PROCEDURE |
CONSERVATIVE CARE |
Clinical Findings |
|
|
|
SUBJECTIVE |
|
OBJECTIVE |
|
IMAGING |
ANTERIOR CRUCIATE LIGAMENT (ACL) REPAIR |
(Not required for acute injury with hemarthrosis)
Physical therapy
OR
Brace |
AND |
Pain alone is not an indication for surgery
Instability of the knee, described as "buckling or give way"
OR
Significant effusion at the time of injury
OR
Description of injury indicates rotary twisting or hyperextension incident |
AND |
Positive Lachman's sign
OR
Positive pivot shift
OR
Positive anterior drawer
OR
Positive KT 1000
>3-5 mm = +1
>5-7 mm = + 2
>7 mm = +3 |
AND |
(Not required if acute effusion, hemarthrosis, and instability; or documented history of effusion, hemarthrosis, and instability)
ACL disruption on:
Magnetic resonance imaging (MRI)
OR
Arthroscopy
OR
Arthrogram |
LATERAL RETINACULAR RELEASE
OR
PATELLA TENDON REALIGNMENT
OR
MAQUET PROCEDURE |
Physical therapy (not required for acute patellar dislocation with associated intra-articular fracture)
OR
Medications |
AND |
Knee pain with sitting
OR
Pain with patellar/femoral movement
OR
Recurrent dislocations |
AND |
Lateral tracking of the patella
OR
Recurrent effusion
OR
Patellar apprehension
OR
Synovitis with or without crepitus
OR
Increased Q angle >15 degrees |
AND |
Abnormal patellar tilt on:
x-ray, computed tomography (CT), or MRI |
KNEE JOINT REPLACEMENT
If only 1 compartment is affected, a unicompartmental or partial replacement is indicated.
If 2 of the 3 compartments are affected, a total joint replacement is indicated. |
Medications
OR
Visco supplementation injections
OR
Steroid injection |
AND |
Limited range of motion
OR
Night time joint pain
OR
No pain relief with conservative care |
AND |
Over 50 years of age
AND
**Body Mass Index of less than 35 |
AND |
Osteoarthritis on:
Standing x-ray
OR
Arthroscopy |
DIAGNOSTIC ARTHROSCOPY |
Medications
OR
Physical therapy |
AND |
Pain and functional limitations continue despite conservative care |
|
AND |
Imaging is inconclusive |
MENISCECTOMY
OR
MENISCUS REPAIR |
(Not required for locked/blocked knee)
Physical therapy
OR
Medication
OR
Activity modification |
AND |
Joint pain
OR
Swelling
OR
Feeling of give way
OR
Locking, clicking, or popping |
AND |
Positive McMurray's sign
OR
Joint line tenderness
OR
Effusion
OR
Limited range of motion
OR
Locking, clicking, or popping
OR
Crepitus |
AND |
(Not required for locked/blocked knee)
Meniscal tear on MRI |
CHONDROPLASTY
(Shaving or debridement of an articular surface) |
Medication
OR
Physical therapy |
AND |
Joint pain
AND
Swelling |
AND |
Effusion
OR
Crepitus
OR
Limited range of motion |
|
SUBCHONDRAL DRILLING OR MICROFRACTURE |
Medication
OR
Physical therapy |
AND |
Joint pain
AND
Swelling |
AND |
Small full thickness chondral defect on the weight bearing portion of the medial or lateral femoral condyle
AND
Knee is stable with intact, fully functional menisci and ligaments
AND
Normal knee alignment
AND
Normal joint space
AND
Ideal age 45 or younger |
AND |
Chondral defect on the weight-bearing portion of the medial or lateral femoral condyle on:
MRI
OR
Arthroscopy |
OSTEOCHONDRAL AUTOGRAFT (MOSAICPLASTY OR OSTEOCHONDRAL AUTOGRAPH TRANSFER SYSTEM [OATS] PROCEDURE) |
Medication
OR
Physical therapy |
AND |
Joint pain
AND
Swelling |
AND |
Failure of previous subchondral drilling or microfracture
Large full thickness chondral defect that measures less than 3 cm in diameter and 1 cm in bone depth on the weight bearing portion of the medial or lateral femoral condyle
AND
Knee is stable with intact, fully functional menisci and ligaments
AND
Normal knee alignment
AND
Normal joint space
AND
**Body mass index of less than 35 |
AND |
Chondral defect on the weight-bearing portion of the medial or lateral femoral condyle on:
MRI
OR
Arthroscopy |
AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) |
Physical therapy for a minimum of 2 months |
AND |
Injured worker (IW) is capable and willing to follow the rehabilitation protocol. |
AND |
Failure of traditional surgical interventions (i.e., microfracture, drilling, abrasion, osteochondral graft). Debridement alone does not constitute a traditional surgical intervention for ACI
AND
Single, clinically significant, lesion that measures between 1 to 10 sq cm in area that affects a weight-bearing surface of the medial femoral condyle or the lateral femoral condyle.
AND
Full-thickness lesion (*Modified Outerbridge Grade III-IV) that involves only cartilage
AND
Knee is stable with intact, fully functional menisci and ligaments.
AND
Normal knee alignment
AND
Normal joint space
AND
IW is less than 60 years old.
AND
**Body Mass Index of less than 35 |
AND |
Chondral defect on the weight-bearing surface of the medial or lateral femoral condyle on:
MRI
OR
Arthroscopy |