After knee replacement, therapy resistant, chronic synovitis is common and leads to effusion and pain. A cohort of 55 patients with 57 knee replacements and chronic synovitis underwent radiosynoviorthesis. In summary, 101 joints were treated using 182±9 MBq of 90Y-citrate. The number of radiosynoviorthesis ranged from 1 to 4 (53%, 21%, 23%, and 4%). Every patient received a 99mTc-MDP scintigraphy before and three months after every radiosynoviorthesis. Follow-up ranged from 5.7 to 86.7 months. For qualitative analysis, an four steps scoring was used (0 = no response or worsening, 1 = slight, 2 = good, 3 = excellent response). For quantification, the uptake was determined within the 99mTc-MDP scintigraphy soft tissue phase before and after therapy. At the end of long-term follow-up 27% of patients have an excellent, 24% good, 30% slight and 20% no response. The duration of response was 7.5±8.3 months (maximum 27 months). In repeated treatment, the effect after the first therapy was lesser than in patients who received a single treatment in total. However, three months after the last radiosynoviorthesis, patients with repeated treatment showed a similar effectiveness than single treated patients. At the end of long-term follow-up, patients with repeated radiosynoviorthesis had a higher effectiveness at similar duration response. In the 99mTc-MDP scan 65% of patients showed a reduction of uptake. When comparing subjective and objective response 78% of patients showed a concordance in both, symptoms and scintigraphy. Pilot histological analysis revealed that the synovitis is triggered by small plastic particles. Radiosynoviorthesis is effective in patients with knee replacement and chronic synovitis. It shows good subjective and objective response rates and long response duration. Repeated treatment leads to a stronger long-time response. The chronic synovitis is caused by plastic particles, which result from the abrasion of the polymeric inlay of endoprothesis

Introduction and Objective. Septic arthritis is an acute infective presentation of the joint calling for urgent intervention, thus making the differential diagnosis process difficult. An increase in temperature in the area containing the suspected septic arthritis is one of the clinically important findings. In this study, it was aimed to investigate whether or not the temperature changes obtained through thermal camera can be used as a new additional diagnostic tool in the differential diagnosis of septic arthritis. Materials and Methods. The study was approved by the local ethics committee as a prospective cohort. A total of 49 patients, 15 septic and 34 non-septic ones, both male and female ones from all ages admitted to the emergency room or evaluated with the consultation of another clinics who were also present with a pre-diagnosis of arthritis (septic or non-septic) in the knee (with complaints of redness, swelling, pain, effusion, increased temperature, edema, and inability to walk) were included in the study. The patients with non-joint inflammatory problems and a history of surgery in the same joint were excluded from the study. The temperature increase in the joint area with suspected septic arthritis was observed, and the difference in temperature changes of this suspicious area with the joint area of the contralateral extremity was compared after which the diagnosis of septic arthritis was confirmed by taking culture with routine intra-articular fluid aspiration, which is the gold standard for definitive diagnosis. Results. The mean age of the patients was 39.89 ± 27.65°C. A significant difference was found between the group with and without septit arthritis in terms of ASO, sedimentation, and leukocyte increase in the analysis of joint fluid (p <0.05). When the thermal measurements were compared, the mean temperature was 37.93°C in the septic group, while it was 36.79°C in the non-septic group, which showed a significant difference (p <0.000∗). The mean temperature difference in both joints was 3.40°C in the septic group, while 0.94°C in the non-septic group (p <0.000∗). While the mean temperature was 37.10°C in the group with septit arthritis, it was measured to be 35.89 °C in the group without (p <0.020). A very strong positive correlation was found between the difference between the mean temperatures of both groups and the values of the hottest and coldest temperature points (r = 0.960, r = 0.902). Conclusions. In the diagnosis of septic arthritis, a thermal imager can be used as a non-invasive diagnostic tool. With the help of this device, a quantitative value, in addition to palpation, can be given to the local temperature increase in the joint, which is an important finding in the clinic of septic arthritis. In future studies, specially designed thermal devices developed with special software for septic arthritis can be developed

Painful OA is linked to CNS changes in pain processing. Temporal summation of pain (TSP) is a measure of one such CNS change, central sensitization. TSP is defined using a series (≥0.33Hz) of painful stimuli and is a predictor of postoperative pain, experienced by 20% of patients after total knee replacement (TKR) surgery. This study has developed a protocol to use functional MRI to assess CNS changes in OA pain processing. This pilot includes 3 participants with chronic knee OA pain awaiting TKR (62 ± 4.4) and 5 healthy volunteers (50 ± 13.6). 3-Tesla BOLD fMRI brain scans were recorded during short series of one second painful stimuli, applied using an automated inflatable cuff to the calf muscle of the leg with the affected knee or left side in healthy volunteers. The pain intensity at onset and during the 10 painful stimuli were recorded using a numerical rating scale. The pattern of brain activation was averaged across noxious stimuli, and the differential activation compared the 1st vs. 10th (last) stimulus. Bone marrow lesions (BMLs), synovitis and effusion size were scored from 3-Tesla knee MRI's using MOAKS scoring. TSP was raised in OA patients compared to control group (p=0.023). TSP brain activity in the chronic OA patients displayed higher signal within the subgenual anterior cingulate (sgACC) compared to healthy volunteers. Knee MRI identified OA patient's exhibited higher BML scores (p=0.038) and more knee effusion (p=0.018), but the lack of synovitis did not differ from control group (p=0.107). Enhanced TSP in chronic knee OA pain may be linked with augmented responses in emotional circuitry. BMLs and effusion size appear to contribute more with pain than synovitis. These results may help understand sensitization to improve outcomes for patients with knee OA undergoing TKR surgery

Total knee arthroplasty (TKA) is a common orthopaedic procedure with over 1,500 done in 2016 in Ireland alone. 96% of all TKAs are due to pain in the knee associated with osteoarthritis. According to the UK National Joint Registry (NJR), there is a 0.47%, 1.81%, 2.63% and 4.34% probability risk of undergoing a revision TKA within one, three, five and ten years respectively post-index surgery. A variety of reasons for failure of TKA have been described in the literature including infection, aseptic loosening, pain, instability, implant wear, mal-alignment, osteolysis, dislocation, peri-prosthetic fracture and implant fracture. The NexGen Posterior Stabilised Fixed has NJR revision rates of 0.44%, 1.61% and 2.54% at years one, three and five respectively. A retrospective review was carried out of 350 NexGen TKAs that were performed directly by, or under the supervision of, a fellowship trained arthroplasty surgeon in a dedicated orthopaedic hospital between April 2013 and December 2015. 26 (7.4%) of these were revised as of 31 December 2017. Three were for septic arthritis with the remaining 23 (6.6%) for aseptic loosening. Patients typically started to experience symptoms of medial tibial pain with supra-patellar swelling from a combination of effusion and synovial thickening at 12–24 months. Inflammatory markers were normal in all cases. Radiographs of symptomatic knee replacements showed bone loss on the medial tibia with a tilt of the tibial component into a varus alignment. The high number of revisions of this particular prosthetic has led to its use being discontinued at this centre

Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure. A total of 76 cadaver acromioclavicular joints were injected with a solution containing methyl blue and subsequently dissected to distinguish intra- from peri-articular injection. In order to assess the importance of experience in achieving accurate placement, half of the injections were performed by an inexperienced resident and half by a skilled specialist. The specialist injected a further 20 cadaver acromioclavicular joints with the aid of an image intensifier. The overall frequency of peri-articular injection was much higher than expected at 43% (33 of 76) overall, with 42% (16 of 38) by the specialist and 45% (17 of 38) by the resident. The specialist entered the joint in all 20 cases when using the image intensifier. Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection

Background. We herein report a case of isolated hip pain in a four year old boy. The unique aspect of this case study is the unusual history, presentation, ultrasonography, MRI and blood culture results, which lead to the diagnosis and treatment of adductor pyomyositis with a rare organism (Streptococcus Mitis) in a temperate country. The objectives of this case study is to discuss the key learning outcomes with respect to assessment and management of this case. Methods. The patient presented with a one day history of malaise, fever, left groin pain and inability to weight bear on the left leg. There was no history of any trauma, predisposing infections or recent travel. A working diagnosis of transient synovitis / septic arthritis of the hip was made on clinical examination. Results. Plain radiograph and ultrasound of the hip was normal with no effusion. Two consecutive blood cultures suggested Streptococcus Mitis bacteriaemia and MRI scan confirmed pyomyositis of the left hip adductors that was too small to drain. Streptococcus Mitis is a normal commensal organism of the oral cavity however it can lead to opportunistic infections particularly endocarditis. Echocardiogram revealed no cardiac complications, in particular no endocarditic vegetation. Patient was treated with intravenous benzylpenicillin for a week followed by oral phenoxymethylpenicillin for a week. Conclusion. Adductor pyomyositis must be considered as a differential diagnosis in a child with unusual presentation of hip pain. When an ultrasound is normal, MRI scan is warranted to confirm diagnosis. Septic screen should include blood cultures. The commonest causative organisms are the Staphylococcus family. However if Streptococcus Mitis is isolated, cardiac sources of infection resulting in septic emboli must be investigated. Repeated MRI scans are required particularly if the patient does not respond to medical management. Level of Evidence. IV

Introduction. We compared ultrasound guided methylprednizolone-lidacaine infiltrations around inflammatory area of plantar aponeurosis with systematic use of NSAID'S. Also, we investigated the reliability of the sonographic criteria (a. swelling of aponeurosis more than 20% in comparison to the healthy foot, b. effusion around aponeurosis, c. calcium deposits) most used to identify plantar fasciitis in clinically suspicious patients. Methods. A prospective randomised controlled clinical trial, including 28 patients (mean age: 47 years, range: 36–65 years, 85% females) with typical clinical symptoms of plantar fasciitis. All of these patients undertook a soft tissue ultrasonography of the plantar aponeurosis, without Doppler. Then, we randomly divided our sample in 2 groups, group A (14 patients) and group B (14 patients). In group A patients we performed an ultrasound guided injection –in transverse view- around the swollen part of aponeurosis, while we managed group B patients with per os NSAID's treatment (meloxicam 15 mg, once per day) for 2 weeks. Results. From the 28 suspicious patients we found 20 (71.4%) matching at least in one of our sonographic criteria. Swelling in comparison to the contralateral foot was the most usual found on these patients (14/20: 70% of the -ultrasound positive- patients). In group A patients the mean visual analogue scale (VAS) 100/100 after 1 month reduced –from 69/100 prior to injection- to 34/100, while 6 patients (42.85%) declared free of symptoms and 4 had poor or no improvement. In group B patients, the mean VAS decline was 21/100 (from 66/100 prior to injection, to 45/100 1 month later), but only 1 patient reported pain free. Conclusion. High frequency ultrasound of the foot is a good standing -but not excellent- diagnostic tool for plantar aponeurositis. Ultrasound guided methylprednisolone injections seems to have better short-term results than per os anti-inflammatory treatment on these patients

We report an unusual case of knee disease where calcific tendonitis occurring in both quadriceps and patellar tendon simultaneously in the same knee. A 47 year old female presented to orthopaedics outpatient clinic with acute onset of swelling and knee pain with no history of trauma. She was found to have a moderate effusion of the knee joint with mild tenderness over the mid quadriceps tendon. Active flexion of the knee joint was painful with a range of motion between 0-90 degrees. She is otherwise healthy with no past medical history. Plain radiographs and Magnetic Resonance Imaging (MRI) Scan revealed calcification of both tendons. Calcific tendonitis is classically found in the supraspinatus tendon of the shoulder. In addition, it has been described in other areas of the body such as the wrist, thigh, hip, knee and ankle. This condition usually occurs in the quadriceps or patellar tendons separately and rarely affecting both tendons in the same knee simultaneously. The patients condition improved significantly with physiotherapy, anti-inflammatory medications and ultrasound therapy. Calcific tendinitis of both quadriceps and patellar tendon is a very rare cause of knee pain. Most of the time it is treated conservatively with non-steroidal anti-inflammatory drugs and ultrasound therapy and some times steroid injection. However; patient may require surgical intervention especially in refractory cases to resolve the condition

Background. Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA. Method. All children with a presentation of ‘atraumatic limp’ and a proven effusion on hip ultrasound between 2004 and 2009 were included. Patient demographics, details of the clinical presentation and laboratory investigations were documented to identify a response to each of four variables (Weight bearing status, WCC >12,000 cells/m3, CRP >20mg/L and Temperature >38.5 degrees C. The definition of SA was based upon microscopy and culture of the joint fluid collected at arthrotomy. Results. 311 hips were included within the study. Of these 282 were considered to have transient synovitis. 29 patients met criteria to be classified as SA based upon laboratory assessment of the synovial fluid. The introduction of CRP eliminated the need for a four variable model as the use of two variables (CRP and weight bearing status) had similar efficacy. An algorithm that indicated a diagnosis of SA in individuals who could not weight-bear and who had a CRP >20mg/L correctly classified SA in 94.8% individuals, with a sensitivity of 75.9%, specificity of 96.8%, positive predictive value of 71.0%, and negative predictive value of 97.5%. CRP was a significant independent predictor of septic arthritis. Conclusions. CRP was a strong independent risk factor of septic arthritis, and its inclusion within a regression model simplifies the diagnostic algorithm, such that a two-variable model correctly classified 95% individuals with SA. Nevertheless, this and similar algorithms are generally more reliable in excluding SA, than confirming SA, and therefore a clinician's acumen remains important in identifying SA in those individuals with a single abnormal variable

In order to determine the usefulness of MRI in assessing autologous chondrocyte implantation (ACI) the first 57 patients (81 chondral lesions) with a 12-month review were evaluated clinically and with specialised MRI at three and 12 months. Improvement 12 months after operation was found subjectively (37.6 to 51.9) and in knee function levels (from 85% International Cartilage Repair Society (ICRS) III/IV to 61% I/II). The International Knee Documentation Committee (IKDC) scores showed an initial deterioration at three months (56% IKDC A/B) but marked improvement at 12 months (88% A/B). The MRI at three months showed 82% of patients with at least 50% defect fill, 59% with a normal or nearly normal signal at repair sites, 71% with a mild or no effusion and 80% with a mild or no underlying bone-marrow oedema. These improved at 12 months to 93%, 93%, 94% and 91%, respectively. The overall MR score at 12 months suggested production of normal or nearly normal cartilage in 82%, corresponding to a subjective improvement in 81% of patients and 88% IKDC A/B scores. Second-look surgery and biopsies in 15 patients (22 lesions) showed a moderate correlation of MRI with visual scoring; 70% of biopsies showed hyaline and hyaline-like cartilage. Thus, MRI at 12 months is a reasonable non-invasive means of assessment of ACI

Osteoarthritis (OA) is an important cause of pain, disability and economic loss in humans, and is similarly important in the horse. Recent knowledge on post-traumatic OA has suggested opportunities for early intervention, but it is difficult to identify the appropriate time of these interventions. The horse provides two useful mechanisms to answer these questions: 1) extensive experience with clinical OA in horses; and 2) use of a consistently predictable model of OA that can help study early pathobiological events, define targets for therapeutic intervention and then test these putative therapies. This paper summarises the syndromes of clinical OA in horses including pathogenesis, diagnosis and treatment, and details controlled studies of various treatment options using an equine model of clinical OA.

Objectives

The major problem with repair of an articular cartilage injury is the extensive difference in the structure and function of regenerated, compared with normal cartilage. Our work investigates the feasibility of repairing articular osteochondral defects in the canine knee joint using a composite lamellar scaffold of nano-ß-tricalcium phosphate (ß-TCP)/collagen (col) I and II with bone marrow stromal stem cells (BMSCs) and assesses its biological compatibility.

Objective

Excessive mechanical stress on synovial joints causes osteoarthritis (OA) and results in the production of prostaglandin E2 (PGE2), a key molecule in arthritis, by synovial fibroblasts. However, the relationship between arthritis-related molecules and mechanical stress is still unclear. The purpose of this study was to examine the synovial fibroblast response to cyclic mechanical stress using an in vitro osteoarthritis model.

We have studied the effects of bupivacaine on human and bovine articular chondrocytes in vitro. Time-lapse confocal microscopy of human articular chondrocytes showed > 95% cellular death after exposure to 0.5% bupivacaine for 30 minutes. Human and bovine chondrocytes exposed to 0.25% bupivacaine had a time-dependent reduction in viability, with longer exposure times resulting in higher cytotoxicity. Cellular death continued even after removal of 0.25% bupivacaine. After exposure to 0.25% bupivacaine for 15 minutes, flow cytometry showed bovine chondrocyte viability to be 41% of saline control after seven days. After exposure to 0.125% bupivacaine for up to 60 minutes, the viability of both bovine and human chondrocytes was similar to that of control groups.

These data show that prolonged exposure 0.5% and 0.25% bupivacaine solutions are potentially chondrotoxic.

Injection or aspiration of the ankle may be performed through either an anteromedial or an anterolateral approach for diagnostic or therapeutic reasons. We evaluated the success of an intra-articular puncture in relation to its site in 76 ankles from 38 cadavers. Two orthopaedic surgical trainees each injected methylene blue dye into 18 of 38 ankles through an anterolateral approach and into 20 of 38 through an anteromedial. An arthrotomy was then performed to confirm the placement of the dye within the joint.

Of the anteromedial injections 31 of 40 (77.5%, 95% confidence interval (CI) 64.6 to 90.4) were successful as were 31 of 36 (86.1%, 95% CI 74.8 to 97.4) anterolateral injections. In total 62 of 76 (81.6%, 95% CI 72.9 to 90.3) of the injections were intra-articular with a trend towards greater accuracy with the anterolateral approach, but this difference was not statistically significant (p = 0.25). In the case of trainee A, 16 of 20 anteromedial injections and 14 of 18 anterolateral punctures were intra-articular. Trainee B made successful intra-articular punctures in 15 of 20 anteromedial and 17 of 18 anterolateral approaches. There was no significant difference between them (p = 0.5 and p = 0.16 for the anteromedial and anterolateral approaches, respectively). These results were similar to those of other reported studies. Unintended peri-articular injection can cause complications and an unsuccessful aspiration can delay diagnosis. Placement of the needle may be aided by the use of ultrasonographic scanning or fluoroscopy which may be required in certain instances.

We evaluated the histological changes before and after fixation in ten knees of ten patients with osteochondritis dissecans who had undergone fixation of the unstable lesions. There were seven males and three females with a mean age of 15 years (11 to 22). The procedure was performed either using bio-absorbable pins only or in combination with an autologous osteochondral plug. A needle biopsy was done at the time of fixation and at the time of a second-look arthroscopy at a mean of 7.8 months (6 to 9) after surgery.

The biopsy specimens at the second-look arthroscopy showed significant improvement in the histological grading score compared with the pre-fixation scores (p < 0.01). In the specimens at the second-look arthroscopy, the extracellular matrix was stained more densely than at the time of fixation, especially in the middle to deep layers of the articular cartilage.

Our findings show that articular cartilage regenerates after fixation of an unstable lesion in osteochondritis dissecans.