Important educational information for Mr Hardy's
patients on Knee Injury, Sports Injury and Orthopaedics and Trauma.
The following topics are about knee conditions. Click on the image for an
information brochure to print off...
Plica Syndrome
Plicae
are some of the normal structures of the knee joint cavity (Dupont
JY. Synovial plicae of the knee. Clin Sports Med. 1997;16(1):87-122).
They are folds of the capsule of the joint that surround the patella
(kneecap). The pleats are variable in structure between individuals. There
are at least 4 in most knees.
The
least common is the lateral patella plica. The most common is the medial
patella plica. The medial and lateral patella plicae are load sharing for
the patella and trochlea (kneecap and thigh bone) in much the same way as
the menisci (cartilages) are for the tibio-femoral joint (thigh bone and
shin bone). The suprapatella plica, medial plica and infrapatella plica
are not without clinical relevance.
The relief of pain and prevention of
progression of osteoarthritis is the main benefit of both conservative
management using physiotherapy and knee patella
braces and supports. Occasionally minor day case keyhole surgery is
needed. The results are very successful for plica syndrome before grade 3
degenerate change of the cartilage has taken place. (O'Dwyer
KJ and Peace PK. Injury. The plica syndrome 1988;19(5):350-2). ......
The
complete suprapatella plica causes knee pain in long distance cyclists and
runners.....
Intra-articular band
An
intra-articular band of the knee is often easy for the patient to localise
but rarely are there clinical signs of this painful condition. The MRI
scan us usually normal. However, take a careful history in these
patients and the condition can be demonstrated and cured easily with day
case keyhole surgery.
Torn Ligamentum Mucosum
The
infrapatella plica is usually known as the ligamentum mucosum. The
ligamentum is intact in early life and may or may not be present
in the elderly implying in life it has ruptured in some patients lifetime. It
lies in the same plane as the anterior cruciate ligament (ACL).
This suggests that the same type, but not necessarily magnitude, of injury
that ruptures the ACL
also ruptures the ligamentum mucosum (Abreu
MR et al. Hoffa's fat pad injuries and their relationship with anterior
cruciate ligament tears. Skeletal Radiol. 2008;37(4):301-6).
The ligamentum mucosum can be
considered to be equivalent to a washing line that supports the Hoffa’s
infrapatella fat pad. Tear of the ligamentum mucosum is not without
clinical relevance. The relief of pain and prevention of
progression of osteoarthritis is the main benefit of both conservative
management using physiotherapy and knee patella
braces and supports or keyhole surgery for this condition.....
Patella Tendonitis
Patellar
tendonitis is a common sport related injury. It is most common in jumping
sports. It is a painful degeneration of the patella tendon usually
involving microtearing of the collagen bundles of the patella tendon.
The pathology of the microtear is related to cyclic loading and possible
also to the relative ischaemia suffered by the tendon during activity in
which compressive
forces occur. It may occur at any location along the patellar tendon,
but the most commonly affected site is beneath the inferior pole of the
patella. When looked at beneath the microscope there is “mucoid”
degeneration of the tendon collagen.......
Mr
Hardy's analysis of his arthroscopic experience since January 2001 is that
on its own it accounts for approximately 12% of anterior knee pain. His
analysis also shows it is associated with meniscal tears in nearly 25% of
all patients undergoing arthroscopy for this condition. The
treatment for this condition was described
in the scientific literature 18 years ago (Magi
M, Branca A, Bucca C, Langerame V).
The condition was first reported by German surgeon Albert Hoffa in
1904 (Albert Hoffa, 1859-1907) so it is odd that it has taken so long to
recognise it as a common genuine condition in athletes
(Emad
Y and Ragab Y).
The relief of pain and prevention of
progression of osteoarthritis is the main benefit of both conservative
management using physiotherapy, patella taping, patella
braces, patella
straps and knee
supports.
It is Mr Hardy's experience that a third of patients can be treated with
patella taping (similar to that employed by Rafael Nadal) and
physiotherapy.
The
rest need
minor day case keyhole surgery. The results of surgery are very successful
for Hoffa's posterior fat pad impingement syndrome before grade 3
degenerate change of the cartilage has taken place.
Below is a clip posted on YouTube
by one of John Hardy's patients. It is a great example of a combined
injury of meniscal tear and Hoffa's posterior fat pad syndrome. Impingement
of the fat pad causes the fibrous synovial tag to develop. If missed by an
inexperienced knee surgeon during arthroscopy these tags explain
persistent pain and arthritis after partial menesectomy or ACL
rupture in some patients.
Knee Arthroscopy
Arthroscopy
of the knee is an operation on a joint which is done by a "keyhole"
technique. A narrow lens, on the back of which is a video camera, is
inserted into the joint to allow examination of the inside. By using
specially designed probes and instruments, the surgeon can also do some
treatments to the inside of the knee joint.
Why should it be done?
It would only be done if you have persistent symptoms from your knee such as pain, locking, swelling or giving way.
These symptoms are indicative of ongoing impingement and wear in the
knee.
Look at this video below of a lateral meniscal tear missed by an MRI
scan. There has been little wear and tear of the surface of the joint
from the hard gristle of the unstable meniscal tear as it was dealt with
promptly by keyhole surgery. Compare it to the video above where time
has elapsed between onset and treatment. It is easy to see why a
neglected or missed meniscal tear is the most common cause of
unicompartmental osteoarthritis.....
Arthroscopy of the
knee is usually done after an injury which is failing to settle at 6
weeks with conservative treatments such as RICE, knee
supports and physiotherapy and where
there is evidence of damage to the ligaments, cartilages, lining or surfaces of the
knee joint. If it is done for an injury, a MRI scan of the knee will be
done first to alert the surgeon to what may be found inside the joint
before the procedure so that he can properly advise on the
prognosis.......
ACL Reconstruction
Knee
ACL reconstruction is highly successful these days. However, about
50% of all athletes that rupture their ACL do not require surgery but
rehabilitation and an ACL
Brace. In the patient not requiring surgery rehabilitation is as important, if
not more so, than the athlete who does want surgery to stabilise their
knee. Anterior Cruciate ligament surgery and rehabilitation have
undergone dramatic changes recently.This is due to scientific research, improved surgical
technique, extensive clinical experience and better understanding of
the consequences of rehabilitation.....
Osteochondritis Dessicans
Osteochondritis
Dessicans of the knee is a degenerative condition of the cartilage and
underlying bone on the surface of a
joint.The cartilage provides a low friction, impact resistant,
bearing that contributes to efficient pain free stability in posture
and locomotion. Cartilage
like any other tissue or material can be damaged by high pressure or
repetitive loading.In osteochondritis dessicans the repetitive loading is caused
by conditions like Hoffa's Posterior Fat Pad Impingement as in the
information sheet above.....
Knee Arthritis
Arthritis
of the knee is a degenerative condition of the cartilage on the surface of a
joint.The cartilage provides a low friction, impact resistant,
bearing that contributes to efficient pain free stability in posture
and locomotion. Cartilage
like any other tissue or material can be damaged by high pressure or
repetitive loading.The medial
meniscal
tear in the clips
below were responsible
for the wear and tear of the surface of the joint in both these knees.
The one on the left was not locking the patient's knee the one on the
right was. Both patients had been told incorrectly they should expect
knee pain as they got older!
Knee
pain is not normal and the longer it is endured the worse the
prognosis.
Knee Replacement
Although
other measures like medications, osteoarthritis
knee braces and kneearthroscopy
may be helpful with symptoms, the bestcure
may be knee replacement of the affected knee withan
artificial joint (prosthesis). An artificial knee joint or knee
arthroplasty can
help you return to many of your routineactivities....Many
patients offered knee replacement surgery might not need it or do not
want a knee replacement. Fill in an Oxford Score Sheet (click on the
image above left) and bring it to your consultation to help you decide
if this is the correct option for you....
Gout
Gout
is an inflammation of soft tissue caused by the deposition of monosodium
urate crystals in joints and soft tissues.
There are four phases of gout including: asymptomatic hyperuricemia,
acute gouty arthritis, intercritical gout and chronic tophaceous gout...
Aspiration & Injection
This
is a patient information sheet for patients who are going to receive an
aspiration and injection and for doctors who are going to give them. If
rest after injection is indicated do not forget a post
operative knee
brace......
