the important ones for us as GPs is the management of knee osteoarthritis and knee pain in terms of avoiding surgery, and often the medications that we use have side effects for people with comorbidities and we do not want to get people onto opiates and things. What do you recommend in terms of nonsurgical management for osteoarthritis.
Dr Michael Dan
My spiel and Sams might be different is that arthritis is loss of the articular cartilage and that results in the symptoms of pain, stiffness and swelling. Our goals are to manage your pain, stiffness and swelling, and we can do this largely through the load that with the exercises we do and we carry around and as a general rule of thumb, one kilo here point to the belly is five kilos at the knee, so any weight we can lose is very beneficial, and one study showed that if we can lose five kilos, we get a 50% reduction in our pain, easier said than done, and then I say that we can reduce the loads going through our knee, through the activities that we do, and I say high impact activities probably less beneficial to you and more likely to cause you inflammation and pain and swelling, and I suggest everyone get gets an exercise bike because it has got lower loads going through the knee than walking. You are able to maintain the mobility to the knee through the repetitive cycling and then you are able to help build up your quadriceps, so stronger quadriceps, less load. I tell patients that my main thing is for a non-steroidal anti-inflammatory, and I encourage my patients to use it as required when they are on their feet for a long day and the day after potentially, but again, not to use it all the time, and I warn them of the side effects. I tell patients that they can trial a corticosteroid injection. For my older patients with degenerative meniscal tear, I really like a local corticosteroid injection into the meniscal tibial recess because that slide that I tried to show you that has been very beneficial for me in terms of reducing the acute pain that they might have related to the inflammation of the synovium, and then if they do not have any mechanical symptoms, there has no need for any arthroscopic surgery, and the majority of times when I am giving patients this, they are not ready for any joint replacement surgery, and I just tell them I do not want to be injecting anything to the knee for a minimum of three months prior to any replacement surgery because of the risk of infection, but that is my general rule of thumb. I generally get asked about glucosamine. I tell patients there is no high level evidence to support it but if you want to try it, try these things, go ahead and trial it, and if you get benefit, great, if it is not costing you too much money. I try to steer patients away from PRP injections.
Dr Tim Senior
Lovely. Sam, is there anything that you would add to that?
Associate Professor Sam Adie
No, that was really comprehensive. I do not think I would differ much with Mike on that topic.
Dr Michael Dan
I often recommend to my patients as well work in swimming pools, so walking in a swimming pool or something that takes some of the weight bearing load off, but they are walking against resistance, and so one of my patients find that quite useful too.
Associate Professor Sam Adie
The only thing I would add is really the the elephant in the room and no pun intended, I promise, is obesity and overweight. Honestly it is a major, major public health issue and probably the main reason why everyone is getting early knee arthritis while we are seeing skyrocketing rates of total knee replacement, and the problem is the solution to that is not really a surgical solution. It is not really what we are talking about here today that is more like managing weight. I often find myself having conversations about different surgeries with patients that are like obese. I even talk about drug treatment or even sometimes bariatric surgery because we know that when patients lose weight, then a massive proportion of those patients do not even need anything done for their knees anymore. It is crazy.
Dr Tim Senior
Absolutely, and and maintaining activity works for both the joints and the weight loss. I am just looking through the other questions. Any advances on stem cell treatment for meniscal replacement?
Dr Michael Dan
Not as far as I am aware. It is very experimental at the moment. I do get occasionally asked that question. I remember looking up the data for it. It was a little while ago admittedly, it was like a couple of years ago and all of the studies are like very low level observational, no controls. I mean, this is the stuff that you want to see before you recommend something routinely especially I think I would argue for something that is inherently, I guess, less risky for the patient, like if we are talking about just a needle, if you are going to tell me that patients are going to benefit from that needle, I need to see a really well constructed, well designed placebo controlled trial before I am going to change practice.
Dr Tim Senior
We had a good question earlier that I know you have typed in and answered, but I think is worth revisiting as well about the way the advice we give to people given that evidence around risk of recurrence and the baseline risk and the sports that people can do, do you direct people back to particular activities or how do patients choose the activity that they go back to?
Dr Michael Dan
For me, I tell patients that generally speaking you can self-select the patients, any younger patient who wants to have a more active lifestyle, I will push them towards surgery because although there is not evidence to support that we decrease the risk of osteoarthritis, we know that in those that have a chronic ACL, that the reconstruction is not as effective and they are more likely to have meniscal injuries, and we know that those that have meniscal and chondral pathology, as Sam said have decreased return to sport and poorer longer term patient reported outcomes. I tend to push my younger patients because of the type of lifestyle that they want to live towards surgery in a patient as a general rule of thumb, once they are into their 30s, I will push that the goal of surgery is only for functional stability to the knee. I treated a 32-year-old emergency doctor just a couple of months ago, and he was interested in playing volleyball. He had anterior laxity, grade three, but he did not have a high-grade pivot. He has been able to return to his high level beach volleyball without any issues to the knee, and again, because he does not have any functional instability to the knee, there is no need for me to intervene surgically, and then as they age beyond that, I tell patients that if they fail to meet their goals of returning to sport, they change the sport they want to do to in-line activities, but if they really want to get back to it, then that is when we can intervene surgically. It is just about telling the patients about the relative risks not being naive and telling them that every patient that has an ACL reconstruction is going to do perfectly and go on to have an NRL career.
Dr Tim Senior
I note that evidence that you quoted was from professional footballers, so they may not be typical of all of our patients.
Associate Professor Sam Adie
Very similar approach. Mike. I would just I would say though if patients ask me beforehand, I guess the way that that question was phrased is do you restrict them or do you tell them to limit their activities afterwards? and I generally do not do that. I do not want to, I guess take away people's dreams and hopes and things like that. I find that people will do that on their own, really. I try not to be, I guess, the instrument of why they become unhappy, if that makes sense. Patients will generally self-select and they will probably modify their own activities if they do not feel up to it, with or without surgery, and I did quote those rates and that is what I see in my practice like people that I do ACLs on, not everyone gets back to the high level of sport that they were playing. That is not for me. That does not come from me. That is just them like changing their own like approach to their life, choosing different sorts of activities than the ones that they were doing before. I guess it probably was not an important thing to them to begin with and having gone through a very painful negative experience with an injury and then surgery probably means that it was not important enough for them to put themselves back in that position. Patients generally self-select when it comes to modifying their own activities.
Dr Tim Senior
Thank you very much. We have ticked over to 8:30 pm. I will hand back to Jasmine to tell us all how we get our CPD points.
Jasmine
Thanks so much, Tim. Thanks everyone for speaking today.