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

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

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

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

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

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

8. 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

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

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

11. Primary Care Management Osteoarthritis Of The Knee

12. 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)

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

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

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

16. 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

17. 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…

18. 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

19. 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

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