Common Knee Problems and how they are treated with Mr Dan Withers

Watch this video of Mr Dan Withers, Consultant Orthopaedic Surgeon, specialising in knee pain, discussing common knee problems and how they are treated.

This recording is from UPMC Sports Surgery Clinic’s first Online Public Information Meeting, intended for anybody interested in learning more about surgical and conservative measures for treating joint pain.

In this video, Mr Withers discusses the common causes of knee pain. He outlines how knee injuries are treated using surgery such as Total Knee Replacement for severe knee osteoarthritis or by adopting conservative methods of treatment such as exercise and physiotherapy for less serious knee pain.

Read Mr Withers’ presentation on common causes of knee pain here.

My name is Dan Withers, I am one of the Consultant Orthopaedic Knee Surgeons at the UPMC Sports Surgery Clinic in Dublin.

The talk I am going to give is on common knee problems, the common knee conditions that I would deal with here at SSC.  As most of you probably already know, UPMC Sports Surgery Clinic is an Orthopaedic Hospital which opened in 2007 covering all aspects of orthopaedic surgery. It has got five theatres and is in the process of building two more and it has a full suite of  Radiology Services, a Sports Medicine Department, a Physiotherapy Department and Strength and Conditioning.

In terms of joint replacements and the types of surgery that we do, last year, SSC did approximately eighteen hundred total hip replacements and total knee replacements and roundabout a thousand ACL ligament reconstructions.

In terms of the bulk of the stuff that I would see would be a lot of sporting injuries, a lot of ligament injuries. When you are looking at the knee, there are four main ligaments that stabilize the knee.

There are the two cruciate ligaments which are inside the knee, which is the posterior cruciate ligament and the anterior cruciate ligament. Then towards the inner aspect of the knee, there is the medial collateral ligament and towards the outside of the knee is the lateral collateral ligament. Those four ligaments provide the knee stability that these are dealing with their commonly injured when playing sports.

In terms of the medial collateral ligament, it is normally an injury which happens whenever a valgus force is produced on the knee. A valgus force happens normally when you take a hit towards the outer aspect of the knee or if your foot possibly gets caught in the ground and causes a valgus force on the knee itself.

It is quite a common injury in terms of its treatment, generally speaking, it rarely ends up needing any form of surgery if it is an isolated MCL injury that has happened and a lot of times we can just rehab these injuries, possibly with a small brace for a period between two to four weeks and maybe taking some painkillers but it rarely causes enough instability to require a reconstruction. The only time that we would really need to do a reconstruction of this is if it is injured in combination with another ligament.

The other ligament on the outside of the knee is the lateral collateral ligament and its more likely that this gets injured in sport whenever you get a knock to the inside of the knee and this is called a varus producing force.

An isolated injury of the lateral collateral ligament is fairly rare on its own, it normally happens in combination with other ligaments possibly with the ACL or PCL and as a ligament itself in terms of the surgery, the level of stability in the ligament decides whether or not surgery is required.

With conservative management, its is normally a brace for a period of weeks but if it needs reconstruction, sometimes we take ligaments elsewhere around the knee and do a reconstruction of that ligament that is normally in the setting of a multi-ligament injury.

The Posterior Cruciate Ligament, normally it takes quite a high energy impact to cause a posterior cruciate ligament injury sometimes people used to call this a dashboard-type injury whereby in a car crash, people’s knee used to hit off the dashboard and force the tibia backwards, which causes the posterior cruciate ligament to rupture.

In terms of the treatments of posterior cruciate ligaments it depends on how high-grade injury it is and on the whole, again, they can be managed conservatively but if they are very unstable or are very high grade we may need to do constructions of these ligaments as well.

This is the most common injury that I would see and it is the most common one people have heard of, it is the Anterior Cruciate Ligament and commonly it’s a non-contact injury. Around about 70 to 80 per cent of ACL injuries are noncontact, whereby in a match someone goes to change direction and it produces a valgus type injury and twist and the ACL is torn but it can also happen in contact injuries or indirect contact injuries as well.

In terms of the treatment of an ACL, normally, we end up needing to reconstruct an ACL ligament and how we would go about that is by taking ligaments from elsewhere around the knee. For example, the patella tendon where we take the middle third of the patella tendon and we drill tunnel’s within the femur, and one within the shin bone, and then we pass that ligament up through the tunnels and lock them in place with screws.

The picture on the right side of the screen is an arthroscopic picture of an ACL reconstruction. Afterwards, it does take quite a bit of rehab and strength and conditioning, and it takes between nine to twelve months, normally, to get back to return to play after an ACL injury.

Other ligament conditions that I would commonly treat are meniscal tears. There are two types of meniscal tears. There are tears that happen in the younger population and then there is the more commonly degenerative meniscal tear in the older population.

In terms of degenerative tears, the more common degenerative tears, a lot of times these can be treated conservatively but they may end up needing to go on to have an arthroscopy, which is at the bottom of the screen there, whereby you need to go and remove a flap of tissue through two small little nicks in the skin. This is another common condition that I would treat.

Osteoarthritis is basically is a degenerative joint disease. Its wear and tear of the articular cartilage and the issue with this is cartilage doesn’t have any capacity to heal itself. It has got no nerve supply or no blood supply so when you get wear and tear on it, it doesn’t repair itself and then it causes the symptoms such as pain, stiffness and swelling within the affected joint. Osteoarthritis most commonly affects the knee or the hip but it can present all around the body, even the back and neck and joints of the hand.

Often, people talk about the various stages of osteoarthritis, and sometimes you might hear people talking about grade 4 changes as end-stage osteoarthritic change. There are four stages and the picture here represents that. In stage one, which is picture A, normally what happens is that the cartilage starts to become a little bit softer. In stage two you start to get some fibrillation of the cartilage, then in stage three, you start to get partial thickness of the cartilage worn away and in stage four the cartilage is completely worn away basically the bare bone underneath.

There are various risk factors. I suppose age is one thing. The older you get, the more sort of the ‘miles are on the clock’. Approximately 50 per cent of people throughout their lifetime will develop some symptoms of knee osteoarthritis and around about a quarter of the adult population will have at some stage symptoms of hip osteoarthritis. So age just a big factor.

Obesity is a risk factor due to the fact that when there is an extra force going through the joints, obviously, you’re going to have more wear and tear within that joint.

Previous injuries, if you’ve ever had any previous injuries playing sports. You can damage the cartilage and as I mentioned it doesn’t actually repair itself, so the injuries there that can progress to full-blown osteoarthritis down the line.

If you have a family history or a genetic predisposition to developing osteoarthritis, there’s another risk factor.

Overuse and also muscle weakness and muscle imbalance. If you have weakness around the joints, or if muscles around the joint are weaker, you are going to put more force through that joint and therefore you may develop osteoarthritis quicker.

We know that osteoarthritis is very commonly asymptomatic. Normally I describe to people, the more miles on the tyre the lower the thread. So everyone to some degree will have a little bit of wear on their joints. There was a recent paper reported that up to 43 per cent of people over 40 years old have MRI signs of osteoarthritis, but no symptoms at all. That’s a quite interesting thing for me, why those people have no symptoms.

Some other studies suggest reasons for this could be to do with biomechanics and strength. We know that if you have a stiffer walking gait or an altered walking pattern, you tend to have more symptoms.

Also, if you have lower muscle strength, especially in your quadriceps muscles, then you are more prone to being symptomatic and having functional deterioration actually in the osteoarthritis process itself.

So the importance of exercise and being active is very, very important.

Some people get quite down if they are told that they have osteoarthritis of the knee and this is something I would normally tell people as well, is that if someone says you have osteoarthritis, it doesn’t mean that you actually end up needing any form of operation.

There was a paper that came out a little while back and they looked at everyone who was given a diagnosis of osteoarthritis and they went on to look at how many of them ended up needing some form of knee replacement or hip replacement and actually only 30 per cent of the people in that cohort ended up going on to have a knee replacement and 14 per cent ended up going on to have a hip replacement.

Some factors that were associated with a higher risk of going on to need an operation included increased weight that is something that we know is quite a risk factor.

So the actual osteoarthritis itself in the knee what happens is that there is a fissure in the cracks within the cartilage itself. Sometimes you have what’s called osteophytes, which is just basically a reaction of your knee joints trying to repair itself and you get some abnormal growths of little bone, which is an osteophyte and sometimes you can even get a little fluid-filled cyst in the bone underneath the knee joint as well and that is all part and parcel of the process of osteoarthritis.

The most common symptom of knee osteoarthritis is obviously a pain in the knee. Other symptoms include a limited range of motion and stiffness. People may have swelling from time to time. They can have that pain when standing or walking for long periods. And some people even end up getting night pain. I think night pain is probably the one thing that would trigger you to think that you may end up needing to have something like a knee replacement if you are starting to get night pain and you can’t quite control it.

The diagnosis normally involves an x-ray, sometimes we will have an MRI. This x-ray here shows the knee on the left side of the screen. You can see no gap in the joint itself. On the right-hand side, there’s a fairly evident gap so that knee is very arthritic and we would normally get an X-ray to diagnose that.

In terms of treatment, I always start off treatment with conservative management as much as possible and conservative management normally involves pain medication and you could start off with the simple things like paracetamol or anti-inflammatory tablets.

Normally, I recommend if somebody is finding that they are getting painful during certain activities, then taking the tablets one or two hours just before that activity is something that’s quite beneficial.

I mentioned before weight loss is important. We know that around about seven times your body weight goes through the knee on activities such as walking up and downstairs so even if you lose one kilo, that is around about seven kilos less, that is going through the knee on certain activities. Weight loss is definitely something that would help.

Other conservative methods, which are very important are exercise and specifically physiotherapy. Physiotherapy, normally what that involves is muscle strengthening. If you strengthen up your quadriceps and your gluteal muscle which is your bum muscle and your core muscle, it acts like springs’ on the car suspension. It tightens everything up and puts less force through the knee joint itself and less force through the knee joint means that you are going to have fewer symptoms of the osteoarthritis.

Staying active is very important, I encourage people to stay active and they are the main things for conservative management of knee osteoarthritis.

If you have exhausted all conservative treatments, the next thing that you might think about is an injection. There are different types of injection. The most common one is a steroid injection and this is a very strong anti-inflammatory which you inject into the joints and it reduces the pain and inflammation within the knee joint itself.

For some people, they can get quite long periods of time out of that, in terms of the length of pain relief, other people, not so much. There are other types of injections, such as hyaluronic acid, which sometimes people call a gel injection and also a plate rich plasma (PRP) Injection.

This is basically removing some blood and spinning it in a centrifuge and then siphoning off part of that plasma with the platelets in it. Then as you spin, the platelets, disaggregate and release a lot of natural anti-inflammatory properties and then you inject that back into the knee.

None of the injections do anything structurally to the knee. Their basic function is, as an anti-inflammatory to try and dampen down the symptoms. Sometimes people ask how often can you get injections? I would say to have injections twice a year.  If you are starting to need an injection more than that, then you may need to start upping the treatment ladder.

Another thing is sometimes people ask about supplements. If you look at the evidence for supplements, there is no clear evidence that any of the supplements actually prevent osteoarthritis. It is very difficult to prove with studies. So in the evidence, there is no clear evidence for that. Common ones such as glucosamine and Chondroitin have been shown to have a small role in the relief of the symptoms of osteoarthritis but whether or not they protect against it is difficult to say.

If you have gone through all of those treatment options and then the symptoms are ongoing and severe enough, then the next thing that you might need is a knee replacement.

Total Knee Replacement

A Total Knee Replacement involves basically shaving away the diseased end of the bones and putting on metal replacements with a very strong plastic in between the two metal pieces. That is a typical scar on the right of the screen there that it might have afterwards and that’s what a typical X-ray might look like afterwards.

Knee replacements are a very good operation when they are needed but I normally warn everyone that it can be quite tough for the first six weeks and then it can take a good six months to a year before you feel as if you’re back to any sort of normality. The key to any improvement afterwards is the physiotherapy.

Normally you will be in the hospital for around four or five days and you will have crutches for about six weeks afterwards and physiotherapy is the key to avoiding stiffness afterwards.

Partial Knee Replacement

Another option is a partial knee replacement or unicompartmental knee replacement. If you have a certain type of wear and tear pattern, mainly if the wear and tear is more towards the inner aspect of the knee, you may be suitable for a partial knee replacement.

The advantages of unicompartmental knee surgery versus a total knee are that the recovery is probably slightly quicker and also people would say that down the line this would feel a little bit more like a normal knee compared to the total knee replacement.

So those are some of the advantages but it has to be very specific wear and tear pattern to qualify it to have a partial knee replacement.

If you are someone who is very young and you have a lot of wear and tear in the knee joint and specifically on the inside part of the knee joint an option could be a Tibial Osteotomy and this is an X-ray of somebody that I performed tibial osteotomy on.

Normally you have to be probably 40 years old or less to qualify for this and the idea behind this is if you draw a line from the centre of the hip to the centre of the ankle, the mechanical access of your limb normally runs through your knee, through the middle part of the knee if you are looking from the front but when you get a lot of wear and tear on the inner aspect of the knee, then the mechanical access is shifted more towards the midline.

The idea of this is to have to essentially break the bone and then realign the tibia so that you realign the mechanical access and essentially, you are putting the forces more towards the outside of the knee where you have better cartilage, then this dampens down a lot of the symptoms that you have.

In summary, osteoarthritis is very common. It can be symptomatic or asymptomatic. The keys behind reducing symptoms for it are staying active and staying strong and conservative approaches to treatment is the treatment that I would always go for first.

Thank you.

Date: 6th May 2020
Location: Online
This event is free of charge