Anatomy and Physiology 101 for Attorneys

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1 Knee Injuries Anatomy and Physiology 101 for Attorneys Phil Davidson, MD Heiden-Davidson Orthopedics Salt Lake City, UT May 2011

2 Introduction Dr. Phil Davidson Park City and SLC clinics Education: Harvard, Cornell, Baylor, Kerlan-Jobe Clinic Surgical Specialist in Cartilage Restoration & Joint Resurfacing Knee and Shoulder Injuries Affiliated NFL, MLB, PGA, FDA

3 Outline Introduction to the Knee Types of Injuries Meniscal Cartilage Ligament Treatment Options What to Look for in Medical Records and Diagnostic Tests Acute- Chronic Exacerbation Questions and Answers

4 Knee Anatomy 101 Distal Femur Proximal Tibia Patella 4 Ligaments 2 Menisci Chondral (articular) surfaces

5 Surgical views of the knee

6 Meniscal Injuries

7 Meniscal Injuries Very common, subject to injury AND degeneration Acute Injuries vs. Chronic Tears Most common indication for arthroscopic surgery Most common orthopedic surgery in the US Chronic injuries with acute exacerbations How do you tell the difference Can occur with MVA twist or dashboard injury

8 Diagnosis History Physical Findings Meniscal Injuries Tenderness- along joint line Effusion (swelling) McMurray s (lateral) Pain with Hyperflexion or hyperextension Radiographs MRI is most sensitive no contrast needed Xrays do not show soft tissues

9 Meniscal Injuries Mechanisms Twisting Slip and Fall USUALLY NOT DIRECT BLOW Symptoms Pain Swelling Catching Locking Give out

10 Treatment- Meniscal Injury Not all positive MRI s require surgery Symptomatic treatment NSAIDS/Cortisone injections- inflammation only Physical therapy very limited, appx 10 visits or 1 month max Meniscus little or no capacity to heal

11 Arthroscopic Surgery Partial Meniscectomy Debridement Easy recovery Vast majority of tears Meniscal Repair Vascular Zone Acute, clean tears 1/3 don t heal Meniscal Injuries

12 Meniscal Injuries Recovery Period Meniscectomy (clean up) Immediate walking, bending Return to transitional duties 7-10 days Little PT or Rehab Full duties at 3-6 weeks Meniscal Repair (Rare ie. Less than 10%) Brace/crutches for 4-6 weeks PT 2-3x/week 4-8 wks Seated duty at work appx 8 wks Full duties appx 12 weeks

13 Chondral (Cartilage) Injuries Articular Cartilage Damage Smooth, shiny cartilage on ends of bone Damage or loss can lead to early arthritis Produce loose bodies

14 Cartilage Different types Articular cartilage Meniscal cartilage Many different in body Joint surface Articular cartilage Tidemark region Subchondral bone Analogy, tire tread

15 Articular Cartilage Grading Grade 1 Grade 2 Grade 3 Grade 3 Grade 4

16 Multiple Etiologies Yield Grade IV (full thickness) Lesions Trauma Focal degeneration Instability associated with injury

17 Weight Bearing Articular Cartilage Defects Pain, Clicking, Catching Loose pieces Progressive problem Limits activities Can be result of injury or gradual problem Cartilage has NO healing capacity!!!

18 Cartilage Restoration & Joint Resurfacing A wide realm between.. Arthroscopic debridement

19 Spectrum of Pathology Spectrum of Treatments.solution lies in understanding comprehensive pathology and full realm of treatments

20 Treatment Options for Symptomatic Cartilage +/- Bone Defects Based on Size Small < 1 cm 2 Debridement MST Mosaicplasty Medium 1 4 cm 2 Debridement MST Scaffolds Mosaicplasty OCA Chondrocytes +/- scaffolds Inlay Prosthesis Large >4 cm 2 OCA Chondrocytes +/- scaffold Onlay Prosthesis Total Joint

21 Demand Expectations Job Age Activities Complicity Biological, not just chronological Comorbidities BMI Diabetes Smoking Medical Illness

22 Cartilage Restoration/Joint Resurfacing Treatments: an evolving continuum of options Marrow stimulation Biological restoration Mosaicplasty / OATS OCA Chondral Auto and Allografts Bio-synthetics/scaffolds Modulated therapy Cellular therapy Joint Resurfacing Polymeric/Hydrogels Inlay Arthroplasty Micro-invasive prostheses Digitally custom onlay Total Joint

23 Biological Options Autologous Chondrocytes ACI MACI Osteochondral Grafts Autogenous Allogeneic Chondral grafts Biologically Active Scaffolds

24 Illustrative Case 22 yr old semi truck driver Jackknife MVA

25 Orthobiologic scaffold Off the shelf alternative theoretically better than microfracture Less morbidity than mosaicplasty Fill donor sites mosaicplasty No allograft donor issues Smaller type defects < appx 2cm

26 Post Op MRI 17 mos

27 Rehabilitation Protected weight bearing 6 weeks Med + Lat FC Full WB PF Early full motion CPM when possible Return to light work weeks MMI appx 4-5 mos

28 Osteochondral Grafts - Auto vs. Allo Autograft (OATS) No donor needed Limited availability Small lesions only Repair OCD Allograft (OCA) Very effective Young patients Handle Bone loss Larger lesions Generally > 2 cm²

29 OCA (osteochondral allograft) Procedure

30 OCA - Procedure

31 OCA - Procedure

32 OCA - Procedure

33 OCA - Procedure

34 OCA - Procedure

35 OCA - Procedure

36 OCA - Procedure

37 OCA - Procedure

38 What if biologics will not or cannot work?...next step beyond biologic Inlay Prostheses

39 A new paradigm for joint resurfacing Geometry based on patient s native anatomy Intraoperative joint mapping Account for complex asymmetrical geometry Extension of biological resurfacing

40 Knee Inlay Implants HemiCAP small unipolar knee UniCAP Medial and Lateral Includes Tibial Inlay PF HemiCAP Regular & XLT wave

41 Inlay resurfacing medial knee 46 year old construction worker, injured at work

42 Inlay medial knee resurfacing

43 UniCAP medial knee resurfacing

44 UniCAP medial knee resurfacing

45 UniCAP medial knee resurfacing

46 UniCAP medial knee resurfacing

47 50 year old day care worker fell taking care of children

48

49 Combining Biologics with Inlay Arthroplasty 29 year old firefighter

50

51

52 6 wks post op back at work light duty 12 wks post op full RTW as firefighter

53 More extensive than Inlay Very little bone resection Implants custom made from CT scan Onlay Resurfacing beyond inlay

54 42 year old FedEx Driver

55

56

57

58 Onlay Resurfacing Outpatient or one night stay Full WB immediately RTW Light duty 6 weeks Full duty appx 12 weeks

59 Ligament Injuries

60 Ligament Injuries ACL Anterior Cruciate Ligament PCL Posterior Cruciate Ligament MCL Medial Collateral Ligament LCL Lateral Collateral Ligament

61 Ligament Injuries MCL Inner part of the knee Most common ligament injury Tenderness medially Laxity medially Most commonly treated conservatively in a brace 4-6 weeks, physical therapy for ROM, modalities

62 Ligament Injuries Posterior Cruciate Ligament Prevents posterior translation of tibia on femur Most commonly occurs from direct blow to anterior tibia, fall onto knee or dashboard injury Isolated injuries potentially treated conservatively Physical therapy for ROM, strengthening Arthroscopic assisted reconstruction

63 Ligament Injuries PCL Tear on MRI

64 Ligament Injuries ACL Prevents anterior translation of tibia on femur Most common surgical treated ligament rupture Twisting, noncontact, slip and fall Most common complaint is instability

65 ACL Tear ACL Graft

66 Torn Ligament (ACL seen here)

67 Bone Tendon Bone Autograft ACL Reconstruction- Replace not Repair Patellar Tendon Graft Diminishing popularitypost op pain! Hamstring Tendon- Autograft Allograft Donor Tissue Not all tissue is the same

68 ACL Protects mensicus from shear injury Surgical Recovery 3-12 wks RTW 5-6 mos full activities Ligament Injuries

69 PRP- platelet rich plasma Supercharged healing Concentrate healing elements from own blood Growth factors Can create variety of forms, liquid, gel, membrane to facilitate biologic healing of surgical repairs ACL reconstruction, Meniscal repair, Rotator Cuff Repair

70 Biological ACL Surgery Graft, incorporates allograft, autograft and PRP Allograft gives large amount of collagen Autograft, gracilis Promotes healing Very small, not missed

71 Fractures about the Knee Tibial plateau fractures Falls from height, MVAs Patellar fractures Slip and fall Direct blow Both involve articular cartilage Joint congruency is the goal

72 Fractures about the Knee Diagnosis History Physical exam Radiology Plain fims MRI for associated injuries CT scan for complex fractures Primarily plateau fracture

73 Fractures about the Knee Operative vs. nonoperative 2mm guideline Surgery Patella fractures Open procedure Screws and wires Physical therapy and recovery 8-12 weeks

74 Fractures about the Knee Operative vs. nonoperative 2mm guideline Surgery Patella fractures Open procedure Screws and wires Physical therapy and recovery 8-12 weeks

75 Medical Records Review History Injury report, ER visit, Occ Med visit, Ortho visit, OP NOTE, follow ups, MRI reports, PT notes, DC notes OP NOTE What is said acuity, degeneration, technique What is NOT said (joint observations) Imaging MRI, MR Arthrogram (contrast), plain films IME s (Author, requesting party, findings) Rating letters and correspondence Return to work and permanent restrictions

76 Acute, Chronic, Recurrent, Aggravation Evaluation and imaging techniques to determine acuity vs. chronicity of an injury Energy/Injury Equation Detailed history Understanding the mechanism of injury Common causes of common injuries Biomechanical forces in injuries Does it add up?????

77 Imaging Techniques Plain X ray Standard views needed Can show Degenerative pre-existant findings Can show DJD over time Soft tissues not seen MRI Soft tissues- Ligaments, Meniscus, Cartilage Can show bleeding and acuity

78 How to decide chronicity Credibility of patient, reliability of story Are they believable? Reported history What happened? When? How? Witnessed? Mechanism of injury Does it make sense? Physical Findings Does it match mechanism? Is it acute? Imaging Findings Identify objective data

79 Did this happen when and how the patient said it happened? Meniscal Tear, Ligament Tear, Cartilage Injury Mechanism of injury Physical exam Plain Xray Diagnostic injections MRI imaging Acuity

80 Physician Conclusions medical- legal evaluations Physician needs to evaluate data and decide upon causal relationship This includes notion of apportionment Is the physician credible? Was valid data available to form opinion? Assigning and allocating disability Assigning and projecting further care and costs

81 Thank You now accepting new WC and Legal patients offices: Park City and SLC (Holladay)

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