The guidelines presented by the New York State Workers Compensation Board provide fundamental principles for performing therapeutic procedures: operative. These directives are designed to aid healthcare professionals in identifying suitable therapeutic approaches within the context of a comprehensive assessment.
Healthcare professionals with expertise in therapeutic procedures: operative can depend on the guidance outlined by the Workers Compensation Board to make informed decisions about the most appropriate therapeutic methods for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The final decision regarding therapeutic procedures: operative should entail collaboration between the patient and their healthcare provider.
Clinical Decision-Making for Operative Interventions
All surgical procedures must be grounded in a positive correlation among clinical findings, the clinical course, and diagnostic tests. A thorough integration of these factors must result in a specific diagnosis, positively identifying the pathologic condition(s). It is essential to eliminate non-physiologic factors influencing pain presentation or non-operative conditions that may mimic radiculopathy or instability (e.g., peripheral neuropathy, piriformis syndrome, myofascial pain, sclerotogenous or sympathetically mediated pain syndromes, sacroiliac dysfunction, psychological conditions, etc.) before contemplating elective surgical intervention.
Additionally, surgical treatment is warranted when the natural progression of surgically treated lesions is more favorable than the natural history for lesions treated non-operatively. All patients being considered for surgical intervention should undergo a comprehensive neuromusculoskeletal examination initially to identify mechanical pain generators that may respond to non-surgical methods or may not be receptive to surgical intervention.
Knee Fusion
Description / Definition : Surgical fusion of the femur to the tibia at the knee joint.
Diagnostic Testing Procedures : Radiographs, MRI, gallium scan (to rule out infection), and lab work as indicated.
Non-Operative Treatment : Therapy involving weight-sharing braces and NSAIDs is recommended for select patients as clinically indicated.
Operative Treatment : Operative treatment, typically involving open reduction, grafting, and internal fixation, is recommended for select patients as clinically indicated. External fixation or intramedullary rodding may also be considered.
Indications : Recommended when all reasonable conservative measures have been exhausted, and other reasonable surgical options have been seriously considered or implemented.
Post-Operative Therapy : Post-operative care involves rest, restricted activity, off-loading with crutches or a cane, NSAIDs, and APAP, followed by active therapy for protected weight-bearing and gait training. Recommended for select patients as clinically indicated.
Knee Arthroplasty
Knee Arthroplasty (Total or Partial Knee Joint Replacement) is not pre-authorized. Providers seeking to perform these procedures must request pre-authorization from the carrier before proceeding.
Amputation Description / Definition
- Surgical removal of a segment of the lower extremity.
Mechanism of Injury
- Typically occurs due to compromised post-traumatic bone, soft tissue, vascular, or neurologic conditions affecting a part of the extremity.
Specific Physical Findings
- Identifiable by the presence of a non-functional or non-viable segment in the lower extremity.
Diagnostic Testing Procedures
- Involves the use of radiographs and vascular studies, recommended as per clinical necessity.
Non-Operative Treatment
- Discouraged.
Operative Treatment Amputation
- Advised for specific patients based on clinical indications. Indications include the existence of a non-functional or non-viable segment in the extremity.
Post-Operative Therapy
- Involves rest, restricted activity, off-loading with crutches or cane, NSAIDs, APAP, followed by active and/or passive therapy for prosthetic fitting, construction, and training. Recommended selectively based on clinical indications.
Manipulation Under Anesthesia (MUA) Description / Definition
- Involves passive range of motion of a joint under anesthesia.
Mechanism of Injury
- Joint stiffness typically resulting from traumatic injury, compensatory surgery, or other treatments.
Specific Physical Findings
- Manifests as stiffness in both active and passive joint movements.
Diagnostic Procedures
- Involves the use of radiographs.
Non-Operative Treatment
- Therapy for active and passive range of motion exercises is recommended selectively based on clinical indications.
Surgical Indications
- Indicated in cases of intractable restriction and may be performed by a duly qualified surgeon. Consideration is given if routine therapeutic modalities, including physical therapy and/or dynamic bracing, fail to restore the expected motion after a reasonable period, usually at least 12 weeks.
Operative Treatment
- Discouraged.
Post-Operative Therapy
- Therapy for active and passive range of motion is recommended selectively based on clinical indications.
Bursectomy
Description / Definition
– Surgical elimination of the peri-articular bursa.
Mechanism of Injury
– Typically arises from a local traumatic injury or repetitive minor local irritation.
Specific Physical Findings
– Evidenced by swelling and tenderness over the bursa.
Diagnostic Testing Procedures
– Involves radiographs. Recommended as per clinical necessity.
Non-Operative Treatment
– Involves therapy for splinting, rest, NSAIDs, and steroid injection. Recommended selectively based on clinical indications.
Surgical Indications
– Presence of persistent pain and swelling despite treatment.
Operative Treatment
– Involves the surgical removal of the bursa.
Post-Operative Therapy
– Comprises rest, restricted activity, off-loading with crutches or cane, APAP, NSAIDs, followed by active and/or passive therapy for graduated range of motion exercises. Recommended selectively based on clinical indications.
Osteotomy
Description / Definition
- A reconstructive procedure involving the surgical cutting of bone for realignment, beneficial for patients who would gain from realignment rather than opting for total joint replacement.
Mechanism of Injury
- Post-traumatic arthritis or deformity.
Specific Physical Findings
- Painful decreased range of motion and/or deformity.
Diagnostic Testing Procedures
- Radiographs, MRI, CT scan. Recommended selectively based on clinical indications.
Non-Operative Treatment
- Involves therapy for activity modification, bracing, and NSAIDs. Recommended selectively based on clinical indications.
Operative Treatment
- Involves peri-articular opening or closing wedge of bone, usually with grafting and internal or external fixation. Recommended selectively based on clinical indications. Indications include the failure of non-surgical treatment, with the preference for avoiding total joint arthroplasty.
Post-Operative Therapy
- Comprises rest, restricted activity, off-loading with crutches or cane, NSAIDs, APAP, followed by active and/or passive therapy for protected weight-bearing and progressive range of motion. Recommended selectively based on clinical indications.
Hardware Removal Description
Definition
- Surgical extraction of an internal or external fixation device.
Mechanism of Injury
- Typically occurs after the healing of a post-traumatic injury that necessitated fixation or reconstruction using instrumentation.
Specific Physical Findings
- Local pain upon palpation, swelling, and erythema.
Diagnostic Testing Procedures
- Involves radiographs, tomography, CT scan, MRI. Recommended selectively based on clinical indications.
Non-Operative Treatment
- Active and/or passive therapy for local modalities, activity modification, NSAIDs. Recommended selectively based on clinical indications.
Operative Treatment
- Removal of instrumentation. Some instrumentation may be removed as part of standard treatment without local irritation. Recommended selectively based on clinical indications.
Post-Operative Therapy
- Comprises rest, restricted activity, off-loading with crutches or cane, NSAIDs, APAP, followed by active and/or passive therapy for progressive weight-bearing, range of motion. Recommended selectively based on clinical indications.
Release of Contracture Description
Definition
- Surgical incision or elongation of a contracted tendon or periarticular soft tissue.
Mechanism of Injury
- Usually follows a post-traumatic injury.
Specific Physical Findings
- Shortened tendon or stiff joint.
Diagnostic Testing Procedures
- Involves radiographs, CT scan, MRI scan. Recommended selectively based on clinical indications.
Non-Operative Treatment
- Therapy for stretching range of motion exercises. Recommended selectively based on clinical indications.
Operative Treatment
- Surgical incision or elongation of involved soft tissue. Recommended selectively based on clinical indications.
Post-Operative Therapy
- Comprises rest, restricted activity, off-loading with crutches or cane, NSAIDs, APAP, followed by active and/or passive therapy for stretching, range of motion exercises. Recommended selectively based on clinical indications.
Meniscectomy Description
Definition
- The surgical removal of a meniscus.
