Thomas DeBerardino, M.D. Deposition PDF

1 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · · · · · · · · ·CAUSE NO. DC-19-18636 · · ·· ·2· · ·CICILY JOHN AND TONY· · · ·§ IN THE DISTRICT COURT · · · ·JOHN, INDIVIDUALLY AND AS··§ ·3· · ·PARENTS AND NEXT FRIENDS· ·§ · · · ·OF S.T., A MINOR CHILD,· ··§ ·4· · ·...

1 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · · · · · · · · ·CAUSE NO. DC-19-18636 · · ·· ·2· · ·CICILY JOHN AND TONY· · · ·§ IN THE DISTRICT COURT · · · ·JOHN, INDIVIDUALLY AND AS··§ ·3· · ·PARENTS AND NEXT FRIENDS· ·§ · · · ·OF S.T., A MINOR CHILD,· ··§ ·4· · · · · · · · ··Plaintiffs,· ·§ · · · · · · · · · · · · · · · · ··§ ·5· · · · · · · · · · · · · · · ··§ · · · · · · · · · · · · · · · · ··§ ·6· · · · · · · · · · · · · · · ··§ · · · ·VS.· · · · · · · · · · · ··§ DALLAS COUNTY, TEXAS ·7· · · · · · · · · · · · · · · ··§ · · · ·TOUCHSTONE MEDICAL· · · · ·§ ·8· · ·IMAGING, LLC; TOUCHSTONE· ·§ · · · ·MEDICAL IMAGING, LLC· · · ·§ ·9· · ·D/B/A TOUCHSTONE IMAGING· ·§ · · · ·RICHARDSON; TOUCHSTONE· · ·§ 10· · ·IMAGING OF MESQUITE, LP· ··§ · · · ·D/B/A TOUCHSTONE IMAGING· ·§ 11· · ·RICHARDSON, BTDI JV, LLP· ·§ · · · ·D/B/A TOUCHSTONE IMAGING· ·§ 12· · ·RICHARDSON; RICHARDSON· · ·§ · · · ·PEDIATRIC ASSOCIATES;· · ··§ 13· · ·GREGORY C. DOWNING, MD;· ··§ · · · ·GDX, PA; AND NORAH K.· · ··§ 14· · ·RANDLES, MD,· · · · · · · ·§ · · · · · · · · · ··Defendants· ··§ 191st JUDICIAL DISTRICT 15· ·· · · · ··***************************************************** 16· ·· · · · · · · · · · · ·REMOTE ORAL DEPOSITION OF 17· ·· · · · · · · · · · · · ·THOMAS DEBERARDINO, MD 18· ·· · · · · · · · · · · · · ·DECEMBER 16, 2021 19· ·· · · · ··***************************************************** 20· ·· · · ·· 21· ·· · · ·· 22· ·· · · ·· 23· ·· · · ·· 24· ··Reported by: · · ·· 25· · · ··Christi Sanford, CSR, RPR, CRR Corona Court Reporting, Inc. 214.528.7912  2 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·REMOTE ORAL DEPOSITION OF THOMAS DEBERARDINO, MD, ·2· ·attending remotely from his location in San Antonio, ·3· ·Texas, via Zoom videoconference, produced as a witness ·4· ·at the instance of the Defendants, and duly sworn, was ·5· ·taken in the above-styled and numbered cause on the ·6· ·16th day of December, 2021, from 3:33 p.m. to 8:44 p.m., ·7· ·before Christi Sanford, CSR in and for the State of ·8· ·Texas, Registered Professional Reporter and Certified ·9· ·Realtime Reporter, reported remotely by machine 10· ·shorthand from her location in Taylor, Texas, pursuant 11· ·to the Texas Rules of Civil Procedure and the provisions 12· ·stated on the record or attached hereto. 13· · 14· · 15· · 16· · 17· · 18· · 19· · 20· · 21· · 22· · 23· · 24· · 25· · Corona Court Reporting, Inc. 214.528.7912  3 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · · · · · · · · ·APPEARANCES VIA ZOOM · ·· ·2· ·For the Plaintiffs: · ·· ·3· · · ·Russell Button · · · · ·Ashley Washington ·4· · · ·The Button Law Firm · · · · ·4315 West Lovers Lane, Suite A ·5· · · ·Dallas, Texas 75209 · · · · ·(214) 699-4409 ·6· · · ·[email protected] · · · · ·[email protected] ·7· · · · · · ·Tobias A. Cole (Not present) ·8· · · ·The Cole Law Firm · · · · ·1616 South Voss Road, Suite 450 ·9· · · ·Houston, Texas 77057 · · · · ·(832) 539-4900 10· · · ·[email protected] · ·· 11· · · ·Heather Lynn Long · · · · ·Heather Long Law, PC 12· · · ·4310 North Central Expressway · · · · ·Dallas, Texas 75206 13· · · ·(214) 699-5994 · · · · ·[email protected] 14· · · · ·For the Defendants Norah Randles, MD, and Richardson 15· ·Pediatric Associates: · ·· 16· · · ·Rikki L. Hirshman · · · · ·Peter H. Anderson (Not present) 17· · · ·Kershaw Anderson, PLLC · · · · ·12400 Coit Road, Suite 570 18· · · ·Dallas, Texas 75251 · · · · ·(214) 347-4993 19· · · ·[email protected] · · · · ·[email protected] 20· · · · ·For the Defendants Greg Downing, MD, and GDX, PA: 21· · · · · · ·Reagan Boyce 22· · · ·Chamblee Ryan, PC · · · · ·2777 North Stemmons Freeway, Suite 1257 23· · · ·Dallas, Texas 75207 · · · · ·(214) 905-2003 24· · · ·[email protected] · ·· 25· · Corona Court Reporting, Inc. 214.528.7912  4 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · · · · · · · · · · · ··INDEX · · · · · · · · · · · · · · · · · · · · · · · · · ··PAGE ·2· · · · ·Appearances.................................· · ·3 ·3· · · · ·WITNESS:··THOMAS DEBERARDINO, MD ·4· · · · · · ·Examination by Ms. Hirshman.............· · ·5 ·5· · · ·Examination by Ms. Boyce................· ·194 · ·· ·6· ·Signature and Changes.......................· ·205 · · ·Reporter's Certificate......................· ·207 ·7· · · · · · · · · · · · · · · · ·EXHIBITS ·8· · · · ·NUMBER· ·DESCRIPTION· · · · · · · · · · · · · ·PAGE ·9· · · · ·Exhibit 1...................................· ·165 10· · · · · ··Defendants Norah Randles, MD, and · · · · · · ··Richardson Pediatric Associates' 11· · · · · ··Notice of Intention to Take the · · · · · · ··Oral Deposition of Thomas DeBerardino, 12· · · · · ··MD, and Subpoena Duces Tecum · ·· 13· ·Exhibit 2...................................· ·192 · · · · · · ··Video clip 14· · · · ·Exhibit 3...................................· ·193 15· · · · · ··Video clip · ·· 16· · · ·· 17· · · ·· 18· · · ·· 19· · · ·· 20· · · ·· 21· · · ·· 22· · · ·· 23· · · ·· 24· · · ·· 25· · Corona Court Reporting, Inc. 214.528.7912  5 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · · · · · · · ··P R O C E E D I N G S ·2· · · · · · · · ·THE REPORTER:··My name is Christi Sanford, ·3· ·and I am reporting the deposition remotely from Austin, ·4· ·Texas.··The witness is located in San Antonio, Texas. ·5· · · · · · · · · ·THOMAS DEBERARDINO, MD, ·6· · ·having been first duly sworn, testified as follows: ·7· · · · · · · · · · · · ·EXAMINATION ·8· ·BY MS. HIRSHMAN: ·9· · · ·Q.· ·Good afternoon, Dr. -- is it DeBerardino?··Is 03:33 10· ·that right? 11· · · ·A.· ·Correct.··That's perfect.··Or Dr. D. 12· · · ·Q.· ·Okay. 13· · · ·A.· ·Whatever's easier. 14· · · ·Q.· ·Okay.··Just want to make sure. 03:34 15· · · · · · · · ·My name is Rikki Hirshman, and I work with 16· ·the law offices of Kershaw Anderson.··I believe that you 17· ·have run into my law partner, Peter, a few times, but 18· ·this is our first time meeting, correct? 19· · · ·A.· ·That is correct. 03:34 20· · · ·Q.· ·I'm here today on behalf of Dr. Norah Randles 21· ·and her group, Richardson Pediatric Associates.··Okay? 22· · · · · · · · ·Do you know or have you ever met 23· ·Dr. Randles? 24· · · ·A.· ·I have not. 03:34 25· · · ·Q.· ·Do you have any experience with her or her Corona Court Reporting, Inc. 214.528.7912  6 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·practice? ·2· · · ·A.· ·I have no experience with her or her practice. ·3· · · ·Q.· ·Do you know any of the parties to this lawsuit? ·4· · · ·A.· ·I do not personally know any of the parties to 03:34 ·5· ·this lawsuit. ·6· · · ·Q.· ·Outside of the context of this lawsuit, have ·7· ·you heard of any of them? ·8· · · ·A.· ·I have not. ·9· · · ·Q.· ·Do you know any of the Plaintiffs in this 03:34 10· ·lawsuit? 11· · · ·A.· ·I do not know any of the Plaintiffs. 12· · · ·Q.· ·Have you ever met the minor Plaintiff, Sandra 13· ·Tony? 14· · · ·A.· ·I have not. 03:35 15· · · ·Q.· ·You've never examined her? 16· · · ·A.· ·I have not examined Sandra. 17· · · ·Q.· ·And have you had a chance to read her or her 18· ·parents' depositions? 19· · · ·A.· ·All three. 03:35 20· · · ·Q.· ·Have you read the Defendants' depositions in 21· ·this case as well? 22· · · ·A.· ·Yes, I have. 23· · · ·Q.· ·I know that you've given a few depositions, so 24· ·I won't go through all the rules, but if I do ask you 03:35 25· ·something you don't understand, just ask me.··I'm happy Corona Court Reporting, Inc. 214.528.7912  7 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·to rephrase it.··And everything we talk about here today ·2· ·is under oath as if we're in the courtroom. ·3· · · · · · · · ·Are you on any medications that would ·4· ·prevent you from understanding my questions? 03:35 ·5· · · ·A.· ·I am on no medications. ·6· · · ·Q.· ·Okay.··Do you understand that this is my ·7· ·opportunity to ask you about all of the -- the full ·8· ·extent of your opinions before we end up at trial, ·9· ·correct? 03:35 10· · · ·A.· ·I understand. 11· · · ·Q.· ·And it's fair for me and my clients to have an 12· ·opportunity to know your opinions, the bases for them 13· ·and any additional opinions that may not be in your 14· ·report, correct? 03:36 15· · · ·A.· ·Correct. 16· · · ·Q.· ·And so in doing so, in taking this deposition, 17· ·it's fair for me and my clients to expect that you will 18· ·give full and complete answers, correct? 19· · · ·A.· ·Correct. 03:36 20· · · ·Q.· ·And just so you know, my goal today is just to 21· ·make sure that by the end of this deposition, we've 22· ·discussed, in some fashion, all of your opinions, the 23· ·bases for them and even at, like, a broad stroke kind of 24· ·factual basis.··Okay? 03:36 25· · · ·A.· ·Okay. Corona Court Reporting, Inc. 214.528.7912  8 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·Q.· ·As discussed before, we've never met, correct? ·2· · · ·A.· ·That is correct. ·3· · · ·Q.· ·And so that just -- before today, we haven't ·4· ·had a chance to discuss any of your opinions? 03:36 ·5· · · ·A.· ·That is correct. ·6· · · ·Q.· ·To your knowledge, have you ever been hired by ·7· ·my law firm or Peter Anderson? ·8· · · ·A.· ·No, to my knowledge. ·9· · · ·Q.· ·I'm going to jump right in.··I want to talk to 03:37 10· ·you a little bit about Osgood-Schlatter's disease.··Can 11· ·you explain to me what that is? 12· · · ·A.· ·Yes.··Osgood-Schlatter's disease, or OSD as 13· ·it's commonly acronymed and referred to, is a disease of 14· ·adolescence.··It's very common.··I was in the military 03:37 15· ·for 24 years, so we saw it every day in sick call. 16· · · · · · · · ·It's a lot of anterior-based knee pain 17· ·over the prominence of the tibial tubercle.··It's often 18· ·swollen, red, erythematous and hurts with resisted 19· ·activities because it's the insertion site of the 03:37 20· ·extensor mechanism termination.··The patellar tendon 21· ·inserts on the tibial tubercle.··And during adolescence, 22· ·it's an ironic tug of war.··The tubercle is trying to 23· ·fuse at a normal growth center to the tibia diaphysis 24· ·just below the metaphyseal junction, but the patellar 03:38 25· ·tendon, with chronic jumping and activities of daily Corona Court Reporting, Inc. 214.528.7912  9 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·living in that age group, pulls, and that's the tug of ·2· ·war. ·3· · · · · · · · ·So it's a push me/pull you.··It's trying ·4· ·to fuse in one direction toward the main bone, but it's 03:38 ·5· ·trying to be pulled away by the extensor mechanism in ·6· ·the strong thigh muscle through the patellar tendon and ·7· ·the infrapatellar tendon itself.··And we usually win the ·8· ·battle, but can have discomfort along the way. ·9· · · · · · · · ·So it's anterior knee pain, pain with 03:38 10· ·kneeling, often remedied by a significant period of rest 11· ·and toning down very active adolescents from jumping, 12· ·climbing, kneeling and whatnot.··Sometimes you have to 13· ·immobilize them just to get them through it and put them 14· ·on a short course of anti-inflammatories to negate the 03:38 15· ·inflammatory process. 16· · · ·Q.· ·What's the typical age range that you would 17· ·expect to see Osgood-Schlatter's? 18· · · ·A.· ·So it presents as early as young adolescence, 19· ·maybe 11 years old in a female, but a little older in 03:39 20· ·guys because they -- they skeletally mature a little 21· ·slower.··As they start to get active in middle school 22· ·and beyond is the crux of the matter from a complaint 23· ·standpoint. 24· · · · · · · · ·It's often thrown in a conglomerate of 03:39 25· ·growing pains or patellar tendonitis.··They all kind of Corona Court Reporting, Inc. 214.528.7912  10 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·focalize to that one area in a quarter-size patch on the ·2· ·front of the knee, very superficial and almost visible ·3· ·sometimes with localized swelling and sometimes some ·4· ·redness and heat.··So that's the propensity.··And so 03:39 ·5· ·it's usually young adolescents, to be more specific. ·6· · · ·Q.· ·And so your definition of a young adolescent ·7· ·would be 11 years old in a female and a little older in ·8· ·a male? ·9· · · ·A.· ·That's the age range we've seen it in. 03:39 10· ·Usually, it's 12 to 15 in women, in girls, and a little 11· ·older, 13 to 17, in guys.··But at West Point, we saw it 12· ·every day.··So the clinical manifestations can go on. 13· ·You can have symptomatic Osgood-Schlatter ossicle 14· ·disease well into adulthood, but the onset isn't usually 03:40 15· ·before the age groups we just discussed. 16· · · ·Q.· ·And when you mentioned swelling, redness and 17· ·heat to the area, are those symptoms required to have a 18· ·diagnosis of Osgood-Schlatter or are they just 19· ·differentials? 03:40 20· · · ·A.· ·They're common.··They're nonspecific, 21· ·obviously.··Those things can happen with an infection. 22· ·They can happen with a fracture.··It can happen with a 23· ·bruise.··But it's usually focal and local to the front 24· ·of the knee. 03:40 25· · · · · · · · ·There's a tenderness in the area right -- Corona Court Reporting, Inc. 214.528.7912  11 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·the skin in that area is never -- no matter what size of ·2· ·the individual, is never more than about a centimeter ·3· ·thick, so you can actually palpate the tibial tubercle ·4· ·and the insertion of the patellar tendon.··It's one of 03:41 ·5· ·those landmarks that we point to when we teach learners ·6· ·every day, like, how to kind of negotiate your way ·7· ·around a knee, to start.··Kind of that's home plate, if ·8· ·you will. ·9· · · ·Q.· ·Okay.··When you palpate the tibial tubercle, 03:41 10· ·are you expecting to feel a bump or a lump?··Or what are 11· ·you expecting on that physical examination? 12· · · ·A.· ·You can -- it -- expectations are one thing, 13· ·but just observations and palpation.··It's usually you 14· ·use the opposite side as a normal template, although the 03:41 15· ·propensity is that these are at least 30 percent of the 16· ·time bilateral, but clinically not on the same course or 17· ·timeline.··One is worse than the other, more commonly 18· ·than not.··The other one either hasn't caught up yet or 19· ·has already resolved, but it's often in about 30 to 03:41 20· ·40 percent of the cases said to be bilateral, and that's 21· ·expected. 22· · · · · · · · ·So if we see radiographic hallmarks, which 23· ·we haven't gotten into yet, we often get opposite-sided 24· ·x-rays to make sure there's not a subtle fracture of the 03:42 25· ·tibial tubercle that just requires immobilization Corona Court Reporting, Inc. 214.528.7912  12 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·normally for six to eight weeks of fracture healing ·2· ·because you can actually fracture the apophysis. ·3· ·Besides just making it painful and irritated, you can go ·4· ·that extra step and almost tug it off. 03:42 ·5· · · ·Q.· ·Okay.··Are radiographic findings required if ·6· ·you believe that Osgood-Schlatter's disease is the ·7· ·condition being suffered? ·8· · · ·A.· ·No.··If you have isolated, focal, anterior, in ·9· ·about a quarter-size area tubercle pain, you don't 03:42 10· ·have to get x-rays to make the presumptive diagnosis. 11· ·It's when we have other coincidental -- or not 12· ·coincidental -- other concordant symptoms that make us 13· ·point to a wider, broader differential, especially in an 14· ·adolescent. 03:42 15· · · ·Q.· ·Okay.··And if you order radiographic findings, 16· ·like an x-ray, are there findings that you would -- that 17· ·you would expect to see with Osgood-Schlatter's? 18· · · ·A.· ·Certainly in more advanced Osgood-Schlatter's, 19· ·you can see the obvious Osgood ossicle, Osgood-Schlatter 03:43 20· ·ossicle.··It's a frozen pea-size ossicle of varying 21· ·lengths.··It can be bipartite or tripartite, meaning 22· ·one, two or three parts, with varying degrees of 23· ·displacement from its origination site, which is the 24· ·tibial tubercle itself. 03:43 25· · · · · · · · ·So these ossicles can form or break off, Corona Court Reporting, Inc. 214.528.7912  13 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·one or both, and they can become mechanically ·2· ·symptomatic because it's like having a pebble in your ·3· ·shoe, except this pebble is in the deep side of your ·4· ·patellar tendon.··So kneelers and crawlers and military 03:43 ·5· ·folks that are crawling in the woods oftentimes become ·6· ·provoked and clinically symptomatic, and that's often ·7· ·when we see it; so that's a late manifestation. ·8· · · · · · · · ·Early on, you hopefully don't see any ·9· ·aberrations in x-rays.··In pediatric and adolescent 03:44 10· ·patients, we often get comparison views to see if 11· ·there's a delta or a difference in this growth plate 12· ·fusion because it's a -- it's a spectrum. 13· · · · · · · · ·The growth plates in certain age 14· ·individuals are expected to be open versus partly 03:44 15· ·closed, closing or closed all the way.··And once they're 16· ·closed all the way, you're kind of out of the woods for 17· ·frank Osgood-Schlatter ossicle formation because you've 18· ·kind of won the battle, if you will, and you've got 19· ·frank fusion in a normal-appearing lateral radiographic, 03:44 20· ·which is a classic view.··Although there can be 21· ·rotational issues, it's the best two-dimensional, 22· ·simplistic, low-morbidity imaging study that we kind of 23· ·lean on to see if there's an ossicle of 24· ·Osgood-Schlatter's disease. 03:44 25· · · ·Q.· ·Early on in Osgood-Schlatter's, especially in Corona Court Reporting, Inc. 214.528.7912  14 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·an adolescent, is it fair to say that there could be no ·2· ·radiographic findings seen? ·3· · · ·A.· ·There could be no radiographic findings and ·4· ·then the differential necessarily widens because it's a 03:45 ·5· ·tight shot group.··It could be patellar tendonitis, ·6· ·jumper's knee, patellar tendinosis, actually disease of ·7· ·the patellar tendon, less likely in an adolescent at ·8· ·that age perhaps, it could be a tibial tubercle, a ·9· ·nondisplaced fracture that is not visible on plain 03:45 10· ·x-rays or you could see, as we alluded to before, the 11· ·frank formation of a small ossicle. 12· · · ·Q.· ·Okay.··When Sandra Tony presented to 13· ·Dr. Randles in November of 2017, she presented with knee 14· ·pain with activity, and then the physical exam findings 03:45 15· ·revealed tenderness to palpation of the tibial 16· ·tuberosity.··Do you agree with that? 17· · · ·A.· ·That's part of it.··I agree with what you said, 18· ·but the marked important buzz word in what she 19· ·complained about, locking, with a day where she just had 03:46 20· ·frank locking described by the patient and alluded to by 21· ·Dr. Randles, I believe, was the -- kind of the golden 22· ·nugget of the complaint in the -- in the remarks posted 23· ·by Dr. Randles in her -- in her first note when they 24· ·talked about this issue. 03:46 25· · · ·Q.· ·And acknowledging that locking can be a symptom Corona Court Reporting, Inc. 214.528.7912  15 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·of osteochondritis dissecans, do you agree or is it fair ·2· ·to say that one episode of locking one month prior is ·3· ·not consistent with osteochondritis dissecans? ·4· · · ·A.· ·I disagree.··You can have locking with a foot 03:46 ·5· ·meniscus just once in your life, but have a perpetuation ·6· ·of a meniscus, which is the classic internal derangement ·7· ·issue that leads to a locking knee.··And you pray that ·8· ·it only happens once before we get a chance to make the ·9· ·diagnosis to make the fix because the fix is a 03:46 10· ·timeliness issue with both OCD lesions and things like a 11· ·flipped meniscus or a loose body because the timeline is 12· ·only getting worse with time, not better, unfortunately, 13· ·with all the three things we just mentioned. 14· · · ·Q.· ·Okay.··Do you agree with me that locking is 03:47 15· ·typically a mechanical symptom seen in OCD that is in 16· ·its later stages or is unstable? 17· · · ·A.· ·I agree that locking can occur with a stage III 18· ·lesion that is nondisplaced, but potentially unstable. 19· ·And the manifestation of locking as a symptom is 03:47 20· ·different than, like, with a Wilson test, when I provoke 21· ·locking. 22· · · · · · · · ·So never in the notes did I see, 23· ·throughout the course of the clinical requiem that I 24· ·looked at, was there a positive Wilson test, where we 03:47 25· ·actually mechanically provoke locking by internally Corona Court Reporting, Inc. 214.528.7912  16 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·rotating and compressing that medial condyle lateral ·2· ·aspect flare.··We're trying to grab it, kind of like a ·3· ·McMurray's test, which is a mechanical test, to see if ·4· ·we can catch or create mechanical symptomatology right 03:48 ·5· ·before our eyes as the clinician is examining the knee. ·6· · · · · · · · ·So she complained of locking temporarily, ·7· ·and that's usually because these lesions, as noted on ·8· ·the arthroscopy views, is typical.··They look like -- ·9· ·almost like a popcorn kernel getting ready to pop off. 03:48 10· ·It's getting ready to bud.··They're a little 11· ·hypertrophic because they're a little bit displaced, but 12· ·in situ. 13· · · · · · · · ·And just that bulkiness of the lesion as 14· ·you're moving through the articulation of bone A, the 03:48 15· ·femur, and bone B, the tibia, there's no free space.··So 16· ·if you're standing all day -- she was in the marching 17· ·band -- or you're provoking it, water sucks into the 18· ·cartilage or sucks out transiently during the day as a 19· ·living organ.··And if you have a propensity for this 03:48 20· ·unstable stage III OCD lesion to suck in more water, it 21· ·becomes more prominent and it can catch.··Kind of like a 22· ·prominent scab on an elbow, like, you don't catch it all 23· ·day, every day, but you might catch it and it might 24· ·provoke symptomatology. 03:49 25· · · · · · · · ·That's kind of a good analogy for -- hers Corona Court Reporting, Inc. 214.528.7912  17 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·wasn't catching every time she bent and extended her ·2· ·knee.··That's a trap door flap lesion, unstable, almost ·3· ·a grade IV loose body.··That's, like, right on the ·4· ·tipping point.··Hers, based on the x-rays and even the 03:49 ·5· ·subsequent MRI, butted into an unstable grade III, but ·6· ·it always stayed what looks like a stage III lesion. ·7· · · ·Q.· ·All right.··And we'll get further into the ·8· ·radiograph studies in a little while.··I want to go over ·9· ·those with you, so I'll just come back to that. 03:49 10· · · · · · · · ·I know you mentioned the locking.··So if 11· ·we take the locking out, the physical exam findings of 12· ·the tenderness to the tibial tuberosity and then the 13· ·general knee pain with activity, those are -- alone, 14· ·separate from locking, those are textbook signs of 03:50 15· ·Osgood-Schlatter, correct? 16· · · ·A.· ·They're nonspecific signs for something wrong 17· ·with the knee, but they aren't textbook signs or 18· ·pathognomonic for any one thing.··They're so general. 19· ·They're -- kind of like fever and achiness isn't -- you 03:50 20· ·know, is very nonspecific for just illness. 21· · · · · · · · ·So her complaints, as you described the 22· ·big three, are very nonspecific and don't really hone 23· ·down a differential that much, unless there's point 24· ·tenderness and pain with resisted extension, which, 03:50 25· ·unfortunately, wasn't discussed at all in any of the Corona Court Reporting, Inc. 214.528.7912  18 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·notes early on by Dr. Randles.··That's a dynamic test, ·2· ·besides the Wilson test I mentioned, that one can do to ·3· ·check for provocative pain there in the clinic right ·4· ·before your eyes. 03:51 ·5· · · ·Q.· ·How many cases or patients with ·6· ·Osgood-Schlatter would you say you treat in a year? ·7· · · ·A.· ·Oh, in a year, probably -- probably at least ·8· ·one, maybe two a month, so we'll say 20 to 30 a year for ·9· ·26 years.··My gosh.··A lot.··Hundreds, for sure.··I've 03:51 10· ·fixed a lot of them, unfortunately, because they get 11· ·to us in later stages of -- they're older patients that 12· ·had an OCD lesion that was thought to be treated in one 13· ·way or another, and then they break off and whatnot and 14· ·they have to be treated more aggressively by something 03:51 15· ·that I do as a sports medicine specialist. 16· · · ·Q.· ·Is it fair to say that patients with 17· ·Osgood-Schlatter don't come directly to you?··They're 18· ·not immediately referred to you? 19· · · ·A.· ·It depends.··It depends on your environment and 03:51 20· ·your referral stream and your filter process.··At West 21· ·Point, we were the gatekeepers, I would say.··In a 22· ·general community setting, the family practitioners, 23· ·internal medicine folks, if they see young patients, but 24· ·mostly the pediatricians become the gatekeepers for 03:52 25· ·Osgood-Schlatter anterior knee pain. Corona Court Reporting, Inc. 214.528.7912  19 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·Q.· ·And so then in that situation where the ·2· ·pediatrician is the gatekeeper, the patients then are ·3· ·referred to you if the pain doesn't go away or symptoms ·4· ·worsen or things of that nature.··Is that fair? 03:52 ·5· · · ·A.· ·I think what's better fair to say is if ·6· ·patients have something other than nonspecific ·7· ·symptomatology, they're referred to us.··If they have ·8· ·locking, catching or giving way is the classic, kind of ·9· ·mechanical, symptomatic issues that kind of raise it, 03:52 10· ·obviously, immediately to the level of a referral or 11· ·advanced imaging, one or the other. 12· · · · · · · · ·Uh-oh.··Something happened there. 13· · · ·Q.· ·Sorry.··Can you hear me? 14· · · ·A.· ·Yes. 03:53 15· · · ·Q.· ·Okay.··For some reason, my AirPods that are 16· ·here, but not in my ears, connected to my Zoom. 17· · · ·A.· ·Smart devices. 18· · · ·Q.· ·Okay.··And as far as advanced imaging, what are 19· ·you referring to? 03:53 20· · · ·A.· ·Advanced imaging can be just comparison views. 21· ·That's going above and beyond just a standard four-view 22· ·weight-bearing radiographic series that we always get. 23· ·Getting comparison views, getting stress views, those 24· ·are all under that listing of advanced imaging. 03:53 25· · · · · · · · ·Advanced imaging, other than that, in Corona Court Reporting, Inc. 214.528.7912  20 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·another realm, is an MRI and/or a CT scan if it's ·2· ·unusually indicated.··But for, you know, soft tissue ·3· ·things, things that can go wrong in someone's knee that ·4· ·you can't see on an x-ray, we all immediately think of 03:53 ·5· ·an MRI because we can see that which we can't see only ·6· ·by inference on an -- on an x-ray.··We can see the ·7· ·cartilage of all the surfaces in the knee.··We can see ·8· ·the fat pad.··We can see chondral loose bodies.··We can ·9· ·see meniscus.··We can see all the important structures, 03:54 10· ·including the patellar tendon and the cruciate ligaments 11· ·and the collaterals that we can't see directly on an 12· ·x-ray.··We can only see radiographic bony manifestations 13· ·of disease on an x-ray, in fact, but it's the best 14· ·go-to, first line of imaging always is x-ray, and then 03:54 15· ·we go to MRI if we have locking or catching or giving 16· ·way or complaints of instability and those type of 17· ·things. 18· · · ·Q.· ·Switching gears now to osteochondritis 19· ·dissecans, which we can just call OCD -- I just wanted 03:54 20· ·to make sure it was on the record for everybody what we 21· ·were talking about -- explain to me what that condition 22· ·is. 23· · · ·A.· ·So an OCD, it can happen in many places in the 24· ·body.··It's a growth center.··When we're young, we have 03:55 25· ·lots of growth centers that need to fuse to the main Corona Court Reporting, Inc. 214.528.7912  21 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·bone, in a sense.··And it's all about vascularity. ·2· ·Normally, they all heal to the bone as we're growing and ·3· ·that cartilage anlage forms into bone at the growth ·4· ·plates.··So at these growth centers, we're praying for 03:55 ·5· ·fusion and normal growth and maturation of the bony ·6· ·structure three dimensionally with a cartilage cap that ·7· ·makes up the joint, which is basically a shiny cue ball ·8· ·coated with white, shiny cartilage, which is the joint. ·9· · · · · · · · ·So what happens in OCD lesions is not 03:55 10· ·actually known.··It's surmised in the literature, even 11· ·in 2021 now as we end this year, that it's some sort of 12· ·either micro or repetitive trauma that disrupts this 13· ·normal physiologic pattern of fusion of the progeny bone 14· ·or the growth center back to the main aspect of the 03:56 15· ·bone, in this case, the lateral aspect of the medial 16· ·femoral condyle being the most common area to see an OCD 17· ·lesion in the body, but even in the knee it's the -- 18· ·it's the high -- high-propensity location, 19· ·statistically.··It affects men more than girls probably 03:56 20· ·at about a rate that varies between two to one and four 21· ·to one I think I've seen in the literature throughout 22· ·the decades. 23· · · · · · · · ·It often has -- like anything in 24· ·orthopedics and radiology, it's got a grading scheme: 03:56 25· ·Grade 0, nonexistent or barely there, just painful, Corona Court Reporting, Inc. 214.528.7912  22 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·grade I and II are the lesser two, and grade III and IV ·2· ·are the worser [as said], as is typical with a simple ·3· ·ratings scheme.··So they're -- the diagnosis is -- ·4· ·often, the buzz words or catchphrases are, for the 03:57 ·5· ·advanced grade III and IV -- so we have grade I and II ·6· ·and III and IV kind of separated by the lesser lesions ·7· ·and the worse lesions. ·8· · · · · · · · ·The grade IIIs we worry about because they ·9· ·always happen in the younger adolescents where their 03:57 10· ·plates are starting to fuse.··And we know we have a 11· ·higher likelihood of healing when the growth plates are 12· ·still open or somewhat open versus when they're closed 13· ·because maturation has occurred and the body just kind 14· ·of says, you know, last call for all aboard.··The 03:57 15· ·train's left, and if you're not fused, you know, bony 16· ·maturation, that little progeny piece of bone, which is 17· ·the ossicle that we see in the OCD lesion, can just be 18· ·left out as a satellite piece of bone forever, unless 19· ·somebody does something to it, it becomes symptomatic, 03:57 20· ·it fragments, it dissolves or becomes a loose body. 21· · · · · · · · ·One or those three or four things kind of 22· ·has to happen or it just sits there and becomes 23· ·asymptomatic until later in life when somebody knocks it 24· ·off because these happen in the trochlea.··And when you 03:58 25· ·dislocate a patella, that can be like a hammer hitting Corona Court Reporting, Inc. 214.528.7912  23 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·kind of a piece of bone and cartilage.··It's just ready ·2· ·to be perforated off, and it sails off into the lateral ·3· ·gutter as a loose body. ·4· · · · · · · · ·But the one that Sandra has is in the 03:58 ·5· ·typical location, typical age group.··She's a woman, as ·6· ·opposed to a guy, so that's just bad luck because ·7· ·they're supposed to happen more to guys than girls. ·8· · · ·Q.· ·Even though these grade III lesions, as you ·9· ·explained, happen in these younger adolescents, even if 03:58 10· ·the lesion is found and still there even when the growth 11· ·plates fuse, that doesn't mean that they cannot heal and 12· ·recover the lesion, correct? 13· · · ·A.· ·So it's never all or never in orthopedics or 14· ·anything in medicine.··As far as I know, it doesn't work 03:58 15· ·that way.··There's a spectrum.··And it's not a light 16· ·switch.··It's truly a continuous spectrum of disease 17· ·and -- and results or expected results.··So stage III 18· ·makes up the bulk of the lesions diagnosed, complained 19· ·about, visualized and talked about in the literature 03:59 20· ·because that's when you catch them.··So it's the -- it's 21· ·the propensity of the timeline. 22· · · · · · · · ·A grade III lesion, there's the early 23· ·grade III and the late grade III, and you've kind of got 24· ·to break them up that way because you can drive right 03:59 25· ·through over a year or two and still stay a grade III Corona Court Reporting, Inc. 214.528.7912  24 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·and not become the grade IV, which is a whole different ·2· ·clinical can of worms.··That's a loose fragment floating ·3· ·through the knee like an -- like an asteroid, and that ·4· ·causes a whole nother level of problems and symptoms and 03:59 ·5· ·necessary high-grade, highly-morbid treatment options. ·6· · · · · · · · ·But a grade III can be visible, obviously, ·7· ·as this one was way back in the first x-ray or it can ·8· ·become fragmented, but still stable and minimally ·9· ·displaced, as long as it's still sort of in situ, which 04:00 10· ·just means it's where it's supposed to be, it's just 11· ·obvious that there's a separation of the progeny from 12· ·the main bone.··It's sort of a grade III.··It's either 13· ·an early grade III or it drives across the calendar in 14· ·time and becomes a late grade III that's on the verge of 04:00 15· ·becoming a grade IV, or a loose fragment, basically. 16· · · ·Q.· ·Okay.··Let me back up just a little bit. 17· ·Explain to me exactly what characteristics you expect to 18· ·see of a grade III OCD lesion. 19· · · ·A.· ·Well, a grade III OCD lesion on plain x-rays is 04:00 20· ·hopefully not fragmented.··It's minimally sclerotic in 21· ·its early phase III and then becomes more defined 22· ·visibly on x-ray as a late grade III.··And the host 23· ·bone, the main bone, becomes more defined later in a 24· ·grade III.··Early on, it just looks like it just cracked 04:01 25· ·off like a puzzle piece and I could just slip it back Corona Court Reporting, Inc. 214.528.7912  25 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·in.··With time, the cartilage cap can get hypertrophied ·2· ·because its irritated.··And cartilage is a funny thing. ·3· ·It doesn't have a blood supply.··It's bleached white for ·4· ·a reason.··It gets its nutrients from the joint fluid. 04:01 ·5· · · · · · · · ·So it's moving through space and time with ·6· ·normal activities of an adolescent's daily living and ·7· ·it's sucking in fluid.··It's not as contained because ·8· ·it's in the loose progeny fragment.··And it can get ·9· ·hypertrophied, and that alters its three-dimensional 04:01 10· ·shape. 11· · · · · · · · ·So the bone won't change.··It may fragment 12· ·or dissolve, but it won't get bigger because this is a 13· ·vascular disease in the end.··It either has a blood 14· ·supply or it doesn't.··And if it's disconnected from its 04:01 15· ·host bone, it, by definition, doesn't have a blood 16· ·supply anymore that's worth anything or that's 17· ·perceivable that allows for any growth of that progeny 18· ·bone in the lesion. 19· · · · · · · · ·So the lesion can't get bigger.··It should 04:02 20· ·exactly stay the same total overall volumetric size, but 21· ·it can fragment with time because it's cyclically loaded 22· ·irregularly and it's not attached to the main bone.··But 23· ·the cartilage cap can get hypertrophic, and that's 24· ·unfortunate because when we try to fix them late, the 04:02 25· ·first thing we notice as orthopods is that tile in the Corona Court Reporting, Inc. 214.528.7912  26 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·main foyer is a little proud.··It doesn't fit just like ·2· ·it should because it's maybe later in the process versus ·3· ·if you catch them early it's -- you can do it ·4· ·arthroscopically and just put a couple screws in it.··If 04:02 ·5· ·you have to fix it at all and can't get it to heal with ·6· ·immobilization, you just put a couple screws across it, ·7· ·you may open the trap door if you think you need to, if ·8· ·it's less than acute, if it's subacute, put some bone ·9· ·graft behind it, kind of hit the reset for healing, and 04:02 10· ·compress with it two headless compression screws of 11· ·choice.··Lots of choices there. 12· · · · · · · · ·So it looks like a piece of bone, a 13· ·grade III that's away and visibly separate from the main 14· ·bone, and it's that amount of bipartite nature or one 04:03 15· ·little piece of bone that we follow with time.··And we 16· ·follow the sclerosis and that, on a plain radiograph, is 17· ·talking about kind of the calcification or the bone 18· ·maturity.··It can't do that much, actually, except kind 19· ·of crumble because it doesn't have a blood supply to go 04:03 20· ·through the normal maturation process of calcifying and 21· ·becoming harder, firmer, more mature bone.··It's just 22· ·sitting there in this little satellite of cartilage, and 23· ·it stays a stage III as long as it doesn't move away or 24· ·become obviously displaced on an x-ray or with more 04:03 25· ·advanced imaging, which is the better way to define them Corona Court Reporting, Inc. 214.528.7912  27 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·and to categorize them in the truest sense, with an MRI. ·2· · · ·Q.· ·So an early stage III lesion, you would have -- ·3· ·it would be minimally sclerotic and not fragmented.··Are ·4· ·those the two main things that you're looking for? 04:04 ·5· · · ·A.· ·No.··It just looks -- it looks similar to the ·6· ·host, the main bone, I guess, is the most important ·7· ·thing, and it's not significantly displaced.··It looks ·8· ·like you can visually fit A into A prime.··It looks like ·9· ·it fits right there.··A later stage III might not 04:04 10· ·because the surrounding cartilage literally displaces it 11· ·a little bit.··It's like an expanding sponge.··The 12· ·cartilage isn't where it's supposed to be, along with 13· ·the progeny piece of bone, so it can hypertrophy, which 14· ·just means it gets bigger, and then it's like a -- it 04:04 15· ·just doesn't quite want to get jammed back or fit back 16· ·into its spot. 17· · · · · · · · ·So a late stage III can look a little more 18· ·displaced, but it still -- to be a stage III, it can't 19· ·be disparate or away from its host bone very far.··It 04:05 20· ·has to be in plane with it.··And, again, an x-ray is 21· ·just two-dimensional imaging, so it's really hard to 22· ·define if it's truly displaced or not just with an AP 23· ·and a lateral x-ray.··You sort of need three-dimensional 24· ·imaging to really define those characteristics. 04:05 25· · · ·Q.· ·Okay.··Is it a fair statement to say that Corona Court Reporting, Inc. 214.528.7912  28 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·x-rays also are really not very reliable when it comes ·2· ·to the staging of the lesion itself? ·3· · · ·A.· ·It's fair to say no imaging study is ultimately ·4· ·reliable.··You base your decision on age, bilaterality, 04:05 ·5· ·all the stratification processes that are talked about ·6· ·in the literature, the timeline of symptomatology, the ·7· ·location if it's in a typical location, the degree, or ·8· ·lack thereof, of fragmentation.··All of those things are ·9· ·really what is important, I guess. 04:06 10· · · ·Q.· ·Okay.··You agree that Sandra Tony's lesion was 11· ·stable in November of 2017? 12· · · ·A.· ·It appeared on the limited imaging sequences 13· ·that we saw, basically plain films, to not be unstable. 14· ·So I guess, by default, it appeared to be stable at that 04:06 15· ·time, yes. 16· · · ·Q.· ·Okay.··Kind of going back to this late and 17· ·early stage, is it your opinion that Sandra -- according 18· ·just to the plain x-rays we had, Sandra Tony's OCD 19· ·lesion was in an early stage III in November of 2017 and 04:06 20· ·then had progressed, then, to a late stage III by the 21· ·time she had her procedure in 2019? 22· · · ·A.· ·Yes, that's fair to say. 23· · · ·Q.· ·Do you have opinions on whether -- if she was 24· ·already in the late stage III in December of 2018? 04:07 25· · · ·A.· ·It's hard to say.··You have the added benefit Corona Court Reporting, Inc. 214.528.7912  29 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·eventually of getting an MRI, which shows that it was ·2· ·actually displaced and fragmented and includes sclerosis ·3· ·mostly on the main bone.··You can see some cavitation ·4· ·and some just maturation of that surface, so that it 04:07 ·5· ·obviously had been there a while by the time the MRI was ·6· ·obtained. ·7· · · · · · · · ·I forget the actual date of the MRI, but ·8· ·it was in that time frame.··Unfortunately, one wasn't ·9· ·obtained early on to do a comparison study.··But 04:07 10· ·expectedly, based on the x-rays we did have early on, 11· ·the MRI would have gone along with that and agreed that 12· ·it was, more likely than not, an early stage III lesion 13· ·that is still amenable to healing with either 14· ·immobilization perhaps or just in situ fixation, more 04:08 15· ·likely than not. 16· · · ·Q.· ·What's the typical timeline for progression 17· ·from an early to a late stage III lesion? 18· · · ·A.· ·There's nothing typical.··We see a lot of 19· ·different characteristics based on habitus, so size of 04:08 20· ·the patient, and a lot of what they do or don't do to 21· ·the lesion.··If it's treated appropriately, the 22· ·expectation is that a stage III could heal. 23· · · · · · · · ·If it's picked up and imaged appropriately 24· ·and immobilized and treated appropriately with therapy, 04:08 25· ·but not sheer or rotational or too much load is put onto Corona Court Reporting, Inc. 214.528.7912  30 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·it during that healing phase, the expectation is that it ·2· ·would go on to heal in a couple months.··Likewise, if ·3· ·you picked it up early and decided that, you know, it's ·4· ·just better, based on what this patient specifically 04:08 ·5· ·wants to get back to, that we fix it to make sure it ·6· ·doesn't potentially heal or partially heal, we're going ·7· ·to one-up it and add some hardware of some sort to kind ·8· ·of make sure.··We're going to reinforce it to let it go ·9· ·on and heal and be sure that this best-chance effort 04:09 10· ·early on to get it to heal and to become one, that 11· ·changes the downstream, you know, decades-later 12· ·trajectory of what does or doesn't happen to that 13· ·individual's knee, based on early decisions, honestly. 14· · · · · · · · ·So if it's an early stage III, it's still 04:09 15· ·fixable.··If it's a late stage III, you can try to fix 16· ·it, but the data and the literature suggests that with 17· ·physeal closure that happens with time and this age 18· ·group, it's right during that time frame, you have a 19· ·statistically-documented less chance of it to actually 04:09 20· ·heal, even if you do your best surgery possible at that 21· ·time. 22· · · · · · · · ·So a late stage III almost always needs 23· ·surgery.··An early stage III, in the literature, you 24· ·could do either a period of immobilization and then an 04:10 25· ·in situ compression fixation, plus or minus biologics Corona Court Reporting, Inc. 214.528.7912  31 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·and bone grafting, sort of what was done eventually for ·2· ·her knee. ·3· · · ·Q.· ·And so just because it was an early stage III ·4· ·doesn't mean that surgery would not have been required? 04:10 ·5· ·It's possible that surgery still would be required in an ·6· ·early stage III? ·7· · · ·A.· ·Anything is possible because it depends on ·8· ·who's looking at it and who's treating it.··So in ·9· ·someone who's just had one go bad, they're going to be 04:10 10· ·biased and more likely to recommend fixation early 11· ·because they don't want badness to sneak up on their 12· ·next patient, which could be Sandra. 13· · · · · · · · ·If you have a long series, like we have, 14· ·of treating these non-operatively and early and 04:10 15· ·aggressively non-operatively, meaning true 16· ·immobilization, true non-weight-bearing, working on 17· ·motion only and therapy and just really educating the 18· ·patient and family by, first, making the diagnosis and 19· ·then sharing with them what that means, whether we get 04:11 20· ·it to heal without surgery or whether we need to do a 21· ·lower-morbidity surgery, the in situ fixation is a 22· ·little bit dealer's choice, but that's far less morbid 23· ·than what is required later, which is a more open 24· ·approach and sometimes, like they did, bone grafting and 04:11 25· ·they added some biologics, some BMA, I believe, and, Corona Court Reporting, Inc. 214.528.7912  32 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·obviously, the compression screws. ·2· · · · · · · · ·It's just less likely to have success the ·3· ·longer we wait.··It's with -- true with any fracture. ·4· ·It's true with a -- you know, a bone fracture of any 04:11 ·5· ·type, a metacarpal in the hand, a fibular fracture in ·6· ·the ankle, a clavicle fracture.··They're best treated ·7· ·during that initial traumatic event.··And, ·8· ·unfortunately, OCDs don't often have a traumatic event, ·9· ·so we're left with when they first become symptomatic, 04:12 10· ·as hers was when she saw Dr. Randles that first visit. 11· · · ·Q.· ·Okay.··Sorry.··Just taking a couple of notes 12· ·here as we go. 13· · · · · · · · ·About how many OCD patients would you say 14· ·you treat in a year? 04:12 15· · · ·A.· ·I treat OCDs of this type in adolescents, 16· ·counting young adults, too, because sometimes they don't 17· ·show up in different parts of the knee.··I do mostly 18· ·knee and shoulder.··So the propensity of the ones -- I 19· ·see one to two a month and I end up fixing about one a 04:13 20· ·month, actually, nowadays because I get a referral.··I 21· ·do such a big cartilage practice in the knee, I see a 22· ·lot of these with patellar dislocations or just writing 23· ·up a small series of trochlear OCDs that get knocked off 24· ·the block and become a loose body or a grade IV lesion 04:13 25· ·with a patellar dislocation. Corona Court Reporting, Inc. 214.528.7912  33 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·Q.· ·How many OCDs of the knee and the medial ·2· ·femoral condyle, like here, would you say you see? ·3· · · ·A.· ·So it's hard to say because they come in ·4· ·clusters, but over 26 years, I've seen several hundred, 04:13 ·5· ·I would say, that are typical.··These are the propensity ·6· ·lesions, meaning the highest numbers occur in the ·7· ·lateral aspect of the lateral condyle.··And I'm one of ·8· ·those super subspecialized sports guys that sees the ·9· ·problem child -- not ironically child, but the problem 04:13 10· ·child lesion, meaning, specifically, the ones that go on 11· ·to need that final fixation, either an OC allograft or 12· ·even a partial knee replacement downstream.··So I see 13· ·the residual of the chronic ones, as well as the front 14· ·end where I make the diagnosis, essentially, that are 04:14 15· ·referred to me from a local pediatrician or a family 16· ·practitioner. 17· · · ·Q.· ·Have you ever referred an OCD patient to 18· ·another surgeon for treatment and evaluation? 19· · · ·A.· ·No.··I've always been the recipient of the 04:14 20· ·referral, actually.··I see kind of the worst of the 21· ·worst, unfortunately. 22· · · ·Q.· ·Okay.··What percent of your patients with -- 23· ·and let's just stick with the OCD lesions in the knee. 24· ·What percentage of your OCD knee patients would you say 04:14 25· ·are surgical versus non-surgical? Corona Court Reporting, Inc. 214.528.7912  34 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·A.· ·My practice is highly skewed and highly ·2· ·filtered, so it's about 80 percent are surgical and only ·3· ·20 percent.··So it's a flip of the natural history.··We ·4· ·expect, more often than not, that if you pick these up 04:14 ·5· ·early, that they're treated non-operatively ·6· ·appropriately and they don't require any surgery ·7· ·whatsoever.··So I'm -- my practice is biased as a ·8· ·tertiary referral practice, so I see the -- literally, ·9· ·the worst of the worst. 04:15 10· · · ·Q.· ·What were the -- this year, I know you said 11· ·about -- you've seen one to two OCD lesions per month. 12· ·How many of those would you say are the knee? 13· · · ·A.· ·They're all the knee, actually.··Yeah, the 14· ·one -- I don't -- I don't see any foot or ankle or any 04:15 15· ·OCDs of the elbow.··Those go to either the foot and 16· ·ankle group or the elbow group.··I just see OCDs of the 17· ·knee, in fact. 18· · · ·Q.· ·So if you fixed one a month, surgery once a 19· ·month, so you'd say you've done about 12 OCD procedures 04:15 20· ·this year alone? 21· · · ·A.· ·I think I've done actually 15, but on average, 22· ·it's one a month because I have a couple that are just 23· ·clustered at the end of the year here that have -- 24· ·they're actually -- one is a stage IV that got an OC 04:16 25· ·allograft because it wasn't -- the puzzle piece was too Corona Court Reporting, Inc. 214.528.7912  35 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·big.··We talked about hypertrophy.··We just couldn't get ·2· ·it to fit and the bone looked dead, so we elected to do ·3· ·a fresh osteochondral allograft transplantation plug to ·4· ·restore the joint. 04:16 ·5· · · ·Q.· ·Out of the 15 that you performed this year, how ·6· ·many were stage III? ·7· · · ·A.· ·They were all at least stage III late or ·8· ·stage IV.··We were only able to get one or two, because ·9· ·they were a little later in their -- in their 04:16 10· ·presentation on referral, to heal with compression 11· ·screws with some significant bone grafting, but it was 12· ·well-contained.··It wasn't this marginal one that Sandra 13· ·has that was juxtaposed to the notch right near the PCL. 14· ·Those are -- those are tougher and require early 04:16 15· ·aggressive treatment. 16· · · · · · · · ·The one I had that was able to be fixed 17· ·was actually a chondral/trochlear lesion in conjunction 18· ·with the patellar dislocation.··They thought it was a 19· ·chunk of the patella, and it was most of the condyle and 04:17 20· ·the trochlea actually at the conjunction. 21· · · ·Q.· ·All right.··So explain to me -- you just said 22· ·that Sandra's was a little different and requires 23· ·earlier intervention.··Explain to me what you mean by 24· ·that.··How was hers different? 04:17 25· · · ·A.· ·So it's in a typical location.··It's different Corona Court Reporting, Inc. 214.528.7912  36 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·than the ones where you can -- if it's well contained ·2· ·circumferentially, it's got surrounding good cartilage. ·3· ·These high-propensity ones happen on the lateral edge of ·4· ·the medial condyle, so the notch.··We talk about the 04:17 ·5· ·notch in that center bare area on a flexed knee view ·6· ·between the condyles.··So it occurs right at the edge of ·7· ·the notch, so it's not as circumferentially contained. ·8· · · · · · · · ·So they're a little less intrinsically ·9· ·stable, so they often require fixation if you can't get 04:17 10· ·good compression or a reduction.··And if it won't -- if 11· ·it doesn't stay reduced by the time they're diagnosed, 12· ·you have to go on to give it some rebar with these 13· ·headless compression screws to get it replaced from its 14· ·minimally-displaced location.··And, hopefully, it's not 04:18 15· ·fragmented, so it's an early stage III. 16· · · ·Q.· ·Okay.··And so the ones you said that were able 17· ·to be fixed, they were not, obviously, in that area, so 18· ·they were more contained, correct? 19· · · ·A.· ·Those are the easier ones to fix.··We can 04:18 20· ·parachute them in with shoulder implants, actually.··I 21· ·do a lot of shoulder.··So we -- I've described some 22· ·newer techniques that are kind of slick that negates 23· ·hardware at all.··We can use bridging knotless suture 24· ·anchors to parachute down the fragment in its 04:18 25· ·well-contained location in the trochlea, more in the Corona Court Reporting, Inc. 214.528.7912  37 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·middle or central part of the condyle, and avoid the ·2· ·need for a second surgery for hardware removal.··It's ·3· ·just something we've described and we're starting to do ·4· ·more and more of. 04:19 ·5· · · ·Q.· ·The few procedures that you were able to fix ·6· ·with just compression screws and bone grafting, how many ·7· ·procedures out of the 15 would you say that is? ·8· · · ·A.· ·I think I said two.··This year, I just recall ·9· ·two that were done with screws. 04:19 10· · · ·Q.· ·What were the outcomes of your other 11· ·procedures? 12· · · ·A.· ·The other -- in total, the other 13 -- I don't 13· ·know them all.··None of them have been reoperated on, so 14· ·it's still early to stay.··It's in the same year of the 04:19 15· ·surgery.··They're all doing well, but none of them have 16· ·gotten to five years until we get to the five-year mark. 17· ·So it's hard to say how they're going to do downstream 18· ·until they clear to three- to five-year mark and they're 19· ·part of our cohort for a clinical study. 04:19 20· · · ·Q.· ·So over the last five years, how many -- how 21· ·many -- I'll take that back. 22· · · · · · · · ·Right now, this year, how many patients 23· ·would you say you have at your five-year mark post-OCD 24· ·repair? 04:20 25· · · ·A.· ·Well, it's a rolling thunder, hard to say Corona Court Reporting, Inc. 214.528.7912  38 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·because we don't pull them all in and we aren't actively ·2· ·looking from five years back because we just started ·3· ·this newer technique lately in my practice, which is ·4· ·unique.··But I don't know.··I'd have to look it up.··But 04:20 ·5· ·I would say at any one time, we have -- at five years or ·6· ·more -- it's a difficult question to answer.··You'd have ·7· ·to be more specific because every one I've done more ·8· ·than five years ago, literally hundreds of them were ·9· ·more than five years, so hard to say. 04:20 10· · · ·Q.· ·And that's understandable.··And I'll see if I 11· ·can do a better job at trying to explain what I'm 12· ·looking for. 13· · · · · · · · ·In your last -- when we were talking about 14· ·the patients you've operated on this year, you said none 04:20 15· ·of them have reached the five-year mark, so we can't 16· ·really talk about outcome.··So, really, what I want to 17· ·talk to you about is now, if you're looking at patients 18· ·who you operated on five years ago, how are they doing 19· ·post-operatively after repair? 04:21 20· · · ·A.· ·Remembering my -- my population is different, 21· ·it's a little more skewed to the complex ones, the ones 22· ·that have later stages that require the more aggressive 23· ·forms of treatment, including osteochondral allograft 24· ·transplants and the like.··That's a lot of what I do on 04:21 25· ·these -- on the failed ones.··They've already had prior Corona Court Reporting, Inc. 214.528.7912  39 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·surgery with someone else and then they're sent to me as ·2· ·a -- as a kind of a treatment failure, so they get the ·3· ·terminal biologic procedure, which is, in most people's ·4· ·hands, either living without the lesion as a crater or 04:21 ·5· ·doing an osteochondral allograft transplant, which I ·6· ·do. ·7· · · · · · · · ·I did three this morning on the way into ·8· ·the deposition, actually, three OC allografts.··Not for ·9· ·OCDs, any of them.··But that's -- that's what I do a ton 04:21 10· ·of, probably the most of anyone in the country right 11· ·now. 12· · · · · · · · ·So my population is skewed.··It's not fair 13· ·to use it as a parameter for a general orthopedic sports 14· ·practice, for sure.··But the ones that are five years 04:22 15· ·out with that treatment have actually done very well. 16· ·We were very happy with that form of aggressive 17· ·treatment to save the knee from the eventual likely need 18· ·for either a partial knee only or maybe a total knee. 19· · · · · · · · ·And the literature says that people that 04:22 20· ·have OCD lesions that need surgery get a total knee, you 21· ·know, more likely than not, sooner than an untreated, 22· ·uninjured cohort of similar-aged people.··So instead of 23· ·in their 60s, they may, hopefully, not get their plastic 24· ·and metal knee arthroplasty until their late 40s or 50s, 04:22 25· ·but it certainly seems to happen in the literature Corona Court Reporting, Inc. 214.528.7912  40 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·earlier than an otherwise expected timeline of late 50s ·2· ·to mid 60s, which is not uncommon these days for just ·3· ·people with generic bad knees. ·4· · · ·Q.· ·But the need for a knee replacement is, in the 04:23 ·5· ·literature, common and expected with people with OCD ·6· ·lesions, regardless of whether or not they're caught ·7· ·early on or later? ·8· · · ·A.· ·Not true, actually.··The ones that are late ·9· ·stage III and stage IVs are kind of lumped together 04:23 10· ·as -- actually, in the literature, in general, 11· ·throughout all the decades of literature that we talk 12· ·about OCD lesions specifically and have had options for 13· ·treatment up through a total knee, they get their knees, 14· ·generally, earlier. 04:23 15· · · · · · · · ·And more often than not, the ones that are 16· ·in the grade I, II and early IIIs that are fixed in 17· ·situ, they jump right on the normal timeline of either 18· ·not needing knee arthroplasty and not getting a high 19· ·rate of progression to post-traumatic arthritis, which, 04:23 20· ·as an orthopedic surgeon, that's what kind of our adult 21· ·clinics are full of, in a general sense, but usually at 22· ·a later age.··So the folks with the later-stage lesions 23· ·actually have a higher propensity of progression of 24· ·post-traumatic, post-injury arthritis, and that 04:24 25· ·necessitates an earlier likelihood of transition to knee Corona Court Reporting, Inc. 214.528.7912  41 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·arthroplasty, unfortunately. ·2· · · ·Q.· ·When you say there's a higher rate, so a higher ·3· ·likelihood of needing an earlier knee replacement, can ·4· ·you put that into statistical data for me?··Like, what, 04:24 ·5· ·in your opinion, is the difference in the rate between ·6· ·stage III late and IV and then I, II and III early? ·7· · · ·A.· ·So it's not so much the rate.··It's just the ·8· ·occurrence in the timeline.··If we make the gross ·9· ·oversimplified assumption that ten people without an OCD 04:24 10· ·or anything else in their knee -- we'll say that's the 11· ·only thing that can go wrong in your knee -- maybe half 12· ·of them might need a total knee at age 65 to 70. 13· · · · · · · · ·So if you had ten people with OCDs and 14· ·they all happen to be late stage III or stage IV, God 04:25 15· ·forbid, they would, more likely than not -- the same 16· ·amount of them would need a total knee, but they'd need 17· ·it sooner.··They'd need it maybe in their 50s, their 18· ·young 50s.··There's some quotations of at the age right 19· ·around 52, I believe.··And you can't hold us to that 04:25 20· ·number.··It's just in their young 50s versus their mid 21· ·to late 60s. 22· · · · · · · · ·So it's a -- and that's the difference in 23· ·the end -- when you think of, like, people's life span, 24· ·that's a difference of at least one total knee, if they 04:25 25· ·last, on average, 12 years.··So if you get your index Corona Court Reporting, Inc. 214.528.7912  42 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·times zero total knee at age 52 or 50, you're going to ·2· ·need one more than you otherwise would have needed if ·3· ·you'd just rode the normal curve of progression of just ·4· ·standard run-of-the-mill arthritis and needed a total 04:25 ·5· ·knee when you wear it out from life's woes in your late ·6· ·to mid 60s. ·7· · · ·Q.· ·Okay.··So late stage III and IV -- and, ·8· ·obviously, I'm not going to just hold you to these ages, ·9· ·but just for reference -- early 50s or so, and then 04:26 10· ·whereas, like, normal natural progression, you'd say 11· ·late 60s.··Is that fair just as far as -- 12· · · ·A.· ·That's fair, yeah.··It's about a decade and a 13· ·half apart.··It's about a 15-year delta. 14· · · ·Q.· ·Where do stage I, II and early III fall in 04:26 15· ·between that? 16· · · ·A.· ·They actually jump back on the normal timeline 17· ·of just -- you know, people forget -- if they had a 18· ·stage I or II lesion that either was never picked up or 19· ·was treated with immobilization or even early in situ 04:26 20· ·fixation, they jump right on -- or they don't jump on -- 21· ·they remain on a normal -- normal population timeline, 22· ·actually.··They don't really vary. 23· · · · · · · · ·So it's the ones that are treated late 24· ·that require the more aggressive forms of treatment, 04:26 25· ·just like Sandra had, or worse.··The OCs that I talked Corona Court Reporting, Inc. 214.528.7912  43 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·about in my practice, they -- those tend to be bridging ·2· ·operations that get you through early adulthood because ·3· ·these happen in adolescence, but they come to someone ·4· ·like me and maybe get the next morbid operation, which 04:27 ·5· ·is the OC allograft to hopefully restore the compartment ·6· ·one more time. ·7· · · · · · · · ·And all of these operations become literal ·8· ·bridging operations to avoid, effectually, a very early, ·9· ·younger-than-50 knee arthroplasty.··I mean, there's 04:27 10· ·obviously some OCD lesions, some that I have seen that 11· ·are referred to me that are so bad that I can't even do 12· ·an OC allograft because the progression of disease in 13· ·their 40s requires a partial knee replacement, which I 14· ·do a lot of, too, unfortunately.··So, again, my 04:27 15· ·population is too skewed and biased to really make any 16· ·generalizations to, but that's the ones I see. 17· · · ·Q.· ·So the osteochondral lesions, which I know you 18· ·have some lesion literature on that, versus -- what's 19· ·the difference between just a lesion versus what we have 04:28 20· ·here, the OCD lesion?··Is there a difference? 21· · · ·A.· ·No.··There's -- that -- they're kind of 22· ·synonymous, I guess.··We're saying the same thing. 23· · · ·Q.· ·I just wanted to make sure I wasn't missing 24· ·something, that there was some difference. 04:28 25· · · · · · · · ·Have you -- in the last five years, have Corona Court Reporting, Inc. 214.528.7912  44 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·you operated on a patient with a similar lesion as ·2· ·Sandra? ·3· · · ·A.· ·Yes, quite a few. ·4· · · ·Q.· ·Of those patients, have you had any 04:28 ·5· ·complications or, thus far, negative outcomes? ·6· · · ·A.· ·So negative outcomes, some of them still have ·7· ·pain and swelling and some kneeling pain and trouble, ·8· ·like jumping and cutting, but many of them, ·9· ·unfortunately, go on to get other secondary or tertiary 04:28 10· ·problems with menisci, with their cruciate ligaments or 11· ·the collateral ligaments.··So a lot of them lose that -- 12· ·that isolated nature of just being their OCD lesion on 13· ·the lateral aspect of the medial condyle.··They actually 14· ·develop some baggage to go along with it. 04:29 15· · · · · · · · ·A meniscal tear is probably the most 16· ·common numerically.··And that becomes a problem because 17· ·that's the main shock absorber, obviously, of the knee 18· ·joint.··So as the cartilage wears out and the OCD lesion 19· ·either crumbles or the fixation is lost or the healing 04:29 20· ·doesn't really occur -- unfortunately, sometimes in 21· ·these late stage III and stage IV, you take the 22· ·hardware -- you put it in, you take it out and you cross 23· ·your fingers, you go through rehab, some of them fall 24· ·apart still and you get a couple years out of it. 04:29 25· · · · · · · · ·So it's like having a retread tire.··You Corona Court Reporting, Inc. 214.528.7912  45 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·don't expect it to last the duration.··You just want it ·2· ·to get you to the next couple exits.··And that, ·3· ·unfortunately, leads to someone like me, where then we ·4· ·have to do an OC allograft or a partial knee replacement 04:29 ·5· ·downstream to negate a very early total knee ·6· ·arthroplasty.··Those are very functional bridging ·7· ·operations to get you yet a couple more decades into ·8· ·life and through the working years of adulthood before ·9· ·you get that potential total knee. 04:30 10· · · ·Q.· ·Okay.··Have you -- of the patients in the last 11· ·five years or so -- or five years that you've operated 12· ·on like Sandra, with a lesion like hers, have any of 13· ·them needed a reoperation thus far? 14· · · ·A.· ·Yes.··Those are the ones that get some of those 04:30 15· ·OC allografts that I do so many of.··So they -- what 16· ·happens is that -- the course -- they either heal or 17· ·they don't heal.··The ones that don't heal find someone 18· ·like me or are referred to someone like me.··If the 19· ·hardware wasn't taken out, we have to take that out. 04:30 20· ·Usually, it's taken out as soon as one can, usually 21· ·between three and five months, hopefully, before you get 22· ·some iatrogenic hardware-caused damage on the other side 23· ·of the joint from that metal screwhead. 24· · · · · · · · ·So we -- if they still have pain, we 04:30 25· ·obviously get imaging and an MRI and sometimes Corona Court Reporting, Inc. 214.528.7912  46 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·comparison views, even as adults, to see what or how big ·2· ·or how bad the defect is.··We have to size it, ·3· ·basically.··We need three-dimensional sizing to see if ·4· ·that lesion now is amenable to a bigger operation, 04:31 ·5· ·frankly, instead of replacing and repairing that which ·6· ·was there and bone grafting behind it. ·7· · · · · · · · ·It's kind of like having a loose brick on ·8· ·a doorway.··You get some cement and you make -- you mix ·9· ·it up -- that's the bone graft -- and you put it back. 04:31 10· ·Well, if that's -- if that brick is crumbled, you've got 11· ·to make the hard decision, like, is that resurrectable 12· ·or do I need to go to somebody else's knee and take a 13· ·precious gift of life and take a like-sized piece of 14· ·cartilage and bone and press fit it in, very analogous 04:31 15· ·to a cork in a bottle. 16· · · · · · · · ·And that's what I did three of this 17· ·morning.··We actually took three plugs in one patient -- 18· ·one of the three had three plugs of cartilage and bone 19· ·from a similar-sized condyle, took it out like we're 04:31 20· ·changing the hole on a golf green, except the golf green 21· ·is another patient's knee or condyle donated as a gift 22· ·of life and it's refrigerated, fresh and living, and we 23· ·press fit that in with biologics, like a cork in a 24· ·bottle, into the lesion that's now refined and defined 04:32 25· ·as a circular lesion so that we can press fit it in Corona Court Reporting, Inc. 214.528.7912  47 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·without hardware. ·2· · · · · · · · ·And that gives them the next best bridging ·3· ·opportunity to avoid plastic and metal downstream. ·4· ·Those work really well, but they're not a panacea.··They 04:32 ·5· ·just get you at least another decade or two of ·6· ·functionality and avoiding that partial or total knee ·7· ·arthroplasty. ·8· · · ·Q.· ·Okay.··How common would you say OCD is ·9· ·percentage-wise? 04:32 10· · · ·A.· ·It depends.··I mean, if you're talking 11· ·population-based, it's not that common.··It's common in 12· ·a pediatric orthopedic population because, again, that's 13· ·a highly filtered group.··It's -- it's more common in my 14· ·clinic because I see the worst of the worst, the end 04:32 15· ·runs, so it's a little skewed and I'm a knee sports guy. 16· · · · · · · · ·But in the normal population, the lateral 17· ·aspect of the medial femoral condyle is the most common 18· ·location for OCD lesions.··But in the end, we don't know 19· ·how common they are because -- in fact, when you ask 04:33 20· ·that question, we have to be specific -- we only ever, 21· ·as clinicians, see the ones that become symptomatic. 22· ·There are people that get into adulthood where we get an 23· ·MRI and we say, "Gosh, you really have a bad meniscus 24· ·tear.··You flipped it when you were playing lacrosse the 04:33 25· ·other day or noontime basketball.··Did you know you had Corona Court Reporting, Inc. 214.528.7912  48 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·that OCD lesion in the lateral part of your medial ·2· ·condyle?" ·3· · · · · · · · ·So a lot of them exist in situ and never ·4· ·become symptomatic the first time.··And even in 04:33 ·5· ·adulthood, when I'm in there doing a bucket handle ·6· ·repair, we kind of look for it, but we don't see it.··So ·7· ·we don't know what the true denominator is.··We only ·8· ·know the numerator.··And the numerator is the one of the ·9· ·patients that come in to see either a pediatrician, a 04:34 10· ·family practitioner or an orthopedic surgeon. 11· · · ·Q.· ·Is it fair to say that OCD lesions mostly will 12· ·develop in adolescents, but they can also develop in 13· ·adulthood? 14· · · ·A.· ·They always develop in pre-adolescents.··They 04:34 15· ·become initially symptomatic in adolescents.··And if 16· ·they don't become symptomatic, they -- you can die with 17· ·an OCD lesion.··I mean, that's not unheard of.··But if 18· ·they're going to become symptomatic, the tight shot 19· ·group of when they become initially symptomatic is in 04:34 20· ·that adolescent time frame, more likely than not, just 21· ·on a numbers game.··But, again, we don't know the 22· ·denominator, truly, because we don't know how many 23· ·people are walking around with completely asymptomatic 24· ·stage I and maybe early stage II OCD lesions anywhere in 04:35 25· ·their knee. Corona Court Reporting, Inc. 214.528.7912  49 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · · · · · · ·MS. HIRSHMAN:··Okay.··I'm going to switch ·2· ·to your report and some of the opinions in your report ·3· ·now.··We've been going about an hour.··Do you want to ·4· ·just take a quick five- or ten-minute break and then 04:35 ·5· ·we'll reconvene? ·6· · · · · · · · ·THE WITNESS:··Sounds great. ·7· · · · · · · · ·MS. HIRSHMAN:··Okay.··Thanks. ·8· · · · · · · · ·(Recess from 4:35 to 4:46) ·9· · · ·Q.· ·(BY MS. HIRSHMAN)··Doctor, we just took a brief 04:46 10· ·break before we transitioned here.··So far, you know, 11· ·we've talked generally about OCD and then 12· ·Osgood-Schlatter.··Right now, is there anything that you 13· ·can think of about your testimony that you'd want to 14· ·change or clarify at this time? 04:46 15· · · ·A.· ·No. 16· · · ·Q.· ·Transitioning into your report, I first want to 17· ·talk to you about some of the standard-of-care opinions 18· ·that you have lodged against Dr. Randles. 19· · · · · · · · ·What is your focus in practicing medicine? 04:47 20· · · ·A.· ·My focus is orthopedics, musculoskeletal 21· ·ailments of the body, most of the extremities. 22· · · ·Q.· ·And is there a specialty or a subspecialty that 23· ·you are in? 24· · · ·A.· ·I'm a sports medicine, fellowship-trained, 04:47 25· ·orthopedic surgeon. Corona Court Reporting, Inc. 214.528.7912  50 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·Q.· ·Do you have any specialized training in ·2· ·pediatrics? ·3· · · ·A.· ·Just some pediatric orthopedics vis-a-vis my ·4· ·orthopedic residency and just pediatrics, in general, 04:47 ·5· ·through medical school, but no pediatric residency, ·6· ·certainly. ·7· · · ·Q.· ·Okay.··And what -- first, what is your ·8· ·definition of pediatrics? ·9· · · ·A.· ·Pediatrics is treating infants through about 04:47 10· ·age 18, in general.··That's the age range treated.··Any 11· ·and all medical, musculoskeletal included, ailments is 12· ·kind of in their wheelhouse. 13· · · ·Q.· ·And so when you say during -- sorry.··Was it 14· ·during medical school or when did you say you had 04:48 15· ·general pediatric training? 16· · · ·A.· ·Pediatric training?··You get some pediatric 17· ·training during your rotations.··And then during my 18· ·transitional internship, I did three months of 19· ·pediatrics training, but no residency training.··My 04:48 20· ·residency was orthopedics.··As part of that, we 21· ·necessarily do some -- a pediatric orthopedic rotation 22· ·where we specifically hone in on pediatric orthopedic 23· ·ailments of the musculoskeletal system as an orthopedic 24· ·surgeon. 04:48 25· · · ·Q.· ·The rotation and transitional internship where Corona Court Reporting, Inc. 214.528.7912  51 Thomas DeBerardino, M.D. 12/16/2021 ·1· ·you did general pediatrics, were you in a clinic doing ·2· ·pediatrics or were you doing pediatrics in a hospital ·3· ·setting? ·4· · · ·A.· ·It was in both.··It was Triple Army Medical 04:48 ·5· ·Center is the hospital setting.··So it was all in the ·6· ·hospital setting, actually, to be honest.··It wasn't -- ·7· ·we weren't in outbound -- private clinics.··We were in ·8· ·the medical center doing rotations with the medical ·9· ·center pediatric group. 04:49 10· · · ·Q.· ·Would you say that you were treating general 11· ·ailments of the children or were you treating more 12· ·specialized trauma events? 13· · · ·A.· ·It was true pediatrics, runny noses, injured 14· ·knees, headaches, nausea, vomiting, everything.··It was 04:49 15· ·pediatrics. 16· · · ·Q.· ·Okay.··And that was a few months, is that what 17· ·you said? 18· · · ·A.· ·I believe it was a three-month rotation 19· ·formally, just pediatrics, yes. 04:49 20· · · ·Q.· ·Okay.··And when did you have your rotation? 21· ·What year was that? 22· · · ·A.· ·I was an intern -- oh, my gosh -- from July 1 23· ·of 1989 to June 30th of 1990.··And I don't remember 24· ·which block of that time was pediatrics, honestly -- 04:49 25· · · ·Q.· ·Okay. Corona Court Reporting, Inc. 214.528.7912  52 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·A.· ·-- because I did orthopedics for about five ·2· ·months of the year.··I finagled to do extra orthopedics ·3· ·since that's where I was really heading.··And during my ·4· ·orthopedic rotation, I happened to be on the pediatric 04:50 ·5· ·orthopedic team because I knew the staff that was the ·6· ·leader of that group as the pediapod, and they ruled ·7· ·right together.··So I -- probably early on, but I don't ·8· ·remember.··It was too many decades ago. ·9· · · ·Q.· ·And that's okay.··I at least have a general 04:50 10· ·timeline now where I can say, okay, three months, in 11· ·there. 12· · · · · · · · ·Since that time, so since 1990, we'll say, 13· ·have you -- other than in your orthopedic practice 14· ·seeing children, have you had any clinical -- have you 04:50 15· ·practiced as a clinical pediatrician? 16· · · ·A.· ·No, I have not, at all. 17· · · ·Q.· ·And that's because you're not trained as a 18· ·pediatrician.··You're trained as an orthopedic surgeon 19· ·who will see pediatric patients.··Is that fair? 04:51 20· · · ·A.· ·Yes. 21· · · ·Q.· ·What percentage of your practice today would 22· ·you say is pediatrics? 23· · · ·A.· ·18 and younger, if that's our cutoff as we 24· ·define it, it's probably about 20 percent of my 04:51 25· ·practice, maybe a little more, but at least 20 percent. Corona Court Reporting, Inc. 214.528.7912  53 Thomas DeBerardino, M.D. 12/16/2021 ·1· · · ·Q.· ·And I know you focus on shoulders and knees, ·2· ·correct? ·3· · · ·A.· ·That is true. ·4· · · ·Q.· ·Could you give me, out of the 20 percent, how 04:51 ·5· ·many knees you would say are in that range? ·6· · · ·A.· ·So as a surgeon -- we'll go from the surgical