Bilateral Knee Pain Research Articles

ANALYZING THE RELATIONSHIP AMONG CLINICAL SYMPTOMS, X-RAY RESULTS, AND CARTILAGE WEAR PATTERNS IN KNEE OSTEOARTHRITIS USING T2 MAPPING MRI

Objectives: Osteoarthritis (OA) is a condition that causes joint pain, varying degrees of functional limitations, and a decrease in overall quality of life. The purpose of this study was to examine the progression of cartilage degeneration in knees affected by symptomatic OA and determine its relationship with X-ray and T2 map MRI findings. Methods: This study was conducted at a Tertiary Care Teaching Institute in India and involved 40 patients. It was an observational type of study. For our assessment, we utilized the Western Ontario and McMaster University (WOMAC) osteoarthrosis index to evaluate function, quality of life, and joint pain. Medical imaging technique A standing AP view of the affected knee joint was taken using plain radiographs. Once the X-rays were obtained, they were graded using the Kellgren–Lawrence Classification, which ranges from 0 to 4 grades. Results: Out of the total patients, 6.0% were <40 years old, 21.2% were between 41 and 50 years old, 27.2% were between 51 and 60 years old, 39.3% were between 61 and 70 years old, and 6.0% were above 70 years old. In this study, there were 21 females (63.6%) and 12 males (36.4%). In this study, the researchers found that there was no distinction between the sides of the limb affected. Both the left and right sides were involved in 13 cases each, accounting for 39.39% of the total cases. In addition, 7 cases, or 21.21%, reported experiencing bilateral knee pain. Merchant grade reported that out of the knees examined, 17.5% had Grade 0, 45% had Grade 1, 27.5% had Grade 2, 10% had Grade 3, and none had Grade 4. Conclusion: The findings of this study suggest that T2 map MRI has the ability to accurately measure abnormal cartilage changes in conditions that affect the mechanical properties of the knee joint. It is crucial to have non-invasive methods that can assess early cartilage matrix changes. These methods are important for initiating early treatment, monitoring disease progression, planning operative procedures, and following up on operative cartilage repair.

The effectiveness of Transcutaneous Electrical Nerve Stimulation and strengthening exercises on the functional ability of patients with osteoarthritis of the knee joints: A case report

Knee osteoarthritis (OA) is the most common musculoskeletal disease among elderly individuals. It affects the ability to sit on a chair, stand, walk, and climb stairs. Our objective was to evaluate the effectiveness of tens and strengthening exercises on functional ability in patients with OA of knee joints. We present a case of a 55-year-old female housewife with bilateral knee pain, which manifested suddenly as a dull ache exacerbated by walking and stair climbing and alleviated by rest. Clinical examination revealed crepitus, grade 1 tenderness, and reduced range of motion (ROM) in the left knee. The radiographic evaluation confirmed grade 3 osteoarthritis according to the Kellgren and Lawrence grading system, indicating moderate multiple osteophytes, definite joint space narrowing, some sclerosis, and potential bone deformity. The patient underwent a 4-week intervention comprising strengthening exercises and TENS. Pain intensity was assessed using the Numeric Pain Rating Scale (NPRS), knee ROM with a goniometer, and functional limitations with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Assessments were conducted weekly throughout the intervention. The findings suggest that the combined application of TENS and strengthening exercises effectively alleviates pain and improves functional ability in patients with knee osteoarthritis.

Management of Knee Osteoarthritis with integrative approach using Regimenal therapy (Massage and Medicated Steam Fomentation) and Pharmacotherapy (Habb-e -Muqil): A Case Study

Osteoarthritis (OA) is the most common progressive musculoskeletal disorder, that is characterized by pathological changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of day to day life activities. It affects an estimated more than 240 million people worldwide. It can involve almost any joint but typically affects the hands, knees, hips, and feet. In India, 28.7% of adults ≥ 40 years of age and 45.5% of adults ≥ 60 years of age have KOA. The annual incidence rate of KOA in India is 2.4%. The management of KOA involves a comprehensive approach, including non pharmacological management, pharmacological management, and surgical management. In Unani medicine, KOA comes within the domain of a broader term, “Waja-ul-Mafasil”, which refers to joint pain. It occurs due to quantitative and qualitative derangement of Akhlat (humors) and derangement of optimal temperament (Mizaj). We present the case of a 48 year old male patient, who was presented to the OPD of Regimenal therapies at National Institute of Unani Medicine, Bengaluru. Patient complains of bilateral knee pain, stiffness, limited mobility and difficulty in daily activities since 3 years. Pain exaggerates on walking for more than 50 minutes and standing continuously for more than 30 minutes. The patient was assessed and examined clinically prior to intervention and was diagnosed with bilateral KOA, which was further accentuated by radiological investigations. The patient received treatment for 6 weeks. The patient was assessed using multiple assessment parameters at baseline, 3rd and 6th week. The patient reported improvement in both subjective and objective parameters. The study found that massage therapy and steam fomentation along with pharmacotherapy can be an effective approach in treatment for KOA, however it merits further research. Keywords: Osteoarthritis, joint pain, bilateral knee pain, stiffness, limited mobility

Mining for Gems: Early Detection of Calcinosis in Juvenile Dermatomyositis Using Low-Dose Computed Tomography.

Calcinosis, a common complication in juvenile dermatomyositis (JDM), affects up to 40% of patients and can be associated with uncontrolled disease activity and morbidity.1A 9-year-old female with a 17-month history of JDM presented with worsened bilateral knee pain.

Autoimmune Neurobeachin Cerebellar Ataxia.

There are more than 30 immunoglobulin G (IgG) autoantibody biomarkers of autoimmune cerebellar ataxia reported. To describe a novel IgG biomarker targeting neurobeachin, a scaffolding protein integral to synapse formation and function. Clinical and laboratory-based assessment was used for a novel diagnostic biomarker of autoimmune ataxia. A 46-year-old woman had ataxia onset followed by bilateral knee pain, attributable to rheumatoid arthritis. She was negative for standard neural antibodies. Her ataxia stabilized and tremor initially improved after corticosteroid treatment, but she progressed to wheelchair-dependence (on methotrexate and then rituximab) over 4 years, in keeping with the trajectory encountered by many with autoimmune ataxia. In contrast, her inflammatory arthritis remitted with immunotherapy. Neurobeachin-IgG was unmasked in serum and cerebrospinal fluid using protein arrays and confirmed using neurobeachin-specific confocal immunofluorescence and Western blot. Neurobeachin-IgG is a new neural antibody biomarker of cerebellar ataxia among a growing antibody repertoire, collectively common but often individually rare. © 2024 International Parkinson and Movement Disorder Society.

Demonstrating antibiotic stewardship while diagnosing and treating bilateral pseudoseptic arthritis: a case report

IntroductionAlthough viscosupplementation is a commonly used treatment for osteoarthritis and is widely regarded as a safe treatment option, it is associated with the rare complication of pseudoseptic arthritis. Most existing case reports that cite this rare complication employed the use of early broad-spectrum antibiotics.Case presentationIn this case report, we present a 61-year-old African American female patient who presented with bilateral knee pseudoseptic arthritis in the setting of viscosupplementation. She presented 3 days after bilateral viscosupplementation injections with bilateral knee swelling, discomfort, and pain with micromotion. Her white blood cell count (WBC) was 12.83 (4.5–11 normal), her C-reactive protein (CRP) level was 159 mg/L (0–10 normal), and her erythrocyte sedimentation rate (ESR) was 79 mm/hour (0–40 normal). Her left knee aspirate yielded 38,580 WBC with a negative gram stain and negative cultures. Her right knee aspirate yielded 29,670 WBC with a negative gram stain and negative cultures. Through the utilization of careful clinical monitoring, ice therapy, and non-steroidal inflammatory medication, we were able to successfully treat this patient while maintaining proper antibiotic stewardship.ConclusionPseudoseptic arthritis in the setting of viscosupplementation can be adequately treated and monitored without the use of antibiotics.

P185 Anatomical patterns of pain in primary care patients with polymyalgia rheumatica compared to the general population

Abstract Background/Aims Polymyalgia rheumatica (PMR) is common in older adults, causing severe pain and stiffness, particularly in the shoulder and hip girdles. A tapered course of glucocorticoids is recommended, but not always straightforward, with frequent symptom recurrence. Reasons are unclear, but partial masking of painful comorbidities (e.g., osteoarthritis) may play a part. Methods 652 people with incident PMR were recruited from English general practice (2012-2014) to a postal survey study (questionnaires at diagnosis, 1, 4, 8, 12, 18, 24, [mean] 61 months). Surveys included a body manikin (front and back views). Participants were asked to shade anywhere they experienced pain >1 day in the last month. 44 mutually exclusive areas were defined as painful or not. For comparison, an age-gender matched random sample of 652 people was selected from a general population survey in North Staffordshire that used the same manikins. Pain prevalence was compared between the 2 studies. Results In the PMR study, surveys were completed by 244 participants at 24 months and 197 at 61 months. Pain was reported in a mean of 17.1 areas at diagnosis (Table). Bilateral shoulder and hip pain were present in the majority at diagnosis (shoulder 81%; hips 59%) and in around a third and a fifth of patients respectively throughout the study. The prevalence of bilateral shoulder and hip pain remained higher than in the general population sample, while unilateral pain in these areas was less common. Bilateral hand (27%) and knee (45%) pain were also common at diagnosis. After 1 month, the mean number of pain areas was 7 - similar to the general population. However, prevalence of bilateral shoulder and hip pain remained higher than the general population throughout follow-up. Unilateral hip and knee pain were persistently less common in those with PMR, whilst unilateral hip pain was more common. Conclusion Bilateral pain was reported more commonly across the disease course in people with PMR than the general population. Causes of pain cannot be accurately attributed, but are likely multifactorial, including PMR disease activity, treatment and painful comorbidities. However, the persistence of bilateral pain suggests untreated PMR symptoms, requiring further research. Disclosure N. Hammad: None. R. Partington: None. S. Hider: None. H. Butt: None. T. Helliwell: None. C. Mallen: None. S. Muller: None.

High Rates of Abnormal Patellofemoral Morphology in Adolescents With Anterior Knee Pain: A Retrospective Review.

Background: Anterior knee pain is a common reason for referral to a pediatric orthopedic surgeon. Although previous studies have found that adults with anatomic risk factors for patellofemoral instability (patella dislocation) are predisposed to anterior knee pain, no studies have elucidated the relationship between anatomic risk factors for patellofemoral instability and anterior knee pain in children. Purpose: We sought to characterize common radiographic findings in adolescent patients with a chief complaint of anterior knee pain and to determine the prevalence of abnormal patellofemoral morphology. Methods: We conducted a retrospective review of patients 13 to 18 years old with anterior knee pain at a single tertiary care metropolitan institution from 2016 to 2021. X-rays and magnetic resonance imaging (MRI) were evaluated in those diagnosed with "chondromalacia patellae," "chondromalacia," "patellofemoral disorders," or "anterior knee pain." Patella alta, tibial tubercle-trochlear groove (TT-TG) distance, tubercle height, Wiberg patella type, patellar tilt, and trochlear dysplasia characterization were recorded. Results: Of the 293 adolescents with anterior knee pain included, 62 had bilateral anterior knee pain. Of the 172 MRIs, 72 (42%) met criteria for patella alta, Caton-Deschamps Index (CDI) >1.3, 35% had a TT-TG distance >15 mm, and 32% had lateral patellar tilt >15°. Magnetic resonance imaging findings included infrapatellar fat pad signal hyperintensity (41%) and patellofemoral dysplasia (23%). Of all 293 adolescents, 74% had images showing abnormal patellofemoral morphology, of which 30% had a history of 1 or more patellar dislocation. Overall, 40% of the adolescents had surgery, most commonly medial patellofemoral ligament (MPFL) reconstruction (18%). Conclusions: In this retrospective review, nearly 3/4 of adolescents with anterior knee pain had images showing abnormal patellofemoral morphology, including patella alta, increased TT-TG distance, trochlear dysplasia, or abnormal lateral patellar tilt; only 18% had MPFL surgery. These findings suggest that primary care providers might consider obtaining X-rays and/or MRIs to evaluate for pathology that warrants orthopedic evaluation.

Osteonecrosis of the Knee: The Unintended Consequence of Steroid Abuse.

The anti-inflammatory and immunosuppressive properties of steroids allow their use in a wide variety of rheumatological diseases, asthma, inflammatory bowel disease, cancer therapy, and severe viral infections. Though life-saving or organ-saving, long-term clinical use leads to a vast array of complications. Osteoporosis is the most common orthopedic side effect of steroid abuse, while osteonecrosis is a rare occurrence. The risk of osteonecrosis appears to be dose and duration dependent, but several patient factors also play a major role and usually affect the femoral head followed by the knee joint. The long-term effects of steroids must be explained to all patients on therapy, but this risk is missed in individuals who abuse steroids for recreational or performance-enhancing purposes. We describe a male, aged 29 years, who presented with dull aching bilateral knee pain of 2-years' duration after a long-term steroid abuse for weight and muscle mass gain. Radiological and magnetic resonance imaging studies confirmed osteonecrosis of femoral and tibial condyles and secondary degenerative arthritis of the knee joint. Prompt suspicion, early diagnosis, and intervention in osteonecrosis of knee joints, and termination of steroids may reverse the pathology and prevent progression of disease.

Risk Factors for Depression in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis.

Knee osteoarthritis (KOA) is a widespread chronic condition. Depression frequently occurs among patients with KOA. The objective of this meta-analysis was to identify risk factors associated with comorbid depression in patients with KOA. A comprehensive search of the PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases was conducted for studies related to comorbid depression in patients with KOA. We conducted statistical analyses to obtain relevant results, followed by heterogeneity tests and assessment for publication bias. The prevalence of comorbid depression among patients with KOA was 34% (95% CI, 28%-41%). Notable risk factors linked to comorbid depression in patients with KOA included female sex (relative risk [RR], 1.17; 95% CI, 1.11-1.23), obesity (mean difference [MD], 1.30; 95% CI, 0.88-1.71), use of analgesics (RR, 1.50; 95% CI, 1.38-1.63), comorbidities (MD, 0.20; 95% CI, 0.10-0.31), unmarried or widowed status (RR, 1.72; 95% CI, 1.56-1.91), bilateral knee pain (RR, 1.38; 95% CI, 1.11-1.71), high total Western Ontario and Mc-Master Universities Arthritis Index (WOMAC) score (MD, 14.92; 95% CI, 10.02-19.82), high WOMAC pain score (MD, 5.76; 95% CI, 2.86-8.67), low gait velocity (MD, -0.12; 95% CI, -0.16 to -0.09), and extended duration in the Timed Up and Go Test (MD, 1.56; 95% CI, 0.87-2.25). Based on the current evidence, female sex, obesity, use of analgesics, comorbidities, unmarried or widowed status, bilateral knee pain, high total WOMAC score, high WOMAC pain score, low gait velocity, and prolonged time on the Timed Up and Go Test were identified as risk factors for depression in patients with KOA. Focus should be given to these aspects when preventing depression among these patients. [Orthopedics. 2024;47(5):e225-e232.].

Management of Delayed Hemolytic Transfusion Reaction in a Patient with Sickle Cell Disease: A Case Report

Background: Sickle cell disease (SCD) is a group of inherited blood disorders characterized by abnormalities in hemoglobin (Hb), leading to distortion in shape of red blood cells (RBCs) and their breakdown, potentially blocking blood flow and resulting in pain and anemia. This can significantly impact the patient’s quality of life. Patients often require multiple blood transfusions to prevent complications associated with SCD by reducing the concentration of damaged hemoglobin. However, one of the significant complications of blood transfusions is Delayed Hemolytic Transfusion Reaction (DHTR), which occurs due to RBC alloimmunization (i.e., formation of antibodies against donor RBC antigens). DHTR can manifest as a sudden decrease in hemoglobin levels, which may progress to rapid multiorgan failure and death. Thus, prompt diagnosis is crucial for timely management. This case report highlights the diagnosis and management of a 56-year-old African American female with SCD who presented with bilateral severe knee pain and low Hb levels. Case Presentation: The patient’s symptoms, past medical history, and investigation findings led to a diagnosis of DHTR. Management was conducted within the framework of Bloodless Medicine, incorporating strategies to minimize blood loss and optimize erythropoiesis. Treatment included the use of erythropoietin (EPO) to manage hemoglobin levels and the administration of opioids and supplemental oxygen for symptom relief. Conclusion: Our case report highlights the challenges and various management strategies employed in treating DHTR in SCD patients. It emphasizes the importance of early recognition of the complication and compares the risks and benefits of additional blood transfusions in such patients. By presenting this case, we aim to contribute to the growing literature on DHTR in SCD patients and highlight the need for further research and optimized management strategies in this population.

SAT189 Giant Parathyroid Adenoma

Abstract Disclosure: S. Shah: None. P. Fujikawa: None. Parathyroid adenomas rarely weigh more than 4 grams. Our patient had a 5.3gram adenoma causing bilateral knee pain limiting mobility, constipation, low back pain, and frontal headache. Presenting with calcium of greater than 17 mg/dL, patient was treated with 2 rounds of hemodialysis, calcitonin, Zoledronate, and aggressive IV hydration to decrease calcium levels prior to parathyroidectomy. Patient then went onto develop Hungry bone syndrome which was treated with calcium carbonate and calcitriol. This rare giant parathyroid adenoma presents a unique opportunity to learn about pathogenesis and treatment of longstanding hyperparathyroidism causing hypercalcemia associated symptoms and hungry bone syndrome after parathyroidectomy. Presentation: Saturday, June 17, 2023

SAT213 Post-parathyroidectomy Acute Pseudogout Flare-up; A Case Report

Abstract Disclosure: S. Rabiei: None. V. Kantorovich: None. Introduction: Acute post-parathyroidectomy pseudogout has been reported in the early post-operative. Although the exact mechanism is unknown, accepted theories include decreased solubility of calcium pyrophosphate and unbalanced equilibrium between production and hydrolysis of inorganic phosphate. We present a patient who developed an acute pseudogout attack after parathyroidectomy. The Case: Patient is a 45-year-old male with a history of nephrolithiasis who presented to outpatient clinic with a right-sided neck mass that has been present for several years with recent increase in size. He reported unintentional weight loss (25 pounds) and night sweats. On physical examination, a right lateral neck mass measuring 6 x 4 cm was noted. CT scan of the neck demonstrated a complex mass with calcification. Serum calcium (Ca), phosphorus (P), potassium (K), and alkaline phosphatase levels were 17.2 mg/dL, 1.8 mg/dL, 2.6 mmol/L, and 1,782 U/L, respectively. Serum intact parathyroid hormone (iPTH) was 3,341 pg/mL. The patient was then admitted. He received intravenous fluid, zolindronic acid, and started on vitamin D supplementation in preparation for surgery. Pre-operative CT scan of the chest, abdomen, and pelvis was concerning for metastatic disease (retroperitoneal lymphadenopathy, multiple bilateral lung solid nodules, liver, kidney and bone lesions). The patient underwent complete resection of the tumor. Intra-operative frozen section confirmed parathyroid tumor with atypia. Twenty-minute post-excision iPTH was 476 pg/mL. In the early post-operative period, serum Ca level was reduced to 7.5-8.5 mg/dL and oral Ca and calcitriol supplementation were administered. However, serum PTH reached levels as high as 900 pg/mL. Post-operative MRI demonstrated benign liver and kidney lesion with non-visualization of the previously reported retroperitoneal lymph nodes and pulmonary nodules on the CT.A few days later, the patient complained of bilateral knee pain. Serum Ca, P, and PTH levels were 7.9 mg/dL, 3.0 mg/dL, and 861 pg/mL, respectively. The skeletal survey revealed diffuse osseous metabolic process with scattered lucent osseous lesions compatible with osteitis fibrosa cystica/brown tumors as well as chondrocalcinosis of knees and hand joints. Prednisone was started for treatment of presumed acute CPPD attack with subsequent significant resolution of patient’s joint pain. Discussion: This case demonstrated the importance of thorough evaluation of musculoskeletal complaints in patients with hyperparathyroidism. Bone and joint pain in patients with hyperparathyroidism is common and is most often the result of high bone turnover. However, other etiologies including acute pseudogout should be contemplated in order to provide the appropriate treatment. Post-parathyroidectomy acute pseudogout attack should generally be treated in the same way as in the general population. Presentation: Saturday, June 17, 2023

Magnetic Resonance Image Findings in A Rare Case of Bilateral Knee Pain in A Small Patella Syndrome Patient

Congenital aplasia or hypoplasia of the patella can manifest as an isolated disease or more commonly part of rare genetic disorders such as small patella syndrome (SPS). To our knowledge this is the first report of a patient with small patella syndrome who complained of bilateral knee pain with no preceding injury. Magnetic resonance imaging (MRI) revealed early degenerative changes of the knee joints which had not been mentioned in any literature. The MRI findings in our case are important as it would help in finding the cause of the pain and allow early treatment to be initiated thus delaying the progression of the arthritic changes. Bangladesh Journal of Medical Science Vol. 22 No. 04 October’23 Page : 926-931

Titrated segmental epidural anesthesia for bilateral total knee replacement in a patient with severe aortic stenosis and severe bilateral carotid artery stenosis: a case report

BackgroundTotal knee replacement is a major orthopedic procedure for severe, painful, and mobility-limiting knee arthritis. Aortic valve stenosis is the most frequent valvular heart disease and the most commonly performed valvular procedure. Stenosis of the valve may lead to left ventricular hypertrophy, ventricular dysfunction, myocardial ischemia, and a state of fixed cardiac output. Changes in hemodynamic parameters such as hypotension and bradycardia in patients with carotid artery stenosis may lead to cerebrovascular accidents, especially during anesthesia.Case presentationA 76-year-old woman with a 6-year history of bilateral knee pain. The pain was dull, aching, and severe in intensity, and it prevented her from sleeping despite optimal analgesics. A general physical examination revealed an elderly, frail woman in mild respiratory distress. She had bilateral small-volume radial pulses, positive hepatojugular reflux, and heart sounds of S1, S2, and S4 with an ejection systolic murmur, and carotid bruits were heard bilaterally. Epidural anesthesia was done by injection of 2.5 mL of 0.5% plain bupivacaine in aliquots every 5 min until the level of the block reached the suprapubic region (titrated segmental epidural anesthesia). The patient was not preloaded with intravenous fluid prior to the establishment of epidural anesthesia, and the epidural anesthesia-induced hypotension that may ensue was managed with intraoperative dopamine infusion at 5 µg/kg/min.ConclusionsTitrated segmental epidural anesthesia with intraoperative infusion of low-dose dopamine reduces the perioperative risk of myocardial infarction, cerebrovascular accident, and neurocognitive deficit in a patient with severe aortic stenosis and severe bilateral carotid stenosis.

E56 A 16-year diagnosis delay of a patient with Pigmented Villonodular Synovitis

Abstract Introduction Pigmented villonodular synovitis (PVNS), a subtype of tenosynovial giant cell tumours, is a rare non-cancerous proliferative synovial disorder usually affecting the knee in adults(1). The incidence rate is 1.8 patients per million people of the general population, with few reports amongst the paediatric population, hence it is frequently misdiagnosed(2). It has a slow onset of symptoms and has been noted to take ∼18 months to make a definitive diagnosis(3). Objective To describe a case of pigmented villonodular synovitis in a seventeen-year-old African female. Methods A retrospective chart review was done to ascertain the clinical presentation and management of the patient. Case description We present a case of a 17-year-old African female who presented with bilateral knee pain and swelling from 10 months of age. She had been on follow-up at a peripheral facility for 14 years, where she was being managed with methotrexate 12.5 mg weekly and folic acid 5 mg OD for Juvenile Idiopathic Arthritis with no marked improvement in her symptoms. In view of her poor response to therapy, the mother stopped her treatment 3 months prior to presentation in our facility. She initially had intermittent bilateral swelling of the small joints of the hand that were tender which eventually evolved to involve both knee joints. The pain was worse in the morning and was associated with the inability to ambulate and occasional night awakening. The systemic inquiry was otherwise unremarkable. She had an unremarkable birth history, and normal developmental milestones. She was however shorter than her peers and had not attained menarche. The patient had been admitted 8–10 times per year during the span of her illness for similar complaints and had undergone multiple knee joint fluid aspirations to relieve the swelling and several laboratory tests and radiological studies were done. On assessment, she was noted to be of fair general condition with gross asymmetric swelling of both knees and a surgical scar over the right knee with no limitation in the range of movement. There was minimal effusion of bilateral elbows and ankles, and the MCP, ICP and wrist joints weren’t affected. The patient had thoracic scoliosis, a grade 3/6 systolic murmur on the left lower sternal border, no radiation, and hepatomegaly 4 cm below the costal margin. She was prepubertal on sexual maturation rating. There was no central nervous system, abdominal, or respiratory abnormalities. A series of lab investigations to exclude the possibility of juvenile idiopathic arthritis were conducted. This panel included a complete blood count, which showed hypochromic, microcytic anaemia, c-reactive protein was raised at 61 mg/l but normal biochemistry and unremarkable autoantibody profile. Imaging done included a bilateral knee X-Ray followed by a bilateral knee MRI which showed large volume bilateral knee joint effusions associated with synovial-based masses causing extrinsic periarticular bony erosions and intra-articular synovial proliferation forming a villonodular appearance. The patient was referred to orthopaedic surgery and bilateral arthrotomy, drainage and synovectomy of both knees were done. She continues to be followed up in our paediatric rheumatology and orthopaedic clinic with good mobility and no other co-morbidities. She is currently undergoing work up for a delayed puberty. Conclusion Pigmented villonodular synovitis is a rare disease in the paediatric population. In the absence of awareness of its existence and expertise on how to diagnose it, patients may be misdiagnosed and mismanaged over a long duration of time as seen in the presented case.

Neglected bilateral geno valgum deformity managed with a dynamic compression plate and the ilizarov construct: a case report.

A 20-year-old male has suffered from bilateral knee pain and genu valgum deformity centered at both tibias with a closed physis. Management was challenging, requiring multiple surgeries and high patient cooperation. The patient underwent two surgeries: a right-sided osteotomy and Ilizarov fixation with gradual deformity correction. In the second operation, a proximal tibia osteotomy of the left side was executed with acute correction of the deformity and open reduction and internal fixation of the tibia with a medial tibial dynamic compression plate. Ultimately, the authors successfully corrected both leg deformities. This results reflect the efficacy of dynamic compression plates and Ilizarov for correcting genu valgum deformity in patients with closed epiphyseal plates.

A RARE CAUSE OF HYPOPITUITARISM - SHEEHAN SYNDROME

Sheehan syndrome is a rare complication of post-partum hemorrhage causing post-partum ischemic necrosis of the pituitary gland. It is a disease with declining incidence, more prevalent in developing countries. The incidence of Sheehan syndrome is 1 in 100,000 births. It was first described by a British pathologist Harold Leeming Sheehan in 1937.We present the case of a 42 year old female who presented with bilateral knee pain for 4 years, on over-the-counter steroids. She gave a history of lactational failure and secondary amenorrhea following childbirth. Her investigations revealed central hypothyroidism and she was diagnosed as Sheehan syndrome.

Testování stability kolena u adolescentních sportovců s m. Osgood-Schlatter pomocí Y-Balance testu

PURPOSE OF THE STUDY Osgood-Schlatter disease develops secondary to chronic patellar tendon overloading. The present study was designed to determine whether athletes with Osgood-Schlatter disease perform significantly worse in the Y-Balance Test compared to healthy subjects in a control group. MATERIAL AND METHODS The study involved ten boys (average age 13.7 years). Seven participants had bilateral knee pain, swelling and tenderness whereas three had unilateral knee pain, swelling and tenderness (left knee in two cases, and right knee in one). Overall, 17 knees were assessed (left knee in nine cases and right knee in eight).Ten healthy adolescent professional football players (mean age 14.6 years) were selected as a control group. In both groups, complex knee stability was assessed using the Y-Balance Test and their data were analyzed using the methodology developed by Plisky et al. The test outcome was expressed in indexed (normalized) values for the right and left lower extremities, and averaged values for the individual directions were compared. RESULTS Significant differences between both groups were shown in the posteromedial and posterolateral directions. CONCLUSIONS Using the Y-Balance Test, our study documented reduced performance in the above directions in patients with OsgoodSchlatter disease. Key words: Osgood-Schlatter disease, knee, balance test, movement patterns patellar tendon overload.

Scurvy, abnormal MRI, and gelatinous bone marrow in an adolescent with avoidant restrictive food intake disorder

BackgroundAlthough medical literature describes pediatric scurvy as “rare”, a growing number of case reports suggests otherwise. Patients often undergo costly and unnecessary workup due to unfamiliarity with the presentation of scurvy. This case report further supports the small yet growing literature documenting scurvy and its manifestations in patients with eating disorders.Case presentationA 15-year-old female presented to the emergency department with bilateral knee and ankle swelling and pain in the setting of chronic lower limb rash and BMI of 16.3. For years, she had restricted her diet to carbohydrates. Exam showed perifollicular petechial hemorrhagic rash with corkscrew hairs, knee edema, ankle edema with restricted range of motion, and antalgic gait. She was admitted for severe malnutrition from avoidant restrictive food intake disorder. Her hospital course was complicated by recurrent normocytic anemia and fever. Hematology workup revealed anemia from iron deficiency, vitamin K deficiency, and anemia of chronic disease. Rheumatology workup was negative. MRI findings showed dark T1 and bright T2 signals and were read as consistent with leukemia/lymphoma, chronic multifocal osteomyelitis, or Langerhans cell histiocytosis. However, bone marrow biopsy showed gelatinous transformation secondary to malnutrition. She was treated with vitamin C and a nutrition plan and her symptoms improved.ConclusionsAlthough this patient had common manifestations of scurvy, including perifollicular petechial hemorrhagic rash, joint effusions, anemia, and recurrent fevers, she still underwent an extensive workup. Clinicians should be aware that scurvy can present with multiple symptoms that mimic infectious, rheumatic, oncologic and hematological disease. Clinicians should have a high index of suspicion for scurvy in patients with malnutrition and eating disorders.