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How To Know If You Can Recover From A Knee Injury

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(1)

David R. Cooper, M.D.

www.THEKNEECENTER.com Wilkes-Barre, Pa.

(2)

Knee Joint- Anatomy

Is not a pure hinge

Ligaments are

balanced

Mechanism of injury

determines what

structures get

damaged

(3)

Medial meniscus

tears 10x as often

as lateral

Gaps can exist

normally behind the

meniscus

Can be read as torn

(4)
(5)

 Enables us to do soft tissue imaging  Does not use radiation

 May not enable us to determine whether a finding

is acute or chronic

 There are false positives and false negatives  Watch out for degenerative tears

(6)

Meniscal Tears on the MRI

Cannot age tear or absolutely tell whether

it is mechanical or degenerative.

Any prior meniscal surgery will always

show up as an abnormality on a

subsequent MRI

Do not pick up a meniscal tear on an NCP

solely based upon the MRI report

(7)

Single tear

Flap displaces

anteriorly

No chondral injury

ACL is normal

Lateral meniscus is

normal

Can expect full

(8)

Only the torn

portion is removed

Remainder of

meniscus is

normal

Unlikely to retear

(9)
(10)

Inner segment

displaced into joint

blocking full

extension

Can be removed

and/or repaired

ACL intact

Good prognosis

(11)

 Segment is removed  No blood supply; Thus

will not heal

 Good maintenance of

joint space after removal

 No chondromalacia

(cartilage

(12)

Multiple small tears

Subchondral bone

is exposed

Lateral side normal

A poor result not

(13)

 A trauma related meniscal tear occurs with a twist

or squat under weight bearing

 Direct blow does not tear a meniscus  Degenerative tears are not caused or

“aggravated” by arthritis

 Arthroscopic surgery effects a full recovery in a

(14)

• Direct blow to front of

tibia does not tear ACL

• It actually loosens the

ACL

• Posterior or Lateral

stress can tear ACL

• ACL tear leads to a

(15)

• Blood vessels course along

the ACL in the synovium.

• As the ligament tears, the

blood vessels rupture.

• Large, tense effusion of

blood.

• Does not occur from a

frontal blow.

• Can be associated with

(16)
(17)

Linguini- like appearance

Hemorrhage shows it is recent Non-repairable; It must be reconstructed using a graft that does not have the same properties or placement

Do you really want a cadaver graft in your knee?

(18)

 Twist or hyperextension

 Knee fills with blood- can be seen by ER doc and

X-ray

 No prior history of knee injury

(19)

• Full recovery is unlikely

• Working at heights is not recommended • Difficult to objectively define recovery

• Post traumatic arthritis can ensue in 25% even

with a good surgical result

• Usual restrictions are light duty with no repetitive

(20)
(21)

 Visible only on an MRI

 May be a precursor of traumatic arthritis  High association with ACL tears

 Serial MRI’s may show resolution if chronic pain

(22)

 Any condition that causes inflammation of a joint

that may progress to destruction and loss of the articular cartilage.

(23)

 It is a disease process of unknown etiology.

 Articular surface of joints are made of protein and

water.

 For some reason(s) the articular surface breaks

down exposing underlying bone.

 Articular cartilege has no nerve fibers.  Bone has less protection----i.e. pain.

(24)

 200mg/day for 30 months.

 431 overweight women 45-64yrs.

 Women on doxycycline had 33% less cartilage

deterioration than those on placebo.

 They also had less pain.

(25)
(26)

 NO! That is a separate condition

“traumatic arthritis”

The surface of the knee is damaged, and the underlying bone is exposed

(27)

 Articular surface dries

up and flakes off

 Not related to trauma  No nerve endings to

(28)

• Raw bone exposed • Surrounding cartilage

is normal

• No other damage seen • May be seen on an

MRI along with a bone bruise

(29)
(30)
(31)

 Serial MRI’s after trauma show no more

deterioration

 Subsequent weightbearing x-rays show no more

narrowing

 Joint space

(32)

 Knee replacements never get done on someone

who falls down at home

 I’ve personally done over 600 TKR

 Gradually increasing pain with inability to walk

level surfaces

 Only when litigation is involved do TKR’s get

(33)

 “I didn’t hurt before, but now it is killing me.”

 If pain is the sole indicator, then why can’t other

conditions “aggravate” arthritis.”

 No scientific or statistical evidence to link trauma

(34)

 Frye, Daubert, Rule 702  Daubert- scientific studies

 Frye- preponderance of opinions

 Frye- may also include statistical studies or lack of

them

 Worker’s comp in Pa. does not need the above to

(35)

 Scientifically, Smoking increases rate of cartilage

degradation

 2007 Mayo Clinic study

 Male smokers had 2x loss of Art Cart compared

to nonsmokers

(36)

 Get past medical records and look for prior x-rays

and statements indicating a knee replacement was considered prior to the work event

 Request follow-up MRI or WB x-ray to see if

(37)

 No anatomic change in Knee = No Aggravation  See if prior medical records indicate prior surgery

from a different employer

 May actually be post traumatic arthritis from a

(38)

 Viscosupplemntation- Synvisc, hyalgan, Supartz,

Euflexxa, Orthovisc

(39)

 Can be work related if indicated for traumatic

arthritis

 If indicated for osteoarthritis may not be work

related.

 Can be used off label for synovitis following

surgery

 Be wary of bills for this- you may be picking up

(40)

 Meniscal tears are usually benign, and occur with

a minor twist

 ACL tears are obvious and have a definite clinical

presentation

 Osteoarthritis is not related to trauma

 Get how your knee injury occurred. Can make or

(41)

References

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