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Surgical Guideline for Work-Related Knee Injuries 2016

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Surgical Guideline for Work-Related Knee Injuries 2016 Surgical Guideline for Work-related Knee Injuries 2016 TABLE OF CONTENTS I. Review Criteria for Knee Surgery .................................................................................... 2 II. Introduction ................................................................................................................... 9 A. Background and Prevalence ................................................................................................ 9 B. Establishing Work-relatedness .......................................................................................... 10 III. Assessment .................................................................................................................. 11 A. History and Clinical Examination ....................................................................................... 11 B. “Overuse Syndrome” and Contralateral Effects ................................................................ 11 C. Diagnostic Imaging ............................................................................................................. 12 IV. Non-Operative Care ...................................................................................................... 12 V. Surgical Procedures ...................................................................................................... 13 A. Marrow Stimulation Procedures ....................................................................................... 13 B. Autologous Chondrocyte Implantation ............................................................................. 14 C. Patellar Tendon Realignment Procedure ........................................................................... 14 D. Meniscal Disorders ............................................................................................................. 15 E. Anterior Cruciate Ligament Reconstruction (ACL) ............................................................. 16 F. Osteochondral Autograft/Allograft Transplantation ......................................................... 17 G. Arthroplasty ....................................................................................................................... 18 VI. Rehabilitation, and Return to Work .............................................................................. 19 VII. Appendices .................................................................................................................. 20 Appendix A - Assessment Tools ................................................................................................ 20 Appendix B – The Bree Collaborative ........................................................................................ 23 VIII. Acknowledgements ...................................................................................................... 24 IX. References ................................................................................................................... 25 1 Washington State Department of Labor and Industries Surgical Guideline for Work-related Knee Injuries – July 2016 I. Review Criteria for Knee Surgery Kellgren Lawrence (KL) Scoring System and Modified Outerbridge Classification A request may be If the patient has AND the diagnosis is supported by all the following subjective and objective Required or appropriate for findings and imaging results: recommended Surgical Procedure Condition or Subjective Objective Imaging Non-operative care Diagnosis Knee arthroscopy Diagnosis: MRI is now the diagnostic method of choice. Arthroscopy for diagnostic purposes will only be considered if an for diagnosis or for MRI is contraindicated, (e.g. for a patient with a cochlear implant or pacemaker). osteoarthritis Osteoarthritis: Arthroscopic debridement and lavage is not covered as treatment for osteoarthritis; based on a 2008 HTA decision. Chondroplasty Chondroplasty is most commonly done in conjunction with a meniscal surgery or marrow stimulating procedure; it is rarely done as a stand-alone procedure. A chondroplasty, by itself, is covered only when: a) During a previously authorized surgery that was aborted, a chondral lesion was discovered and documented with intraoperative imaging (e.g. photo), OR b) A chondral lesion, such as a loose flap, is seen preoperatively on MRI and surgery is indicated to remove or correct it. Autologous Non-covered procedure (for explanation, see Autologous Chondrocyte Implantation in the narrative section) Chondrocyte Implantation (ACI) Patellar tendon Patellar dislocation History of acute Lateral tracking of the MRI (not x-ray or CT 6 weeks of physical realignment traumatic dislocation patella scan) shows: therapy is required for procedure with or OR first time dislocation; without lateral Recurrent effusion Medial Patellofemoral physical therapy is not retinacular release OR Ligament (MPFL) required for recurrent Positive patellar disruption dislocations or if loose apprehension test OR osteochondral body is OR Osseous contusion confirmed by MRI or Synovitis with or without OR x-ray and needs to be crepitus Cartilage injury surgically addressed. OR Recurrent dislocations 2 Washington State Department of Labor and Industries Surgical Guideline for Work-related Knee Injuries – July 2016 A request may be If the patient has AND the diagnosis is supported by all the following subjective and objective Required or appropriate for findings and imaging results: recommended Surgical Procedure Condition or Subjective Objective Imaging Non-operative care Diagnosis Meniscectomy, full Acute meniscal tear Discrete event Positive McMurray’s sign MRI shows: Not required for or partial (in a non- in an otherwise associated with the OR Non-degenerative locked or blocked degenerative knee) non-degenerative acute onset of any of Anatomically consistent meniscal tear knee knee the following joint line tenderness AND AND symptoms: OR KL score < 2 on weight If not locked or Onset of symptoms • Pain Effusion bearing x-rays blocked, recommend: within 12 weeks of • Swelling OR injury • Locking, catching, Limited range of motion At least 6 weeks or popping OR (post-injury) of: Mechanical locking, catching, or popping Physical therapy OR Note: The combination of Non-narcotic positive McMurray’s sign medications with joint line tenderness OR has a higher predictive Activity modification value than any one sign alone. Repeat Knee is still Continued symptoms Positive McMurray’s sign A NEW MRI shows: Recommended: Physical therapy arthroscopic symptomatic with of: OR Meniscal tear during 12 weeks post- meniscectomy in continued disability • Pain Anatomically consistent AND op period after initial the absence of new AND • Swelling joint line tenderness KL score < 2 on weight- injury as long as there injury (in a non- At least 12 weeks • Locking, catching, OR bearing x-rays is no mechanical degenerative knee) has passed since or popping Effusion locking meniscectomy for OR original acute tear Limited range of motion OR Mechanical locking, catching, or popping Note: The combination of 3 Washington State Department of Labor and Industries Surgical Guideline for Work-related Knee Injuries – July 2016 A request may be If the patient has AND the diagnosis is supported by all the following subjective and objective Required or appropriate for findings and imaging results: recommended Surgical Procedure Condition or Subjective Objective Imaging Non-operative care Diagnosis positive McMurray’s sign with joint line tenderness has a higher predictive value than any one sign alone Meniscectomy, full Acute or chronic History of locking of Mechanical locking MRI shows: Not required or partial (in a Meniscal tear in a the knee OR Large meniscal flap or degenerative knee) degenerative knee Effusion fragment (Degenerative is OR AND defined as a KL Restricted motion KL score ≥ 2 on weight- score ≥ 2) bearing x-rays Repeat Acute or chronic History of locking of Mechanical locking A NEW MRI shows: Not required arthroscopic Meniscal tear in a the knee large meniscal flap or meniscectomy in degenerative knee fragment the absence of new (Degenerative is AND injury (in a defined as a KL KL score ≥ 2 on weight- degenerative knee) score ≥ 2) bearing x-rays Meniscal Allograft A previous acute, Knee pain that has not Previous meniscectomy MRI demonstrates Recommended: Transplantation work-related event responded to with at least 2/3 of the absence of meniscus Physical therapy (MAT) that caused the conservative treatment meniscus removed AND OR need for a AND Weight bearing AP and NSAID meniscectomy Stable knee with intact lateral x-rays with or OR ligaments, or intent to without notch view show Activity modification repair torn ligament; with a KL score < 2 normal alignment or AND/OR intent to realign, and Chondrosis meeting normal joint space; has Modified Outerbridge sufficient articular Scale, Grade I or II cartilage in the affected OR compartment to ensure Grade III with evidence 4 Washington State Department of Labor and Industries Surgical Guideline for Work-related Knee Injuries – July 2016 A request may be If the patient has AND the diagnosis is supported by all the following subjective and objective Required or appropriate for findings and imaging results: recommended Surgical Procedure Condition or Subjective Objective Imaging Non-operative care Diagnosis the continued integrity of that articular surface is the allograft meniscus sufficiently free of AND irregularities to maintain Age < 50 integrity of transplanted AND meniscus. BMI < 35 Exclusion criteria:
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