MR. BISHOP: At this time I'd like to enter the Doctor's curriculum vitae into the record and offer the Doctor as an expert in the field of orthopedic surgery.

MR. SLATER: I have no objections. I am familiar with the Doctor's qualifications.

DIRECT EXAMINATION

BY MR. BISHOP:

Q. Doctor, at this time I would like to ask if you had an opportunity to see and treat Philip Keller over the years?

A. Yes, I have.

Q. Doctor, when was the first time that you saw Mr. Keller?

A. Mr. Keller first came under our care, that is, the care of our office, in 1976.

Q. What was the occasion that Mr. Keller came to your office for care and treatment, Doctor?

A. Well, he came with a painful left knee. He had injured his knee on December 24, 1974, when he fell from a dock at work. This fall was approximately four and a half feet, and he sustained fractures of his left lower leg and knee area. He was treated originally in Grove City and then subsequently in Philadelphia.

Then in 1976 he eventually came under our care. At the time I saw him, he had severe traumatic arthritis of his left knee as a result of that injury.

Q. Doctor, I'd like to make reference to what is dated December 19, 1991. Would that be your most recent report that we requested relative to your treatment of Mr. Keller?

A. Yes, it is.

MR. BISHOP: I am going to mark that into the record as Claimant's Exhibit 2.

(At this time Claimant's Exhibit No. 2 was marked for identification.)

BY MR. BISHOP:

Q. Now, Doctor, subsequent to your initial history and examination of Mr. Keller, I know from your report that you initially conducted surgery on him in March of 1977. Would you care to elaborate on that please, Doctor?

A. Yes. On March 25, 1977, my partner, Dr. William Davis, and I performed a total knee replacement arthroplasty on Mr. Keller's left knee.

Q. Doctor, would that surgery have been as a result of the injury, the work injury, that Mr. Keller incurred on December 24, 1972

A. Yes. That surgery was performed as a direct result of the injuries that Mr. Keller sustained on December 24, 1974.

Q. Since such time, has Mr. Keller been a continuous patient of yours?

A. Yes, he has.

Q. Doctor, was this the only surgery that you conducted on Mr. Keller relative to his knee injury?

A. No. It became necessary to re-operate on Mr. Keller's knee in 1982. He developed mechanical failure of the total knee implant, and it required to have the operation done over.

Q. Doctor, you described a mechanical failure. Do you recall specifically what that failure was?

A. I don't recall offhand. I'd have to look back at my records here if we can do that. Well, our notes indicate back in 1982 at that time he was primarily followed by Doctor Davis.

In July of 1982 a note states that Phil's geometric prosthesis of the left knee is beginning to give him trouble. If he becomes more symptomatic over the next months, we will consider rescheduling him for a re-do of that total knee, arthroplasty which is now old and beginning to wear.

When he came back at the end of August in 1982, the decision was made to revise his knee at that time. There aren't a lot of details as to specific complaints then.

Q. So the second surgery would have taken place on September 29 of 1982; is that correct?

A. That's correct.

Q. You have, once again, been seeing Mr. Keller relative to this knee since that second surgery?

A. That's correct.

Q. What would that second surgery have been? That would have been a complete total knee replacement arthroplasty?

A. That was a complete total knee replacement, yes.

Q. Doctor, these knee replacements, are they prone to frequent or occasional failure, especially mechanical failure?

A. Yes. The most common cause of failure is mechanical, and the most common cause of mechanical failure is what we call aseptic loosening of the components. They also do wear out and break, particularly the older designs which we think we've improved. The total knee has certainly gone through its growth and its learning curves to bring it up to the point of the success we now enjoy with it, but the ones we were doing 10 and 15 years ago are quite archaic compared to the ones we do now.

Q. Would that constitute the type that Mr. Keller currently has in place? A. Yes.

Q. You described, if I am correct, aseptic failure.

A. Aseptic meaning noninfectious origin for failure or loosening. It is a rather complicated physiological reason. I don't think we have to get into that right now, but the reasons they fail many times are because they become loose or one part becomes loose; and it progresses very rapidly to failure, to the point where they have pain, swelling, and often times, fracture, or deformity.

Q. Generally, what would be the actual physical procedure as far as this type of surgery; and if such became necessary again for Mr. Keller, what would have to be done?

A. Well, if possible, we would try to revise it; that is, we would take out the old parts and put in a brand-new knee joint. If this were not possible, then the only other option would be to fuse the knee in a straight position. The revision surgery is really the most difficult and most challenging surgery that we do.

The total knee revisions are very difficult; and the results, the satisfactory results, drop off_. a great deal the more times the surgery has to be done. Personally, I've never tackled one the third time around. We have had several that had to be done a second time, but I was never personally involved with one the third time.

Q. Doctor, in your letter and report of December 19, 1991, I notice that you point out that Mr. Keller is being very protective of the joint as per your strong recommendations. What would be the basis of those strong recommendations? What would your strong recommendations be, relative to Mr. Keller's knee, first of all?

A. When we revised Mr. Keller's knee, he was only, I believe, 50 years old in 1982. So if we assume he has a normal life span, we don't -- most of the knees that we have done of the type that Mr. Keller has in, either the patients have passed away or their knees have been revised because most of the type of implants that he has have failed for one reason or another.

So he certainly, if he lives, has a high risk of the knee going on to mechanical failure because it does wear. The plastic wears about a millimeter a year, and this is going to wear out on him. So the more he is on it, the more stress, the more load, the more activity, the higher the chance the knee is going to fail.

And since to operate the third time around -- the second time around is a major operation. The third time around is even bigger and would pose a lot the technical problems and mechanical problems for us with a much less rate of success. I felt it was in his best interest to be very careful and cautious on this leg, and he's very lucky that he has been getting around as he has for ten years.

Q. Everything that you just described, Doctor, as far as your recommendations and your concerns with Mr. Keller, are these strictly as they relate to his knee and independent of any other health problems that he may or may not have?

A. Yes, that's correct.

Q. Are you aware of his other health problems?

A. Yes, I am.

Q. As you understand them, generally, what are they?

A. Phil has had at least one heart attack. I believe he has had cardiac surgery. I'm not certain of that. In fact, in my records, it certainly would be in here. I also know that he has a lung problem, an emphysema-type problem. These medical problems have no direct effect on his knee, but they have -- they certainly are things we have to consider if we are going to operate on him.

And it would increase his risk if he had to have additional surgery on his knee, especially of the magnitude that we are talking about. It would be high risk with his present cardiac and pulmonary problems; so that certainly adds another reason for him to take it easy and not risk jeopardizing the left knee.

Q. Doctor, irrespective of Mr. Keller's other non-knee related health problems within a reasonable degree of medical certainty, do you have an opinion as to his ability to sustain gainful employment?

A. Yes. It's my opinion that he does not have the ability to sustain gainful employment because of his knee and for the reasons I think we mentioned here or tried to mention.

Q. Doctor, once again within a reasonable degree of medical certainty, what is your prognosis as to Mr. Keller's knee at this time?

A. Well, the prognosis is guarded. That means we don't know what really will happen here, but we worry about it. And he is certainly at risk to walk into my office any day from here on out and say I'm starting to have pain in my knee; and we get an X-ray and see a crack developing. The rate of failure after ten years increases quite dramatically.

MR. BISHOP: I have no further questions for the Doctor at this time.

CROSS-EXAMINATION

BY MR. SLATER:

Q. Doctor, my name is Alan SLATER, and I represent Lambert and Company which is the defendant in this matter. Judging from what you have just said about the condition, the current condition, of Mr. Keller's knee, it sounds to me like he has lost the use of that knee and its function with regard to the entire leg. Would that be a true statement?

A. Well, if you were just going to rate the disability in terms of percentage for his leg, yes, there is a degree. Actually, the knee implant functions reasonably well. He has a satisfactory range of motion. He can bend his knee to 90 degrees, and it comes out straight. He still has a mild deformity there, but not a severe one; so it's not a question that he -- that the knee doesn't function. The knee functions all right.

Q. Let me ask that another way. Has he lost of the use of his leg because of the knee for all practical intents and purposes?

A. Well, not in the conventional sense that I think of it.

Q. If the leg were to be fused, if the knee were to be fused, it would be nothing more than a prop, a post, a peg. Would that be a fair statement?

A. Yes.

Q. How much more is it currently than that?

A. The major difference is that he can bend the knee, obviously. He can bend it to 90 degrees.

Q. What purpose or what function will that permit him to do with that knee?

A. Actually, a fused knee would be a more -- it would hold up better. It would take more abuse than the total knee will.

Q. You performed that second surgery in September of 1982, and that was a joint replacement. In fact, it was a reconstruction of the left knee; is that right?

A. That's right.

Q. From what I read in your report, you had an excellent result from that surgery?

A. Yes. We were very proud of our result.

Q. In fact, he has done very well in terms of function with that second knee replacement from the time of its installation right up to the current time; is that right?

A. Absolutely.

Q. He doesn't have any neurological problems in the lower part of the left leg; is that right?

A. No. He has no neurological problems.

Q. He hasn't developed any additional arthritis in the area around the arthroplasty; is that right?

A. No. He does have arthritis of his left ankle secondary to the old injury. He has not complained a great deal about

that, but he does take a lot of the stress off of the leg by using a cane.

Q. Now, we have talked about these mechanical defects. To this point there has not been any mechanical defect in that

implant; is that right?

A. I haven't -- up to the latest X-rays which -- I last X-rayed him on November 13, 1990; so that's approximately a year and four months, and at that time things looked good.

Q. No reason to believe that they changed significantly based on his complaints since that time?

A. No. If there had been -- if he had started complaining, we would re-X-ray his knee right away.

Q. He hasn't done that?

A. Not to the moment, no.

Q He is able to engage in the activities of daily living even in consideration of the condition of his knee?

A. Yes, he is.

Q. You described a little bit earlier some of the functions, the ranges of the motion; and I think you said he has flexion up to 90 degrees?

A. Yes.

Q. Is that an acceptable level for you, considering the knee replacement?

A. Yes. Considering the knee was done the second time around, that's very good.

Q. Is that about 65, 70 percent of normal? Is 130 degrees normal?

A. Yes. But if you talk about the functional range of motion, you need 90 degrees so you can get up easily from a chair. As far as walking, all you need is to get the leg straight.

Q. It sounds to me like you did a nice job on the surgery, that he has got at least some functional use of the leg. So my concern and my question is: why can he not

do some sedentary employment where he isn't required to walk great distances or stand for long periods of time?

A. Well, I understand your argument; and I would agree with you that, if he had a job at home where he was sedentary and sitting, it may not be a problem for him. His brain still works very well. He can use his hands, but if you are talking about someone who has to go out and work for someone else five days a week, year in and year out, he obviously would have to park his car somewhere and walk back and forth.

If he -- you know, on days when it is slippery and particularly three or four months during the wintertime, he is at risk. If he slips and falls on that knee, that could be the death knell because all it takes -- that knee won't take the abuse that an ordinary normal knee will. These implants will fail.

Most of this type of surgery, the vast majority of it, are done in people well over -- that are retired, that are in -- they're 65-, 70-year-old people; and most of them don't outlive the knee. The knee outlives them, so to speak; and they get five years, maybe even ten years, out of it.

And even if they do start to have failure symptoms, many times they can put up with it because they have other overwhelming problems that preclude even considering operating on it. But when we have someone who is only 50 when you operated on him and you operated on him now for the second time, this is major surgery.

This isn't, you know, go to the arthroscope and take out a little piece of cartilage. This is the biggest operation you can do on the knee; and you know, the more mileage he puts on it, the more stress and strain, the more he puts himself at risk, the increased likelihood he has that this is going to fail.

And when it fails, we have no conservative way of treating it because, once it begins to fail, it fails very quickly. It falls apart rapidly, and it's very painful; and that requires a major operation, a life-threatening operation now because of his heart problem.

Q. It sound to me like the operative word in this is “if.” If this happens or if that happens, it can be a problem; but currently those contingencies have not occurred. There is no mechanical failure. He has at least an acceptable range of motion and function and use of that leg with which you are satisfied; is that a fair statement?

A. And part of the reason for that is that he has been very limited, and he has taken it very carefully on his leg at our admonishment. We are on him every time to take it easy. He knows. He is well aware of what the problem is.

Q. So out of an abundance of caution, you recommend to him not to overuse that knee or not to use it too much.

A. Absolutely; and he has followed those instructions very carefully. He can walk. Technically, he can walk without a cane most of the time, but we told him to use a cane because the cane takes a big load off of that knee; and maybe you increase the longevity by using that.

Q. He has some other problems. You'll agree with me that those, the heart problem because he did have an infarct, I believe he has got the chronic obstructive pulmonary problem --

A. Right.

Q. -- those are not in any way related to the work injury to his left leg; is that right?

A. No, they are not.

Q. So as a candidate for surgery absent those and still with this same age, he could have that knee replaced the third time even though you say in your experience you haven't seen them.

A. No. They have been done. I just haven't had personal experience the third time around.

Q. And the real complicating factors to that third knee replacement would be the weakened heart and the obstructive

lung disease that you are talking about.

A. Now, you are taking a situation that would be -- let's assume that he had a good heart and good lungs and was otherwise a safe risk for a major surgical operation.

Now, you are taking an operation that is just a difficult technical procedure which may not work out too well mechanically for him, but he would still be all right, to a situation where just the surgery alone is now a significant risk to his life.

So you are going to really think twice. So certainly as a physician I have to use my judgment here and tell him to be careful because he may feel well enough to try to do other things, but when it comes down to stressing his system with a major operation, he may not -- his heart may not be able to stand that.

Q. It sounds to me like what you are saying is that it is a difficult operation the third time around and made considerably more difficult and, in fact, life-threatening by the fact that he has a bad heart and obstructive lung disease.

A. That is correct.

Q. So in and of itself the surgery would be feasible, but for his other non-work related ailments or conditions.

A. Yes. It may even be feasible with his medical conditions, but it certainly increases the risk.

Q. But you don't want to confront that problem?

A. No, I don't want to. That's why I agree.

Q. But everything is acceptable the way it is. It is working properly, and you have no complaints at least at this point.

A. At this point in time; but he is now getting into the second decade on this knee, which, you know, is just lucky. He has ten years under his belt already. That's a lot.

Q. Is there any reason to believe based on your experience or your review of studies to think that that knee could not

last another 10 to 15 years?

A. Well, It's going to get -- it depends on a lot of things, obviously. I don't know. There haven't many studies.

With this particular implant lasting twenty -- there are not many twenty-year follow-ups because, like I say, most of these implants are put into older people.

And when you put them into younger people who are active, they fail. They fail very quickly. They are not made for the stresses that we usually think of, even the stresses that we normally think of in our ordinary life, the amount of walking and so forth.

Possibly, the ones that we are putting in presently, we hope will last longer. The designs are better. The techniques are much better and so forth, but even those we certainly don't tell our patients that they can go out and do silly things on.

Q. Doctor, have you had an opportunity to review any of the possible jobs that were made available to Mr. Keller?

A. No, I haven't.

MR. SLATER: That's all the questions I have.

REDIRECT EXAMINATION BY MR. BISHOP:

Q. I have one follow-up question: Doctor, Attorney Slater was asking you and talking about some of the obvious complications of another surgery relative to some of Mr. Keller's other ongoing medical problems. In your letter, report of December 19, 1991, you point out another revision of his total knee will be extremely difficult from a technical standpoint and certainly could not be predicted to work as well as his previous one.

MR. SLATER: Objection. That's a leading question.

MR. BISHOP: Objection noted.

BY MR. BISHOP:

Q. That sentence that I just read out of your report, Doctor, is that irrespective of his heart and lung condition? A. Yes, it is.

Q. Could you please elaborate on that sentence and what you mean by that.

A. Well, the knee surgery all by itself, going back in there a third time, you have loss of bone stock. You have – they don't even make the implant that we used ten years ago; so we would have to revise this knee to one of the present implants.

We have to use special, maybe even some custom-made parts to put in his knee if we're going to do it. We're going to encounter a great deal of scar tissue from his previous surgeries. It makes dissection much more difficult and leads to additional stiffness after the surgery is over. Just to try to rehabilitate that knee could be a difficult job.

So at least from the studies I have seen, you know, the third time around, maybe you will have maybe a 50 percent good result instead of a 80 or 90 percent good result. What happens if he falls to the 50 percent that is not a good result? Then what do you do? He is on a walker or crutches for the rest of his life.

MR. BISHOP: I have no further questions, Doctor.

MR. SLATER: I don't have anything else.

(At this time the deposition in the above-captioned matter was concluded.)

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