Boqing Chen

Continuous passive motion after total knee arthroplasty: a prospective study.

ObjectiveContinuous passive motion (CPM) has been shown to increase significantly the amount of knee flexion for patients with total knee arthroplasty in the acute care hospital. Whether there is any additional benefit to using CPM for these patients who are transferred to a rehabilitation hospital is not known. There have been no prospective, randomized, controlled studies in this area. DesignFifty-one such patients on an inpatient rehabilitation service were randomly assigned to two groups. Group 1 (n = 23) received CPM for 5 consecutive hours per day plus physical therapy, whereas group 2 (n = 28) received only physical therapy. Knee flexion was measured by a blinded physical therapist on admission, on the third and seventh days of hospitalization, and at the time of discharge. ResultsThe results indicated no significant difference in passive range of motion between group 1 and group 2. Patients in group 1 achieved an average increase in passive range of motion of 16 degrees, whereas those in group 2 achieved an average of 19 degrees (P = 0.33). ConclusionAlthough power analysis indicated the need for differences in results for 32 patients per group to achieve significance, the difference between the two groups suggested neither statistical nor clinical significance. We concluded that the use of CPM in the rehabilitation hospital is likely of no added benefit to patients admitted after single total-knee replacement.

Pain, dizziness, and central nervous system blood flow in cervical extension: vascular correlations to beauty parlor stroke syndrome and salon sink radiculopathy.

Foye PM, Najar MP, Camme A Jr, Stitik TP, DePrince ML, Nadler SF, Chen B: Prospective study of pain, dizziness, and central nervous system blood flow in cervical extension: Vascular correlations to beauty parlor stroke syndrome and salon sink radiculopathy. Am J Phys Med Rehabil 2002;81:395–399. Objective Professional shampoos have previously been implicated in beauty parlor stroke syndrome and salon sink radiculopathy. The purpose of this study was to record pain, dizziness, and cervical blood flow while subjects were specifically placed into the salon sink position and to determine whether an additional cervical support would alter these symptoms and measurements. Design In 25 volunteers who reported previous dizziness from salon shampoos, we recorded subjective levels of pain and dizziness and objective measurements of blood flow within the vertebral and carotid arteries at baseline and then during cervical extension into a salon sink, with and without additional cervical support. Results When the additional cervical support was not used, there was significantly greater dizziness, neck pain, and carotid blood flow. No statistically significant differences were seen in the vertebral artery blood flow when comparing the three positions. Conclusions Pain and dizziness were commonly reproduced in this previously symptomatic population but significantly less frequently when a supplemental cervical support was used. Individuals with a history of such symptoms should probably exercise caution when deciding whether to receive a salon sink shampoo.

Osteoarthritis and body weight

Osteoarthritis (degenerative joint disease) is the most common type of arthritis, and is a significant source of pain and disability. Osteoarthritis has multiple risk factors, including some that are potentially modifiable, such as body weight. Increased body weight is associated with an increased risk of developing osteoarthritis. Relatively minor weight loss can effectively decrease the risk of the onset of osteoarthritis, and can decrease symptoms and progression in patients who already have osteoarthritis. Mechanisms of weight loss include an appropriate exercise program and adjustments in dietary intake. Additional considerations could include anorectic agents and gastric stapling.

Optimal Needle Placement for Ultrasound-Guided Knee Joint Injections orAspirations

Although the inferomedial and inferior midline approaches are commonly used for intra-articular injection or aspiration of the knee joint, they may not be ideal for optimal needle placement. With these approaches, the fat pad may be contacted, which may lead to the injection of medication in the incorrect region, cause severe pain during the injection procedure, or present a false sign of low yield of fluid aspiration. Therefore, the objective of this study was to compare various approaches for knee injection and aspiration to identify the optimal one for needle placement. In this retrospective study, the ultrasound images of bilateral knee joints in 33 consecutive patients with knee pain were studied. This patient population was divided into two groups: Group A with knee effusions (n=10) and Group B without knee effusions (n=23). The results showed that among 90% of patients in Group A and 100% of patients in Group B, the superolateral view allowed visualization of the greatest amount of intra-articular knee fluid and the least amount of fat pad. In conclusion, the ultrasound-guided superolateral approach appears to be an optimal approach for knee intra-articular injection or aspiration compared to the conventional inferomedial and inferior midline approaches.

Ganglion cyst at the fibular head causing common peroneal neuropathy diagnosed with ultrasound and electrodiagnostic examination: a case report.

ABSTRACTThe common peroneal nerve is a major source of innervation to the lower limb, but it is sometimes compressed or entrapped at the fibular head. The authors present what they believe is the first reported case where peroneal nerve impingement caused by ganglion cyst compression of the nerve at the fibular head was diagnosed using a combination of ultrasound imaging and electrodiagnostic studies. The authors described the history, physical examination, electrodiagnostic findings, and musculoskeletal ultrasound findings of a patient with a left foot drop caused by a ganglion cyst compressing the common peroneal nerve at the fibular head. The increasing role of ultrasound imaging to evaluate musculoskeletal pathology is discussed.

Safety of interlaminar and transforaminal epidural steroid injections.

January 2014 • Volume 118 • Number 1 In Response We agree with Chen et al. 1 that neither midline interlaminar nor parasaggital interlaminar approaches of epidural steroid injection are completely risk free with respect to potential needle-related vascular injury because of wide variation of spinal vascular anatomy. While we did conclude that the administration of epidural steroid injection was without complication with both parasaggital interlaminar and midline interlaminar approaches in our study subjects,2 this does not imply that complications cannot occur with these procedures. Our study was not powered to detect vascular complications with these procedures. What we implied in our article was that transforaminal epidural steroid injection is associated with higher incidence of catastrophic complication, and this is supported by literature. At least 18 cases of severe neurological damage and permanent paralysis are reported subsequent to transforaminal epidural steroid injection3 as compared with only 3 cases of paraplegia after interlaminar epidural steroid injection.4 Two of 3 patients reported with previous interlaminar epidural steroid injection, had prior spine surgery at the level of the interlaminar injection,4,5 and in one of the cases, a 21-gauge IM needle was used.4 Postsurgical changes in the epidural space and arterial spinal vasculature4,5 and the use of IM needle might have contributed to this complication.4 Also, the overall rate of intravascular injection with lumbosacral transforaminal epidural steroid injection is reported to be 11.2%6 as compared with 1.9% after interlaminar epidural steroid injection.7 We clearly mentioned in the introduction of our article that “there are concerns regarding the safety of the transforaminal route, and there is a search for a technically better route with fewer complications for drug delivery into the ventral epidural space.”2 To the Editor Based on the results of their study comparing the efficacy of lumbar epidural steroid injection via a parasagittal interlaminar approach with that following a midline interlaminar approach, Ghai et al.1 concluded that a lumbar transforaminal epidural steroid injection (TFESI) targeting the “safe triangle” does not guarantee safety due to potential radiculomedullary artery (Adamkiewicz artery) injury. While we agree with this conclusion, we respectfully disagree with the authors’ implied opinion that the parasagittal interlaminar approach may be safer than the approach following traditional TFESIs. At least 3 cases of lumbar paraplegia have been reported after interlaminar lumbar epidural steroid injections.2 The proposed mechanism is similar to that for paraplegia from a lumbar TFESI in which the epidural needle injured or penetrated the radiculomedullary artery and particulate corticosteroid was injected into the spinal canal with resultant spinal cord embolism and subsequent paraplegia. In fact, anatomic studies have demonstrated that after the radiculomedullary arteries enter the neuroforamina near the anterior aspect of the dorsal root ganglion and exiting nerve root,3,4 they often travel a distance superiorly and laterally in the lateral epidural space joining the anterior spinal artery which ultimately supplies the anterior 2/3 of the spinal cord. In addition, in about 63% of cadavers studied, there is a posterior branch of the radiculomedullary artery which supplies the dorsal aspect of the cauda equina.5 It is conceivable that the epidural needle might encounter the radiculomedullary artery in the lateral or in the midline posterior epidural space. In light of the radiculomedullary artery anatomical positions inside the spinal canal as described above, neither midline nor parasagittal interlaminar lumbar epidural steroid injections are completely risk-free with respect to potential needle vascular injury and paraplegia, particularly if particulate corticosteroids are used, as has been determined for TFESIs. Furthermore, Kambin’s triangle approach for TFESIs might be the safest of all approaches.6–8

Medical student feedback: a mechanism to improve a multi-instructor clinical lecture series?

It is ironic that physicians are not ordinarily educated on how to effectively teach or lecture at any time during their training or professional careers but are routinely called on to do so for medical students, residents, other healthcare professionals, and the general public. In fact, Gray and Fine observed that up to 86% of general practitioners have been asked at some point to lecture. Specialists have also been increasingly requested to lecture within multiinstructor courses given to medical students during their clinical years, yet lectures by specialists in this setting have been shown to be poor at times. Despite the prevalence with which physicians teach and the questionable efficacy of some of the lectures, training on how to effectively teach/lecture is rarely offered at any stage of a physician’s education or career. In fact, only a few cases of experimental teaching workshops for attending physicians or teaching classes for residents are cited in the literature. Another irony is that there has been widespread use of subjective indicators such as student evaluations since the 1970s but much less use of objective measures such as student performance to assess and improve teaching quality. Although several issues concerning student evaluations, such as the effectiveness, fairness, and reliability, along with the logistical issue of when to perform evaluations, have been addressed to some extent by a limited number of studies, there are still significant gaps and some conflicting data in the literature.

Successful Treatment of Gluteal Pain from Obturator Internus Tendinitis and Bursitis with Ultrasound-Guided Injection

Abstract This case report describes what the authors believe is the first case of a patient with obturator internus tendinitis and bursitis successfully treated with a corticosteroid injection using a trans-tendinous lateral to medial approach. The patient presented with right gluteal pain not relieved by physical therapy or right hip and ischial bursa corticosteroid injections. Pelvic and lumbar spine MRIs and EMG/NCS findings were unremarkable. Physical examination demonstrated tenderness to palpation at the right middle lower gluteal region. Ultrasound imaging with sonopalpation identified the maximal local tender point as the right obturator internus muscle and/or its underlying bursa. A 22-gauge 3.5-inch needle was inserted in-plane to the transducer and longitudinal to the obturator internus from a lateral to medial direction, an approach previously described in cadavers.1 The obturator internus tendon sheath and bursa were injected with 2.5 ml of 0.5% lidocaine combined with 10 mg of triamcinolone. The patient reported immediate complete relief of pain with continued relief at 2 and 6 months post-injection. This case report demonstrates an injection of the obturator internus tendon sheath and bursa using a trans-tendinous approach, which may be successful for treatment of patients presenting with persistent gluteal pain from obturator internus tendinitis and bursitis.

Poster 172 Ultrasound Guided Injection of Obturator Internus Bursa: A Case Report.

edema and worsening knee effusion. Given concern for deep vein thrombosis (DVT), patient was empirically treated with enoxaparin. Lower extremity ultrasound demonstrated a Baker’s cyst and a small, right peroneal DVT, for which he was subsequently started on rivaroxaban. Despite anticoagulation, patient developed right calf ecchymosis, limb pain and edema continued to worsen, and he required crutches for ambulation. Repeat ultrasound confirmed resolution of the peroneal DVT, but revealed a new 4x6x20 cm medial gastrocnemius dissecting hematoma contiguous with the ruptured Baker’s cyst. Setting: Outpatient sports medicine clinic. Results: Right knee MRI confirmed these findings and rivaroxaban was discontinued. Ultrasound-guided aspiration could not be performed due to clotting of the dissecting hematoma and patient underwent an urgent, open surgical excision. He had gradual resolution of symptoms and ambulation improved over the next 3-5 months. Discussion: A Baker’s cyst is a benign synovial fluid-filled mass in the popliteal fossa that represents enlargement of the medial gastrocnemius-semimembranosus bursa, resulting from a communication with the knee joint. Baker’s cysts can be associated with a wide array of knee pathologies, including gout, arthritis, and meniscal tears. Potential complications of Baker’s cysts include rupture, phlebitis, nerve entrapment, and compartment syndrome. Dissecting hematomas are an extremely rare complication of Baker’s cysts and our review revealed only two documented cases. One case occurred following a work-related trauma, whereas the other was in a male on aspirin who had previously underwent several knee joint injections for osteoarthritis. This case represents the first report of a non-traumatic, dissecting hematoma resulting from a ruptured Baker’s cyst in a patient receiving novel oral anticoagulation for DVT. Conclusions: Novel oral anticoagulation may increase the risk of dissecting hematoma formation in cases of ruptured Baker’s cysts. Level of Evidence: Level V

Reply: To PMID 25687110.

1. Lai LP, Stitik TP, Foye PM, Georgy JS, Patibanda V, Chen B. Use of platelet rich plasma in intra-articular knee injections for osteoarthritis: A systematic review. PM R 2015;7:637-648. 2. Braun HJ, Kim HJ, Chu CR, Dragoo JL. The effect of platelet-rich plasma formulations and blood products on human synoviocytes: Implications for intra-articular injury and therapy. Am J Sports Med 2014;42:1204-1210. 3. Kon E, Mandelbaum B, Buda R, et al. Platelet-rich plasma intraarticular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: From early degeneration to osteoarthritis. Arthroscopy 2011;27:1490-1501. 4. Sampson S, Reed M, Silvers H, Meng M, Mandelbaum B. Injection of platelet-rich plasma in patients with primary and secondary knee