Acute Knee Research Articles

Early diagnosis and treatment of acute brucellosis knee arthritis complicated by acute osteomyelitis: two cases report

BackgroundBrucellosis is an endemic systemic infectious disease, the most common complication is bone and joint involvement. Sacroiliac joint and spinal joint are the most frequently involved sites in adults, but knee joint infection is rare, and acute infectious knee arthritis complicated by acute osteomyelitis is even extremely uncommon in adults. Here, we report two cases of acute septic knee arthritis complicated by acute osteomyelitis caused by Brucella melitensis (B. melitensis).Case presentationBoth patients had a history of traveling in animal husbandry areas within three months. On clinical examination, their right knee joint was tender, swollen, had limited movement and an effusion was present. Imaging examination showed effusion and synovial thickening of the right knee joint, as well as subchondral bone edema of the distal femur and proximal tibia. Laboratory examination showed that the serum agglutination test (SAT) in both patients were positive (1: 640 and 1: 320) without leukocytosis, although the proportion of lymphocytes, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) significantly increased. Both patients underwent knee joint aspiration. Real-time polymerase chain reaction (Real-time PCR) analysis of synovial fluid showed that there was B. melitensis, and blood bacterial culture was negative. We determined that two patients had acute brucellosis knee arthritis complicated by acute osteomyelitis. Antibiotic treatment was given during hospitalization consisting of doxycycline (0.1 g po bid) and rifampicin (0.6 g po qd) for six weeks, and the changes of inflammatory indexes were closely monitored. At discharge, the symptoms had completely resolved, imaging abnormalities disappeared, and inflammatory indexes returned to normal. There was no recurrence of the disease at 1-year follow-up.ConclusionAcute brucellosis knee arthritis complicated by acute osteomyelitis is a rare but serious complication of brucellosis in adults. There is no obvious specificity of clinical manifestation and imaging examination. Early diagnosis and treatment can prevent the occurrence of knee joint deformity and even pathological fracture. Clinicians should fully consider the possibility of brucellosis where the travel or occupational history is suggestive.

Hip and ankle strength and range of motion in female soccer players with dynamic knee valgus

BACKGROUND: Dynamic knee valgus (DKV) is a known risk factor for acute and chronic knee injuries and is more frequently diagnosed in females. A real-time single-leg squat test (SLST) could screen for DKV to prevent injuries. OBJECTIVE: To compare the differences in lower extremity strength and range of motion (ROM) in female soccer athletes with and without DKV during an SLST. METHODS: Eighteen subjects with DKV (DKV group) and 18 subjects without DKV (control group) during a single-leg squat were included. Hip strength (flexion, extension, abduction, adduction, internal rotation, and external rotation) was measured with a hand-held dynamometer. Hip ROM (internal and external rotation), and ankle ROM (dorsiflexion with the knee flexed and extended) were measured. Independent t-test was used to compare the averages of the groups. RESULTS: There were significant differences in hip abduction to adduction strength ratio (DKV: 1.48 ± 0.3, control: 1.22 ± 0.26, p< 0.01) and ankle dorsiflexion with knee flexed (DKV: 17.22 ± 6.82, control: 21.22 ± 4.55, p< 0.05) and extended (DKV: 10.14 ± 4.23, control: 14.75 ± 3.40, p< 0.001) between the groups. CONCLUSION: The hip abduction to adduction strength ratio and gastrocnemius and soleus flexibility may be associated factors in dynamic knee valgus and therefore should be assessed and treated, if indicated, as a possible preventive measure in female athletes with this variation.

How much can a small bursa stretch? A curious case of massive superficial infrapatellar bursitis in the emergency department

Introduction: Inflammation of the infrapatellar bursa results from various causes like trauma, infection and overuse. Superficial skin or soft tissue infection can also lead to occasional septic bursitis. Infrapatellar bursa has two parts, superficial and deep bursae. Superficial bursa inflammation reactive to adjacent superficial skin infection may occasionally lead to secondary bursitis. Case Presentation: We report a rare finding of acute right knee pain with extraordinary amount of fluid collection within superficial part of infrapatellar bursa in an elderly male patient. A secondary, septic and massive superficial infrapatellar bursitis was unusual in its appearance mimicking neoplastic lesion. Judicious use of clinical assessment and imaging helped to diagnose the condition. Conclusion: Early diagnosis and treatment of bursitis can ensure optimal outcome and it can be used to check further complications. Atypical presentation of any bursitis should be acknowledged and the judicious use of clinical assessment and imaging is critical for prompt diagnosis and treatment.

Do acute inflammatory cytokines affect 3- and 12-month postoperative functional outcomes\u2013a prospective cohort study of 12 patients with proximal tibia fractures

BackgroundPatients with intra-articular fractures tend to develop post-traumatic osteoarthritis (PTOA). The initial inflammatory response with elevation of inflammatory cytokines following joint trauma might be responsible for triggering cartilage catabolism and degradation. We aimed to identify and quantify cytokine levels in fractured and healthy knee joints and the correlation of these cytokines with clinical outcomes.MethodsIn this prospective cohort study, synovial fluid and plasma were collected from 12 patients with proximal intra-articular tibia fractures before surgery. The concentration of sixteen inflammatory cytokines, two cartilage degradation products and four metabolic mediators where measured, comparing the acute injured knee with the healthy contralateral knee. Patients were evaluated 3- and 12-months after surgery with clinical parameters and radiographical scanning. Non-parametrical Wilcoxon rank-sum and Spearman tests were used for statistical analysis, and a P-value below 0.05 was considered significant.ResultsWe found an elevation of the pro-inflammatory cytokines IL-1β, IL-2, IL-6, IL-8, IL-12p70, TNF-α, IFN-y, MMP-1, MMP-3, and MMP-9 and a simultaneous elevation of the anti-inflammatory cytokines IL-1RA, IL-4, IL-10, and IL-13 in the injured knee. Several pro- and anti-inflammatory cytokines and metabolic mediators were correlated with clinical outcomes 12 months after surgery, especially with pain perception.ConclusionsOur results support that an inflammatory process occurs after intra-articular knee fractures, which is characterized by the elevation of both pro- and anti-inflammatory cytokines. There was no sign of cartilage damage within the timeframe from injury to operation. We found a correlation between the initial inflammatory reaction with clinical outcomes 12 months after surgery.

Clorpactin: An Alternative Irrigation Method for Total Knee Arthroplasty Joint Infection Revisions.

Different combinations of irrigation solutions have been used in attempt to eradicate microorganisms for the prevention and treatment of prosthetic joint infections (PJIs). Clorpactin WCS-90 was evaluated as an alternative irrigation intraoperative technique for the treatment of PJI using both debridement, antibiotics, and implant retention (DAIR) and 2-stage total knee arthroplasty (TKA) procedures. We retrospectively reviewed PJIs irrigated with Clorpactin between January 2015 and January 2020. We found 13 patients who underwent a DAIR procedure for an acutely infected primary TKA, 18 patients underwent a 2-stage procedure for a chronically infected primary TKA, two patients underwent a DAIR procedure for an acutely infected revision TKA, and 18 patients underwent a 2-stage procedure for a chronically infected revision TKA. The odds of reinfection and need for additional surgery were analyzed at a mean follow-up of 20 to 26 months between groups. Only one patient (7.69%) became reinfected in the acute infected primary TKA group, three patients (16.67%) in the chronic infected primary TKA group, 0 patients (0%) in the acute infected revision TKA group, and six patients (33.33%) in the chronic infected revision TKA group. When the acute primary TKA infection group was compared with the chronic revision TKA infection group, the odds of reinfection (Chi-square test [χ2] = 21.7, df 3, p < 0.001) and odds of additional surgery (χ2 = 13.6, df 3, p < 0.003) were significantly higher for the chronic revision TKA infection group. Overall, the reinfection rate for DAIR revisions was 6.67% (range = 0-7.69) and 2-stage revisions was 25.00% (range = 16.67-33.33). The use of Clorpactin WCS-90 irrigation prior to wound closure is a useful option for the treatment of acute and chronic knee PJIs. Our study provides evidence that infection eradication with the use of Clorpactin is comparable to other irrigation methods and surgical techniques in reported literature.

Validity of the KLIC and CRIME80 scores in predicting failure in late acute infection treated by debridement and implant retention

It is very important to treat prosthetic infections correctly in order to ensure a higher success rate. Debridement with implant retention (DAIR) is widely used in acute and late infections, however patients who fail after this surgery are known to have a higher risk of failure in subsequent surgeries. Therefore, it is important to find a scale that enables us to predict the risk of DAIR failure. Hence the KLIC and CRIME80 scores for acute and late acute infections, respectively. This study analysed the validity of both scores in acute late periprosthetic knee infections. We observed that the KLIC score has no predictive value for this type of infection, but the CRIME80 score does.

Study of reliability of meniscus damage signs using high intensity 1,5 tesla mri compared to the results of arthroscopic interventions in acute and obsolete knee injury

Annotation. Among the large joints, the knee joint is most often injured, which is due to the peculiarities of its structure and functional loads in the process of human life. The most common injuries are meniscus damages of the knee joint, that is the evidence of steady increase in the number of partial arthroscopic meniscectomies, which have become the most common orthopedic procedure. Diagnosis of meniscus damage is based on the results of clinical examination, sonography and MRI. Increasing the resolution of MRI machines, improving the technique of their implementation allows to improve the quality of diagnosis of meniscus ruptures and improve the results of surgical arthroscopic interventions on the knee joint. The aim of the study – to demonstrate the capabilities of high-intensity 1.5 Tesla MRI and to study the reliability of MRI signs of meniscus damage in comparison with the results of arthroscopic interventions in acute and chronic knee joint injury. The work is based on the results of MRI examinations and arthroscopic interventions of 247 patients with acute and chronic knee joint injuries aged 14 to 59 years. Medial meniscus damage was diagnosed in 206 (83.41%) patients. Lateral meniscus ruptures were diagnosed in 34 patients (13.76%). Simultaneous damage of both menisci was found in 7 (2.83%) patients. It was found that ruptures of the medial meniscus by location were: the root of the posterior horn of the medial meniscus in 4 (1.94%) patients, ruptures of the posterior horn in 82 (39.81%) patients. Injury of the posterior horn with the transition to the body of the meniscus was diagnosed in 117 (56.79%) patients. Anterior horn ruptures were detected in 3 (1.46%) patients. With ruptures of the lateral meniscus: damage of the root of the posterior horn of the lateral meniscus was found in 2 (5.88%) patients, damage of the posterior horn in 9 (26.47%) patients. Posterior horn rupture with transition to the body of the meniscus was diagnosed in 19 (55.89%) patients. Isolated ruptures of the anterior horn were found in 4 (11.76%) patients. Simultaneous damage to both menisci was found in 7 (2.83%) patients. 206 (83.40%) partial meniscectomies were performed during arthroscopic interventions and meniscus suturings were performed over 41 (16.60%) patients. In order to identify meniscus damage and their location during MRI knee joint investigations 21 pseudo-positive and 18 pseudo-negative cases of diagnosis were revealed. The sensitivity of MRI for defining damage and localization of meniscus rupture was 91,7%, specificity 92,6%, diagnostic accuracy 94,8%. Discrepancies in the evaluation of meniscal damage most often occurred in cases of their combined ruptures and degenerative changes in the menisci.

Acute Total Knee Replacement in Rheumatoid Arthritis Patients with Proximal Tibial Fractures: A Case Series.

Management of proximal tibial fractures is a challenging issue in patients with rheumatoid arthritis (RA). In the present study, we aimed to describe our experience of acute total knee replacement in RA patients. This case series included 11 RA patients with simultaneous insufficiency fractures of the proximal tibia, who were treated by acute total knee replacement. Midterm functional results, severity of pain, Hospital for Special Surgery (HSS), and Knee Society Score (KSS) parameters were evaluated in this study. The patients were followed up for 24 months. Eleven women with proximal tibial fractures and history of RA (mean age: 54.3 ± 4.7 years) were enrolled in this study. The mean score of Tegner activity scale was 2.2 ± 1.4 preoperatively, which significantly improved to 4.3 ± 1.4 postoperatively (p < 0.001). The two sections of KSS (knee and function section) averaged 88.7 ± 5.4 and 59.4 ± 8.2, respectively. There wasn't poor outcome and excellent result was in knee section 54.5% and function section 36.3% based on KSS. The mean score of pain severity during normal activity before fracture was 65.2 ± 12.3, which significantly reduced to 35.5 ± 11.3 in the final follow-up (p = 0.02). The score of HSS scale improved from 42 (range: 16-58) in the preoperative stage to 78 (range: 72-91) after surgery (p < 0.001). In the 6-month follow-up, deep vein thrombosis was reported in two patients. The time required to return to normal activity was 5.5 ± 2.3 months. Based on the findings, total knee replacement therapy in patients with RA and proximal tibial fractures produced excellent clinical outcomes, which led to rapid return to normal activity. This is a Level IV, therapeutic study.

Radiological outcome following proximal realignment procedure for habitual dislocation of patella

Introduction: Instability of the patellofemoral joint may manifest as acute patellar dislocation, recurrent patellar dislocation or subluxation, habitual patellar dislocation or chronic patellar dislocation. Habitual dislocation of patella is a condition where the patella dislocates whenever the knee is flexed and spontaneously relocates with extension of the knee. We conducted this study to know the radiological outcome following proximal realignment procedure (Campbell procedure) for habitual dislocation of patella. Materials and Methods: The study was conducted from June 2017 to January 2019 with a minimum follow up of 6 months and a maximum follow up of 2 years. Inclusion Criteria: All patients with habitual patellar dislocation, age between 5 to 40 years. Exclusion Criteria: Patient age less than 5 years and aged above > 40 years, past history of knee surgery, acute patellar dislocation and knee effusions. Radiological assessment was done by measuring sulcus angle and congruence angle. Conclusion: we conclude that following proximal realignment procedure (Campbell procedure) for habitual dislocation of patella radiological parameters were brought back to normal. There were no significant changes in sulcus angle. Congruence angle was brought back to normal, which was statistically significant (p Keywords: Habitual dislocation of patella, Campbell procedure, Sulcus angle, Congruence angle.

The lateral femoral notch sign: a reliable diagnostic measurement in acute anterior cruciate ligament injury

PurposeTo describe the validity and inter- and intra-observer reliability of the lateral femoral notch sign (LFNS) as measured on conventional radiographs for diagnosing acute anterior cruciate ligament (ACL) injury.MethodsPatients (≤ 45 years) with a traumatic knee injury who underwent knee arthroscopy and had preoperative radiographs were retrospectively screened for this case–control study. Included patients were assigned to the ACL injury group (n = 65) or the control group (n = 53) based on the arthroscopic findings. All radiographs were evaluated for the presence, depth and location of the LFNS by four physicians who were blind to the conditions. To calculate intra-observer reliability, each observer re-assessed 25% of the radiographs at a 4-week interval.ResultsThe depth of the LFNS was significantly greater in ACL-injured patients than in controls [median 0.8 mm (0–3.1 mm) versus 0.0 mm (0–1.4 mm), respectively; p = 0.008]. The inter- and intra-observer reliabilities of the LFNS depth were 0.93 and 0.96, respectively. Secondary knee pathology (i.e., lateral meniscal injury) in ACL-injured patients was correlated with a deeper LFNS [median 1.1 mm (0–2.6 mm) versus 0.6 mm (0–3.1 mm), p = 0.012]. Using a cut-off value of 1 mm for the LFNS depth, a positive predictive value of 96% was found.ConclusionThis was the first study to investigate the inter- and intra-observer agreement of the depth and location of the LFNS. The depth of the LFNS had a very high predictive value for ACL-injured patients and could be used in the emergency department without any additional cost. A depth of > 1.0 mm was a good predictor for ACL injury. Measuring the depth of the LFNS is a simple and clinically relevant tool for diagnosing ACL injury in the acute setting and should be used by clinicians in patients with acute knee trauma.Level of evidenceDiagnostic study, level II.

Bone marrow lesions of the knee: longitudinal correlation between lesion size changes and pain before and after conservative treatment by extracorporeal shockwave therapy.

Bone marrow lesions (BMLs) of the knee have become a common finding on magnetic resonance imaging (MRI), leading to a growing interest in BML, not only for its potential role in the progression of several musculoskeletal conditions, but also for its clinical impact and treatment implications. At present, there is limited and conflicting evidence regarding whether or not pain may be correlated to BML size or not. To verify the longitudinal correlation between BML size and knee pain. Longitudinal. Italian Orthopedic Institute. The study sample was composed of 72 patients, 27 males and 45 females, with a mean age of 55.9±10.22 years and a mean BMI of 26.1±3.7 kg/m2. All patients presented with BMLs and acute knee pain. All 72 patients underwent a knee MRI before and 6 months after a course of high energy ESWT, in order to perform a quantitative measurement of the BML areas. KOOS (Knee Injury and Osteoarthritis Outcome Score) Pain subscale scores were obtained at the same time point. A regression analysis was performed to verify the correlation between knee BML size and KOOS pain subscale score before treatment and the correlation between the reduction of BML size and the improvement of KOOS pain score 6 months after treatment. A statistically significant correlation between the KOOS Pain subscale and the BML size (beta=-0.362 [CI95%: -0.019/-0.05], P=0.002) was demonstrated. The clinical score and BML area significantly improved after treatment (P<0.001). The clinical improvement was correlated to the BML size reduction (beta=0.254 [CI95%: 0.001/0.017], P=0.031). This study confirmed a significant correlation between the BML size and the intensity of knee pain. Furthermore, the before and after study using ESWT to treat symptomatic BMLs, revealed a correlation between size reduction of BML and KOOS pain subscale score improvement, demonstrating the utility of BML reduction as a therapeutic goal. Finally, ESWT was validated as a safe and potentially effective treatment of subchondral bone marrow lesions. Our results confirm that severity of pain is correlated with BML size, and furthermore, demonstrate that increases and decreases in the amount of pain reflect growth or reduction in BML size, respectively. This information may be useful for rehabilitation and decrease the reliance on MRIs for checking the progress of bone lesions. Absence or marked reduction of pain should allow for the resumption of weight-bearing and more strenuous exercises for an adequate musculoskeletal recovery.

Reliability assessment of a mechanism-based approach to post-injury knee magnetic resonance imaging interpretation by general radiologists.

BackgroundA mechanism-based approach to post-injury knee magnetic resonance imaging (MRI) interpretation, following acute complex knee injury, is cited by several authors to provide increased reporting accuracy and efficiency, by allowing accurate prediction of injury to at-risk structures. This remains to our knowledge untested in a developing world setting and is of interest to us as South African general radiologists.ObjectiveTo assess the reliability of a mechanism-based approach to complex post-trauma knee MRI interpretation when implemented by general radiologists in a South African setting, and compare our results with the findings of North American authors who compiled and assessed the same classification. To measure the agreement between the observers.MethodsA quantitative, observational, investigative, retrospective study was performed using a sample of 50 post-trauma knee MRI studies conducted at Grey’s Hospital, Pietermaritzburg. Two investigators independently applied the consolidated mechanism-based approach compiled by Hayes et al. as a research tool to interpret the knee MRI studies, blinded to each other’s findings.ResultsInjury mechanism was assigned in 32% of cases by the principle investigator and in 20% of cases by the supervisor, with fair agreement between the observers (k = 0.39). The investigators agreed that 62% of cases were not classifiable by mechanism, 26% because of highly complex injury and 26% because of non-specific findings.ConclusionOur findings indicate that the Hayes et al. classification is a non-ideal tool when used by general radiologists in our setting, as the pure injury mechanisms described in the classification were rare in our study group. Patient epidemiology and investigator experience are highlighted as potential limiting factors in this study. Despite this, we advocate that the concept of a mechanism-based approach for the interpretation of acute post-trauma knee MRI holds value for general radiologists, particularly in patients imaged before resolution of bone bruising (within 12–16 weeks of injury), and those injured in sporting and similar athletic activities.

Online appendix 1:Reliability assessment of a mechanism-based approach to post-injury knee magnetic resonance imaging interpretation by general radiologists

Background: A mechanism-based approach to post-injury knee magnetic resonance imaging (MRI) interpretation, following acute complex knee injury, is cited by several authors to provide increased reporting accuracy and efficiency, by allowing accurate prediction of injury to at-risk structures. This remains to our knowledge untested in a developing world setting and is of interest to us as South African general radiologists. Objective: To assess the reliability of a mechanism-based approach to complex post-trauma knee MRI interpretation when implemented by general radiologists in a South African setting, and compare our results with the findings of North American authors who compiled and assessed the same classification. To measure the agreement between the observers. Methods: A quantitative, observational, investigative, retrospective study was performed using a sample of 50 post-trauma knee MRI studies conducted at Grey’s Hospital, Pietermaritzburg. Two investigators independently applied the consolidated mechanism-based approach compiled by Hayes et al. as a research tool to interpret the knee MRI studies, blinded to each other’s findings. Results: Injury mechanism was assigned in 32% of cases by the principle investigator and in 20% of cases by the supervisor, with fair agreement between the observers (k = 0.39). The investigators agreed that 62% of cases were not classifiable by mechanism, 26% because of highly complex injury and 26% because of non-specific findings. Conclusion: Our findings indicate that the Hayes et al. classification is a non-ideal tool when used by general radiologists in our setting, as the pure injury mechanisms described in the classification were rare in our study group. Patient epidemiology and investigator experience are highlighted as potential limiting factors in this study. Despite this, we advocate that the concept of a mechanism-based approach for the interpretation of acute post-trauma knee MRI holds value for general radiologists, particularly in patients imaged before resolution of bone bruising (within 12–16 weeks of injury), and those injured in sporting and similar athletic activities.

Acute periprosthetic knee infection: is there still a role for DAIR?

Periprosthetic knee infection is a rare complication associated with prosthetic failure; incidence change from 0,4-2% of primary total knee replacement and 5.6% in revisions. Indications for debridment, antibiotics and implant retention (DAIR) are early acute infections or acute delayed infection. Aim of the work is to check if this technique is still a successful in early infections. We have analyzed recent literature data on DAIR and all DAIR procedures in our clinic in the last 10 years, the mean time between onset of symptoms and surgery, the mean antibiotic therapy duration and results we have obtained. We evaluate the diagnostic process and different treatments in early knee periprosthetic infections, especially the DAIR approach. If correct indications are followed, DAIR has a success rate in 31-100% of the cases; if it is applied in late chronic infection the success rate is 28-62%. In our experience DAIR has an 80% success rate: in 20 patients treated with DAIR we had 4 failures. DAIR can be considered a successful treatment, but it depends from individual patient factors, from the microorganisms involved, from the duration of antibiotic therapy and from correct choice in timing and in execution of DAIR by the orthopedic surgeon.

Patellar tendon re-rupture on the opposite end of the previous site of surgical repair.

We describe a rare case of a patellar tendon “re-rupture” at the opposite end of a previous proximal tendon repair. A 32-year-old male with a history of surgically repaired right proximal patellar tendon rupture presented with an acute non-traumatic right knee pain and instability during sports. Magnetic resonance imaging confirmed a complete rupture of his distal patellar tendon at the tibial tuberosity. The patellar tendon was repaired using two 5.5 mm BioCorkscrews (Arthrex) inserted into the tibial tuberosity; the tendon was stitched with the No. 2 fiberwires using Krackow technique. As the patellar tendon was degenerative, the repair was augmented with a semitendinosus tendon harvested using an open tendon stripper, leaving the distal attachment intact. At 2.6 years followup he had mild anterior knee pain, range of motion 0-130° and was able to squat. MRI scan done at followup revealed good healing of repaired patellar tendon.

Characteristics of patients with knee and ankle symptoms accessing physiotherapy: self-referral vs general practitioner’s referral

ObjectivesTo determine patient characteristics, frequency of use, type of symptoms and treatment outcomes in patients with knee or ankle symptoms, separately, for patients referred by their general practitioner (GP) and patients who self-referred. DesignLongitudinal study. SettingDutch primary care physical therapy practices. ParticipantsAll patients who visited a physiotherapist with knee or ankle symptoms between 2006 and 2012. MethodData were collected from the NIVEL Primary Care Database. The mode of access (self-referred or GP-referred) was determined for all patients. For analyses, descriptive statistics, unpaired t-tests, Chi-square test and logistic regression analyses were applied. ResultsThe study included 6179 patients with knee or ankle symptoms. The use of self-referral increased from 26% in 2006 to 56% in 2012, and stabilised between 2010 and 2012. Self-referred patients were younger, had a higher education level and had a shorter duration of symptoms compared with GP-referred patients. Self-referred patients had fewer treatment sessions than GP-referred patients. ConclusionsAmong patients with knee or ankle symptoms, younger patients, and those with a higher education level, a shorter duration of symptoms and recurrent symptoms were more likely to self-refer than other patients. Self-referred patients had fewer treatment sessions. After 2009, the frequency of self-referrals to physical therapists stabilised. Future studies should examine the effectiveness of physical therapy for patients who self-refer with acute knee and ankle symptoms.

Football Player with Acute Anterolateral Knee Pain and Swelling

Football Player with Acute Anterolateral Knee Pain and Swelling

Secondary hemochromatosis presenting as acute noninflammatory knee joints arthropathy

Secondary hemochromatosis presenting as acute noninflammatory knee joints arthropathy

Hemarthrosis: Concurrent acute presentation of pyrophosphate dehydrate and uric acid crystals in an elderly patient with a history of rheumatoid arthritis diagnosed with septic arthritis

Concomitant septic arthritis in the presence of crystalline disease is a rare presentation of acute hemarthrosis and knee pain. Literature review showed that co-occurrence of these entities is an infrequent phenomenon but it needs to be acknowledged that these studies are few in number and were done on small patient population. This case challenges the notion that presence of crystals in the synovial fluid rules out septic arthritis even in the setting of low synovial WBC count. Additionally, the presence of pseudogout in patients suffering from gout is a rare entity as well. These findings in literature are described in case reports dispersed over the past three decades. We present a case where concurrent treatment of gout, pseudogout, and septic arthritis in a patient who presented with acute hemarhtrosis.

The effect of end-of-range grade A+ knee mobilisation following acute primary total knee arthroplasty: A randomised controlled trial

Background/Aims: Although the number of total knee arthroplasty procedures being performed is increasing worldwide, the rehabilitation protocols following surgery are poorly studied in the literature. Research suggests that exercise therapy and joint mobilisation are recommended in the later stages of osteoarthritis. However, best practice for rehabilitation in the immediate postoperative period is yet to be determined. This prospective randomised controlled trial examined whether adding grade A+ joint mobilisation to the standard in-hospital rehabilitative approach would increase pain (based on recordings of pain intensity on the visual analogue scale) and improve range of motion in the knee. Methods: Participants (n=32; mean±SD age: 71.1± 8.9 years) undergoing primary total knee arthroplasty at a university hospital were randomly assigned to two equal groups. Measurements were recorded before surgery and on the first, third and seventh days following total knee arthroplasty. All participants received standard care postoperatively, with participants in the experimental group receiving additional grade A+ joint mobilisation for knee flexion and extension twice a day for 20 minutes using the JAS Knee system (Joint Active Systems®, Effingham, Illinois). Results: There were no statistically significant differences in visual analogue scale scores or range of motion in all measurements (p &gt; 0.05). Increased range of motion at a faster pace was observed in the obese subgroup of patients (p = 0.016). Other factors such as age, body mass index, type of anaesthesia and implant model did not influence the final outcome. Conclusions: Early grade A+ joint mobilisation combined with the standard in-hospital rehabilitative approach is safe to be used during the post-acute phase of rehabilitation after total knee arthroplasty. Despite increasing trends in the obese subgroup of patients, adding grade A+ joint mobilisation to the standard protocol did not significantly improve overall range of motion. The results of this study and heterogeneities in the literature identify the need for further research and development in this area.