Knee problems

Contributed by Dr Jean Watkins, a sessional GP in Hampshire.

Osteoarthritis

Osteoarthritis is one of the main causes of disability in the elderly. It is the breakdown in articular cartilage, as a result of excessive wear and tear on the joint over the years and/or a predisposing problem that has caused damage.

By the age of 65, most people will have some evidence of the problem, although some remain asymptomatic. Arthritis progresses slowly over the years, with pain, reduced range of movement, crepitus and malalignment of the joint with varus or valgus deformities. Clinical signs and X-ray confirm the diagnosis and its extent.

Management of osteoarthritis

Where all else fails and the patient's pain is incapacitating, surgery may be necessary to restore mobility and ease pain. Options include arthroscopic lavage to remove loose bodies and trim the articular surfaces of the joint.

Some patients will be offered partial or total knee replacement but complications include DVT, periprosthetic fractures, instability of the patella or loosening of implant components. Arthrodesis may ease pain. Some of these options may be delayed and symptoms improved with physiotherapy and exercise.

Genu valgum in children

It is not uncommon for children to have 'knock knees' at the time they first begin to walk. Most are otherwise healthy and the deformity can be expected to correct itself by the age of six. For a few, it may be related to a genetic disorder or metabolic bone disease.

This three-year-old was brought to the surgery complaining of pain in the knee on rising from the kneeling position and he seemed to swing his leg outwards and 'held' the inner side of the knee when walking, as if in pain. If the condition persists and is still painful beyond the age of about 12, surgery may be considered.

Effects of osteomyelitis of the femur in childhood

At 77, this woman was still experiencing complications as the result of a fall in the playground at the age of six. Her knee had swelled and she was found to have osteomyelitis in her left femur, involving the knee joint. Eventually the infection responded to antibiotics. Subsequently, she developed abscesses in the scar before it became quiescent.

She was left with a spinal scoliosis and a short left leg that required a built up shoe to compensate and a marked valgus deformity, for which further surgery was being considered.

Prepatella bursa

Although often known as housemaid's knee, prepatella bursitis can occur in anyone who spends a lot of time kneeling, such as carpet fitters, roofers and gardeners, or following a fall or blow to the knee. The patient presents with a tender, fluctuant swelling at the front to the knee and reduced knee flexion.

Aspiration of the bursa may provide relief but it is important to send the fluid to the laboratory to exclude infection. Once infection is excluded, a steroid injection into the bursa can be given. Recurrence depends on avoiding kneeling in the future.

Popliteal cyst

Popliteal cyst (Baker's cyst) presents as a usually painless swelling that fluctuates in size in the popliteal fossa. It may cause limitation of movement and can occur at any age. It can form in a bursa or be associated with a knee problem such as rheumatoid arthritis or osteoarthritis.

The cyst connects with a defect in the capsule of the joint. Occasionally the cyst may rupture causing inflammation and swelling of the leg. This can be easily misdiagnosed as phlebitis or a DVT. The cyst can be aspirated and a steroid injected. This patient was referred to a specialist and was awaiting surgical excision.

Osgood-Schlatter disease

Osgood-Schlatter disease presents as pain, tenderness and swelling over the tibial tubercle. It is most common in adolescents, particularly boys who play a lot of sports. The knee joint itself is normal. It is caused by stress of repeated contractions of the quadriceps tendon on the tibial tuberosity, when it has not fully matured. This results in small avulsion fractures, inflammation of the tendon and excess growth of the bone.

With rest and analgesia, spontaneous resolution will follow. A three-month rest is recommended with a gradual return to normal activity over at least six months.

Gout in the knee

The knee is one of the many joints that may be affected by gout. The patient complains of the sudden onset of severe pain and, on examination, the joint may be red, hot and tender and may be swollen due to an effusion. Usually only one knee is affected.

There may, or may not be, a previous history of the condition. Gout is most common in men, and the risk may be increased by the use of diuretic drugs. The diagnosis can be confirmed if urate crystals are found in fluid aspirated from the inflamed joint. Treatment choices in this acute phase are colchicine or an NSAID, which should quickly relieve the pain.

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