The Hampshire Clinic – ACL/ Meniscal and Osteotomy update

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 “All acute knees should be referred “

Another great seminar presented last night by the likes of Mark Wotherspoon, Adrian Wilson and Mike Risebury.

The message they were bringing :

“We (first contact practitioners)  are failing acute knees”

The seminar was interesting, relevant and provided interesting incites on new surgery being developed by the Hampshire Clinic knee surgeons. A similar theme that developed throughout the talk is the huge wait between initial ACL rupture and a review by a surgeon. One chap shared his experience, a 25 year old who had waited one year from first injury to an MRI. There were also horror stories of an 18 year old with Grade IV arthritis because he had been mobilising on an unstable knee. Could we have done more? The simple answer is yes. I have to agree we are failing these patients. By the time the surgeons are reaching them they have significant damage that is much more difficult to ‘fix.’

So how can we do our part?

As physiotherapists we should be extremely familiar with the mechanism of injury: 

  • Usually non contact injury.
    Concussion in rugby
  • Immediate swelling.
  • Fell to ground, couldn’t play on.
  • Changing direction.
  • Heard a  POP.

 

Next patient usually:

  • Limping 3-4 weeks
  • Function returns.
  • Tries to return to sport but knee gives way. 

Usual route which we need to change

  • A and E – saw a triage nurse
  • X-Ray – Normal – Go home and if doesn’t resolve see your GP. (tries to return to sport gives way)
  • GP – Physio
  • Referred back to GP recommending ortho opinion
  • Referred to consultant.
  • Time lapse between each stage average in uk: One year injury to MRI.
Take home message from Adrian Wilson

  • Protect the knee
  • Any further twisting on the knee/giving way are likely to damage the cartilage and joint surfaces.
  • 60% ruptured ACL’s also damage meniscal.
  • Refer on the mechanism of injury before the secondary damage has occurred.

Recommendations after brain stormings::

Short flashcard/ sheet for GP’s/ sport physicians (Refer acute knee with ACL mechanism of injury).

5 bullet letter to GP’s – patient’s suitable for acute knee service.

Direct number to refer to: 01256 357111 ask for Jennie and ask for the acute knee service.

Patient education: “Protect the knee, educate that serious injury, potential ligament damage, protect your knee until we have checked with a surgeon, straight lines, don’t do anything silly”.

Anything more that a Grade I MCL needs to be assessed for brace, 30 degree bracing immediately.

Consider ACL repair in those older that 50.

Physio’s can refer directly to surgeon.

 

Osteotomies

They also discussed osteotomies and their use for the ‘younger patients (30-55)’ as an alternative for knee replacements.

This operation looks to offload the lateral compartment (depending on deformity) and aims to reduce pain and improve function in those who wish to be active. The surgeons aim to regain normal alignment by correcting through a wedge osteotomies. A large, strong fixation allows patients to weight bear from day 1 and patients can be expected to be off crutches and back at work at 6 weeks. Operation time is 30 mins

Most patients will partial weight bear as pain allows but can be back to activity relatively quickly. Can potentially return to impact exercise ie tennis etc. Consider this for those who are too young for a TKR who need something to reduce pain and improve function.

Summary

The advice that was given regarding the Acute Knee service was that patients could be seen in the first instance by:

  • The Consultants in Sport and Exercise Medicine, Drs Mark Wotherspoon and Mike Rossiter whose skill is in diagnosis (bringing years of relevant experience), including access to all the diagnostic tools on offer either privately or through the NHS (MRI, CT, xray and ultrasound).
  • If the patient needs surgical intervention, then they get referred to the Knee Surgeons, with all the appropriate investigations done – Mssrs Neil Thomas, Adrian Wilson and Mike Risebury, either privately or through the NHS
  • If the patient does not need surgical intervention, then they get referred back to the original physio with all the investigative information to hand and with a plan to work towards their recovery

Overall an informative evening and some great snacks too! 

 

Resources

Mr. Wilson – New ACL surgery  

Knee Problems..

The Hampshire Knee (Informative website)

The Hampshire Clinic

The Newbury Clinic – Phil Harris works closely with Hampshire Clinic knee surgeons to provide physiotherapy. 

Mark Wotherspoon offers his golden gems of advice in our consultant directory…..

All Sports medicine sec: Julie Fourt : juliefourt@allsportsmedicine.co.uk or 01256 377637

 

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