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Clinical assessment Knee osteoarthritis Surgical management of knee osteoarthritis Meniscal tears Anterior cruciate ligament injuries Spontaneous osteonecrosis Synovial chondromatosis

The author

ASSOCIATE PROFESSOR PETER J PAPANTONIOU, orthopaedic and lumbar spine surgeon, St George Private Hospital, Kogarah; St Lukes Private Hospital, Elizabeth Bay; Dalcross Adventist Hospital, Killara; and Associate Professor at the Sydney Adventist Hospital Clinical School, University of Sydney.

Background
KNEE disorders affect adults of all ages. They range from traumatic and sporting injuries, which mostly occur in the younger adult, to degenerative conditions in the older patient. Traumatic injuries have different characteristics at different ages. The younger patient often presents with meniscal tears or cruciate ligament injuries. There is a second peak of these types of injuries in veterans sports. Fractures are associated with high-energy injuries of risk-taking behaviour in the younger patient and with lower-energy injuries in the older patient. Degenerative conditions such as osteoarthritis most commonly occur in older patients, but the traumatic injuries in younger adults are often repaid with early arthritis; it is not uncommon for total knee replacements to be necessary in such patients in their 40s or 50s.
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Knee disorders in adults

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HOW TO TREAT Knee disorders in adults

Clinical assessment of the knee

ASSESSMENT of a person with a suspected knee disorder should include the classic orthopaedic examination triad of look, feel and move.

Look
Look at the alignment of the knee with the patient standing. Varus or valgus alignment will point to the likely affected compartment of the knee. Observe their gait as they walk across the room. If the patient has an obvious limp, is it an antalgic (painful) gait? Is it a flexed-knee gait (with an inability to fully extend the knee)? Is there a thrust, with the knee moving medially or laterally when weight is placed on it? Is it a complex gait with several components?

In a large effusion there may be too much fluid to milk it up into the suprapatellar bursa.

Feel
Palpate for an effusion with a swipe test. Swipe any fluid into the suprapatellar pouch; on the medial side of the joint gently slide the back of your hand from distal to

the joint, proximally to above the edge of the femoral condyle. This pushes any fluid up into the suprapatellar bursa. Then use the reverse action on the lateral side sliding the back of your hand on the lateral joint from proximal to distal. At the same time watch the medial side of the joint; any fluid should show as a swelling that suddenly appears on the medial side usually at the level of the joint line. In a large effusion there may be too much fluid to milk it up into the suprapatellar bursa. In this case, a patellar tap may be positive. Place one hand above the patella, pushing posteriorly and gently to push any fluid in the suprapatellar pouch down into the main part of the joint. If there is a large amount of fluid, this will elevate the patella off the femoral condyle. While holding the fluid there, press posteriorly on the patella in short sharp movements. You should feel the posterior sur-

face of the patella tap against the femoral condyle. Next, with the knee in flexion palpate along the joint lines medially and laterally. Tenderness here can be a sign of arthritis in the compartment or a meniscal tear. Palpating along the course of the medial and lateral collateral ligaments can give an idea if there is any ligament strain.

Move
With the knee in extension, see if any varus or valgus deformity can be corrected. Test the collateral ligaments with varus/valgus force. The anterior drawer test aims to test the integrity of the anterior cruciate ligament (ACL). With the knee flexed to 90, gently sit on the foot and using both hands grasp the proximal tibia. Gently pull the tibia back and forward looking for more movement than expected and compare it with the other knee. In a normal knee, the tibia will

move anteriorly less than 5mm. If there is 10mm or more of movement, this means the ACL is completely torn. A normal or partially torn ACL may still have a solid end point (ie, be negative) on anterior drawer. Finally, test the menisci by using the McMurray test. Flex the knee as far as possible beyond 90. With one hand over the knee palpate the posteromedial joint line. Then externally rotate the foot and ankle with the other hand. While holding this alignment, extend the knee. A painful palpable click indicates the test is positive for a medial meniscal tear. For the lateral meniscus palpate the posterolateral joint line, internally rotate the foot and extend the knee. A painful palpable click is positive for a lateral meniscal tear. Advanced arthritis or chondral lesions can also give apparently positive McMurray tests. It should be noted arthritic knees often have degenerate menisci that tear.

Knee osteoarthritis
Aetiology and pathogenesis
OSTEOARTHRITIS is the most common of all joint diseases, affecting millions of people worldwide. The prevalence of frequent pain from osteoarthritis of the knee is about 12% in patients 65 years or older. Osteoarthritis is the common end point of a heterogenous group of conditions that result in similar degenerative changes. It is a degenerative disorder both caused by, and resulting in, further biochemical breakdown of articular cartilage. The process involves the entire synovial joint cartilage, synovium and bone. It most frequently occurs in weight-bearing joints, and osteoarthritis of the knee is the single, most commonly treated condition in orthopaedic surgery. Osteoarthritis is divided into primary osteoarthrits and osteoarthritis secondary to other conditions. Regardless of the cause, the final end point is always degeneration of the articular cartilage and wearing out of the joint. For primary osteoarthritis, the single most consistent risk factor is obesity, and women are more commonly affected than men. The most common cause of secondary osteoarthritis of the knee is trauma, often in early adult life. This may include direct trauma to the articular cartilage, fractures with subsequent incongruity of the joint, meniscal tears and instability such as occurs with ACL tears. Incongruity of the joint refers to the loss or alignment of the joint surfaces and leads to abnormal forces on and accelerated wear of those joint surfaces. Other conditions such as spontaneous osteonecrosis of the knee can also end in osteoarthritis. The pathogenesis of osteoarthritis involves the proteolytic breakdown of the cartilage matrix. This leads to abnormal chondrocyte metabolism and increased production of enzymes such as metalloproteases that destroy the cartilage matrix. and that it may take up to three months to see any benefit. Corticosteroid injections have demonstrated both short- and medium-term effectiveness in reducing inflammation and relieving pain. Generally one injection or two, about six weeks apart, can be given. They should be performed under sterile conditions to minimise the risk of infection. If infection occurs, it is a major management problem. Not only is there the need to treat the infection immediately, but any subsequent total knee replacement has a poorer outcome and higher risk of infection. I generally only administer steroid injections if I am trying to delay a knee replacement (usually because the patient is young) or if I am trying to confirm the knee as the source of the pain. Unfortunately, these injections do not modify the disease process. Therapeutic arthroscopy should be performed in patients with knee osteoarthritis only if there is other pathology to address. A randomised controlled trial has demonstrated that arthroscopy as a treatment for osteoarthritis without any other mechanical issues, such as a meniscal tear, provides no additional benefit to optimised physical and medical therapy. 1 However, it is very common for patients with arthritic knees to have coexistent knee pathology such as a meniscal tear, and an arthroscopy is often very effective in relieving the associated mechanical symptoms. Unfortunately it has the occasional complication of stirring up the arthritis and accelerating the need for joint replacement. Arthroscopy in this setting may of itself ease some of the symptoms of osteoarthritis by irrigating the knee and removing debris, inflammatory mediators and degradative enzymes. However, this benefit is only temporary at best. It is important to be aware that arthroscopy in the presence of limb malalignment (angular deformity) generally has poor results.
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Over time these processes damage the chondral surface, leading to further breakdown of the chondral matrix. Eventually this leads to a chronic inflammatory response within the synovium, further accelerating the destructive process.

Investigations
The classic radiological features of established osteoarthritis of the knee include decreased joint space due to the destruction of cartilage, subchondral bony sclerosis, subchondral cysts, osteophyte formation and angular (varus or valgus) deformity.

Management
The aim of the management of knee osteoarthritis is the relief of symptoms. There are non-operative and operative treatments, and operative management is not undertaken until nonoperative management has been exhausted. Simple measures are often very effective in the early stages of

osteoarthritis of the knee. Paracetamol in appropriate doses can often relieve the symptoms for a long time. Given symptomatic osteoarthritis of the knee is a chronic inflammatory condition, NSAIDs do have a part to play. Assuming no contraindications, an anti-inflammatory will modify the chronic inflammatory response as well as relieving pain. The combination of paracetamol and an antiinflammatory can provide significant relief for long periods, delaying or avoiding the need for surgery. It is important that overweight patients adopt an appropriate diet and undertake a non-impact exercise program to lose weight. A significant number of patients will reduce their symptoms if they are able to lose weight and maintain the weight loss. Physical activity modification is important; high-impact activities should be restricted. Patients need to ensure they obtain adequate rest and do not spend too much time standing or climbing stairs.
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Footwear and orthotics have a place in the treatment of knee osteoarthritis. Energy-absorbing shoes or inserts can reduce the peak pressure in the knee associated with the gait, thereby decreasing the forces across the joint. Orthotics to modify the angles of the knee can be useful. However, most patients are reluctant to wear an orthotic at all times and this generally eliminates any benefit. Therefore, orthotics may have only very limited usefulness long term. Something as simple as a walking stick can help ease the pain, by sharing the load between the affected knee and the walking stick held on the contralateral side. Glucosamine and chondroitin sulfate have demonstrated some efficacy in trials. The effect is only marginally greater than that of placebo and there are contradictory results. Generally, however, it is still worth trying. The patient must be made aware that they should use the combination of glucosamine with chondroitin sulfate

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HOW TO TREAT Knee disorders in adults

Surgical management of knee osteoarthritis

WHEN conservative measures no longer control the pain and disability of knee osteoarthritis, an arthroplasty should be considered. Figure 1: Unicompartmental knee arthroplasty (shown by arrow). Figure 2: A Repicci UKA inserted 14 years earlier, now causing pain because of arthritis of the other compartments. X-ray before revision to a TKR. A: Lateral. B: Anteroposterior. C: Skyline.

Unicompartmental knee arthroplasty

Unicompartmental knee arthroplasty (UKA) using various designs of prosthesis has been performed since 1972 for osteoarthritis of the medial and the lateral compartments of the knee. The theoretical advantages of a UKA are that: It preserves the undamaged compartments of the knee, only replacing the compartment that has the arthritis (figure 1). It preserves the cruciate ligaments, thereby preserving the kinematics of the knee joint. It involves less intraoperative blood loss and, therefore, reduced requirements for blood transfusions. It tends to be less expensive. It is associated with less morbidity and a shorter hospital stay than total knee replacement. Since the advent of UKA and its widespread use, changes in practice have occurred. It is now generally considered that only the medial compartment is suitable for a UKA. The Australian Orthopaedic Association National Joint Replacement Registry has demonstrated the failure rates of lateral UKAs are significantly higher than that for medial UKAs. Patients being considered for UKA should have: A reasonable range of knee motion. Any varus or valgus deformity of less than 20 that can be corrected. No inflammatory or crystalline arthropathy (eg, no rheumatoid, gouty arthritis or pseudogout). Intact cruciate ligaments. UKA is sometimes regarded as a procedure to delay total knee replacement, for example, a UKA in isolated medial compartment osteoarthritis in patients 65 years or younger. The expected lifespan of the UKA and, years later, the subsequent total knee replacement (TKR) should be long enough for the patient to see out the rest of their life. On the other hand, some surgeons adhere to the philosophy that a wellperformed UKA in the older patient can be a definitive procedure (figure 2) and, after a check arthroscopy to assess the joint surfaces, will perform a UKA in older patients as well. The Repicci UKA is one of the first of the newer-generation UKAs. More than 10 years experience with the Repicci has shown that it is possible for a UKA to be the definitive procedure. If inserted in young-enough patients, the rest of the knee will eventually wear out. The principles of a medial UKA are to replace the arthritic joint surfaces with a femoral and tibial implant. It is imperative not to overstuff the medial joint such that the mechanical axis of the knee changes too far laterally and loading of the lateral compartment occurs. Often patients with arthritis mainly in the medial compartment will have varus angulation of the knees resulting in a medially aligned mechanical axis. The principles of the UKA are to maintain this mechanical axis, so most of the weight-bearing still occurs through the now-replaced medial compartment.

If the medial compartment is overstuffed and the angles go back to neutral or valgus, the mechanical axis will shift laterally, load up and therefore wear out the lateral and patellofemoral compartments much faster.
Clinical outcomes of UKA

The clinical outcomes following unicompartmental knee arthroplasty are very surgeon-specific. In general, unicompartmental knee arthroplasties do not last as long as total knee replacements. This crude statistic unfortunately misrepresents the aim of a UKA. In the younger patient, a UKA is often a smaller operative procedure designed to delay the initial total knee replacement to an older age, therefore hopefully avoiding revision knee replacements in the future. In the older patient, a UKA may be the definitive procedure that sees them out the rest of their lives. Unfortunately, in the past UKAs have been plagued with a misunderstanding of the biomechanics and principles involved. This, coupled with the more technically demanding nature of the insertion procedure, has resulted in an overall higher failure rate. It is fairly clear that in the right surgeons hands, a technically wellperformed UKA will achieve the desired results. They should not, however, be considered as an alternative to a total knee replacement.

Total knee replacement

TKR (figure 3, page 32) is one of the most commonly performed orthopaedic procedures. The goals of TKR are to: Relieve pain. Restore the mechanical axis. Restore the joint line. Balance the ligaments. Restore the Q-angle of knee (the angle formed by a line drawn from the anterior superior iliac spine to central patella and a second line drawn from central patella to the tibial tubercle). The most common indication for TKR is knee osteoarthritis. This may be in any or all of the compartments. Patients will often complain of a gradual onset of knee pain and swelling. These may have been present for many years but have become worse. There will often be a trigger event such as a minor trauma, which sets off a more

severe pain that does not settle. The pain could be in the medial or lateral part of the knee, or behind the patella on climbing or descending stairs. It is often painful with each subsequent step and patients often notice they have to walk slower or cannot walk as far before they have to rest. In advanced cases of knee osteoarthritis (figure 4, page 32), patients will often complain of an aching pain at night that may keep them awake. Investigations such as plain X-rays will reveal the classic features of osteoarthritis, as previously described, and there may be angular deformity of the knee. When investigating knee pain, it is important to obtain long weight-bearing films of the knee (from hip to ankle) to allow assessment of the mechanical and anatomical axis of the knee joint. A patella skyline view will help to assess any osteoarthritis in the patellofemoral compartment. Once a clinical and radiological diagnosis of symptomatic osteoarthritis of the knee has been obtained, and the patient has failed all conservative management, the only real solution is a TKR. The principles of a TKR are the replacement of the arthritic weightbearing joint surfaces, so as to relieve the pain associated with weight-bearing and motion. A knee replacement procedure itself is a large physiological challenge to an elderly unwell patient and, as such, preoperative assessment of the patients cardiovascular and respiratory systems as well as a series of blood tests are routinely performed. If the patient is deemed fit enough for the procedure, an appropriate implant and theatre time are selected. Knee replacement prostheses have many different designs and configurations. Most knee deformities can be accommodated with modern knee replacement designs. Options available include designs that include: Fixed bearing: the original type with the polyethylene liner held by the tibial baseplate. All movement then occurs between the femoral component and the poly liner. Mobile bearing: the poly liner can rotate, or slide and rotate, on the smooth tibial baseplate. This allows some of the forces to be spread from the top of the poly to the underside. It appears these wear less
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overall compared with the fixedbearing types. Congruent: the poly design is a tighter fit to the femoral implant. This allows less movement back and forth of the femur on the tibia. Some patients can interpret this movement as instability. Ultra-congruent: a much finer alignment of the femoral component to the tibial poly. This can be used to compensate for a minor amount of ligament laxity. The trade off is that with such a tight fit, some of the normal forces that cause the femur to slide on the tibia must now be taken through the poly liner, potentially causing increased wear. More constrained designs: to compensate for lax or missing colateral ligaments. Complete hinged knee replacement: when there is multi-ligamentous instability.

A knee replacement is basically a soft-tissue balancing procedure. An ordinary knee replacement cannot be performed if the constraints of the collateral ligaments are not present. In this situation it is impossible to balance the knee to varusvalgus stress and obtain adequate stability. During TKR, the ACL is routinely sacrificed and in a large proportion of patients the posterior cruciate ligament (PCL) is as well. The choice of prosthesis takes this into account. The next level up would be a posterior stabilised knee replacement that compensates for some varus/valgus instability. In the most severe cases, such as multiligament instability or multitrauma situations, a hinged knee replacement can be selected. Finally, in the multiply-revised knee where there is extensive bone
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loss, there are more specialised knee replacements to compensate for this bone loss, up to and including tumour-type knee replacements (usually used in the clinical setting of bone tumours). These can replace large portions of the tibia and femur with metal implants. As part of this extensive bone replacement, they are also hinged on the assumption there will be ligamentous loss.
Clinical outcomes following TKR

Figure 3: Cemented total knee replacement.

Figure 4: Varus osteoarthritis of the knee.

The results of a modern knee replacement are generally excellent. In the past 20 years the lifespan of knee replacements has increased from five years, to 10 years, to 20 years in about 90% of patients today. This has changed the entire landscape of knee replacement from expecting that someone in their 60s or 70s will need at least one revision knee replacement in their lifetime to now expecting that the same patient with a modern knee replacement may not need further surgery at all. The current hope is that after a first knee replacement, no revision procedure will ever be needed. Most of this improvement in the longevity of knee replacements appears to be directly related to improvement in the polyethylene bearing surfaces. After a knee replacement it usually takes 12-18 months for a patient to recover completely. By that stage they generally have forgotten they have had a knee replacement and go about their life normally. With modern anaesthetic techniques and early mobilisation,

most patients can be driving and doing virtually all of their usual activities within 2-6 weeks. The average hospital stay has decreased from two weeks to about five days. Some of the more advanced pain-relief techniques allow joint replacement such as hip and knee replacements to be an overnight stay. These patients can

go home the next morning, are self-caring, able to get up out of bed, shower, toilet themselves, eat and drink, and venture out to the shops the morning after a knee replacement. Critics of this technique claim a higher readmittance rate to hospital, but studies of this approach show no higher incidence of readmission than for any other technique.

Knee replacements have now improved to the point where patients are be able to achieve close to if not the same range of motion as they had preoperatively, and regain their mobility rapidly. Some will have minor aches and pains longer term, but most will have an excellent pain-free range of motion and be performing all the activities they wish.

Meniscal tears
THE medial and lateral menisci in the adult are largely avascular in the central 70-90%. It is only the periphery that remains vascularised and innervated. Their main function is to deepen the tibial plateau surface and increase the congruity (fit of the femur to the tibia) of the knee joint. Removal of the menisci causes a marked reduction in the femoral condyle contact area and, thus, increases the contact stresses by up to 2-3-fold. Meniscal tears have a bimodal incidence. The first peak is in young adulthood, often associated with some form of high-intensity trauma, such as sport. The second peak is in later life, when the menisci become degenerate and a much lesser force is required to cause a tear. Men have a three-times higher incidence of meniscal tears than women. The medial meniscus is torn more commonly than the lateral meniscus. The tears themselves can be in any configuration (figure 5). The most common are longitudinal tears along the length of the meniscus (such as a bucket-handle tear), and a horizontal cleavage tear, more common in older patients and associated with degeneration in the body of the meniscus. Oblique and radial tears are the other common patterns. In degenerate menisci, you often find combinations of these (so-called complex tears). The most common mechanism of injury is a twisting injury, often associated with hyperflexion. The patient will often describe something giving way in their knee or a tearing sensation, and suffer immediate pain. The pain may last several days or may continue long term. It is quite common for the pain to subside after 1-2 weeks, and the patient to be asymptomatic for months, if not years. Recurrent episodes of pain or ongoing pain that does not subside is generally an indication for arthroscopy and meniscectomy. The most accurate investigation for suspected meniscal injury is an MRI. However, it should be noted clinical examination can sometimes diagnose an undisplaced meniscal tear better than an MRI. repair. It is rare to have a meniscus that is repairable in the older adult, and the most common arthroscopic procedure for meniscal tears is a meniscectomy. This is typically a partial meniscectomy, but it depends on the exact configuration of the meniscal tear. In a large complex meniscal tear it may be necessary to do a subtotal or even a total meniscectomy. The aims of a partial meniscectomy are: To leave a stable balanced ring of healthy meniscus, which avoids the increase in joint contact forces that would result from a total meniscectomy. To provide a stable pain-free meniscus that is not mobile into the joint and so does not cause recurrent episodes of pain. The results of this procedure are generally good, but when the torn meniscus is also degenerate, a repeat meniscectomy is commonly necessary in the medium term. The long-term consequences of a partial or total meniscectomy are the increase in joint contact forces, accelerating the arthritic process. Attempts to replace a meniscus successfully continue. Artificial replacements have so far been unsuccessful. At present some centres are trying allograft (ie, cadaveric) meniscal transplants, and this raises the possibility of immune rejection.
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Figure 5: Parrot beak meniscal tears (shown by arrows).

Management
It is rare for meniscal tears to heal spontaneously. The only part of the meniscus considered capable of healing is the outer 10-30% which is vascularised. The constant movement and shear forces across the meniscus during knee movement generally preclude any spontaneous healing of the meniscus. At arthroscopy, only peripheral meniscal detachments in young people are considered suitable for

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Anterior cruciate ligament injuries

THE ACL is composed of two major functional bands and is approximately 35-40mm long and 10mm wide. Its origin is on the posteromedial aspect of the lateral femoral condyle, and it goes diagonally forward in the knee joint to insert over a large area of the intercondylar eminence anteromedially on the tibia. Its major blood supply is from the middle geniculate artery. The normal ACL has a very high tensile strength in young adults. One of its major functions is to produce normal knee kinematics, and the different bundles work at different knee flexion angles. Figure 6: ACL complete tear scarred down onto PCL. Other associated injuries in the knee, such as a meniscal tear. Lifestyle factors of the patient, such as a high-demand athlete, skier, football or soccer player. The patients age, with patients over 50 generally not considered as operative candidates. The degree of instability. A patient who may have had an ACL tear in the past, but continues to have significant instability with ordinary activities would be a candidate for a reconstruction. The co-operation of the patient (a non-compliant patient is unlikely to perform the rigorous physiotherapy program required post-operatively). At present, operative treatment of an ACL rupture typically consists of a reconstruction. In the past, acute repairs of the ACL (direct suturing of the torn ligament end to end) were undertaken, but these had a failure rate of up to 50% after five years. The operative intervention of choice is now a reconstruction, either using a hamstring tendon graft (figure 7), or using a bonepatella tendonbone graft. (A small rectangle from the anterior surface of the patella is harvested with the patella tendon piece attached. This is split longitudinally to its insertion on the tibia. The attachment on the tibia for this fragment is also harvested and the complete bonepatella tendon bone graft is used. While there are really only the two methods of graft selection, there are many methods of fixation of the graft, the consequence of which is that postoperative rehabilitation varies depending on the technique chosen. Generally, more modern fixation techniques allow for early mobilisation and return to function in the patient, with most reconstructions now allowing immediate postoperative mobilisation. The patient can often return to work two weeks postoperatively. The most important restriction postoperatively is that it does take 6-12 months for the grafts to consolidate and achieve full strength. Most surgeons will restrict patient activities for the first 12 months after a reconstruction. Specifically this means they are told to avoid activities such as football, soccer, and any other activities that place a high load across their knee. In the high-demand athlete it is possible to do more than one reconstruction in each knee. The choices of grafting material do become limited and the results of a revision reconstruction are never as good as the first reconstruction. Artificial graft material has come and gone and is now making a resurgence. This is mostly used for the multiplyrevised ACL reconstruction, but some surgeons are using it as a primary graft. The results of the first wave of artificial grafts were less than impressive, which led to the downturn in its use. The proponents of the newer materials claim better results. Finally allografts can be used, mostly in revision situations.

References
1. Kirkely A, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine 2008; 359:1097-1107. Erratum in: New England Journal of Medicine 2009; 361:2004.

Online resources
Wheeless Textbook of Orthopaedics: www.wheelessonline.com Professor Papantonious website (includes a demonstration of how to do a swipe test): www.profpap.com.au

ACL

ACL scarred down to PCL

History
Trauma to the ACL is often associated with a high-force injury in a young adult. Commonly implicated sports include football, soccer and skiing. There will often be an abnormally high valgus force applied to the knee with the knee flexed. The patient will often feel a popping sensation, or the knee giving way. There will be immediate pain, but often the swelling will not start until several hours after the event. The swelling is generally due to a haemarthrosis from the middle geniculate artery. After the haemarthrosis has settled and the patient is back to normal mobility, they may experience symptoms of instability. They will often say that with a slight twisting motion the knee feels like it is giving way. They may in fact have falls. It is very common after a complete ACL rupture for the patient to have difficulty re-engaging in their sporting activities. Tears of the ACL can be either partial or complete. A partial tear may go through all similar symptoms to a complete tear initially, including the swelling, but generally the patients do not have instability in the medium term. Complete tears, except in the most trained of athletes, will generally exhibit some signs of instability later. Caution must be exercised in the patients who do have a complete tear, exhibit instability early, and then, several weeks or months later, seem to stabilise. This is often a result of a complete avulsion of the ligament from its origin on the femur, and then as the ACL lies on the anterior surface of the PCL, it sticks and eventually scars down to the PCL (figure 6). While producing some temporary stability, this will not be strong enough to stand up to the rigours of sporting activities. The scarred-down ACL stump may give way at any time and the forces required to do this are far lower than that which caused the initial injury.

Figure 7: Hamstring tendon graft reconstruction in place (shown by arrow).

Complete tears, except in the most trained of athletes, will generally exhibit some signs of instability later.

associated meniscal tears, and other ligament injuries (most commonly the medial collateral ligament).

Management Physical examination and investigations

The classical findings on examination are an effusion, often large, which starts several hours after the injury, due to bleeding from the middle geniculate artery avulsion. The effusion usually settles enough for a proper examination after 7-10 days. The patient will have a positive anterior drawer test. The greatest difficulty in examination is quadricep spasm and guarding. MRI is very accurate for diagnosing ACL tears and will often show Management of the ruptured anterior cruciate ligament consists of non-operative and operative treatments. Non-operative management aims to control the swelling and pain initially, with a rapid restoration of the full range of motion and strength in the quadriceps over the next few weeks. Initial treatment is with ice packs, NSAIDs and physiotherapy. A physiotherapist-supervised strengthening program for the quadriceps and hamstring muscula-

ture should be undertaken immediately. With a complete ACL tear, one of the main stabilising factors in the knee has been removed. The aim of non-operative management is to try to compensate for this by strengthening the muscles surrounding the knee. The patient should not be allowed to undertake their normal activities until they have reached at least 90% of normal strength in the quadriceps. They must avoid any of their high-risk activities for at least three months after the tear. Even with ideal nonoperative management, they may still require operative management to address any associated meniscal tears or chondral injuries. If a patient has ongoing instability and pain, or they have high demands placed on their knee, operative intervention may be chosen. There is little agreement in the literature about the requirement for surgical intervention vs non-operative intervention. Generally however, younger, more athletic patients will do better with operative intervention than older, more sedentary patients. Some of the factors that influence the decision to operate include: The time from initial injury to operation. Ideally two weeks to six months is the best time to operate. After this time, accelerated chondral damage occurs and the results of a reconstruction may not be as good. Preoperative physiotherapy should be undertaken for quadriceps strengthening.
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Spontaneous osteonecrosis of the knee

SPONTANEOUS osteonecrosis of the knee (SONK) is a condition of unknown aetiology, characterised by the development of an area of osteonecrosis on the weight-bearing surface of the medial femoral condyle. Research suggests the medial femoral condyle is more at risk because it is supplied by an end artery. It generally affects people older than 65, and is three times more common in women. The clinical presentation of SONK is with a sudden onset of deep pain within the knee, often localised to the medial side. It is usually in the whole medial side of the knee, rather than just at the joint line. The patient complains of pain and difficulty walking. Any weight-bearing activity tends to aggravate the pain. When pressure is taken off the knee, such as when the patient is sitting or lying down, the pain subsides. Examination reveals a small effusion, but a knee with a good range of motion, generally with ligamentous stability and only some mild tenderness over the medial side of the knee. Initial investigations reveal little change on a plain X-ray, but in the medium to longer term there may be some osteopenia visible in the medial femoral condyle. In the presence of pain with a normal X-ray, with osteonecrosis, a bone scan will reveal a focal area of high activity in the medial femoral condyle. An MRI scan is definitive and shows a discrete area of avascularity within the medial femoral condyle. The differential diagnosis of SONK includes osteochondritis dissecans, osteoarthritis of the medial compartment, a degenerate medial meniscus with or without a tear, stress fractures, and other conditions such as tumours or infections. The importance of SONK is that, similar to avascular necrosis of the hip, there can be progression to subchondral bony collapse and arthritis. SONK is staged similarly to avascular necrosis of the hip, in that it has an incipient stage, an avascular stage, a collapse stage and a degenerate stage (see How To Treat, Non-arthritic disorders of the hip, 9 December 2011 for more detail). The aim of treatment is to avoid progression of any of the early stages. The natural history of SONK is that the earlier stages may recover spontaneously. There is no good evidence that any operative treatment will change the natural history in the early stages. Once a patient has gone on to subchondral collapse and degeneration of the joint, the prognosis is poor. These patients will inevitably develop symptomatic osteoarthritis and will require knee replacements. One of the most important prognostic variables is the total size of the lesion, with smaller lesions tending to have a better prognosis. The treatment of SONK in the early stages is conservative. This involves restricting weight-bearing with the use of crutches and avoiding any impact activities completely. There is some evidence to suggest calcium supplementation and bisphosphonates may be of benefit. In the later stages of SONK, where there is collapse or degenerative joint changes, the only real treatment is either a unicompartmental knee replacement or a TKR. The decision to recommend joint replacement is based on the symptoms and associated deformity.

Synovial chondromatosis
SYNOVIAL chondromatosis is a benign proliferative disorder of the synovium, resulting in multiple loose bodies in the knee joint. There are two types of this disorder. primary synovial chondromatosis is that cartilaginous bodies form and grow within the synovium, and then become loose bodies within the joint. bones and fragments of cartilage break off. These loose bodies then continue to slowly grow within the joint as they are nourished by the synovial fluid. Synovial chondromatosis affects patients in the third to fifth decades of life. More than two-thirds of cases affect the knee, but other joints such as the elbow, ankle, hip and shoulder joints are susceptible to this condition. The disease is monoarticular. Clinically, patients complain of swelling, pain and loss of motion, and occasionally of the knee locking when a loose body impinges between the joint surfaces. There is generally an effusion and synovial thickening. Plain X-rays may not necessarily reveal any of the lesions, especially if they have not undergone any calcification or ossification. An MRI will identify multiple loose bodies. The treatment of synovial chondromatosis is the removal of the loose bodies and a synovectomy. Depending on the size of the loose bodies, this can involve either a mini-arthrotomy or it can all be accomplished through an arthroscopy.

Primary synovial chondromatosis

This involves chondral metaplasia of the synovium. The pathology in

Secondary synovial chondromatosis

This is associated with degenerative joint disease, where there is osteophyte formation on the edges of

How to Treat Quiz

Knee disorders in adults 23 March 2012
1. Which TWO statements are correct? a) A swipe test is the most sensitive clinical test for large effusions b) 10mm of movement using the anterior drawer test indicates a complete tear of the anterior cruciate ligament (ACL) c) A partially torn ACL may have a solid end point (ie, be negative) on anterior drawer d) A patient with knee osteoarthritis will have a negative McMurray test 2. Which TWO statements are correct? a) For primary knee osteoarthritis, the single most consistent risk factor is obesity b) X-ray changes of knee osteoarthritis include decreased joint space, subchondral bony sclerosis, subchondral cysts, osteophytes, and varus/valgus deformity c) Modified footwear and orthotics have no place in the treatment of knee osteoarthritis d) Any benefit from glucosamine and chondroitin sulfate will usually be evident within two weeks 3. Which TWO statements are correct? a) Corticosteroid injections reduce inflammation and relieve pain in the short and medium term b) Corticosteroid injections modify the disease process of osteoarthritis c) Arthroscopy is appropriate in patients with knee osteoarthritis only if there is other knee pathology to address d) Arthroscopic knee irrigation provides longterm improvement in the symptoms of osteoarthritis 4. Which TWO statements are correct? a) Unicompartmental knee arthroplasty (UKA) preserves the cruciate ligaments, and is associated with less morbidity than total knee replacement (TKR) b) Only the lateral compartment is suitable for UKA c) UKA may be used to delay TKR or as a definitive procedure in some patients d) A UKA aims to restore the mechanical axis of the arthritic knee to that of a normal knee 5. Which TWO statements regarding TKR are correct? a) The goals are to relieve pain, restore the mechanical axis, restore the joint line, balance the ligaments and restore the Q-angle of knee b) Long weight-bearing X-rays of the knee (from hip to ankle) and patello-femoral views allow assessment of the mechanical and anatomic axis of the knee joint, and any patello-femoral osteoarthritis c) A fixed-bearing prosthesis is appropriate when there is multiligamentous knee instability

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d) Mobile-bearing prostheses wear more readily than do the fixed-bearing types 6. Which TWO statements regarding TKR are correct? a) During TKR, the ACL is routinely preserved b) The typical lifespan of a modern knee replacement is seven years c) The use of modern pain-relief techniques allows TKR to be an overnight-stay procedure d) Most patients can drive and do virtually all of their usual activities 2-6 weeks after a TKR 7. Which TWO statements are correct? a) It typically takes 12-18 months for a patient to recover completely following TKR b) Range of knee motion following TKR is usually significantly and permanently reduced c) The lateral meniscus is torn more commonly than the medial meniscus d) The most common mechanism of meniscal injury is a twisting injury with hyperflexion 8. Which TWO statements are correct? a) The pain of meniscal injury usually settles after 1-2 weeks, and the patient may be asymptomatic for months or years b) MRI is always more sensitive for undisplaced meniscal tears than is clinical examination c) Injured menisci commonly heal spontaneously d) It is rare for a torn meniscus to be repairable in the older adult, and meniscectomy (partial, subtotal or complete) is usually required 9. Which TWO statements are correct? a) Complete meniscectomy reduces the femoral condyle contact area on the tibia and therefore, increases the stresses in the joint 23-fold, accelerating the development of osteoarthritis b) With a tear of the ACL, there will usually be immediate swelling and pain c) Partial ACL tears tend not to result in instability d) Complete avulsion of the ACL from the femur invariably results in ongoing instability from the time of injury 10. Which TWO statements are correct? a) Following ACL injury, physiotherapy to strengthen the knee musculature should be delayed until the knee is completely pain-free b) Suturing of a torn ACL is usually as effective as tendon-graft reconstruction c) Spontaneous osteonecrosis of the knee (SONK) typically presents with a sudden onset of deep pain in the entire medial side of the knee d) Diagnosis of early-stage SONK by bone scan and MRI is key to preventing progression to bony collapse and osteoarthritis

CPD QUIZ UPDATE

The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2011-13 triennium. You can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.

HOW TO TREAT Editor: Dr Giovanna Zingarelli Co-ordinator: Agilene De Villa Quiz: Dr Giovanna Zingarelli

NEXT WEEK The next How to Treat article attempts to make sense of coeliac disease management for GPs. It details the kinds of patients who should be investigated, as well as the appropriate advice that
needs to be given. The authors are Dr Katie Ellard, gastroenterologist in private practice, St Leonards, NSW; and Sue Shepherd, advanced practising dietitian and accredited nutritionist, Shepherd Works, Box Hill, and senior lecturer, department of medicine, Monash University, Victoria.

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| Australian Doctor | 23 March 2012

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