In this episode of PodMD, Orthopaedic Surgeon Dr Murilo Leie will be discussing the topic of assessing and managing hip and knee conditions. We discuss scans for knee joint problems, ACL injury referrals, steroid and hyaluronic injections, robotic knee replacement, Baker cysts, and arthritic hip and knee surgery.
- Transcript
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Today I’d like to welcome back to the PodMD studio Dr Murilo Leie.
Dr Leie is an experienced Orthopaedic Surgeon specialising in conditions of the hip and knee. Dr Leie pursued multiple fellowships, including Knee Surgery in Sydney and Perth, focusing on ACL surgery, knee replacement, and robotic procedures.
You can read more about Murilo on his profile page on our PodMD website.
*Please listen to our disclosure at the end of this podcast
Today, we’ll be running through 10 quick tips to optimise GP practice regarding hip and knee. Murilo, thanks for talking with us again on PodMD today.
Murilo: No, thank you. It’s my pleasure to be here.
To start us off with the first tip, can you tell our listeners what scans are usual or typical for knee joint problems?
Murilo: Well, the usual scans for knee, which that can be useful include x-rays, MRI, and CT arthrogram. Essentially, x-rays of the knee include an AP lateral and skyline view. The skyline view allows to assess the patellofemoral problems or the kneecap problems in patients with anterior knee pain and mouth tracking. The MAKA view x-ray, it’s a view to assess overall lower limb. and it’s very important for knee problems. The MRI, as everyone knows, is used to assess cartilage, ligaments, and soft tissue components. If you suspect of those problems, MRI will be your scan. But CT arthrogram, it’s also used when MRI is not allowed or for medical related problems or Medicare rebate issues. Ultrasound has really minimal applicability for knee problems.
Say, for example, a patient has hip pain, but their scans appear normal. Are there any other conditions to look at or investigate for?
Murilo: Yes, absolutely. So if a patient presents with groin or hip pain in imaging studies like X-ray, MRI are normal, we need to assess the joints above and below the hip. So in that case, we should look into spine problems or knee problems that could have referred pain to the hip. And we could start with x-rays and subsequent MRI if indicated. But if a spine and knee are clear and not part of the problem, I would consider intrapelvic organ pathologies, and that could include testicular pathology, uterine pathology and disorders, and potential inguinal hernia. So don’t forget those three conditions.
And hypothetically speaking, if I have a patient suffering from knee pain and they can’t have an MRI, maybe because they have a neurostimulator or they’re claustrophobic, are there any alternative scans I can order for my patient?
Murilo: Yes, that’s getting more and more common nowadays. Sometimes they have pacemaker and you see letters from GPs saying the patients are not allowed to have MRI. If they essentially have a knee problem and the surgeon required or the GP required MRI as well, CT arthrogram would be the preferred scan, okay? The CT arthrogram consists of injecting contrast dye into the knee joint. That’s performed, of course, by interventionist radiologists under sterile conditions. So, following the injection, the CT scan is performed, and the CT arthrogram will provide visualisation of soft tissue structures, including meniscus, chondral surface, and cruciate ligaments. So If MRI is not an option, remember, CT arthrogram could be your scan.
Perfect. And now moving on to ACL injuries, would you recommend GPs wait to refer these injuries, or should they refer them immediately?
Murilo: Well, there are essentially two problems in delaying a referral for ACL injury, okay? So firstly, nowadays with high level of pivoting sports, especially in Australia, it’s very rare to have an isolated ACL tear. Most of the time, patients will have concomitant meniscal or other ligaments involved, such as medial collateral ligament, and these additional ligaments injuries make a referral more urgent to orthopaedic surgeon.
Also, more recent literature has shown that delay in ACL reconstruction, or in that case, a refer, or can increase the frequency of medial meniscal tears and subsequent bucket handle tests. What happened is suboptimal stability of the knee, if the ACL is delayed, can cause further injury. So, my recommendation is to refer for a specialist review. and as soon as their diagnosis is made in your rooms. Some structures in the knee joint can be repaired, and repairs are preferable to be done within six weeks to increase the likelihood of success of the procedure.
When should patients with arthritic hip and knee conditions undergo surgery? Are there any particular red flags GPs should look out for when recommending surgery to their patients?
Murilo: Yes, that’s a very good question. And what I use as a red flag for my patients that come here is if the patient demands more opioids and narcotics to manage pain, we all know this is not sustainable in long term. If the pain wakes the patient in the middle of the night and affects their overall lifestyle, if there is a decline in general health of the patient or the patient is putting up white which may indicate they become less active recently, and might require general health optimisation. And of course, non-operative treatments have been exhausted. So, if any of these criteria is met, I would refer your patient for your preferred orthopaedic surgeon for discussion of surgical options.
And GPs often see patients with pain in their knee, who describe their pain as either being dull or sharp. What is the difference between the two types of pain?
Murilo: Yes, that’s an important question because if the simple complaint, you can exclude or direct your investigation to specific conditions. If a patient sits in front of me and tells me they have sharp catching pain in the knee, I will be thinking of osteochondral defects, OCD, cartilage problems. I would be thinking of meniscal tears and sometimes loose bodies may become trapped between the tibiofemoral joint and cause that sort of sharp catching sensation.
On the other hand, if the patient come and say it’s a more chronic, dull, aching, like a toothache type of pain, I would think more about degenerative process of the joint. That’s a sign that joint is aging or has aged. So degenerative meniscal test can present with dull, aching pain. And overall, any osteoarthritic conditions of the knee will present with dull, aching pain.
And we also know that there are several types of injections available to treat these conditions, notably steroid and hyaluronic injections. In which cases can each be used?
Murilo: Yes, the most traditional injections that can be offered include steroid injections, as you said, cortisone and hyaluronic acid. There is limited evidence, but in early case of osteoarthritis, the hyaluronic acid can be used and can provide more pain relief than cortisone, essentially. There are some options, some different brands. They overall are similar in terms of efficiency. Some brands are Medicare rebate-able, so they are good for essentially public patients. Some other brands, they can be a little expensive with some rebate, with some specific health funds.
But more recently, also PRP or also known as platelet-rich plasma, has been discussed. Also limited evidence, but some level 2 evidence show potential benefits of PRP injections. This is not currently recommended to my patients yet. I don’t recommend. And the approach remains to use a steroid or hyaluronic acid for elective case, essentially, for pain management, as I said, without changing much of the natural history of osteoarthritis.
And moving on now to discuss knee replacements. How long does a partial or total knee replacement last?
Murilo: Well, that’s something I ask myself every time I have a patient in front of me and I will recommend option A or B for him. So that depends on how young or old the patient is. And the most reliable data we have here in Australia come from the Australia Joint Registry data. And overall, we know that partial or also known as unicompartmental knee replacement overall last on average 10 to 20 years. 90% of patients after 10 years will still have a partial knee replacement.
On the other hand, a total knee replacement is expected to last between 20 and 30 years, especially the new models of knee replacement. So that’s what I use as a reference to when I want to recommend option A or B for my patients. But remember, partial knee replacement, they don’t last as long as the total knee replacement.
Okay, that’s great to know, actually. And does robotic knee replacement have improved outcomes compared to the conventional knee replacement?
Murilo: Yes. Overall, there are improved outcomes with robotic surgery or robotic knee replacement, I would say. The technology reduced surgeries outliers and improve accuracy in the surgery. Your soft tissue like ligaments are protected during the surgery and the surgery becomes overall less invasive.
So patients tend to recover faster with a shorter length of stay in the hospital. By, I would say, 12 months, robotic knee replacement demonstrates similar outcomes in terms of patient-reported outcomes compared to other types of knee replacement, including conventional or navigated techniques.
And finally, let’s talk about Baker’s cysts in the knee. What are some of the causes and how can GPs treat this?
Murilo: Well, Baker’s cyst is the most common problem, a knee problem, I would say, and very common in GPs practice, patients come. It’s also known as popliteocyst. It is a fluid filled cyst that forms a lump in the back of the knee. Essentially, they are benign and represents a consequence of an underlying problem. That’s what I want you to remember. And it’s usually the problem coming from inside the knee joint. So if there is a tear or a degenerative process affecting the cartilage, I mean, inside the knee joint. These conditions cause the joint to produce excessive fluid, and the fluid can exit through a one-way valve mechanism in the back of the knee, leading to the formation of the cyst. So the management essentially, it’s non-operatively includes physiotherapy as a primary treatment modality.
Cysts can be aspirated if necessary to reduce pain and improve symptoms essentially. Sometimes the steroid can be filtrated as well. But the most important aspect of management, as I said, is to treat the underlying cause rather than the consequence, the cyst itself. So if the patient presents with a Baker’s cyst, the GP should first investigate the underlying cause. As you know, MRI can be helpful in identifying the interarticular problem between the knee joint, and treatment should be directed at addressing the underlying pathology rather than focusing solely on the cyst. So that’s my advice.
Thanks very much, Murillo. To sum up for us, could you please identify the three key take-home messages from today’s podcast?
Murilo: Well, I would say, remember, important scans, especially for knee. So X-rays include AP, lateral skyline, and Markeville. And more sophisticated scans could be MRI and CT arthrogram. Remember the red flags of a patient with arthritic hip or knee and when to refer them for orthopedic surgeon for surgical assessment and consideration, overuse of opioid and decline in general health, as well as difficulty to sleep. And as per Baker’s example, we just discussed, try to treat the cause of the problem and not the consequence, which can be just the tip of the iceberg.
Well, thank you again for your time and the insights you’ve provided today, Murillo.
Murilo: No problems. My pleasure. So see you next time.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
