Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter A - Lower Extremities › Section I-2313 - Therapeutic Procedures- Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A. All operative interventions must be based
					 upon positive correlation of clinical findings, clinical course and diagnostic
					 tests. A comprehensive assimilation of these factors must lead to a specific
					 diagnosis with positive identification of pathologic condition(s). It is
					 imperative to rule out non-physiologic modifiers of pain presentation or
					 non-operative conditions mimicking radiculopathy or instability (e.g.,
					 peripheral neuropathy, piriformis syndrome, myofascial pain, complex regional
					 pain syndrome or sympathetically mediated pain syndromes, sacroiliac
					 dysfunction, psychological conditions, etc.) prior to consideration of elective
					 surgical intervention.
B. In
					 addition, operative treatment is indicated when the natural history of
					 surgically treated lesions is better than the natural history for
					 non-operatively treated lesions. All patients being considered for surgical
					 intervention should first undergo a comprehensive neuromusculoskeletal
					 examination to identify mechanical pain generators that may respond to
					 non-surgical techniques or may be refractory to surgical
					 intervention.
C. Structured
					 rehabilitation interventions are necessary for all of the following procedures
					 except in some cases of hardware removal.
D. Return-to-work restrictions should be
					 specific according to the recommendation in the Therapeutic Procedures,
					 Non-Operative.
1. Ankle and Subtalar Fusion
a. Description/Definition: Surgical fusion of
					 the ankle or subtalar joint.
b.
					 Occupational Relationship: Usually post-traumatic arthritis or residual
					 deformity.
c. Specific Physical
					 Exam Findings: Painful, limited range of motion of the joint(s). Possible fixed
					 deformity.
d. Diagnostic Testing
					 Procedures: Radiographs. Diagnostic injections, MRI, CT scan, and/or bone
					 scan.
e. Surgical
					 Indications/Considerations: All reasonable conservative measures have been
					 exhausted and other reasonable surgical options have been seriously considered
					 or implemented. Patient has disabling pain or deformity. Fusion is the
					 procedure of choice for individuals with osteoarthritis who plan to return to
					 physically demanding activities.
i. Prior to
					 surgical intervention, the patient and treating physician should identify
					 functional operative goals, and the likelihood of achieving improved ability to
					 perform activities of daily living or work activities and the patient should
					 agree to comply with the pre- and post-operative treatment plan including home
					 exercise. The provider should be especially careful to make sure the patient
					 understands the amount of post-operative therapy required and the length of
					 partial- and full-disability expected post-operatively.
ii. Because smokers have a higher risk of
					 delayed bone healing and post-operative costs, it is recommended that insurers
					 cover a smoking cessation program peri-operatively. Physicians may monitor
					 smoking cessation with laboratory tests such as cotinine levels for long-term
					 cessation.
f. Operative
					 Procedures. Open reduction internal fixation (ORIF) with possible bone
					 grafting. External fixation may be used in some cases.
g. Post-Operative Treatment
i. An individualized rehabilitation program
					 based upon communication between the surgeon and the therapist and using
					 therapies as outlined in Therapeutic Procedures, Non-operative. In all cases,
					 communication between the physician and therapist is important to the timing of
					 weight-bearing, and exercise progressions.
ii. When boney union is achieved, treatment
					 usually includes active therapy with or without passive therapy, including gait
					 training and ADLs.
iii. Rocker
					 bottom soles or shoe lifts may be required. A cast is usually in place for six
					 to eight weeks followed by graduated weight-bearing. Modified duty may last up
					 to four to six months.
iv. Return
					 to work and restrictions after surgery may be made by an attending physician
					 experienced in occupational medicine in consultation with the surgeon or by the
					 surgeon.