Knee Effusion Research Articles

Identification of Knee Effusions With Ultrasound: A Comparison of Three Methods.

To determine whether simple methods can improve identification of suprapatellar joint fluid during sonographic evaluation of the knee. Prospective cohort study. Outpatient orthopaedic clinic. Fifty-two patients were sequentially recruited from an orthopaedic clinic. Bilateral sonographic evaluation of the suprapatellar recess with static scanning, parapatellar pressure, or patient-initiated quadriceps contraction. Identification of fluid in the suprapatellar recess. Fifty-two patients (104 knees), consisting of 57 (54.8%) painful knees, were examined. Static scanning identified 45 effusions, parapatellar pressure identified 58 effusions, and quadriceps contraction identified 77 effusions. Quadriceps contraction was superior to parapatellar pressure for identifying an effusion {P < 0.001, proportion ratio [PR] = 1.33 [95% confidence interval (CI) = 1.16, 1.52]}, painful knee effusions [P = 0.036, PR = 1.24 (95% CI = 1.06-1.44)], and painless knee effusions (P = 0.006, PR = 1.50 [95% CI = 1.16-1.93]). Both methods were superior to static scanning. Parapatellar pressure identified effusions in 16.9% of knees not seen on static scanning, whereas quadriceps contraction identified effusions in 54.2% of knees not seen on static scanning. Inter-rater reliability kappa values were 0.771 for static scanning (95% CI = 0.605-0.937), 0.686 for parapatellar pressure (95% CI = 0.531-0.840), and 0.846 for quadriceps contraction (95% CI = 0.703-0.990). Parapatellar pressure and patient-initiated quadriceps contraction both improve sonographic detection of suprapatellar joint fluid with high inter-rater reliability; however, quadriceps contraction was superior to parapatellar pressure when assessing for grade 1 or occult effusions.

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.

Knee Effusion with Peripheral Eosinophilia: A Need to Rule out Idiopathic Eosinophilic Synovitis

Knee Effusion with Peripheral Eosinophilia: A Need to Rule out Idiopathic Eosinophilic Synovitis

Surgical treatment of habitual lateral patellar instability by proximal realignment procedure (Campbell technique)

Background: Patellar instability may manifest as acute patellar dislocation, recurrent patellar dislocation or subluxation, habitual patellar dislocation or chronic patellar dislocation. Habitual patellar dislocation is a condition where the patella dislocates whenever the knee is flexed and spontaneously relocates with extension of the knee. The purpose of this study is to know the functional and radiological outcome following proximal realignment procedure (Campbell technique) for habitual patellar dislocation. 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. Functional outcome was assessed by Kujala score. Conclusion: Campbell technique (lateral release of tight structures and medial plication of patellar retinaculum) is a safe and effective procedure for treating habitual patellar dislocation. Functional outcome evaluated by Kujala score was good for most of our patient’s. Radiological parameters (sulcus angle and congruence angle) 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

Correspondence: Knee Effusion with Peripheral Eosinophilia: A Need to Rule out Idiopathic Eosinophilic Synovitis

Correspondence: Knee Effusion with Peripheral Eosinophilia: A Need to Rule out Idiopathic Eosinophilic Synovitis

Effect of autograph used in anterior cruciate ligament reconstruction surgery on postoperative infection rate

Purpose: The aim of this study was to investigate effect of autograft selection on the infection risk following arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. Materials and Methods: Between June 2004 and October 2018, 840 consecutive patients who underwent primary arthroscopic ACL reconstruction with either a hamstring tendon autograft or a bone patellar tendon bone (BTB) autograft were reviewed retrospectively. Patients were assigned into two groups based on the type of graft used: First group was bone-patellar tendon-bone (BTB) autograft group (n=354) and second group was hamstring tendon autograft group (n=466). These two groups were compared statistically in terms of demographic characteristic and postoperative infection status. After primary ACL reconstruction, local and systemic clinical findings of infection (knee effusion, systemic fever, nausea, weakness) supported by laboratory findings (C-Reactive Protein (CRP), Erytrocyt Sedimentation Rate (ESR)) were defined as infection.Results: There was a statistically increased risk of infection with hamstring tendon autograft compared to BTB autograft. While the infection rate in the first group (BTB) was 0.3 % (n=1), the infection rate in the second group (Hamstring tendon) was 4.7 % (n=22).Conclusion: In this study, a higher infection rate was found in primary ACL cases treated with hamstring tendon autograft compared to those using BTB autografts. Orthopedic surgeons should be aware of the increased risk of infection when hamstring autograft is used in ACL reconstruction surgery and should prefer BTB autograft over hamstring autograft in appropriate indication.

PCL Reconstruction Using Adjustable Buttons with Outside-In Tunnel for Tibial Fixation: A case report

Introduction:Posterior cruciate ligament (PCL) reconstruction needs a large and long graft. An allograft is a preferable option for thicker graft but its availability is limited in Indonesia. Alternatively, autograft needs to be folded several times for sufficient thickness but it will be shorter and only applicable for the inside-out method. We present a case of PCL reconstruction using a double adjustable button fixation with the outside-in tibia tunneling method.Case Presentation:A fifty-five-year-old male came to our office with an unstable right knee after he fell 1 month ago. Physical examination showed positive posterior drawer and mild right knee effusion, other findings were normal. MRI revealed a total PCL rupture. Two weeks later, the PCL reconstruction was done using autograft from gracillis and semitendinous. A large adjustable button was placed on the tibia tunnel, using the outside-in technique. Knee was stable postoperatively.Discussion:PCL reconstruction using double adjustable buttons was chosen to accommodate larger but shorter autografts. The outside-in tibial tunnel has less risk of graft laxity less expensive and more simple technically compared to inside-out adjustable button tunnel.Conclusion:Tibial fixation using an adjustable large button should be considered in PCL reconstruction with short autograft.

Serum and synovial survivin in rheumatoid arthritis: Relation to disease activity and severity

BackgroundRheumatoid arthritis (RA) is a progressive debilitating autoimmune disease, affecting 1% of the world population, leading to cartilage and bone destruction caused by insufficient apoptosis in the inflamed RA synovium. Survivin is a proto-oncogene biomarker known for its anti-apoptotic and cell cycle-regulating properties. Overexpression of survivin in non-cancerous processes has been linked to inflammation, presumably contributing to the decreased apoptosis in the T cells of the cerebrospinal fluid in multiple sclerosis, in skin lesions of patients with psoriasis and in synovial tissue of patients with RA.Aim of the workThe aim of this study is to measure the serum and synovial levels of survivin and clarify their relations to disease activity, functional capacity, and radiographic damage in patients with RA.Patients and methodsThis study was carried outon50patients with RA who hada mean ageof46.4±10.94 years.Theywere39femalesand11males.Thecontrolgroupwasofmatchedageand sex,withameanageof46.03±10.53yearsandfemale:maleratioof23:7.Allpatients were subjected to full history taking, thorough clinical examination, assessment of disease activity by disease activity score 28 activity score, and assessment of functional capacity and disability using Health Assessment Questionnaire. Plain radiographs of both hands of feet were done, scored and graded by Larsen score. Serum survivin from all the studied participants and survivin levelsinthe synovial fluid aspirated from 18 patients with RA who presented with knee effusion at the time of examination were measuredbyenzyme-linked immunosorbent assay, usingapair of matched anti bodies (R&D systems, Abingdon, Uk).ResultsThe mean serum survivin level was highly statistically significantly elevated (P<0.001) in the sera of patients with RA than in the controls, being 239.1 ±115.15 and 77.03±30.20 pg/ml, respectively. Synovial survivin levels ranged between 420 and 575 pg/ml, with a mean of 479.61±52.68 pg/ml, which was statistically significantly higher than the mean serum survivin level in patients with RA (P<0.001). Patients were divided into survivin -ve group, which included 21 (42%) of 50 patients with serum survivin less than 167.63 pg/ml, and survivin +ve group, which included 29 (58%) of 50 patients with RA with serum survivin more than or equal to 167.63 pg/ml. Survivin +ve RA patients group had significantly longer mean disease duration (P<0.001), Higher Health Assessment Questionnaire SCORE, and higher mean Larsen score (P<0.001) than survivin -ve RA patients group. Overall, nine (69.2%) of 13 RA patients with Sjogren’s syndrome, eight (80%) of 10 of the patients with pleural effusion, three (50%) of six patients with Raynaud’s phenomenon, and all patients with SC nodules (five, 100%), episcleritis (two, 100%), and vasculitis (one, 100%) were survivin +ve. Larsen score in the patients with RA ranged from 0 to 65, with a mean of 23.6 ±18.98. Patients with RA who had Larsen score grading more than or equal to 2 (27/ 50, 52%) were considered to have an erosive RA disease. There were no statistically significant differences between patients with RA according to the presence of erosion regarding age, sex, visual analog scale values, disease activity score values, the presence of rheumatoid factor antibodies or anti-cyclic citrullinated peptides antibodies, the mean of hemoglobin %, white blood cells count, platelets count, erythrocyte sedimentation rate first hour value, or the C-reactive protein level. All patients with RA with erosive disease were survivin +ve and had statistically significantly elevated mean serum and synovial survivin levels than those patients with non erosive disease (337.37±55.19 vs. 126.78±24.33 pg/ ml and 422.5±3.53 vs. 486.75±51.52 pg/ml, respectively).ConclusionsHigh levels of survivin are detected in the sera and synovial fluid of patients with RA and are associated with erosive joint damage and poor functional outcomes. Our findings support the role of survivin in the pathogenesis of RA. Further studies are needed on a larger group of RA patients follow-up to ascertain the erosive effect of survivin. Conduction of studies on survivin antagonist to evaluate their effect on ameliorating RA disease progression is recommended.

Role of Diagnostic Musculoskeletal Ultrasound in Assessment of Gouty Arthritis

Background: Gout is a chronic heterogeneous disorder of urate metabolism results in deposition of monosodium urate crystals in the joints and soft tissues, with accompanying inflammation and degenerative consequences. Aim of work: Assessment of the role of musculoskeletal ultrasound (MSUS) in detecting changes in gouty arthritis patients under anti hyperuricimic treatment. Patients and methods: 30 patients with gouty arthritis treated with febuxostat 80 mg once daily for 3 months and 20 (age, sex & body mass index “BMI”) matched controls were included. Patients were assessed by clinical examination, pain by visual analogue scale (VAS), tenderness by Ritchie index, functionally assessed using lower extremity functional scale & examination of joint effusion and tophi by palpation. MSUS findings in knee and first metatarsophalangeal “1st MTP” joints of patients and controls were reported before and 3 months after treatment. Results: BMI mean in patients group was 28.18 ± 1.49 (25-31) and in controls was 27.67 ± 1.56 (25-31). VAS, tenderness & lower extremity functional scale in patients before treatment in knee & 1 stMTP joints significantly improved after treatment (p < 0.001). There was a significant improvement in ESR, CRP, serum uric acid, double contour sign & knee effusion in patients after treatment compared to before treatment. Conclusion: Ultrasonography can detect changes related to treatment of gout with febuxostat. Febuxostat is a safe and efficient anti hyperurecemic drug and is effective in treatment of gouty arthritis. Ultrasound is more sensitive in detecting findings & changes of disease than clinical examination.

A CURIOUS CASE OF MYOCARDITIS WITH ELEVATED ANTISTREPTOLYSIN O TITERS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Acute rheumatic fever can cause a spectrum of rheumatic heart disease, including myositis, pericarditis, or valvulitis. It is mostly seen in children and is considered a disease of poverty. Here, we present a case of a 24 year-old with myocarditis secondary to rheumatic fever. CASE PRESENTATION: A 24 year-old male presented to the emergency department because of chest pain that started 2 nights prior. His pain was rated 8/10, nonradiating, worse with inspiration and associated with nausea. It was the first time he had experienced chest pain. The patient was recently discharged from the the hospital because of acute tonsillitis, where he experienced throat pain, fever, nausea, vomiting, cervical and submandibular lymph node swelling. He was discharged with improvement of his tonsillitis after treatment with clindamycin. He has no significant past medical history. On physical examination, the patient’s temperature was 38.2*C and heart rate was 103 bpm with the rest of physical examination being unremarkable. Chest X-ray showed bilateral pulmonary congestion with cardiomegaly but no infiltrates or consolidation. EKG revealed diffuse ST segment depression. Laboratory studies showed an elevated white count with normal neutrophil and lymphocyte counts. Troponin levels were elevated from 0.359 ng/mL and peaked to 0.447 ng/mL. Urine toxicology was negative. Blood cultures were taken but returned negative. He was admitted to the telemetry unit with elevated troponin levels to rule out acute coronary syndrome. Cardiology performed an echocardiogram, showing no structural or functional abnormalities; a cardiac catheterization showed the patient had nonobstructive CAD. Throughout his hospital stay, he had fluctuating temperatures, with a Tmax of 38.9*C and developed right knee pain and then pain in the left knee two days later. X-rays were taken of both knees, demonstrating moderate effusion of the right knee. Infectious disease was consulted and recommended ASO titers, influenza Ag, stool culture, and gonorrhea and chlamydia urine PCR. All results of the laboratory test were negative except for the ASO titer of 1:200, CRP of 309.1 mg/dL, and ESR of 114 mm/hr. He was started on naproxen as well as benzathine penicillin G with a diagnosis of myocarditis secondary to rheumatic fever. The patient showed much improvement throughout the course of hospital stay and was discharged to follow up with cardiology and infectious disease clinics. DISCUSSION: The differential diagnosis for a young adult with chest pain is usually secondary to drugs or chest wall pain. It is very unusual for a young adult to present with myocarditis secondary to rheumatic fever, which is more commonly seen in children. It is pertinent to consider acute myocarditis associated with GAS tonsillitis as a differential. CONCLUSIONS: An early diagnosis and treatment can significantly improve the prognosis of the patients. Reference #1: Jose L. Aguirre, MD, Margarita Jurado, MD, Mateo Porres-Aguilar, MD, Cristina Olivas-Chacon, MD, Mateo Porres-Muñoz, MD, Debabrata Mukherjee, MD, and  Juan Taveras, MD. Acute nonrheumatic streptococcal myocarditis resembling ST-elevation acute myocardial infarction in a young patient. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by Hung-I Liao, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response

Relation of interleukin-15 with the severity of primary knee osteoarthritis

BackgroundInterleukin-15 (IL-15) is a proinflammatory cytokine. IL-15 could be considered a potential biomarker for primary knee osteoarthritis (OA).AimThis study aimed to assess the serum level of IL-15 in primary knee OA patients and assess its relation to clinical severity, functional disabilities, and radiological grading of knee OA.Patients and methodsThis study included 40 patients with primary knee OA and 40 apparently healthy individuals. Assessment of knee OA was performed using clinical examination, the Western Ontario and McMaster Universities Osteoarthritis Index score, and Health Assessment Questionnaire-Disability Index. Radiological assessment was performed using the Kellgren–Laurence grading scale. Serum level of IL-15 was measured in both patients and control participants.ResultsThere were no statistically significant differences between patients and the control group in sex (P=1.000) and age (P=0.247). The patient group had a statistically significantly higher serum IL-15 level than its level in the control group (P≤0.0001). Serum IL-15 level was significantly higher among patients with knee joint line tenderness and effusion (P≤0.0001). There were statistically significant positive correlations between serum IL-15 level with the Western Ontario and McMaster Universities Osteoarthritis Index total score (P≤0.0001), the Health Assessment Questionnaire-Disability Index score (P≤0.0001), and the Kellgren–Laurence grading scale (P≤0.0001).ConclusionSerum IL-15 is elevated and correlated positively with pain, stiffness, functional disabilities, as well as radiological damage in primary knee OA. This suggests that IL-15 plays an important critical role in the pathogenesis of primary knee OA-related pain, stiffness, and joint damage. IL-15 might be a potential biomarker for assessing the severity of primary knee OA.

2051 Tofacitinib Improves Refractory Crohn’s Disease-Associated Arthritis

INTRODUCTION: Tofacitinib is a Janus kinase (JAK) inhibitor shown to be effective in several inflammatory conditions, though it has limited efficacy in luminal Crohn’s Disease (CD). Here, we report the case of a woman with refractory CD-associated arthritis that improved markedly on tofacitinib. CASE DESCRIPTION/METHODS: A 38-year-old woman with history of CD and enterocutaneous fistula status post right hemicolectomy presented with severe sacroiliitis and arthritis for 20 years. Her Harvey Bradshaw Index (HBI) was 7, notable for “terrible wellbeing” secondary to arthritis and 2 soft stools daily. Her CD-associated arthritis was refractory to sulfasalazine, mycophenolate mofetil, methotrexate, adalimumab and ustekinumab. Family history was notable for a father with rheumatoid arthritis. Exam demonstrated sacral spine tenderness, bilateral knee effusions, and right ankle effusion. Laboratory work-up was notable for negative HLA-B27, rheumatoid factor and double stranded DNA antibody. MRI lumbosacral spine showed fluid signal in the right sacroiliac joint, concerning for sacroiliitis. Based on her CD and imaging, she met criteria for ankylosing spondylitis. Given her continued joint pain, she was initiated on tofacitinib 10 mg twice daily. Within one month of treatment, the patient noted significant improvement in joint pain and stiffness, with HBI now 2, only notable for two soft stools daily. Five months after initiating tofacitinib, her CD-associated arthritis was still in remission. DISCUSSION: Tofacitinib, an oral JAK inhibitor, has been shown to have efficacy in rheumatoid arthritis, psoriasis, and ulcerative colitis (UC). In UC, tofacitinib improves clinical and endoscopic response and remission. By contrast, tofacitinib has been shown to have limited efficacy in inducing clinical response and remission in CD, although it has been associated with decreased CRP and fecal calprotectin. Yet, there are case reports detailing tofacitinib’s use for extraintestinal manifestations of CD, including pyoderma gangrenosum. Despite its use in other inflammatory arthritides, to our knowledge, this is one of the first case reports characterizing improvement of CD-associated arthritis with tofacitinib. This case demonstrates that tofacitinib can quickly improve CD-associated arthritis refractory to other biologic therapy. Although tofacitinib may have a limited role in luminal treatment of CD, future studies should evaluate its use for extraintestinal manifestations of CD, including CD-associated arthritis.

19. Fever, dyspnoea and a raised CRP: just another chest sepsis?

IntroductionAutoinflammatory conditions can arise in patients presenting on the medical take. Patients presenting with an inflammatory response, fever and organ dysfunction are usually (and appropriately) managed as sepsis until proven otherwise. However, a suspicion should be maintained for alternative diagnoses when there is no improvement with conventional antimicrobial therapy.We present a case of a young woman presenting with polyserositis with a wide differential diagnosis including infection, autoimmunity and malignancy. She was treated successfully with colchicine. Subsequent genetic analysis at the Royal Free hospital for fever syndromes has not found a pre-described genetic polymorphism.Case descriptionA 39-year-old woman presented to A&E with dyspnoea, night sweats, lethargy and right upper quadrant pain. Her past medical history included hypothyroidism and two years of intermittent diarrhoea. This diarrhoea was associated with a raised faecal calprotectin. Subsequent investigation with colonoscopy and MRI small bowel were normal. Other past history included pleurisy felt to be secondary to a lower respiratory tract infection aged 38 and a right knee effusion aged 15. She was born in the UK but had a Greek mother.Examination revealed reduced breath sounds in the bases which were dull to percuss, normal heart sounds and mild abdominal distension. There was no peripheral oedema. Observations showed oxygen saturations of 90% on air, BP 90/50, HR 120 and a pyrexia of 38°C. Blood results showed a raised ALT of 100 and CRP 40. She was initially treated with antibiotics for a working diagnosis of atypical pneumonia.Her respiratory failure deteriorated and a CTPA two days later showed bilateral pleural effusions, a massive pericardial effusion with impending tamponade and a right upper lobe PE. A CT CAP show moderate ascites but no evidence of malignancy or lymphoma.Pericardiocentesis showed a reactive picture with no organisms grown and normal cytopathology of the fluid. Pleural and ascitic fluid were also drained and she was commenced on LMWH for the PE. Virology, microbiological and autoimmune screens were unremarkable. CRP at this stage had risen to 78 as had the ALT to 1400.6 days after admission, antibiotics were stopped she was commenced on colchicine 1mg bd. Within 48 hours she rapidly improved both clinically and biochemically.DiscussionSince the index admission genetic analysis has shown she is HLA B51 negative and she has no recognised genetic polymorphism associated with a periodic fever syndrome.20 months since admission she has made a good recovery and is stable on colchicine 1mg od with no recurrence of the pleural and pericardial effusions. She has had one further episode of diarrhoea for 2 weeks associated with a raised faecal calprotectin and red macular rashes on her torso. Anticoagulation for the PE has been stopped.Polyserositis in the absence of infection or malignancy is uncommon and autoinflammatory and autoimmune aetiologies should be considered. This case highlights the importance of keeping a broad mind in patients presenting in an unusual way or when they do not respond to initial treatment.Autoinflammatory conditions are characterised by marked inflammation affecting the skin, serosal surfaces and synovium among others. Her history of colitis is intriguing. There are case reports of patients with familial Mediterranean fever presenting with serositis but she was negative for FMF on further genetic testing. Similarly she did not prove to have any of the genes that have so far been recognised as causing a periodic fever syndrome.We did consider Behçet’s but she denied a history of recurrent oral or genital ulceration or iritis and there was no family history. However Behçet’s can lead to inflammatory bowel disease and this remains an intriguing possibility.The dramatic response to colchicine was remarkable. Within 48 hours a re-accumulated pericardial effusion causing right ventricular strain had disappeared as had clinically apparent ascites. Most autoimmune, infective or malignant aetiologies would not be expected to respond in such a way and a yet undiscovered autoinflammatory syndrome remains a tantalising possibility.Key learning pointsMain learning points so far: Maintain a wide differential in patients presenting with polyserositis, especially when there is a poor response to typical management approaches. Consider autoinflammatory disease and take a detailed past medical and family history.Colchicine is cheap and generally well tolerated at lower doses. Colchicine is first line therapy for recurrent pericarditis.Learning points from the conference: What’s her risk of developing secondary amyloid or other secondary sequelae? How long will she need treatment for and how/ when you would you wean the colchicine? Is her partial Greek genetic heritage relevant? How common are wild type genetic polymorphisms occurring in autoinflammatory conditions? How frequently is colitis a feature of autoinflammatory diseases? If she becomes unwell again what would your second line therapy be?Conflicts of interestThe authors have declared no conflicts of interest.

Comparative Clinical Outcomes After Intra-articular Injection With Adipose-Derived Cultured Stem Cells or Noncultured Stromal Vascular Fraction for the Treatment of Knee Osteoarthritis

Background: Intra-articular injection of adipose-derived stem cells (ASCs) has shown promise for improving symptoms and cartilage quality in the treatment of osteoarthritis (OA). However, while most preclinical studies have been performed with plastic-adherent ASCs, most clinical trials are being conducted with the stromal vascular fraction (SVF), prepared from adipose tissue without prior culture. Purpose: To directly compare clinical outcomes of intra-articular injection with ASCs or SVF in patients with knee OA. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively compared 6-month outcomes in 42 patients (59 knees) receiving intra-articular injection with 12.75 million ASCs and 38 patients (69 knees) receiving a 5-mL preparation of SVF. All patients had Kellgren-Lawrence grade 2, 3, or 4 knee OA and had failed standard medical therapy. The visual analog scale (VAS) pain score and Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline and 1, 3, and 6 months after injection were considered as outcomes. Outcome Measures in Rheumatology–Osteoarthritis Research Society International (OMERACT-OARSI) criteria were also used to assess positive response. A repeated measures analysis of variance was used for comparison between the treatment groups. Results: No major complications occurred in either group. The SVF group had a higher frequency of knee effusion (SVF 8%, ASC 2%) and minor complications related to the fat harvest site (SVF 34%, ASC 5%). Both groups reported improvements in pain VAS and KOOS domains. Specifically, in the ASC group, symptoms improved earlier (by 3 months; P < .05) and pain VAS decreased to a greater degree (55%; P < .05) compared with the SVF group (44%). The proportion of OMERACT-OARSI responders in the ASC group was slightly higher (ASCs, 61%; SVF, 55%; P = .25). Conclusion: It was observed that both ASCs and SVF resulted in clinical improvement in patients with knee OA, but that ASCs outperform SVF in the early reduction of symptoms and pain with less comorbidity.

Comparing the Effectiveness of BloodFlow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial.

We implemented a bloodflow restriction resistance training (BFR-RT) intervention during an 8-week rehabilitation programme in anterior cruciate ligament reconstruction (ACLR) patients within a National Health Service setting. To compare the effectiveness of BFR-RT and standard-care traditional heavy-load resistance training (HL-RT) at improving skeletal muscle hypertrophy and strength, physical function, pain and effusion in ACLR patients following surgery. 28 patients scheduled for unilateral ACLR surgery with hamstring autograft were recruited for this parallel-group, two-arm, single-assessor blinded, randomised clinical trial following appropriate power analysis. Following surgery, a criteria-driven approach to rehabilitation was utilised and participants were block randomised to either HL-RT at 70% repetition maximum (1RM) (n = 14) or BFR-RT (n = 14) at 30% 1RM. Participants completed 8weeks of biweekly unilateral leg press training on both limbs, totalling 16 sessions, alongside standard hospital rehabilitation. Resistance exercise protocols were designed consistent with standard recommended protocols for each type of exercise. Scaled maximal isotonic strength (10RM), muscle morphology of the vastus lateralis of the injured limb, self-reported function, Y-balance test performance and knee joint pain, effusion and range of motion (ROM) were assessed at pre-surgery, post-surgery, mid-training and post-training. Knee joint laxity and scaled maximal isokinetic knee extension and flexion strength at 60°/s, 150°/s and 300°/s were measured at pre-surgery and post-training. Four participants were lost, with 24 participants completing the study (12 per group). There were no adverse events or differences between groups for any baseline anthropometric variable or pre- topost-surgery change in any outcome measure. Scaled 10RM strength significantly increased in the injured limb (104 ± 30% and 106 ± 43%) and non-injured limb (33 ± 13% and 39 ± 17%) with BFR-RT and HL-RT, respectively, with no group differences. Significant increases in knee extension and flexion peak torque were observed at all speeds in the non-injured limb with no group differences. Significantly greater attenuation of knee extensor peak torque loss at 150°/s and 300°/s and knee flexor torque loss at all speeds was observed with BFR-RT. No group differences in knee extensor peak torque loss were found at 60°/s. Significant and comparable increases in muscle thickness (5.8 ± 0.2% and 6.7 ± 0.3%) and pennation angle (4.1 ± 0.3% and 3.4 ± 0.1%) were observed with BFR-RT and HL-RT, respectively, with no group differences. No significant changes in fascicle length were observed. Significantly greater and clinically important increases in several measures of self-reported function (50-218 ± 48% vs. 35-152 ± 56%), Y-balance performance (18-59 ± 22% vs. 18-33 ± 19%), ROM (78 ± 22% vs. 48 ± 13%) and reductions in knee joint pain (67 ± 15% vs. 39 ± 12%) and effusion (6 ± 2% vs. 2 ± 2%) were observed with BFR-RT compared to HL-RT, respectively. BFR-RT can improve skeletal muscle hypertrophy and strength to a similar extent to HL-RT with a greater reduction in knee joint pain and effusion, leading to greater overall improvements in physical function. Therefore, BFR-RT may be more appropriate for early rehabilitation in ACLR patient populations within the National Health Service.

Assessing the effect of per operative intravenous injection of tranexamic acid in patients undergoing arthroscopic anterior cruciate ligament reconstruction

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Anterior cruciate ligament (ACL) tear is a common injury sustained during contact games hampering performance of the sportsmen and thus requires promt management. Arthroscopic ACL reconstruction is commonly associated with postoperative knee effusion which affects the functional recovery. Various treatment modalities are available for managing effusion after ACL reconstruction, which are associated with various grades of success and side effects.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective interventional study was carried out at tertiary care Orthopaedic centre. It involved 48 Young male athletes with ACL tear managed subsequently by arthroscopic ACL reconstruction. Subjects were divided into Injection group and non injection group by randomization and blinding was ensured. Postoperative rehabilitation, prophylactic antibiotic and chemoprophylaxis for DVT was kept standardised for all patients. Patients were assessed for pain at operative site by visual analogue scale, effusion of knee by classification of Coupens and Yates and Lysholm knee scoring at 2nd, 6th and 12th week postoperatively.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; During follow ups it was found that Injection group was having significant less incidence of effusion as compared with Non injection group; which also has reflected in functional recovery.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It can be concluded that use of inj tranexamic acid preoperative dose in case of patients undergoing ACL reconstruction is efficient to reduce the knee effusion.&lt;/p&gt;

Is it Friction? A Rare cause of Medial Knee Pain

HISTORY: A 22-year-old male with no significant past medical history presents with reports of two weeks of progressive medial knee pain, after beginning training for a sprint triathlon. Prior to starting his training, he primarily lifted weights and ran only sporadically. He increased his running significantly up to 3 to 4 miles 4 to 5 times per week. Pain was initially only present while running, but became present with any activity including swimming, especially with a frog-leg kick, after cycling, and finally with day-to-day walking. He notes mild swelling in the medial knee. He denies any catching, locking, buckling, or give-way of the knee. He denies any paresthesias in the right lower extremity. PHYSICAL EXAMINATION: Pain in the right medial knee with single leg squat on the right. No knee effusion, however, there is mild swelling located just below the medial joint line over the proximal medial tibia on the right. Knee range of motion is full bilaterally. Ligamentous exam stable. Pain with valgus stress testing at 30 degrees on the right without laxity. No tenderness over the medial or lateral joint lines. Tenderness to palpation over the proximal medial tibia a few centimeters distal to the joint line and over the MCL in this region. No tenderness to palpation over the proximal MCL or pes anserine bursa. DIFFERENTIAL DIAGNOSIS: 1. Medial tibial plateau stress reaction 2. Distal MCL sprain 3. Pes anserine bursitis TEST AND RESULTS: Plain radiographs: — No acute osseous abnormality. MRI right knee: — focal subcortical marrow edema within the medial aspect of the tibia 2.5cm below the joint line at the site of a bony protuberance compatible with prominent medial tibial cress — No fracture line, or soft tissue mass FINAL/WORKING DIAGNOSIS: Medial tibial crest friction syndrome TREATMENT AND OUTCOMES: 1. Voltaren gel and activity modification with cessation of cycling, and reduction in training volume, with reported improvement. 2. Patient wanted to return to training for a triathlon and ultrasound-guided corticosteroid injection, deep to the MCL over the tibial protuberance, was performed. 3. Patient reported complete resolution of pain immediately after injection that was maintained at 2 weeks. 4. Patient completed his sprint triathlon without development of pain and he was instructed to follow-up should his symptoms recur.

Knee Pain - Baseball

HISTORY: A 16 year old high school hockey player and baseball pitcher noticed lateral knee pain and intermittent swelling for about 2 months prior to presentation. He does not recall any trauma or injury. He did have a viral URI and episode of strep pharyngitis several weeks before this started. He denies radiation of the pain. He does note some catching and locking sensation of the knee. He feels that his knee flexion is limited. He treated the knee with ice, ibuprofen, and acetaminophen through the season and was able to complete his baseball season prior to presenting to his PCP for evaluation. Because no definite etiology was identified in this visit, MRI was ordered, which showed complex loculated effusion, enlarged popliteal lymph nodes, and synovial thickening. There were no structural injuries appreciated. PHYSICAL EXAMINATION: Initial exam in the sports medicine clinic revealed tenderness at the lateral joint line and 1+ knee effusion. There was no erythema or warmth at the joint. He had full active and passive range of motion and full strength. Ligamentous testing was normal. DIFFERENTIAL DIAGNOSIS: PVNS Rheumatologic condition Lymphoma/Leukemia Lyme disease Traumatic hemarthrosis TEST AND RESULTS: Repeat MRI with additional views: Complex loculated effusion; Synovitis/synovial proliferation;No hemosiderin staining with blooming artifact Joint aspiration: 20 cc cloudy yellow synovial fluid; TNC 37,270, Neutrophils 73% Cytology: No malignant cells ANA: 1:80 homogeneous Rheumatoid Factor: Negative Lyme: Negative ESR: 9 CRP: 21.8 CBC: WBC 5.9, Hgb 15.5, Hct 45.4, Plt 287 FINAL WORKING DIAGNOSIS: Juvenile idiopathic arthritis (JIA) TREATMENT AND OUTCOMES: Referred to pediatric rheumatologist Bilateral knee aspiration and corticosteroid injection Prednisone taper Methotrexate therapy Check anti-CCP antibodies Referred to ophthalmology to rule out uveitis

Knee Injury - Dancer

HISTORY: A 20 year old female dance instructor was performing split jump lunges when she developed acute onset of pain and swelling in the medial left knee while loading the leg in the posterior position. She reported feeling a tearing sensation and was unable to immediately weight bear. On presentation to the emergency room was partially weightbearing. Initial left knee radiographs were negative for acute fracture. She was given a soft knee sleeve, started ibuprofen 600mg TID, and initially used ice. She presented to outpatient sports medicine clinic 1 week later with persistent 7/10 pain and swelling in the medial knee. She denied locking or buckling of the knees. PHYSICAL EXAMINATION: Exam revealed mild-to-moderate effusion of the left knee and restricted range of motion due to pain (flexion to 100 degrees, extension to 10 degrees). There was tenderness to palpation over the medial joint line and pain with valgus stress testing. Anterior drawer with bilateral mild laxity but symmetric. McMurray’s was limited by guarding and restricted range of motion. Gait was antalgic with limited knee flexion on the left. Hip abduction strength 4-/5 bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Medial meniscus tear 2. Medial collateral ligament injury 3. Anterior cruciate ligament injury 4. Patellar dislocation/subluxation 5. Osteochondral injury TESTS AND RESULTS: Left Knee X-ray: - No acute osseous findings - Suggestive of lateral patellar tilt and subluxation Left Knee MRI: - Sequela of prior transient lateral patellar dislocation and medial patellar retinaculum rupture - Osseous contusions of the medial patella and lateral femoral condyle - Shallow trochlear groove with minimal lateral patellar subluxation FINAL/WORKING DIAGNOSIS: Acute lateral patellar dislocation and medial patellar retinaculum rupture in setting of trochlear dysplasia TREATMENT AND OUTCOMES: 1. Left knee immobilizer started 1-week post-injury. 2. Isometric quadriceps strengthening exercises started 1-week post-injury. 3. Improved range of motion, swelling, and gait at 1 month follow up. 4. Started in physical therapy for knee range of motion, strengthening and stabilization exercises, hip abduction strengthening, and progression to return to dance/exercise. 5. Discussed orthopedic referral if no further improvement or recurrent dislocation.

Knee Pain and Effusion in a Medically Complex Patient

Knee Pain and Effusion in a Medically Complex Patient