Knee Osteoarthritis and Surgical Interventions with Dr Jonathan Negus

This podcast explores the various facets of knee surgery, including robotic techniques, prehabilitation, and rehabilitation strategies. Dr Jonathan Negus shares insights drawn from nearly two decades of practice as well as emerging technologies that promise to improve patient outcomes. A key aim of the lecture is to clarify the surgical role in treating knee issues, particularly osteoarthritis, which is commonly accompanied by various degrees of degeneration in knee tissues.

In discussing patient demographics, the lecture notes a trend toward younger patients with knee arthritis, often resulting from increased physical activity leading to injuries. Typically, those over 60 are considered for arthroplasty, yet the speaker emphasizes the importance of assessing functional limitations rather than solely relying on imaging reports, such as X-rays or MRIs, to dictate treatment. The speaker explains that many patients present with MRI findings that indicate meniscal tears or other conditions but often overlook underlying osteoarthritis, further complicating their situation. Thus, a more symptom-focused treatment approach is advocated, emphasizing the significance of patient function and quality of life beyond mere radiographic appearances.

The discussion extends to patient expectations, particularly the desire for immediate pain relief and improved function, which guides decision-making in surgical referrals. The speaker emphasizes the need for a thorough assessment, including understanding a patient's level of pain related to activities and the impact of comorbidities, such as BMI on surgical outcomes. Assessments focus less on radiographic severity and more on how these factors influence overall function and lifestyle, particularly during preoperative evaluations.

Further, the speaker addresses rehabilitation's critical role post-surgery, detailing strategies that involve strengthening exercises, education on weight management, and the use of adjuncts like braces and injections. While discussing various treatments like corticosteroids, hyaluronic acid, and PRP, the speaker notes their varied efficacy and expense, stressing a more cautious application. Nerve ablation procedures are introduced as a viable pain management option for certain patients, expanding the range of non-surgical interventions available.

Towards the end of the lecture, robotic surgery is highlighted, showcasing how advanced technologies allow for precision in knee reconstruction. The speaker explains that robotics enable more accurate alignment and surgical outcomes, thereby enhancing recovery times and reducing revision rates in joint replacement contexts. The importance of early referrals for surgical consultations, not just for surgery itself but also for education on lifestyle modifications and nonsurgical treatments, is reinforced.

In summary, the lecture emphasizes a comprehensive approach to knee osteoarthritis and surgery, integrating patient-centered care principles, high-quality diagnostics, and advanced surgical techniques to optimize outcomes and improve quality of life for patients facing knee issues.

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Right, back to me. So yeah, originally from the UK, if there's still an accent, I'm not sure anymore.

But I've been here nearly 20 years and currently based in around St.

Leonard's and more recently up here at Macquarie.

Interest in robotic surgery, also prehab and rehab, do a lot of work with my

patients on pre-optimization with physical therapy and with their rehab and

looking at the outcomes that go with that.

Uh trying to not overlap too much especially with sort of rasvan with the hip

because there's a lot of similarities and also with um bernie's going to talk

a bit about sort of patient demographics and,

um so we'll try and stay away from that been involved in a few different things.

So goal for me today is trying to support your decision making really

on how patients come to us clarify the

role of surgery within the knee and then

share a few new insights on new technologies and what their implications

are hopefully that will bring up a few questions you

all know about osteoarthritis a condition that affects all

the tissues within the knee I think that trying to get

a key from each slide and the key for me on this is that and we'll get to imaging

shortly is that often people will come to me now with an MRI and they'll say

I've been sent in because I've got a meniscal tear and I will say well that's

true but you're 70 and the rest of your knee is worn out and the meniscal tear

is part of the arthritis process,

and i think it's a really important message and that's why when we'll

get to the imaging slides why we prefer just to get an x-ray

because often the mri adds a lot of complication in

terms of explaining to the patient what's going on with their knee commonly medial

more than telephemeral more than lateral that's just what we see and

i'm sure you're the same and a bit like hips with lack of internal rotation

really that reduced range of motion and stiffness is probably one of the more

common signs effusions is very variable some people with terrifically bad arthritis

have no effusions other people with fairly mild arthritis have very swollen knees.

So typically we're looking at over 50s it's um

you know we're seeing younger and younger patients now more active population um

more knee injuries at a younger age leading to that post-traumatic arthritis

but generally for arthroplasty we tend to be considering people over 60 more

commonly obviously there are exceptions in terms of assessment factors i mean

for me the functional impacts the most critical we take pain histories that's

very very important but you know

there's pain in and of itself and there's pain that stops you doing the things

you want to do I mean sleeping is one of those obviously and just getting around

and doing activities of daily living but I think our population now has a higher

expectation than just walking to the shops or,

getting on public transport which a lot of our questionnaires are based on a

lot of people still want to play golf you know they want to go walking on the

on the beach or go walking around the park for a couple of kilometers every

day and that's important for their physical and mental health so we have to

look at how important the loss of function is to them.

Comorbidities, I think, are going to be discussed along with BMI.

We take BMI into consideration, but really, in terms of knee surgery,

it's really only the very morbidly obese that has a significant effect on outcomes afterwards.

It leads to a little bit more sweat and a few more harsh words in the operating

theater sometimes, but it doesn't affect outcomes.

Functional loss greater than radiographic severity. I think Razvan explained that very well.

We don't treat the x-rays. I try and say to patients, they say,

oh, both my knees, which is worse?

And you say, well, they've both got arthritis. So now we've made the decision

that you've got that disease.

Now we're going to look at function and pain and say, which one is worse,

which one needs treating? It doesn't really matter which looks worse on the x-ray.

In terms of things to ask, knowing where it is, sometimes it gives you a good clue.

I'd never heard of the movie theater sign until I did a bit of a search,

but I thought it was quite a nice little description.

I often talk to people about if they're sitting in a car for a long period of

time, but if they're sitting in a movie, an hour, two hours,

do they get stiff and do they need to move their knee? That's normally patellofemoral.

If they're weight-bearing or doing any impact activities and have pain on the

inside of their knee, it's medial, it all makes sense.

But what's nice about that is if they have that medial pain and they're tender

medially and their x-ray shows medial arthritis, it's really reassuring for

us to go, if you do an operation that addresses that medial compartment or along

with other compartments, you're more likely to get a good result.

If they have just purely medial arthritis and

the pain is all over the knee and you just address the medial side you're

going to get less of a good result so just just putting the matching

up the the symptoms to the imaging can be

useful in terms of knowing what to do or whether you're more likely

to get a good result mechanical symptoms of locking

and catching now commonly associated with either loose bodies or

meniscal tears but that can also be arthritis one

because arthritis they have loose bodies and meniscal tears

but also just the quality of the cartilage is very poor

and therefore they can um they end up uh with a

lot of those mechanical symptoms as well on examination they said we're going

to see the antalgic gait that we've already touched on the effusion the stiffness

tenderness over the the joint line they're all things we find out i don't think

they affect too much in what we do um but they're just important to note in

terms of ongoing management and red flags obviously.

So imaging, really, I mean, this is one of the key things. It's so simple,

but I still get a lot of people referred to me with a first line imaging being an MRI and that's fine.

I don't mind, but it just is a pain for the patients, costs money,

costs time, and it's probably more difficult for you guys.

So plain x-rays are absolutely fine.

The important one is the Rosenberg, which is a view that actually goes,

it's not an AP, it's a PA, comes from behind with the knee slightly bent.

And the reason for that is that it shows the cartilage

around the back of the knee when the knee is flexed and sometimes if

i've done this right um in extension

the medial compartment there doesn't look too bad but in the rosenberg you're

down to bone on bone and if you didn't do a rosenberg you might see

the ap and go well you've got mild arthritis so your pain

is is not explainable but actually the rosenberg

shows it is and often these people have got more pain on stairs or activities

where they're bending their knee more when they're standing they say it's not

too bad i'm going downstairs i get pain it feels a bit wobbly so it's

just important to get those views but with a set of x-rays we'll be able to manage

most people you refer in so why an MRI well an MRI for me is someone who's of

an appropriate age where they've got pain and you may have seen them and you

think oh they're going to have arthritis you get a full set of x-rays and their

x-rays are normal then you don't have a diagnosis then it's reasonable to get an MRI.

And then this example I'll put an arrow on there so you can see that's a radial

tear of the posterior horn of the meniscus this often happens quite quickly

and then they get this bone bruising pattern um can i do it on both just back

there so this sort of whiteness in the bone underneath,

um over here and that's just the bone has gone from having a structural support

with the meniscus to a sudden tear no support and it gets very painful very

quickly and they struggle to walk so that can often explain pain when the x-ray

looks relatively normal so mris can be useful,

but essentially there should be second line when the when mri should be second

line when the x-ray is shown to be fairly normal and out of it's not doesn't

fit with the clinical findings.

So what do the patients want? Well, they want to know what's going on.

They want to have a diagnosis.

They want to be out of pain, which might involve interventions.

And then they want to improve their function. I think that's really important.

So rehab and exercise therapy following knee surgeries, especially knee replacement,

I think is critical, especially if we're trying to get them back to a higher level of function.

So when to refer? Well, persistent symptoms if we've trialed non-operative care.

Again, I think RASVAN's highlighted very well that it's not first line is to

make sure that we treat non-operatively and optimize them to see whether we can avoid the surgery.

However, if the symptoms continue despite all the varying treatments,

then we need to consider it.

Functional decline that is affecting them, limitations on work or sport.

Um recurrent effusions more to explain why just

try and work out there's not anything else going on um and

severe radiographic OA of course if it's if it's severe the likelihood

is they're going to be heading towards some sort of surgery so it's worth

considering considering the options and starting the education process

but I think the earlier referral leads to better education and

planning so I like to see people early because

um I'm very happy to then place people

into a physical therapy program and give them

the advice on what they can do advise them on weight loss advise them on

strength and if i focus more on strength and weight

loss actually i think i always talk about power to weight ratio so the problem

one of the problems of weight loss again without touching too much on bernie's

is if you lose weight and lose weight rapidly you lose muscle if you lose muscle

around the knee you get knee pain it's it's simple so i'd rather they get stronger

first and again that's part of the education process i find if i see people earlier.

So as you can see there's some of the kit we have but it's it's you know we

will we'll measure strength and function in order to get a really good idea

of where people are in their journey.

Oh that didn't work well um we also have questionnaires um uh we can do uh we

can ask standardized questionnaires in order to get a uh an idea of where they

are along with the more functional assessments and obviously look at satisfaction

expectation along the way,

so educate first line treatments education is key weight

loss um around about three

to four times your body weight goes through your knee as you walk is around

about seven to eight times your body weight when you run so when people say

when i run it hurts and you go well if you're carrying 10 or 15 k's extra you're

putting another 70 to 90 k's through your knee than you should be so it's going

to hurt so it is important to bear in mind but obviously physiotherapy and strengthening,

is key as well basic analgesia has all been touched on weight loss there are various different,

modalities as we know and again i won't go through that.

When people say they've done physio i think it's really important just to question what

that involved there's obviously unsupervised at home or in the gym there

is there's there's physio where they're they're

actually given exercises and monitored um versus

just being put on a bike or or given a sheet

of exercises and they haven't done them and then there's exercise physiologists

more long-term looking at long-term function so it's important for us to get

a history of what they've actually done so when they say it has or hasn't worked

we actually know whether it's like being given a tablet and not taking it it's

um you have to you have to actually um do it in order to see a result.

In terms of other adjuncts, this particular brace, for example,

is a medial unloader brace. So in the younger patient, this can be useful.

It acts like a spring on the inside of the knee and just actually pushes the joint surface apart.

So when they're walking, it takes a little bit of the impact out of the knee

and it can give people a fair amount of time.

And I find this quite useful in people who've got active jobs,

like builders or in construction, especially if they're just trying to see out

the last few years of their,

of their company or their work um it can

be a useful thing but like all these things i think it's about a thousand dollars

so it's not it's it's got to be it's got to be considered carefully but it can

work very very well it can also be used prior to an osteotomy operation to see

whether the osteotomy may work

it does a similar thing um injections have been touched upon obviously

corticosteroid has been a number of discussions i don't tend to use it in me

very much at all purely because it's so short term i will use it if someone

has a big effusion that is i'm struggling to to get under control and i want

to get them back in the gym and get them get them strong,

or very occasionally i'll use it if someone's got a big cruise or something

coming up and you're just trying to give them a band-aid to go away with but

other than that because it rarely lasts beyond three months in the knee in my

experience i just don't find it to be particularly useful.

Um prp and hyaluronic acid are two that i

get asked about a lot and they have variable

evidence and i think the evidence for every year it seems to go in favor of

one and the other and it comes back um essentially they're both quite expensive

i think prp tends to be about 300 a time and you need two or three for a course

hyaluronic acid is five six hundred dollars a shot depending

but you have one so I tend to tell the patients it's about 60% effective in

those it works it works well but in those other people it does absolutely nothing

at all so if you're willing to spend the money you can trial it if there's no

other option but really only for those people for whom they're maybe the younger

people are really trying to avoid a knee replacement you can give it a go.

But the evidence isn't great. It's one of those things we use when we really

don't have many other options.

Stem cells, the evidence is poor, as in it's good evidence that it is poor effect.

I tell patients it just doesn't work at the minute.

Nerve ablation is a procedure that's getting more popularity in the knee.

It's a day case procedure that takes around about 20 minutes.

Needles are placed in four or five

anatomical locations around the knee with the patient sedated or with general

anesthetic and then i put a probe down into the needle and it does a two and

a half minute burn at each site and it just it just takes the geniculate nerves

so it gives the patient good pain relief it's effective in about 80 85 percent

of people so who's this for well,

insurance weight period is just i get a number of people who come in they go

i've just found out that i'm not i'm covered for knee reconstruction not knee

replacement i've got to wait a year,

but the their insurance level does cover ablation so it can actually give them

really good pain relief for that time while they're waiting um it can be good

in the insufficiency fractures and it could be good for people who have got

other comorbidities maybe like the 94 year old where you're you're looking at

going i really don't want to do a big knee replacement on this person,

um i had a lady who had um she had terminal cancer

she had a life expectancy of 12 months but she had terrific pain from a very

valgus knee so we did it she got great pain relief but she came in even after

all the education but my knee's still bent and I was like I put needles around

your knee I was not going to straighten it out but uh she got good pain relief so it can be a.

Non-replacement surgery, you know, the days of doing a clean out for arthritis

have gone. Patients come in, can you just do a clean up and a tidy up?

And we just know that if you go into an arthroscopy and take away all the little

bits of cartilage and little bits of torn meniscus, they'll just be back.

They'll just be back very shortly. The knee's failing, so cleaning it up just doesn't work.

And you're subjecting that person to unnecessary surgery and risk,

as well as the fact that every time we operate on a knee, we weaken their quads.

So they've just got more work to do to get their strength back and the strength

is really key for them osteotomy um there's just some slides from the the way

that a lot of osteotomies can be done now which is all planned on computer like

most things and specialized jigs made in order to,

cut a wedge of bone in the tibia or the femur and readjust the alignment so

we just take the alignment weight bearing alignment um away from the the damaged

part of the knee and over into the non-damaged part of the knee,

more for the younger, more active patients,

and can be an alternative to joint replacement in those people.

Talking about joint replacement well if we delay surgery we also want to pick

the right people but if we leave things too long prolonged pain leads to prolonged

functional loss muscle loss deconditioning,

can have significant mental health impacts and it can compromise outcomes post-surgery

i think things have to get pretty bad to compromise the outcomes in terms of

stiffness but if people start to get a progressive deformity that gets fixed

that does actually lead to bigger procedures so,

generally we tend to see people before that happens but there are some impacts to delaying surgery.

From the point of view of replacement you've got partial or total.

Partial can be medial, lateral or just patellofemoral.

By far and away the most common is the medial which is the one up there that's

because medial arthritis is the most common.

It's been done more, it's more reliable the others are a

little bit more tricky and and just less reliable um so uh most most people

instead of a lateral or a pteropheromal will just have a total but there's there's

a around 15 something like that of of arthroplasty is um will be a unique unicompartmental medial.

So can be a little it's a little less invasive little

faster recovery um and and the

robotic technology that's come in has really helped us with this and

has helped us to um to do it in a more precise way for people so

we're getting i think starting to show some better results with that but still

the majority is total knee replacement which is very reliable and again as raz

van pointed out i'm quoting him a lot today um the uh the polyethylene the plastic

liner that we had in we have in the knees much like the hips has improved so

much that we just get the knees lasting that much longer now.

So why robotics touching on robotics well it

allows us um it allows us greater precision and

alignment and and an ability to balance up

the knees so from a surgical point of view we we like it

gives us more information and more ability to perform a reproducible

operation there's some early data coming out about faster

rehab and maybe some lower revision rates but essentially it's um surgically

it gives us more options to do what we do better um and it's increasingly being

used in centers of excellence this is just one of the screens that gives an

idea of one of the platforms of this is prior to making any cuts in a knee so

we can virtually make cuts,

put prostheses on, work out the gaps,

adjust it all and then we go in and make a cut which is a little different to how it was done before.

So what can you do? Well, encourage weight management and strengthening,

optimize chronic health, educate patients, early imaging with weight-bearing x-rays,

refer early for a discussion not just for surgery and

discuss realistic expectations because surgery is a tool it's not a cure and

it's part of a process of of of your health optimization um rehab and uh everything

that goes with that so our patients want to be out of pain to have better function

i think you guys really are key to the early identification,

and management um and i said if it can make your life easy just do x-rays that's all you need,

and we'll be happy with that uh joint replacement

now offers a more accurate delivery of the prosthesis it's not essential but

it's definitely something that's becoming much more popular and used by more

surgeons and the key is early referral to start the process basically to improve

the patient's function. Thank you.