So I'll just introduce Mustafa. Welcome. Mustafa is a specialist orthopedic

surgeon in the field of lower limb reconstruction, foot and ankle and joint

replacements of the ankle and hip and knee.

He also does sports surgery of the ankle and knee and is a very experienced trauma surgeon.

He completed his post-fellowship training in

Switzerland At the Swiss Ortho Center in Basel And he has particular interests

in total ankle replacement Foot reconstructive surgery Minimally invasive bunion

corrections Lower limb deformity correction And acute and gradual corrections

Particularly acute distal femoral,

high tibial And suprameleole osteotomies As well as frame-assisted corrections

And limb lengthening surgery,

He also is highly trained in designing custom 3D models and implants for patient-specific

surgeries Which is what we just talked about So welcome Mustafa, thank you.

Thanks everyone for being here on a Saturday morning, giving up your time to listen to these talks.

And thank you, Sam, for the introduction.

So I'll just talk about knee arthritis in the young patient and some surgical

and non-surgical management options.

We'll go through the common etiology, the investigations, the non-surgical management

options available, and some of the things that I've got a very special interest in,

which are the surgical management options for young patients with knee arthritis.

And we'll show you some examples.

And then joint replacement surgery. I think Associate Professor Biswineithan

will have that chat, that talk later on this afternoon.

So, disclosures, I am a designer and a consultant for US Integration International.

That's how I do a lot of the designs for the younger patients with their patient

specific guides and their planning.

I'm also a board member and shareholder of Sid Ortho.

So who are we talking about with the young arthritic knee?

It's usually patients who are under 55 years of age, who are often still working, active.

A lot of them are doing quite sort of heavy manual labor or intensive sort of work.

Why do we pick 55? As Sam mentioned,

there is a categorization for arthritis in joint replacement surgery in particular,

more so in the knee than the hip in terms of the outcomes of joint replacement

surgery is definitely inferior with a much higher revision rate for under 55-year-old patients.

So if you compare over 75s, they have 3.5% revision at 20 years.

Under 55, it's 17% at 20 years.

So there's about a six fold increase in the revision rate for joint replacement surgery in under 55.

So for that reason, we were not keen on doing joint replacement surgery in under 55 year olds.

So we put them in a category of a young arthritic knee and we're trying to find

some solutions that would prolong the life of their knee,

provide them the ability to continue their higher sort of impact activity and

hopefully either delay or prevent the need for joint replacement surgery.

So some of the etiologies, as Professor Joshua mentioned, rheumatoid arthritis.

Which can cause synovitis, which affects all the complements of the joint.

And that can be problematic from the surgical point of view because it affects all complements.

So those are the patients that would, you know, land in their rheumatologist

rooms because they're much more adept and can provide better solutions for these patients.

Post-traumatic problems, so patients with fractures, stibial plateau fractures,

distal femoral fractures, intra-articular fractures, or even some extra-articular fractures that,

create alignment issues, you know, various valgus misalignment,

rotational misalignment, or chondral pathology, so that it causes cartilage damage directly,

or ligament injuries that cause multi-ligament or even just single ligament

injuries like anterior cruciate ligament, posterior cruciate ligament injuries,

those often have a tendency to lead to post-traumatic arthritis over time.

And then patients who've had sport injuries leading to meniscal pathology,

which often causes more rapid degeneration because of the loss of the chondroprotective

mechanism of the meniscus within the joint.

So the pathophysiology and the mechanics of biomechanically,

the reason arthritis develops often is the underlying biomechanics of the joint being altered.

And that leads to either abnormal shear forces through the cartilage or direct

damage to the cartilage itself.

So if there's one thing you keep

in mind with the young patient and knee arthritis, it's their alignment.

Alignment, alignment, alignment. That's the key to trying to prevent further

damage. And that's the part that we come in to try and address their problem.

Meniscal deficiency accelerates degeneration, as we've mentioned,

and recurrent instability for

patients who've got either single or multiligament damage to their joint.

So, investigations, I mean, this is something that the patient lands in your

rooms and the thing that I think would be the most helpful from our point of

view, but also your point of view,

is obtaining some weight-bearing images, as Sam mentioned.

X-rays that are weight-bearing give you a good estimation of the degree of misalignment

that's present and the degree of joint space narrowing present within the joint.

So clinically, when you examine them, you can see whether they have varus or

valgus misalignment, so if they're bow-legged or knock-kneed.

So those are the patients that we can help.

So those are the patients we can correct alignment and then help them prevent

progressing to a joint replacement.

There is an EOS scan machine, which is available in inquiry.

That EOS scanner provides a very detailed analysis of alignment.

You've got access to it. It's bulk build, and it's something that gives you a very detailed report.

So if you're ever sort of in doubt about what the alignment is for a particular

patient, you get quite a detailed result that is reasonably easy to interpret.

If we can look at it as orthopedic surgeons, I'm sure you can figure it out as well.

And then MRI scans, which show the chondral injury directly,

any meniscal pathology and associated subchondral bone changes in marrow edema.

So often patients have meniscal pathology but they don't have problems until

there's significant overload and then all of a sudden they present and they have significant pain.

If you get an MRI scan often you see some marrow edema in that compartment under

the meniscus that's degenerated,

it's often then showing you the fact that there has been some process that's

resulted in a deconditioning or loss of the equilibrium within that joint that's

created overload and that's where they become symptomatic.

That's where non-surgical measures that are offloading can help maybe prolong

the life of their knee without surgery.

We do have a weight-bearing CT scanner here as well. It's the only one in,

I think, all of Australia that I'm aware of that goes from sort of the pelvis

all the way down to the foot.

So that helps me, in particular, our team at the Limb Reconstruction Center

in terms of doing preoperative planning,

analyzing the rotational profile of patients and figuring out what their deformity

levels are and then also creating some custom solutions for patients.

So the EOS scan, that's the report that you get.

So it shows you quite a lot of information including various valgus and mechanical

axis and rotational alignment.

And then that's the weight bearing CT scanner.

So non-surgical measures, again, Sam alluded to a large number of these,

but the key one is weight loss.

A few kilos is the equivalent of it's sort of three to five fold in terms of

the knee joint itself, particularly the patellofemoral joint.

Getting patients to do minimal, even small amounts of weight loss can have a

significant impact on their symptoms.

Physiotherapy to do some strengthening gluteal core stability I think Bridget

will be talking about some of those in more detail medication such as anti-inflammatories.

And Professor Josh has already had a chat about the inflammatory arthritis management

so from my point of view I normally give patients the option of having cortisone

injection Synvisc or PRP injections.

Cortezone, it's quite helpful.

It is a law of diminishing return. So once they have one injection, it tends to help.

Second one, a little bit less. Third one, it starts to sort of not really work.

And then you lose that sort of efficacy of the injection. Synvisc.

Modest effect, best I think used in mild arthritis.

The studies are all not placebo controlled. So I think there is a bit of a placebo effect.

But for some of the patients where we're desperate and the placebo effect works,

I think the risk profile is quite low.

And PRP injections, again, there's mixed evidence. There's no formulation that's

standardized and we don't really know how it works.

But for some patients, including actually a colleague of ours who one of the

orthopedic surgeons, he has an injection once a year and it seems to work for him.

So if you've got someone who you're trying to baby along and try and sort of

avoid going down the path of surgery, you can try the PRP injections and see if it works for them.

Offloading braces, when you've got unicompartmental arthritis,

it can help. I'm not sure if there is any real evidence for it.

So when do you refer to us?

I mean, if patients have had failure of non-surgical management three to six

months, if they have mechanical symptoms of locking, catching, or giving way,

recurrent swelling with activity, if there's significant misalignment,

or if a young patient has narrowing of the joint space, refer early.

It's better to try and prevent further deterioration than to try and cure their

arthritis once it's established.

High-demand patients who want to remain active, and if you've got pathology

on an MRI scan in a young patient.

What are the principles of joint-preserving surgery? So offloading,

that's the key. That's through changing alignment.

If they have multiligament problems, stabilizing the joint, ACL,

PCL, postural lateral corner, or the MCL, and then repairing structures.

If they've got a bucket handle, tear of a meniscus, it's really important to

try and attempt an early repair because that might save their joint from deteriorating much more rapidly.

So we want to preserve function in the young active patient and give them as

long a time as they can with their native joint.

Arthroscopic meniscectomy, there's triple-blinded randomized control trials

from more than a decade ago which showed that it does not work.

So in fact, at five years, one of the studies showed that arthroscopic meniscectomy,

patients had worse x-ray outcomes.

So putting a camera into a joint, cleaning it out, it's actually not good. It's detrimental.

Doing a cleanup is a thing of 20, 30 years ago. We shouldn't be doing that in isolation.

So high tibial osteotomy, that's the main workhorse in terms of various arthritis.

So medial compartment arthritis, various malalignment, intact lateral compartment,

high tibial osteotomy works. Obviously, tricompartmental or sometimes inflammatory

arthritis, but it's a relative contraindication.

Or if they've got poor bone quality, we shouldn't be doing it.

So from your point of view, identifying patients who've got very isolated medial

joint line pain and varus malalignment, those are the patients that would benefit

from referring to us because we can offload their joint and prolong the life of their knee.

So this is an example of a patient who has had bilateral, he's a 51-year-old

bricklayer, did not want a knee replacement, severe misalignment.

That's the software that I use.

It's actually through Munjet's company and we basically design,

analyze, design, 3D print the guides in-house and then use them to correct alignment.

You can see that if you look at the alignment here, center of hip,

center of ankle misses the knee.

And then post-surgery, we can draw that line where it goes through a point called Fujisawa's point.

And then do the correction, put the plates on the bone, and then reverse that

to create the guides that then allow us to do this surgery very accurately.

So I spend a bit of time designing these guides for the patient.

So you can see the guides, and they'll come up in a second on the video.

And you can see the before and after for this particular patient.

So the line from center of hip, center of ankle, these are the guides.

So that sort of doesn't go through the center of the knee, whereas post-surgery,

it goes just beyond the lateral tibial spine.

And that's the aim, to offload the medial compartment more onto the lateral

compartment and give them pain relief and give them time with that joint.

And the other option is a distal femoral acetylory, that's for the opposite.

So if they're valgus alignment, so if they're knock-kneed, then we do this.

So, contraindications if, again, advanced disease in the other compartment.

From your point of view, if they have lateral joint line pain and valgus,

those are the patients that are suitable for this surgery.

And again, we can have a look at them and advise them. So, again,

this is a patient that I did a distal femoral ostentomy.

You can see how severely misaligned.

She's only 40. she had had four knee

arthroscopies by two other surgeons because

they wanted to try and sort of address meniscal pathology

in the lateral compartment but it just it doesn't help it it sort of she kept

deteriorating despite the surgery so you can see it involves cutting the bone

wedging it open putting bone graft putting a plate on and then basically correcting

that alignment, I forgot to draw a line here,

but essentially she also had patellofemoral changes.

So we did a tibial tubercle osteoanolateral release for her,

but this is, so we design, I designed the jig through this.

So we reverse the correction and then create

the guide, which then is used intraoperatively to do the surgery. Um.

So the other one is patellofemoral joints, a three compartment,

medial lateral patellofemoral.

The patellofemoral patient has anterior knee pain, often from chronic maltracking

or instability if they've had patellar joint dislocation.

Again, in the past, patients who've got patellar dislocation would just get

told, go and do physiotherapy.

Physio has a very, very important role, but it doesn't fix the underlying problem.

These patients have underlying issues, patella ultralateral tilt,

trochlear dysplasia, multilevel misalignment.

Patellar dislocation really needs to be looked at. These patients need to be

risk stratified in terms of their potential for having recurrent dislocations.

Every time they dislocate, they can take a chunk of cartilage off.

The moment that happens, you cannot reverse it. So you really need,

I think there is an apprehension to intervene early, but the consequences of

not doing that can be devastating for these patients.

And often they have patellar dislocations in their teens.

So the procedures are tibial tubercle osteomy, MPFL, recon, lateral release,

and some multi-level derotation.

So the key is patellar dislocation. I think refer early, we can risk stratify

them. If they have low risk factors, we don't do anything.

Physiotherapy works, if they do have lots of risk factors, they should have it treated.

This is a patient, you know, patella ulta sits very laterally,

the patella. You can see there's an element of malrotation.

These are the issues that cause patellofemoral maltracking.

Femoral antiversion, trochlear dysplasia, patella ulta, lateralized tibial tubercle,

lateral patella tilt, if they're valgus, if they've had an MPFL rupture as part

of a dislocation, if they've got external tibial torsion, or if they've got ligament laxity.

And so we do this analysis, part of the analysis, the 3D modeling that I showed you.

We can measure things like the TTTG distance and look at the rotational profile,

and give them a much more accurate sort of idea of what the problem might be.

So, you know, patients who've got patellofemoral maltracking,

you can see, you know, quite marked sort of J-tracking.

Now, for cartilage, so that was malalignment. for this is cartilage treatment.

So patients who have focal cartilage defects, this is not patients,

generalized arthritis or the entire compartments involved.

This is less than two or three square centimeter weight bearing area.

In a young patient, they've got intact meniscus, they've got good alignment,

or you do this in conjunction with deformity correction, alignment correction.

And you can either take cartilage from an area that they don't need it within

the knee joint. You can do that arthroscopically from here and put it in a defect as little blocks.

Or the alternative is to get a large allograft, so donor femur fresh that's

kept in a special sort of preserved medium.

And then we take the corresponding areas and put it in the joint for a patient

who's got a focal OCD lesion.

And then joint replacement surgery I'll let

Samir have a chat about that but essentially that should

be a last resort we know that the revision rate is substantially

higher for younger patients when they've got advanced when they've got arthritis

requiring a knee replacement so if we can use all of those things that we mentioned

to try and prevent them from getting to this point then I think they'll be much

better off if and when they have a joint replacement, but the key is to prevent.

Return to activities, so high tibial osteotomy, dysofemoral osteotomy,

they can return to sports activities within six to 12 months and they can go back to unrestricted,

after that so the aim is to allow them to do whatever they want once we've offloaded.

Patellofemoral joint surgery also has high success

because you are you take away the instability you take away the malalignment

whereas joint joint replacement it's it's not high impact sort of stuff so just

the takeaways young patients with knee pain deserve early evaluation so if you're

in doubt, just refer them.

We can have a look. If there's any doubt about alignment issues or some early joint degeneration,

I think it'll be beneficial for us to have a look and see if there is a role

for prevention of the arthritis advancing.

And then think alignment. So you've got easy access. I'm not sure if everyone

here is from the Macquarie area or elsewhere.

There are EOS scanners around town, but there's one here. It's very easy to

look at alignment with that.

Investigation, the EOS scan. And weight-bearing x-rays to look,

you know, is it purely medial, purely lateral, purely patellofemoral?

There are options for those patients. MRI long leg x-ray EOS scans crucial.

And early joint referral means then we can hopefully preserve their joint for

longer for these patients.

Thank you for listening today.