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Similar to Shoulder & Knee Conditions | Work-Related Injuries | South Windsor, Rocky Hill Glastonbury CT
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Shoulder & Knee Conditions | Work-Related Injuries | South Windsor, Rocky Hill Glastonbury CT
- 1. Shoulder and knee conditions in work-related Injuries ______JAMES T MAZZARA, MD ORTHOPEDIC ASSOCIATES OF HARTFORD, PC MANCHESTER / ROCKY HILL HARTFORD HOSPITAL GLASTONBURY SURGERY CENTER CONNECTICUT JOINT REPLACEMENT INSTITUTE @ ST FRANCIS HOSPITAL ECHN
- 2. Contact Information James T Mazzara, MD Orthopedic Associates of Hartford, PC 29 Haynes Street Manchester, CT 06040 _________________ 150 Enterprise Drive Rocky Hill, CT 06067 860-649-2267 www.HartfordSportsOrthopedics.com
- 3. Why Workers’ Comp Matters The workers’ compensation system is a medical driven legal compromise described as a “Grand Bargain” between labor and employees
- 4. Causation The cause (injury or history of exposure) is medically probable and occurred while at work or with a specific event The effect is medically probable. Condition is medically diagnosable & consistent with the symptoms, history, examination and clinical studies.
- 5. Causation Cause & effect are probably related
- 6. Causation Medical findings are compatible with the effects of an injury Sufficient exposure is present to have caused the condition The weight of evidence supports the disease as having an occupational rather than non-occupational cause.
- 7. The Method 1. Identify evidence of disease 2. Review and assess available epidemiologic evidence for a causal relationship 3. Obtain and assess evidence of exposure 4. Consider other relevant factors 5. Judge the validity of the facts (Plausibility) 6. Form conclusions about the work-relatedness of the condition
- 8. 1. Identify the condition History Exam Clinical studies Make the correct diagnosis
- 9. 2. Review & assess epidemiologic evidence for causal relationship AMA Guides to Disease and Injury Causation Second edition Analyses the studies based on study design, quality and value Strength of evidence From Very strong evidence to No Risk evidence
- 10. 3. Risk of Exposure Evidence of exposure What tasks. Quantified. Standardized Personal measurement Exposure of other workers Defined job category or trade Defined by employer
- 11. 4. Other relevant factors How does the individual perform the job How long on the job, previous job Has the job changed Other jobs Modifications Previous restrictions or impairments Pre existing conditions Hobbies
- 12. 5. Judge the facts Temporality Strength of association Dose response relationship Consistency Coherence to current science Plausibility Reversibility
- 13. Form a Conclusion Convert data from the whole to data for the individual May not be intuitively obvious Work relatedness involves the concept of medical and legal causation These may be mutually exclusive Medical causation is scientific Legal causation from a desire for social justice
- 14. Justice v. Science The courts are not based in science Therefore, laws are not scientifically derived Accepted wisdom if justice and fair play that underlie the concept of proximate cause are subject to many interpretations in WC law. Each state may determine for itself what constitutes proximate cause Judges and legislature can and will substitute convenience for science The judges have the final say
- 15. Connecticut Law Threshold Standard Reasonable degree of medical probability (certainty) Proving causal relationship is on the claimant Can only be met by competent medical evidence At least one doctor must state RDOMC
- 16. Aggravation Permanent worsening of a prior, or underlying, condition by an event or exposure
- 17. Exacerbation Temporary worsening of a prior, or underlying, condition by an event or exposure that will or has returned to baseline
- 19. The Knee
- 20. Age-related Cartilage Changes Older cartilage is less cellular Cartilage cells do not reproduce after growth plates close Chondrocytes only in lower layers Chondrocytes maintain extracellular matrix Bad news for aging cartilage Water content decreases
- 21. Grading Cartilage Wear I II III IV
- 22. Meniscus Cushion, shock absorber, stabilizer Compression results in hoop (circumferential) stress Laterally 70% load transmitted Medially 50% load transmitted
- 23. Meniscectomy Medial meniscectomy 50-70% reduction in femoral condyle contact w/ meniscus 100% increase in contact stress Lateral meniscectomy Total meniscectomy: 40-50% decrease in contact area Increased contact stresses in lateral compartment 200- 300% Contributes to articular cartilage damage and degeneration
- 24. Meniscectomy and Laxity In ACLR, additional MM resection increased whereas MM repair preserved knee laxity in comparison with the ACLR knee with intact menisci. Neither LM resection or LM repair showed a significant effect on knee laxity. Surgeons should make every effort to repair the meniscus whenever possible to avoid the residual postoperative laxity present in the meniscus-deficient knee. Medial Meniscus Resection Increases and Medial Meniscus Repair Preserves Anterior Knee Laxity: A Cohort Study of 4497 Patients With Primary Anterior Cruciate Ligament Reconstruction Riccardo Cristiani, MD*, Erik Rönnblad, MD, Björn Engström, MD, PhD, ... First Published October 24, 2017
- 25. Orthopedic Evaluation Activity level Expectations & Goals Symptoms Examination Alignment Hip exam Knee Exam ROM Meniscal signs Patellar mobility
- 26. Radiographic Evaluation Standing AP Standing 45o flexion PA Lateral Patellofemoral Each x-ray position tells us something different about the location of problems and the alignment of the knee.
- 27. X-Rays: Standing Films- AP Standing x-rays are performed with the knee in different positions. Each position reveals something about the location and degree of arthritis or other conditions that may lead to knee pain. This is a standing x-ray with knees straight (extended).
- 28. X-Rays: Standing Films- PA w/ Flexion This is an x-ray with the knee bent (flexed) 45 degrees. Properly positioned knee x- rays can reveal a degree of arthritis that may be missed on non-weight bearing x-ray views.
- 29. X-Rays This weight bearing tunnel view can reveal the degree of arthritis not seen on other x-rays This patellar view reveals the position of the patella in mid flexion.
- 32. Knee Arthroscopy
- 33. Knee Arthroscopy
- 34. Knee Arthroscopy
- 35. Knee Arthroscopy: Microfracture Full thickness joint cartilage defects Unstable full thickness lesions Osteoarthritis with proper knee alignment Not for partial thickness defects
- 37. Knee Arthroscopy: Microfracture Cartilage injury Loose cartilage removed After microfracture
- 40. Microfracture: Predictors of Outcome Poorer results in certain patients Increased age Malalignment Higher BMI (obesity) Rim height (condition of adjacent cartilage) Proper technique and rehabilitation
- 41. Autogenous Cartilage Implantation Focal cartilage defects Intact meniscus Meniscus transplant Normal alignment
- 42. MACI: Autogenous Chondrocyte Implantation via Collagen Membrane A sample of the patient’s own cartilage is sent to the lab, regenerated and implanted into a collagen membrane for reimplantation into the patient’s knee.
- 43. Arthroscopy & Microfracture in the Degenerative Knee Different than in non- degenerative knees Surrounding cartilage is thinned Dense, sclerotic bone Joint scarring and contractures Synovitis Osteophytes (Bone Spurs)
- 44. Total Knee Replacement >50% of patients over 65 have at least one joint with OA Over 250,000 TKA performed annually Excellent survival and function in >90% at 10-20 years
- 45. Knee Osteoarthritis – What does it look like? Knee with OsteoarthritisHealthy Knee Tibia (shin bone) Cartilage Femur (thigh bone)
- 46. Knee Replacement Surgery Considered when nonsurgical interventions aren’t alleviating pain The only long-term solution to knee pain
- 50. The Shoulder
- 51. The Shoulder Complex Deltoid Muscle Pectoralis Clavicle (Collar Bone)
- 52. The Shoulder Complex Deltoid muscle removed
- 54. Rotator Cuff Supraspinatus Active in any elevation of the arm Stabilizes the shoulder joint
- 55. Rotator Cuff Infraspinatus Depressor of the humeral head Stabilizer of the back of the shoulder
- 56. Rotator Cuff Teres Minor Rotates the shoulder out from the side
- 57. Rotator Cuff Subscapularis Stabilizes the front of the shoulder Rotates the arm inward
- 58. Rotator Cuff Balance Proper function depends upon balance between all muscle and ligament forces around the shoulder
- 59. Tendon Degeneration Age-related changes Decreased vascularity at the tendon attachment to the bone Leads to weak tendon that tears easily
- 60. Rotator Cuff Tears Tears begin where the stresses are the greatest Tendon fibers fail a few at a time or all at once Arm may be at rest Torn fibers retract when torn Humeral Head Partial Supraspinatus Tear
- 61. Consequences of rupture Increasing loads applied to the intact fibers Muscle fibers become detached from the bone resulting in weakness
- 62. Full Thickness Tears Loads are concentrated at the margins of the tear Further tearing occurs with smaller loads Partial tears become complete Smaller tears become large Large tears eventually become unfixable
- 63. Early Cuff Failure Compression of the humeral head is less effective Deltoid pulls head upward Upward pull of the deltoid results in cuff abrasion & further cuff damage
- 64. Progressive Tearing Spacer effect of the cuff is lost Humeral head displaces superiorly Biceps tendon eventually ruptures
- 65. Chronic Cuff Failure Humeral head forms a joint with the arch above Secondary joint disease occurs called cuff tear arthropathy
- 66. Chronic Cuff Tears Muscle atrophy Fatty infiltration of muscle belly Tendon retraction Bone osteoporosis Loss of muscle and tendon excursion Irreversible Progressively worse Fatty infiltration with muscle wasting Healthy muscle, no fat stripes
- 67. Prevalence of Rotator Cuff Tears Cadaver studies 7-40% MRI & Ultrasound studies 34% of asymptomatic individuals 54% of asymptomatic individuals over 60y Ultrasound study 13% of asymptomatic individuals: 50-59y 51% of asymptomatic individuals: over 80y
- 68. Prevalence of Rotator Cuff Tears 40%: no history of strenuous physical labor 50%: no history of trauma Frequently bilateral Many heavy laborers never get cuff tears
- 69. Healing Potential None without surgery Cuff tears never heal spontaneously Without a blood supply, there is never any chance a cuff healing spontaneously 51% of asymptomatic RCT become symptomatic Small tears increase in size slowly Large tears progress more quickly
- 70. Non Rotator Cuff Shoulder Pain Pain to the back of shoulder upper back or neck Pain to top of shoulder Think arthritis of the neck Pain beyond the elbow Think pinched nerve in the neck
- 71. Radiographs Acromial shape Position of humeral head AC arthritis Calcific tendinitis Glenohumeral arthritis Destructive lesions
- 72. Partial Tendon Tears: Acromioplasty, Excise and 1O Repair For tears >50% tendon thickness Post-op treat same as a full thickness RC repair
- 73. Rotator Cuff Repair Arthroscopic Open repair
- 74. Irreparable Rotator Cuff Tears Superior capsular reconstruction For massive irreparable cuff tears No arthritis Younger patients Older patients who do not want a shoulder replacement Restores superior capsule restraining superior translation Allows deltoid and pectoralis to function normally
- 75. Superior Capsular Reconstruction Indications Irreparable Supraspinatus and Infraspinatus tears Failed non-operative management Intolerable shoulder pain Subjectively unacceptable dysfunction Contraindications Moderate to severe arthropathy Significant bone defects Absent deltoid, latissimus dorsi or pectoralis function Shoulder stiffness
- 77. Biceps Tendon
- 78. Biceps Tendon Tearing SLAP Subluxation Shredded biceps tendon Normal biceps tendon
- 79. Anatomic Shoulder Replacement Osteoarthritis Intact rotator cuff Sufficient remaining bone Intact neuromuscular function Arhtritic shoulder Anatomic shoulder replacement
- 80. Reverse Shoulder Replacements Reverse shoulder replacements are helpful when treating arthritis associated with irreparable rotator cuff tears in patients unable to lift the arm due to tendon tears.
- 81. Reverse Shoulder Replacements Reverse shoulder replacement Anatomic shoulder replacement
- 82. Reverse Shoulder Replacement Indications Pseudoparalysis Antero-superior escape Acute 3-4 part fractures in the elderly Nonunion or malunion of tuberosity Failed arthroplasty Rheumatoid arthritis
- 83. Thank You Be careful out there.