Medical Treatment Update

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Medical Treatment Update

• New Treatment Modalities
• Alan H. Klein, M.D.

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Alan H. Klein, M.D

• Director of Occupational Orthopaedics, Allegheny
  General Hospital, Pittsburgh, PA
• General Orthopaedics

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Orthopaedic Work Injuries

• Neck/Back
• Shoulder
• Elbow
• Wrist/Hand
• Knee
• Foot/Ankle

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Spine

• Sprain/Strain
• Herniation
• Pre-existing Degenerative Disease

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Shoulder

• Strain
• Rotator Cuff
• Dislocation
• Fracture

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Elbow

• Repetitive Trauma
• Tendinitis/Epicondylitis
• Nerve Entrapment

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Wrist/Hand

• Fracture
• Radius
• Scaphoid
• Repetitive Trauma
• Dequervains
• Carpal Tunnel

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Knee

• Sprain
• MCL (Medial Collateral Ligament)
• ACL (Anterior Cruciate Ligament)
• PCL (Posterior Cruciate Ligament)
• LCL/PLC (Lateral Collateral Ligament/Posterior
  Lateral Corner)
• Meniscus/Cartilage
• Fracture
• Pre-existing Arthritis

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Foot/Ankle

• Sprain
• Fracture
• Achilles Tendinitis

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Injury
Diagnosis
Treatment
Return to work
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Diagnosis

• History/Physical Exam
• X-ray
• Magnetic Resonance Imaging
• CAT Scan
• Ultrasound
• Bone Scan/Nuclear Medicine Studies
• Mylegram
• Provocative injection
• Arthroscopy

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Treatment

• Physical/Occupational Therapy
• Cortisone Injection
• Surgery
• Pain Management
• Electrotherapy
• Acupuncture
• Chiropractic

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Knee Sprain

• 43 year old auto mechanic twists his right knee
  while stepping over a garage hose. Immediate
  right knee pain and inability to straighten knee.
  

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Weve all heard this story before. Clearly, this
patient tore his medial meniscus. Hell have his
diagnosis confirmed, will have arthroscopic
surgery, and be back in the game in no time.
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However..

• It doesnt always work out perfectly in the real
  world, especially with pre-existing medical
  conditions and co-morbidities.

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Lets use this patient to learn about appropriate
use of new as well as tried and true treatment
modalities.
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Back to our patient..Past Medical History

• Diabetes
• Prior partial medial meniscectomy.
• Mild obesity
• Sleep apnea

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Emergency Room

• Guarding/Difficult examination
• X-rays minimal arthritis
• Knee immobilizer
• Crutches
• F/U Orthopaedic surgeon /Occupational Medicine
• Temporary Total Disability

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OrthoPod

• Physical Exam- Mild effusion, tender medial joint
  line, mild crepitation, lacks 5 degrees of
  flexion and extension.
• X-rays mild medial compartment narrowing
• Diagnosis Knee Sprain
• Secondary Diagnosis Pre-existing Arthritis,
  Prior Partial Medial Meniscectomy, rule out
  medial meniscal tear.
• Work Status Sedentary

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Treatment Options

• Defer until diagnosis confirmed
• Cortisone
• Physical Therapy (PT)
• Bracing
• Surgery

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MRI

• Likely Positive for Medial Meniscal tear (MMT)
• New vs Recurrent
• Increased sensitivity with MRI-Arthrogram
• Edema within bone may warn of DJD exacerbation.

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Indications for Surgery

• Locked Knee
• Recurrent effusions
• Failure of Conservative Treatment

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Back to T.C.

• Knee Aspiration 20cubic centimeters slightly
  cloudy fluid. Depomedrol 40milligram injected.
• Physical Therapy 3 times per week for 3 weeks.
• Knee sleeve

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RTOrthopod

• Less pain, swelling.
• Still cant walk far without pain. Occasionally
  gives way.
• Trace effusion, full motion.
• MRI ordered.
• Physical Therapy continued.

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MRI

• Poor quality open (claustrophobic)
• Medial meniscal tear (old vs new)
• Medial Femoral Condyle bone bruise
• Degenerative Joint Disease

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RTO

• Still hurts
• Trace effusion
• Tender Medial joint line
• Arthroscopy scheduled

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Arthroscopic Findings

• Medial meniscal tear involving post body and
  horn.
• Medial femoral condyle chondral defect
• Partial medial meniscectomy was performed along
  with chondral picks (Microfracture).

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Surgical Options for Chondral Defects

• Chondroplasty
• Drills/Picks/Steadman Awls/Abrasion Arthroplasty
• OATS (Osterarticular Allograft Transfer System)
• Allograft
• Osteotomy
• Carticel

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RTO

• Still painful and stiff.
• Wounds healing
• Non Weight Bearing x 6 wks
• Continuous Passive Motion (CPM) ordered
• Temporary Total Disability

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RTO 6wks P.O.

• Reports single episode tripping over dog,
  immediate knee pain, now much less.
• Physical Exam Trace effusion, slight quadriceps
  atrophy
• P.T. Ordered Progressive ambulation, begin
  weight-bearing. Quadriceps strengthening.
• Sedentary duties.

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Treatment Options

• Home Exercise Program versus P.T.
• Muscle Stimulator
• Cortisone injection
• Pain Management

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RTO

• Still feels weak, gives out. Medial pain.
• PE Trace effusion, mild quadriceps atrophy
• Cortisone injection, P.T.
• Sedentary Duties

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RTO (3mo.)

• Still complains of medial pain.
• Physical Exam quad atrophy, tender medial joint
  line.
• Medial Unloader Brace ordered
• P.T. Continued.
• Home Muscle Stimulator ordered

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RTO (6 mo)

• Brace helps, but still medial pain. Tried to
  work with brace, but found it too cumbersome.
  Now off work again secondary to knee pain.
• Treatment options??

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Treatment Options

• Second look arthroscopy
• OATS
• Cartricel
• Osteotomy
• Viscosupplementation
• Pain management/ vocational

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Viscosupplementation

• Sequential injections of viscous fluid into the
  knee.
• Contains Hyaluronic acid
• Derived from Rooster Combs
• Chicken shots
• 4 brands available in USA
• Relieves OA pain

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Surgery Planned

• Arthroscopy/Osteoarticular Autograft Transfer
  System

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Surgical Findings

• Only fibrocartilage noted at prior site
• Three plugs placed.
• Required overnight admission for pain relief.

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RTO (2wks)

• Knee swells and hurts. Went to Emergency Room 3
  days after surgery to have knee drained.
• Wound healing well.
• X-rays good position.
• NWB addl 2 wks., then progress.
• TTD

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RTO (6 wks)

• Less pain and swelling, although still c/o medial
  pain. Uses one crutch.
• PE trace effusion, tender medially.
• P.T.
• Sedentary Duties (although no work available)

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RTO 3 mo

• Still medial pain
• PE Tender Medial
• X-ray good incorporation
• More PT, try brace
• Sedentary

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RTO 6 mo

• Still medial pain. Cannot work.
• Treatment options???

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Treatment Options

• PT
• Viscosupplementation
• Osteotomy
• TKA
• Pain management

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Our patient elects to undergo Viscosupplementation
with Synvisc
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3 Injections over three weeks
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RTO (9mo p.o.OATS)

• Synvisc helped 25. Tried to go back to work

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RTO 2wks after RTW

• Still medial pain. No catching.
• Long-Standing x-rays reveal varus alignment
  bilat, right gt left.
• Osteotomy discussed.

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Osteotomy

• To cut and re-align the bone. Usually performed
  on the proximal tibia.

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Proximal Tibial Osteotomy Performed

• 2 day hospital stay.
• NWB in brace.
• Lovenox used 2wks post op for DVT prophylaxis.

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RTO (3mo)

• Ambulating with cane, less pain.
• PE Normal alignment, trace effusion.
• X-ray Osteotomy healed.
• Sedentary duties

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RTO (6mo)

• Min med pain. No cane.
• Osteotomy healed.
• RTW no restrictions
• F/U PRN

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Treatment Failure

• Pain management
• Viscosupplementation
• Bracing
• Partial knee replacement
• Total knee arthroplasty

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Thank You