Michael M. Weinik

Acute Gouty Arthropathy Mimicking Infection After Total Knee Arthroplasty

out is an increasingly common etiology of acute arthritis as a result of longer life xpectancies, increasing rates of obesity, and greater intake of purine-rich foods. Approxiately 1% of Americans suffer from gout, with men being at greater risk than women [1,2]. The deposition of monosodium urate monohydrate (MSUM) crystals into joints and soft issue occurs when extracellular fluid becomes supersaturated with urate. This crystal recipitation results in phagocytosis, leading to inflammatory-mediated clinical symptoms. he development of hyperuricemia can be the result of insufficient renal excretion or verproduction caused by excess intake of purines. Insufficient urate clearance likely ccounts for most cases of gout. Purine-rich diets, alcohol consumption, obesity, insulin esistance, advanced age, and being of male gender all represent independent risk factors hat lead to excess urate accumulation [2]. Medications such as loop or thiazide diuretics, spirin and cyclosporine may impair renal excretion of urate and predispose to gout. Gout typically produces an acute monoarthritis with rapidly presenting pain, erythema, welling, and warmth. This diffuse periarticular erythema may mimic cellulitis, thrombohlebitis, or septic arthritis. Symptoms characteristically develop acutely overnight and are ccompanied by a low grade fever in 50% of polyarticular cases. The first metatarsal-phalangeal joint (podagra) is most commonly affected ( 70% of ases). However, gout commonly involves the mid-tarsal joints, ankles, knees, and olecraon bursa. Shoulder and hip involvement is a rare occurrence. Crystal deposits known as ophi may develop around the elbow, ears, hands, and feet. Preferential involvement of istal joints may be related to the fact that MSUM is less soluble in lower-temperature joints 3]. In addition, joints with a history of repetitive trauma or osteoarthritis demonstrate a redilection for gouty arthritis. Infectious arthritis also can precipitate gout exacerbations. nitial attacks tend to be monoarticular, with later recurrences typically polyarticular in ature. Patients with an unclear etiology for gout may have a genetic predisposition toward ecreased uric acid excretion. Although seldom reported in the literature, gout can present fter total joint arthroplasty (TKA) as acute inflammation in the replaced joint [4-6]. Similar hysical examination and laboratory findings make differentiation from septic arthritis hallenging.

Poster 201: Rehabilitation and Osteopathic Manipulative Medicine for a Patient With Dysphagia Secondary to a Hyoid Somatic Dysfunction: A Case Report

explorative hip surgery, reviewed and treated him unsuccessfully. Given the family’s frustration and fear of an unnecessary operation they explored a fourth opinion at our hospital with a spine surgeon. A lumbar spine magnetic resonance imaging (MRI) study was organized and the patient was subsequently referred to our clinic. After a careful neurologic examination a radicular pattern of pain and weakness after the L5 distribution was discovered. The MRI demonstrated a large cyst extending posteriorly from the L4-5 disk. At first, it was difficult to ascertain the origin of the cyst, but with the assistance of a radiology consultation the cyst was confirmed to extend from the disk itself. Setting: Outpatient interventional physiatry clinic. Results: The L5 radicular symptoms were treated successfully with a transforaminal epidural corticosteroid injection. The patient was able to return to sport and is currently being followed up with serial MRI studies to determine the rate and extent of disk resorption in the adolescent spine. Discussion: To our knowledge, there are only a handful of case reports with radicular symptoms secondary to diskal cyst. Furthermore, none of these have been described in the adolescent population. It is important to consider lumbar etiology for hip and lower extremity pain in young patients. This etiology can be easily missed leading to inappropriate therapies and interventions, which can be time consuming, costly, and detrimental. Conclusions: Diskal cysts are rare, particularly in the adolescent population. They can contribute to extensive radicular symptoms. It is important to consider an appropriate trial of conservative management, especially in the young population.

Poster 208: Bilateral Intratendinous Osseous Bodies in Triceps from Repetitive Work Related Vibration: A Case Report

Disclosures: Gerard Limerick: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient presented with chronic right arm pain and decreased range of motion in both elbows (right greater than left) for the last 10 years. The elbows were tender to palpation, with no associated erythema, edema or warmth. Setting: University Hospital Outpatient Clinic Results: The patient was sent for bilateral elbow x rays that demonstrated large single osteochondral bodies posterior to the distal humerus measuring 1.7 cm on the right and 1.4 cm on the left. Diagnostic ultrasound was used to better define these calcifications with relation to the surrounding tissues and demonstrated that the right osteochondral body was 1.4 cm L 1.2 cm W and 3.55 cm proximal to the olecranon while the left osteochondral body was 1.7 cm L 1.33 cm W and 5.37 cm proximal to the olecranon. The patient was sent for a right elbow MRI, as part of further evaluation. However, it could not be completed as the patient was claustrophobic. Discussion: Osseous bodies are typically formed in intra-articular spaces following disruption to the articular surface. This disruption may occur as the result of direct/indirect trauma, or chronic disease processes such as osteoarthritis, Charcot’s disease or synovial chondromatosis. In the case of this patient, the osseous bodies were identified within the muscle fibers, rather than the joint space. Years of repetitive subclinical trauma from the jackhammer vibrations, as opposed to a single inciting event or a classic disease process, likely spurred the development of these bodies. Conclusions: Osseous bodies are usually found in joint spaces where they cause symptoms of pain and reduced range of motion. However, long-term subclinical trauma can cause these bodies to occur within the tendinous structures where they can cause a similar syndrome. Level of Evidence: Level V

Poster 338: Left Buttock Pain Successfully Treated with Ultrasound Guided Cluneal Nerve Medial Branch Block: A Case Report

Case/Program Description: Three cases of cancer related unilateral lower extremity pain treated with cordotomy: two women with metastatic breast cancer (57 and 63 years old) and a 52-year-old woman with vulvar cancer. All three patients suffered significant unilateral leg pain related to metastatic disease. Conservative management with systemic opioid therapy, adjuvant medications provided suboptimal relief. Furthermore, interventional management with a variety of nerve blocks, bursal and intra-articular injections were performed without sustained benefit. Therefore, more advanced procedural interventions were considered and after careful review of the risks and benefits, percutaneous radiofrequency cordotomy was selected. Setting: Comprehensive Cancer Center Results: In each case, the result of the cordotomy procedure was remarkable. The patients reported near resolution of the lower extremity pain. Two of the patients did complain of residual paresthesia, a well-known undesirable side effect of cordotomy. Interestingly, all three patients continue to report significant improvement in pain (as far as 16 months post-procedure) compared to baseline. Discussion: Percutaneous radiofrequency cervical cordotomy can be effective for the treatment of refractory cancer pain. It is performed under image guidance, usually computed tomography, and a needle is placed upper cervical spine (C1-C2 interspace, contralateral to site of pain) at the anterolateral quadrant spinal cord, targeting the lateral spinothalamic fibers which transmit pain and temperature. Using appropriate myelographic confirmation, impedance measurement, and sensory-motor dissociation testing, radiofrequency thermocoagulation is performed. The reported complication rates are low (<1%) when the appropriate technique is utilized. Most commonly, patients complain of headache or transient dysesthesia after the procedure. Although the efficacy for cordotomy has been demonstrated in at least two large studies, optimal patient selection continues to be an area of ongoing study. Conclusions: Cordotomy is both a safe and effective intervention worth considering for relieving pain in select oncologic patients with unremitting, cancer-related pain unresponsive to aggressive pharmacologic analgesic management. Level of Evidence: Level V

Poster 432: An Unusual Presentation of Cervical Paraspinal Denervation Resulting in Neck Drop: A Case Report

Case/Program Description: A 58-year-old man who suffered a stroke 4 years ago (resulted in mild right hemiparesis with eventual resolution of deficits) presented to his PCP with right lower extremity pain of 1 year duration. Given the patient’s history of uncontrolled diabetes (A1c 13%), he was initially treated for diabetic neuropathy and given gabapentin 300mg TID. Despite this, the patient’s pain was unabated. He had 5/5 strength in his bilateral lower extremities and only mildly decreased sensation on the bottom of his feet; however, he complained of severe, intermittent, sharp, shooting pain down his right leg to the foot. A lumbar spine MRI revealed minimal neural foraminal narrowing from L3-S1 bilaterally. A subsequent NCS/EMG revealed mild slowing of right peroneal, tibial and sural nerves, as well as mildly enlarged MUAPs with reduced recruitment in right L5 innervated muscles. Patient was determined to have chronic mild right L5 radiculopathy and his gabapentin was increased to 600mg TID with only minimal improvement. While obtaining the patient’s history in our clinic, he mentioned that cold temperature produced severe pain in his right foot. On examination, he had allodynia (became tearful upon assessing sensation in right foot), but did not have asymmetric changes in skin color, temperature or hidrosis. Although brain MRI from 4 years ago was unavailable, repeat brain MRI revealed chronic lacunar infarcts in bilateral thalami. Setting: Outpatient PM&R Clinic. Results: The patient was treated with amitriptyline (titrated up to 100 mg daily) for presumed central post-stroke pain with significant pain relief. Discussion: This case highlights the consideration of central poststroke pain in patients with severe and not otherwise well-explained pain status post stroke. Conclusions: Although it is helpful for patients to receive an explanation for their pain, there is no definitive cure for central post-stroke pain, and treatment with neuropathic agents can have a limited effect. Level of Evidence: Level V

Poster 197-E Hip Pain Secondary to Intramuscular Lipoma of Tensor Fascia Lata: A Case Report

Design: Data regarding purchase of new ultrasound devices in the southeastern United States was obtained from the leading ultrasound device manufacturer, Sonosite Fujifilm, during the period of January 2014 to December 2015. We included outpatient musculoskeletal practices in the southeastern United States, specifically covering the states of Georgia, Alabama, Florida, and South Carolina. Hospitals and inpatient services were excluded, as was the purchase of used ultrasound devices. Data were collected from the practices on whether they had received manufacturer training, loaned a device, or were trained in ultrasound during residency, fellowship, or in a prior job. Setting: Primary investigators all from academic setting. Participants: Fifty-two outpatient musculoskeletal practices were included in this study. Interventions: Not applicable. Main Outcome Measures: Percentage of musculoskeletal practice which received manufacturer training, loaned a device, or were trained in ultrasound during residency, fellowship, or in a prior job. Results: Thirty-six devices (61%) were bought by practices where the physicians were trained to use ultrasound during residency, fellowship, or a prior job. Ten devices (17%) were bought by practices where the manufacturer trained physicians, and 7 of these devices were also loaned to the practices after training. Fifteen devices (25%) were bought by practices where the physicians had no prior training with ultrasound nor loaned a device before purchase. Only 12% of practices loaned a device before purchase, and this was not associated with an increased likelihood of purchasing an ultrasound device (P>.05). Conclusions: Our data suggest that ultrasound training during residency, fellowship, or a prior job is more strongly associated with the purchase of new ultrasound devices in outpatient musculoskeletal clinics than other factors, including training by the manufacturer or loaning the device. Thus, earlier exposure to ultrasound seems to promote continued use of ultrasound later in a physiatrist’s career. Level of Evidence: Level III

Thoracic Epidural Varices: A Rare Cause of Nocturnal Back Pain: A Case Report

improved to 4-/5 (baseline 5/5), but right shoulder adhesive capsulitis developed. Ambulation was supported with straight cane (no assistive device at baseline). Discussion: The incidence of spinal cord injection during ESI is unknown and the results can be devastating. Extremity weakness is a complication, but facial symptoms have not been reported. CN V spinal nucleus extends from the medulla to the mid cervical spinal cord and communicates with CNXI. We propose that cranial neuropathies must be considered as a possible risk during IC-ESI. Conclusions: We describe the first reported case of trigeminal and accessory nerve injury after IC-ESI.

Isolated Tibial Neuropraxia after Total Hip Arthroplasty Revision: A Case Report

Results or Clinical Course: CT of the cervical and thoracic spine revealed mild to moderate spondylosis, which did not account for his current symptoms. The patient had multiple neurology evaluations, eventually confirming the bibrachial presentation of amyotrophic lateral sclerosis. He continues to be followed by the PM&R service for ongoing rehab and equipment needs. Discussion: Bibrachial ALS is an atypical variant of ALS. It represents about 10% of all ALS, presenting with upper extremity weakness and predominates in men. Although clinically it can mimic cervical spondylosis, electrodiagnostic testing can be used to determine this as motor neuron disease. Conclusions: Bibrachial ALS is a rare but important diagnosis to consider in patients presenting with upper extremity weakness.

True Arterial Thoracic Outlet Syndrome in a High School Baseball Pitcher: A Case Report

Case Description: 73 symptomatic knee osteoarthritis (OA) patients participating in the multidisciplinary OA management program were evaluated for all potential local and systemic risk factors associated with the progression of knee OA. This included a dynamic assessment of local knee mechanical factors during treadmill walking. 3D knee kinematic data were captured using a knee functional assessment device. Presence of mechanical OA risk factors was identified such as varus thrust and increased internal tibial rotation. Physicians were given a copy of the dynamic assessment report and option to include data in the clinical decision-making process to personalize the treatment. Setting: Knee assessment clinic affiliated with multidisciplinary orthopaedic and sport medicine practices and physical therapy center. Results or Clinical Course: At the initial clinical investigation, physicians only identified static alignment risk factors (standing frontal plane alignment, knee flexum), but did not note any dynamic mechanical deficiencies such as varus thrust, flexum or increased internal tibial rotation. After reviewing the dynamic mechanical reports, physicians concluded that 32 knees in 25 patients exhibited significant varus thrust (range 2.5 to 5.1 ). For all these 25 patients, adjustments were made to their treatment plan based on the dynamic data. Furthermore, 3D dynamic knee alignment had a direct correlation to the affected knee compartment in 85% of the cases, for which the physicians prescribed more targeted therapies based on the identified dynamic deficiencies. Discussion: Dynamic assessment of mechanical factors allowed objective quantification of kinematic factors known to be involved in the progression of OA and to better personalize the treatment plan. This methodology is also transferable to other knee pathologies such as patellofemoral pain syndrome and tendonitis. Conclusions: Dynamic mechanical assessment of the knee and resulting objective data help improve therapeutic decision-making process and patient care by giving novel clinical information not easily seen during clinical assessment.

Poster 209: The Other White Coat Syndrome: Somatic Dysfunctions in Medical Students Wearing White Coats (A Case Series)

ROM, ADLs, and ambulation. Discussion: This is a case of severe and rapid onset of extraintestinal manifestations of Crohn disease not diagnosed until her rehabilitation admission. In a patient previously independent in ADLs and ambulation, this case demonstrates unusually rapid functional decline that may have been mitigated with earlier physiatric intervention. Conclusions: Physiatrists must have a high index of suspicion for potentially debilitating outcomes when encountering patients with Crohn disease accompanied by musculoskeletal complaints. Early diagnosis and treatment are essential in preventing joint deformity and destruction, and preserving maximal function.