Lower limb Sports injuries in patients who are ‘young at heart’ Dr Michael Dan

In this podcast, Michael Dan, an Australian-trained lower limb orthopedic surgeon with specialized training in knee procedures, discusses the management of lower limb sports injuries, particularly as they relate to patients who remain active despite aging. His focus is primarily on the intersection of arthritis and meniscal injuries in the knee, drawing on both his professional expertise and personal experiences, particularly as a participant in athletic events like the City to Surf.

Dan begins by acknowledging the disparities in outcomes following knee replacement surgeries, specifically addressing how younger patients may face a higher revision rate due to their longevity compared to older individuals. He highlights the complexity of treating knee-related issues in younger, active patients with arthritis. In framing his presentation, Dan shares a case study of a 53-year-old woman who has experienced knee pain following meniscal removal, illustrating how imaging techniques can help assess knee alignment and cartilage integrity. He discusses the advantages of performing partial knee replacements in these patients, emphasizing benefits such as improved kinematics and a higher likelihood of returning to sports activities.

Transitioning to another patient case, a 48-year-old male who previously underwent an ACL reconstruction is presented. Dan explains how instability and persistent pain led to a more comprehensive surgical approach, combining ACL reconstruction with a high tibial osteotomy to address medial knee pain and optimize alignment. The lecture stresses the importance of personalized treatment strategies, tailoring interventions based on each patient’s age, activity level, and specific knee anatomy.

Delving deeper into meniscal health, Dan reviews historical attitudes toward meniscal tears, challenging the long-standing practice of meniscectomy. He presents evidence from recent studies that highlight the poor outcomes associated with removing menisci, particularly in older patients, and advocates for repair when feasible, especially in younger individuals. The lecture underscores the critical role of the meniscus as a shock absorber and stabilizer of the knee joint, and the dire consequences that arise when it is removed. The discussion navigates through changing paradigms in orthopedic surgical practices, including the use of innovative techniques to enhance meniscal repair success rates.

Dan also explores the implications of corticosteroid injections, emphasizing the emerging trend of administering them in a targeted manner around meniscal areas rather than intra-articular spaces. This method has shown promise in managing pain associated with meniscal tears while minimizing the need for surgical intervention. With an emphasis on patient-centered care, Dan highlights the importance of education and appropriate referrals for physical therapy to facilitate better outcomes for patients experiencing degenerative changes in their knees.

As the lecture progresses, Dan addresses more specific scenarios, such as acute meniscal tears, emphasizing the importance of recognizing the types of injuries that warrant surgical intervention versus conservative management. He references specific tear patterns, such as root tears, and discusses their significant impact on knee stability and function. The lecture concludes with a summary of key messages: the importance of preserving the meniscus where possible, the consideration of alignment issues as a factor in knee health, and a reminder to avoid unnecessary removal of meniscal tissue unless it is definitively the source of pain. This comprehensive dialogue serves to enhance understanding and inform clinical decision-making regarding sports injuries and arthritis in patients who are "young at heart.

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Our first speaker this afternoon will be Michael Dan. He's an Australian-trained

lower limb orthopedic surgeon with formal subspecialty training from the Lyon Knee School in France.

He specializes in ligament reconstruction, including the anterior cruciate ligament,

meniscal repair and transplantation,

tendon repair and reconstruction, arthroscopy, osteotomy, and arthroplasty.

And he has an interest in research and a passion in helping patients return

to the highest level of function.

And he will speak to us on lower limb sports injuries in patients who are young at heart.

Sports injuries is quite a broad topic, so I've got to narrow it to relating

to arthritis and meniscus given the fact that we've been talking about creaky joints today.

So unlike Dr. Seacat, I haven't designed any knee replacements yet.

My disclosure relates around the fact that these x-rays, these arthritic knee

x-rays that you see here are my own.

And so I'm yesterday's hero and...

My own past subjective experiences I

try to lead to drive me to have better objective outcomes

for my patients and so the city to surf is this weekend and so despite that

arthritic knee I managed to crack the one hour hour barrier last year and two

years ago I had a midlife crisis and won the comp with my local rugby club and

that's my son there with me,

and he's as close in age to the players as I was.

So knee replacements, we've heard already that they do improve people's quality of lives,

particularly for tricompartmental disease, but there is a relatively high dissatisfaction

rate, let's say 10% and it's not without complications.

And in terms of getting back to sport, the

biggest predictor of getting back to sport was what you did before a

knee replacement but generally speaking it's low impact activities

not high impact activities so and

we know that we've already

heard that with our improving materials we've got improved longevity to our

knee replacements but if we put them in the really young there's a much higher

revision rate you can see over the age of 75 there's a 3.5 percent 20 a year revision rate,

mainly because they die before it needs to be revised.

But in the young, we've got a higher revision rate.

And that's both true for unis and totals. And so for start with a case example,

what can we do to improve the sporting outcomes in these younger patients with arthritis?

And so this lady's 53. She's previously had a meniscus removed and she's got

medial-sided knee pain.

If you look at a long leg alignment films from the center of her hip down to

the center of the ankle, it goes through the center of her knee. looking at her MRI and.

You can see the meniscal deficient medial side with the lack of the chondral

surface there compared to a pristine lateral meniscus and lateral compartment articular cartilage.

It's got an intact ACL and an intact PCL.

Both of those are prerequisites for a unique compartmental knee replacement.

And we heard already that it's got, it's more likely to feel like a normal knee

because it's got more normal kinematics, less morbidity, less mortality and

a higher rate of return to sport.

And we've seen, this is Lindsay Vaughn last year, she won the silver medal in

the world championships and that's her knee x-ray seven years after retirement.

Lauren Jackson is another example of someone returning to high level sport.

Not what it's designed for, but patients are more likely to be able to do this

than with a total knee replacement.

But there's still a relatively high revision rate and so the idea is still it is...

They are likely going to need a total knee replacement at some stage in the

future for progression of the disease arthritis.

And the younger they are, the more likely that is to occur.

So what else can we do? So the next case is a 48-year-old male.

He did his ACL eight years ago and then subsequently did his medial meniscus

and he was told to keep putting up with his knee until he needed a knee replacement.

The problem is he's now having that medial-sided knee pain with prolonged standing,

and he's having instability with any pivoting or twisting-type activity.

And if you look at his MRI...

Again, you can see that he's self-minasectomized his knee, thinning of the articular

cartilage through his lateral compartments preceined.

His ACL has tried to scar down to his PCL.

This isn't his knee, but he had a positive pivot shift in the rooms.

And so his issues, and this is his long leg alignment films,

and you can see his weight-bearing axis goes through the medial compartment

of the knee. and he's got increased tibial slope and the idea is looking at the knee from side on.

We've got a tibial slope and it's like parking a car on a hill versus parking on the flat.

The more that slope is higher, the more strain the ACL is under.

So for him, I did an, despite being 47 or 48, did an ACL reconstruction and

combined it with a high tibial osteotomy.

I changed the slope and I changed the coronal axis, which you'll see in a minute.

To try to address that medial side of knee pain through the osteotomy and the

stability through the ACL reconstruction.

And so that's what I did for him. You can see the ACL button there with the tunnels, tibia.

I've done a controlled fracture across the tibia, elevated up that joint surface there.

And so the idea is then you can see him preoperatively,

weight bearing axis coming down through the medial side of the knee and now

post-operatively um uh it's coming

through the lateral spine so it's like a wheel alignment for a worn out tires

in a car and you can see he's young at heart he's wearing shorts and uh nike

sneakers despite being 48 um and this is just showing him at eight weeks once

the osteotomy is united for him to walk in on it enough.

And you can see him walking with a now valgus knee but i

don't think he would have been satisfied uh with

a knee replacement so this is the type of patient that despite having a creaky

joint they might need a knee replacement and so let's bring it back to what's

the basics you know the meniscus is the shock absorber and it's a secondary

stabilizer to the knee generally it's injured through rotational injuries with axial load.

And the idea of the meniscus, it takes the point stress and then distributes

it out evenly throughout the knee through hoop stresses.

And so the old adage was, if it's cut, take it out, treat it like an appendix.

But the funny thing is we've known since 1948, Dr.

Fairbanks described these changes that occur in the knee, but still it persisted

for such a long period of time to just remove any torn meniscus.

And then we saw really good randomized controls like this one from the New England

Journal of Medicine and then our own Ian Harris publicized it in the lay media a lot,

about the issues related to meniscectomies

and how those questioned the benefit and the potential harm.

And then even for degenerative tear, this was for osteoarthritis,

no role for arthroscopy.

Are the degenerative meniscal tears no real benefit to meniscectomy and so should

we be doing meniscal surgery for these degenerative meniscal tears when there's

no benefit and potentially harm.

So, there's another orthopedic surgeon called Scott Dye. He's a North American surgeon.

What he did was he put local anesthetic around the portals where we have an

arthroscopy and then went around and mapped out the sensitive areas of the knee.

You can see here the meniscus is largely aneurial and it's not sensitive.

Same with the articular cartilage.

So, the painful areas are the synovium or the joint lining.

And so, from understanding that, we can break our treatment into how we treat

these meniscal repairs, meniscus tears, sorry, based on if is the patient young?

Well, then let's do a repair to preserve the function of the meniscus,

you know, generalize, generalization, and if you lose your medial meniscus,

forces go up by 100%, lose your lateral meniscus, forces go up by 300%.

So in the young, repair these tears, prevent the sequelae from a meniscectomized knee.

In the older patient, let's educate them as it's being part of the arthritis

pathway that we've seen already and refer them on to physiotherapy.

And so in the background, I just got a repair here I did from a few weeks ago.

The old adage was that meniscal tears, repairs don't work, but with newer surgical techniques,

we know that they do heal and this is from Peter Meyer's group up in Brisbane

by taking a blood clot into an area which is largely avascular we can improve

the healing rates substantially and so this is a volateral meniscus and you

can just see me working my way around the meniscus with this 2-0 PDS,

placing vertical mattress stitches above and below the meniscus to allow it

to oppose and then I'll just see if I can speed it up but, uh,

So you just work your way around, and you get something at the end,

which looks relatively anatomical with good healing rates.

And then something that I wasn't really taught about here, this is from a French

group, the idea of, you know, we heard about, we talked about corticosteroid

injections generically into the knee and the role and the risk of arthritis.

But what I'd like to put you on today is the idea of doing a perimeniscal injection.

And Matthew Olivier's group well publicized this, that rather than injecting

the corticosteroid directly into the knee, I told you before how the synoviums,

the area that's painful,

put your corticosteroid injection into the meniscal tibial recess along that

synovial lining, decrease the inflammation of that area, and you can get significant

pain benefits to these patients with these meniscal tears that come to you saying

they want the meniscus out.

And if we can bide them through that acutely inflamed period,

they'll likely avoid the need for surgery.

And Matthew's group showed that at five years, 83% of them didn't need surgery.

And so if I could put you on to that idea, if you've got one of these patients

with a degenerative knee with a degenerative meniscal tear with some acute inflammation

around the capsule, get an ultrasound guided corticosteroid injection and it'll

largely be settled within the six weeks.

And in my own practice, I follow the patients up at six or 12 weeks after they've

had the injection and they don't want surgery.

So what about in between? Is there potential tears or patients who may benefit from something else?

So if we look at secondary analysis of these randomized control trials,

if there is an acutely blocked or locked knee, they will benefit from a meniscectomy

to improve some of the range of motion in the short term.

And what about in the older patient? Can we do a repair in them?

Yes, the same. If it's an acute meniscal tear, then they've got good long-term

survivorships, and as long as they're physiological young with an acute tear,

they will do well with a meniscal repair compared to meniscectomy.

Jonathan Nagus talked about it before. The idea is there are other tear patterns,

and the one to be aware of is the idea of these root tears. And so my simple

analogy is the meniscus is like a hammock.

And so we have a pole or a horn or a root at either end.

Like the poles of the hammock. And if we lose one of these roots,

then we lose all ability to bear weight. So it's the equivalent of a minisectomized knee.

And you would have seen in your practice, these patients having spontaneous

osteonecrosis of the knee.

Well, it's largely thought that these are more the sequelae of a,

while it's debated, the sequelae of a root tear.

Basically, you're getting a minisectomized knee. So then they get a sudden peak

increase in their forces and they get these subchondral insufficiency fractures.

And so potentially these are patients, even though they are 50,

they've got a root tear without significant arthritis, that we can repair the

meniscus and try to preserve them, getting the rapid degeneration to the knee.

The other one to think about is sometimes you'll see these parameniscal cysts.

Adjacent to the meniscal tear. And that's generally an indication for surgery

because it's putting that pressure effect on the synovium.

And it's taught to be a one-way valve where fluid can come out and adjacent

to the synovial capsule.

And so that pressure effect is what causes the pain. So these patients will

get a benefit from surgery by debriding the one-way valve and debriding the cyst.

So they're my key messages is where we can preserve the meniscus in that patient

in their late 30s, early 50s,

is this an overload problem from a malalignment issue can we extend the life

of the knee through optimising their alignment and if the meniscus isn't the

pain generator why take it out thank you.