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Common Disorders of the Knee

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Common Disorders of the Knee 7/27/2017 Common Disorders of Disclosures the Knee Carlin Senter, MD I have nothing to disclose. Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthopaedics UCSF Essentials of Primary Care August 8, 2017 Knee: Top 3 referral diagnoses from Objectives primary care IM to ortho (at UCSF in 2011) 1. Osteoarthritis (OA) Upon completion of this session, participants should be able to: 2. Anterior knee pain 1. List 4 exam maneuvers for meniscus tear • Patellofemoral pain syndrome 2. List the diagnostic criteria for knee OA • Chondromalacia patella 3. Identify 5 non operative treatment options for knee OA • Patellar tendinopathy 4. Identify indications for surgery for patient with meniscus tear 3. Meniscus tear ‒ Without knee OA ‒ With knee OA 5. Generate a differential diagnosis for chronic anterior knee pain 1 7/27/2017 Case #1 All of the following tests, if positive, would raise concern for a meniscus tear except… 25 y/o man with medial-sided pain and swelling of the R knee for 6 A. Joint line tenderness weeks since he twisted the knee playing soccer. No locking, no instability. B. Pain when he stands and pivots on the knee C. Pain when you axially load and rotate the knee D. Pain when you flex the R knee and extend the R hip with the patient lying on his left side. E. Pain when he squats 4 tests for meniscus tear Joint line tenderness 1. Isolated joint line tenderness 2. McMurray 3. Thessaly 4. Squat Medial: Sensitivity 83%, Specificity 76% Lateral: Sensitivity 68%, Specificity 97% (Konan et al. Knee Surg Traumatol Arthrosc. 2009) Illustration: Solomon et al. Rational Clinical Exam, Meniscus. JAMA 2001. 2 7/27/2017 Meniscus: McMurray Meniscus: Thessaly Sensitivity medial 65%, Specificity medial 93% Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008. Sensitivity 90%, Specificity 98% (Harrison BK et al. CJSM, 2009) Sensitivity 51-67%, Specificity 38-44% (Snoeker BAM et al. JOSPT, 2015) Video used with permission from Anthony Luke, MD Video used with permission from Anthony Luke, MD Meniscus: squat Ober’s Test for tight IT Band Passive hip abduction and extension. Sensitivity 75-77%%, Specificity 36-42% Hip extension ITB positioned over greater trochanter (Snoeker BAM et al. JOSPT, 2015) of femur. 3 7/27/2017 Case #1 Management Case #2 . Exclude bucket handle meniscus tear . 65 y/o man with h/o medial meniscus surgery R knee years ago. Moderate medial-sided pain and generalized swelling of the R knee since • Locked knee, large effusion, acute injury hiking last week. • Crutches, non weight bearing, urgent MRI and surgery . No locking, no instability, no stiffness > 30 min in AM . Exam: . MRI to evaluate for medial meniscus tear • Moderate effusion, no warmth . Refer for knee arthroscopy • Crepitus with range of motion • Meniscus repair vs debridement • Tender medial joint line and above/below medial joint line on the medial femoral condyle and medial tibial plateau. If no bucket handle tear and patient prefers non surgical treatment, • (-) McMurray, knee feels tight with squat, unable to perform complete squat, also okay to try physical therapy first and monitor. unable to perform Thessaly due to pain. • No ligamentous laxity 13 7/27/2017 Diagnosis? Clinical criteria for diagnosis of knee OA A. Medial meniscus tear B. ACL tear C. Medial compartment osteoarthritis D. Gout E. Septic arthritis F. Medial meniscus tear and medial compartment osteoarthritis Altman R et al. Arthritis Rheum. 1986 Aug;29(8):1039-49. 4 7/27/2017 Case #2 What do you recommend? . 65 y/o man with h/o medial meniscus surgery R knee years ago. A. Refer for arthroscopic debridement of cartilage and lavage . Moderate medial-sided pain and generalized swelling of the R knee since hiking last week. B. Nonoperative knee OA program . No locking, no instability, no stiffness > 30 min in AM C. Refer for total knee arthroplasty . Exam: • Moderate effusion, no warmth • Crepitus with range of motion • Tender medial joint line and above/below medial joint line on the medial femoral condyle and medial tibial plateau. • (-) McMurray, knee feels tight with squat, unable to perform complete squat, unable to perform Thessaly due to pain. • No ligamentous laxity Interventions . Control . Arthroscopic surgery • PT: 1 hour/week x 12 weeks • Irrigation with saline • Home ex program 2x/day • 1 or more of the following: • Instruction on ADLS ‒ Debridement or excision of degenerative meniscus • Self management arthritis tears education reading + videotape ‒ Removal loose bodies, chondral flaps, bone . 188 patients, mod-severe knee OA, followed x 2 years • Medications (APAP, spurs NSAIDs, hyaluronic acid . Primary endpoint WOMAC score (knee pain + fxn) injections) • Medical and physical . Avg age 60, 2/3 female, BMI 31 therapy like controls . Excluded bucket handle meniscus and severe varus or valgus alignment Kirkley et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, NEJM, 2008. 5 7/27/2017 Results Kirkley et al. A Randomized Trial of Arthroscopic Surgery for McAlindon TE et al. OARSI guidelines for the non-surgical management of Osteoarthritis of the Knee, NEJM, 2008. knee osteoarthritis. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88. Corticosteroid injections for knee osteoarthritis . Anti-inflammatory . Low quality evidence . Probably inhibit COX-2 and phospholipase-A2, both inflammatory . Results inconclusive mediators . Pain relief (scale 0-10, 10 = extreme pain) • Steroid: 3 pts • Placebo: 2 pts . Improved function (scale 0-10, 10 = extreme disability) • Steroid: 2 pts • Placebo: 1 pt . Duration of steroid effect Goldman: Goldman’s Cecil Medicine, 24th Ed, ch 34 – • Moderate x 1-2 weeks Immunosuppressing Drugs. Accessed via MD Consult 1/6/2013. • Small- moderate at 4-6 weeks Published 22 October 2015. 6 7/27/2017 . 140 randomized patients • Mean age 58 years • 54% women . 2-year RCT . Sig more cartilage loss in triamcinolone group compared to saline . Patients with knee OA (mild-moderate) group . Q3 month triamcinolone or saline knee injection under ultrasound . No sig difference in pain between groups x 2 years . Annual knee MRI, WOMAC q 3 months Intra-articular corticosteroid injections: Hyaluronic acid injections for knee OA take home points . Short-term pain relief (6 weeks average) . No data for 1 brand name over another . Small effect on function . Can provide pain relief for longer than steroid (5-13 weeks) . No evidence for long-term pain relief . Evidence is heterogeneous . Significant placebo response . Clinical effect independent of degree of inflammation present . Risk = 1-3% pseudoseptic reaction • Don’t need to restrict injection just to those with effusion . Less likely to benefit . Frequency: general practice once every 3-4 months max • > 65 yrs old • Concern for cartilage toxicity if given q 3 months x 2 years • Severe joint space narrowing . “Uncertain” recommendation from OARSI 2014 . “Cannot recommend” (strength of recommendation = strong) from AAOS 2013 Gelber AC. In the clinic. Osteoarthritis. Ann Intern Med. 2014 Jul 1;161(1):ITC1-16. 7 7/27/2017 OA: disease modifying treatment? Case #3 . Surgical repair of cartilage 60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight • Efficacious for isolated cartilage lesions bearing. Better with rest, ice, and NSAIDs. • Less useful for global cartilage wear in OA . Injections: some promise, more data needed Exam: Neutral knee alignment when standing. Knee is not warm. • Platelet rich plasma (PRP)1 There is tenderness of the medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, limited by pain. • Mesenchymal stem cells2,3 (+) crepitus. (+) medial McMurray, medial knee pain with squat and Thessaly tests. No ligamentous laxity. 1. Campbell KA et al. Arthroscopy. 2015 May 29. 2. Freitag J et al. BMC Musculoskelet Disord. 2016 May 26;17(1):230. 3. Osborne H et al. Br J Sports Med. 2015 Dec 23. Diagnosis? Case #3 A. Medial meniscus tear 60 y/o woman presents with 3 months of medial knee pain. (+) swelling, and instability. No frank locking. Pain is worse with weight B. ACL tear bearing. Better with rest, ice, and NSAIDs. C. Medial compartment osteoarthritis D. Gout Exam: Neutral knee alignment when standing. Knee is not warm. E. Septic arthritis There is tenderness of the medial joint line + medial femoral condyle + medial tibial plateau. Small effusion. ROM 0-120, F. Medial meniscus tear and medial compartment osteoarthritis limited by pain. (+) crepitus. (+) medial McMurray, medial knee pain with squat and Thessaly tests. No ligamentous laxity. 8 7/27/2017 What do you recommend? A. Refer for arthroscopic debridement of cartilage and meniscus B. Nonoperative knee OA program C. Refer for total knee arthroplasty Surgery vs PT for meniscal tear and OA Interventions . Control (PT) . Arthroscopic partial meniscectomy (APM) . Multicenter RCT • Usually 6 weeks . 351 patients with meniscus tear + mild-moderate OA • Trim damaged meniscus • 3-stage program back to stable rim . Meniscus sxs (clicking, popping, catching, giving way, joint line . APAP, NSAIDs, intraarticular pain, pain with twisting) • Remove loose cartilage and steroid injections as needed bone . Avg. age 60 years . PT protocol . 50% men, 50% women . APAP, NSAIDs, intraarticular . Primary outcome = change in WOMAC physical-function score steroid injections as needed between groups at 6 mo Katz JN et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2; Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84. 368(18):1675-84. 9 7/27/2017 Results Results Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84. Katz JN et al. N Engl J Med. 2013 May 2; 368(18):1675-84. Conclusions What if this same patient had an isolated degenerative meniscus tear and no clinical .
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