Orthopaedic Knee Review
The Knee - a review of current practice
Information written by Tim Spalding
Updated by Adam Pearce, 3rd Year Medical Student
- Acute knee injuries: Diagnosing the Torn ACL in the Acute Knee
- Osteoarthritis of the Knee and Knee Replacement
- Meniscal Injuries
- Patello-Femoral Problems
Appendix A – Arthroscopy of the Knee
Appendix B – Obesity and the Knee
6th Edition -February 2015
Contents
Appendix A – Arthroscopy of the Knee
Introduction
Arthroscopy of the knee is an operation in which a small camera, and possibly surgical instruments, are inserted into the knee through two or three small puncture wounds. Understanding what the basic procedure entails is straightforward if we look at the etymology of the word.
- arthro- : relating to joints
- scopy: viewing, observation or examination
Arthroscopic procedures have equivalents in other branches of surgery. Examples include laparoscopy (laparo-: of the abdominal wall) in general surgery and cystoscopy (cysto-: relating to the urinary bladder) in urology.
Arthroscopic procedures
In the most basic of arthroscopic procedures, the structures within the knee are viewed and assessed using a camera called an arthroscope, with a view to diagnosis. The structures examined include the meniscus, the synovium, the articular cartilage and the cruciate ligaments.
Depending on findings, additional therapeutic procedures can be carried out via the insertion of surgical instruments. Such procedures include:
- Debridement: Particularly in patients with mechanical symptoms such as locking, debridement can be helpful by removing a torn piece of meniscus – in which case the procedure is called an arthroscopic meniscectomy – or other tissue. Rough, damaged articular cartilage can also be treated in this way.
- Mensical repair: In certain cases, repair of a torn meniscus can yield better results than mensisectomy.
- Loose Body Removal: Some injuries can cause fragments of bone, cartilage or other soft tissues to break off within the knee. These can be found and removed arthroscopically.
A first guide to interpreting arthroscopic images
Many patients seen on the ward and in clinics will have arthroscopy reports and associated images in their notes. For medical students, junior doctors and the patients themselves, these images can sometimes be disorientating, as it is necessary to imagine you are inside the knee to work out what the different structures are. Here, a few simple rules for orienting oneself to the images are presented.
- Rule 1: Ensure you determine which knee you are supposed to be looking at. This simple step is key to understanding which side of the image is lateral and is which is medial.
- Rule 2: Most of the images are taken looking antero-posteriorly – i.e. from the front of the knee towards the back. The exception to this rule is those images taken looking upwards at the patella-femoral joint.
- Rule 3: The surgeon handling the arthroscope will keep the tibial plateaus horizontal and towards the bottom of the image whenever they can be seen.
- Rule 4: The surgeon will have manipulated the knee to open up the joint space in the area where each image is being taken. This can give a false impression of the spatial relationship between the articular surfaces and the soft tissues.
The images below, of a left knee joint, are annotated with reference to the rules above, to clarify which part of the joint they show.
This is the inside of a left knee, viewed from the front. Any structures on the left of the page are therefore on the medial side of the knee, and those on the right are lateral.
The tibial plateaus are kept horizontal at the bottom of the image.
The medial meniscus is shown ‘floating’ between the two articular surfaces. Under normal load, the meniscus would be compressed between the two.
This is the inside of a left knee, viewed from the front. Any structures on the left of the page are therefore on the medial side of the knee, and those on the right are lateral.
The tibia plateaus are kept horizontal at the bottom of the image.
In this case, we can see a defect in the articular cartilage of the lateral tibial plateau, as indicated by the probe.
Again, this is the inside of a left knee, this time viewed looking upwards at the patella-femoral joint. Lateral and medial are the same as the images above.
The key to understanding the orientation of this image is to recognise the wedge-shaped posterior surface of the patella and the trochea groove of the femoral condyles.
In this case, the articular surfaces to the bottom of the image are the femoral condyles.
Knee Osteoarthritis and Obesity
But what if I already have knee OA? If you already have problems with your knees there is clear evidence that losing weight reduces the symptoms of pain and immobility and can delay or prevent surgical intervention. These findings are regardless of the level of structural damage caused by OA, improvement in symptoms is found in patients who lose weight no matter what their x-rays say. There are benefits to losing weight if you need a knee replacement too. Performing a total knee replacement operation on an obese patient is technically more challenging for the surgeon, the surgery takes longer to perform and there is a higher risk of complications like infection. Over time implants used in total knee replacement fail more quickly in obese patients. What is the best way to lose weight? Studies show the most effective means of losing weight is following a lifestyle that gives you a ‘continuous energy deficit’. This essentially means that the amount of energy you put into your body as food and drink should be less than the amount of energy you use in your daily activities. Effective, long-lasting weight loss is achieved through adjusting your lifestyle, rather than crash dieting. Finding the best strategy that works for YOU is important and getting support from your family and friends can make a big difference. There are many weight loss plans and methods out there to chose from; here are some suggestions for effective weight loss programs. Weight Loss Guide | How to Lose Weight Exercise is an obvious way to lose weight but knee pain can make weight-bearing activities difficult. Running, football or squash may not be possible due to pain. With all types of exercise, be guided by what you can do comfortably and stop if it hurts too much. Cycling and swimming are excellent exercise alternatives that put minimal strain on the knees, but still get your heart rate up and burn calories. If you can move about comfortably there is evidence that combining weight loss through diet and regular long-term exercise is effective at improving arthritis pain and mobility, in addition to the normal care you receive from your GP. Either weight loss or exercise is better than standard care alone, but combining both gets even better results. If you are overweight or obese aim for losing 5% of your total current weight over 20 weeks to give symptom relief. Losing 10% within 12 weeks has been shown to have even more significant clinical effects. What if I wait until after my surgery to lose weight? The evidence says this is not the general rule! One study showed that after knee replacement 21% of patients gained further weight whilst only 14% lost weight. Don’t put off until tomorrow, what you can do today! Weight loss reduces symptoms, delays surgery and, if surgery does become necessary, improves the outcomes you will experience. Written by Rachel Milner (Medical Student) for the knee team UHCW NHS TrustMake a Booking
To make an appointment please contact Mr Spaldings’s secretary Nicki on 01926 772731 or by email office@timspalding.com
REFERRAL LETTERS: Whilst it is not necessary to have contacted your GP or insurance company before booking an appointment to see Mr Spalding, it is important that do you have a referral letter from your GP, as this summarises the relevant problems and important past history. You can bring this referral letter with you or it can be sent by your GP to the address below.
Address for referral letters:
Nuffield Health Warwickshire Hospital
Old Milverton Lane
Leamington Spa, Warwickshire
CV32 6RW
Payment Terms
Dealing with your Insurance Company
During every step of the process, you need to keep your insurance company informed in order to obtain approval for further appointments, physiotherapy or MRI or surgery etc.
Each insurance company is different with a different level of requirement but they are usually very helpful. If you have any difficulties or need any specific procedure codes and information for the insurance company then please contact Nicki on the office phone number or by email.
Please enquire about Outpatient consultation prices for uninsured or self pay patients
Inside The Clinic
You will be offered an appointment time and Mr Spalding makes every effort to try and keep to that time. However as you may appreciate sometimes appointments may take longer and there may be a wait. It is a balance between keeping to time and offering everyone a high quality of service.
It is helpful if you could please bring with you:
- Referral letter from the GP if it has not already been sent by the GP.
- Any previous letters or correspondence relating to your knee problem.
- Any relevant xrays or MRI scans
- Shorts or appropriate clothing as it is important to be able to examine the whole knee and leg during the consultation.
In clinic Mr Spalding will spend time discussing your symptoms and then examine your knee(s) prior to discussing various options for treatment.
It may be necessary to take xrays which can either be performed on the same day or at a later time. MRI scans are usually performed on another day if required.
Physiotherapy Arrangements
You may well have had physiotherapy prior to the operation and it is expected that you would go back to the same physiotherapist afterwards for the post operative rehabilitation.
Sometimes it is appropriate to undergo different physiotherapy and this should be discussed with Mr Spalding. He has a network of linked physiotherapists who have similar interest and dedication to helping knee problems.
We currently recommend therapists within our physiotherapy network, though this is ever expanding.