Victor Ibrahim

A Call for a Standard Classification System for Future Biologic Research: The Rationale for New PRP Nomenclature

Autologous cell therapies including platelet‐rich plasma (PRP) and bone marrow concentrate (BMC) are increasingly popular options for soft tissue and joint‐related diseases. Despite increased clinical application, conflicting research has been published regarding the efficacy of PRP, and few clinical publications pertaining to BMC are available. Preparations of PRP (and BMC) can vary in many areas, including platelet concentration, number of white blood cells, presence or absence of red blood cells, and activation status of the preparation. The potential effect of PRP characteristics on PRP efficacy is often not well understood by the treating clinician, and PRP characteristics, as well as the volume of PRP delivered, are unfortunately not included in the methods of many published research articles. It is essential to establish a standard reporting system for PRP that facilitates communication and the interpretation and synthesis of scientific investigations. Herein, the authors propose a new PRP classification system reflecting important PRP characteristics based on contemporary literature and recommend adoption of minimal standards for PRP reporting in scientific investigations. Widespread adoption of these recommendations will facilitate interpretation and comparison of clinical studies and promote scientifically based progress in the field of regenerative medicine.

Platelet-Rich Plasma as a Nonsurgical Treatment Option for Osteonecrosis

Avascular necrosis (AVN) is a progressive condition characterized by bone tissue cell death as a result of ischemia, which is most often seen in weight‐bearing joints. The traditional treatment of this disease process in the hip includes surgical decompression and joint replacement. This case report describes a novel nonsurgical approach for treating advanced‐stage degenerative AVN of the hip with the use of autologous platelet‐rich plasma. The patient demonstrated significant functional improvements after this intervention without the need for further treatment except for physical therapy. The report suggests the potential utility of platelet‐rich plasma for the treatment of degenerative AVN.

Advanced Knee Osteoarthritis in an Active Male: Biologics or Total Knee Replacement

A healthy 54-year-old man presents to your office for your opinion regarding his progressively worsening right knee pain. At age 24, he underwent a primary anterior cruciate ligament reconstruction as a result of a skiing injury. He subsequently has had 2 arthroscopic surgeries, the first a partial resection undergone 15 years ago for a degenerative tear, followed 5 years later by a complete medial meniscus resection. His pain now interferes with his ability to complete a full round of golf, and he does not want to resort to using a cart. During the previous 2 years, he has tried a variety of treatments, including nonsteroidal anti-inflammatory medications, physical therapy with home exercises, unloader and patellar bracing, 2 corticosteroid injections, and 2 hyaluronic acid injections. He has experienced some temporary relief, but none of these treatments have allowed him to fully engage in golfing. Knee radiographs demonstrate Kellgren-Lawrence Grade 3 osteoarthritis, predominately affecting the medial compartment, but there is tricompartmental involvement. He consulted with an orthopedic surgeon, who recommended a total knee replacement (TKR). A second physician suggested he try stem cell therapy for osteoarthritis. He would like to re-engage in golfing and even skiing, and he seeks your advice regarding whether the total knee replacement (TKR) or stem cell treatment would provide the optimal treatment for his knee pain and function. Dr. Wayne Colizza will argue that a TKR will offer the best possible outcomes. Dr. Victor Ibrahim will argue that stem cell therapy is a viable treatment option for this patient.

Poster 127 Brachial Artery Pseudoaneurysm Contributing to Nerve Symptoms in the Hand: A Case Report

reflexes and upper motor neuron tests were normal. Setting: County public hospital, PM&R EMG Clinic. Results or Clinical Course: Motor nerve conduction studies (NCS) of the median and ulnar nerves demonstrated significantly decreased amplitudes, prolonged distal latencies, and decreased conduction velocities bilaterally, right side more affected than left. Sensory NCS of the median and ulnar nerves and lower extremity NCS were normal. Needle electromyography (EMG) of the bilateral upper extremity revealed signs of early reinnervation in all muscles (polyphasic motor units, slightly increased amplitude, and reduced recruitment) in addition to ongoing denervation in distal muscles. Proximally, it revealed reinnervation featuring polyphasia with decreased recruitment. The findings were consistent with multilevel, bilateral cervical radiculopathy. The patient was referred for magnetic resonance imaging (MRI) of the spine which showed extensive cervical and thoracic syringohydromyelia with enlargement of the spinal cord and small, ribbonlike spinal cord tissue remaining along the periphery of the cavity. Discussion: The clinical and EDx findings in this patient are consistent with those found in patients with syringomyelia. These findings include decreased compound muscle action potential amplitudes and normal sensory nerve action potentials on NCS. EMG findings include spontaneous activity such as fibrillations and positive sharp waves. However, these abnormalities are also found in motor neuron disease, poliomyelitis, and radiculopathy. MRI is an important tool to distinguish syringomyelia from these other conditions. Conclusions: This case report illustrates the role of EDx in diagnosing syringomyelia in a patient who presented with bilateral hand weakness and numbness with no other symptoms of spinal cord involvement.

Poster 228 Ultrasound-Guided Injection of Platelet Rich Plasma in a Degenerative Meniscal Tear: A Case Report

crucial. Abnormal results on common screening tests (24-hour urinary cortisol excretion, overnight dexamethasone suppression test, and late night saliva cortisol level) should prompt referral to an endocrinologist. Conclusions: Back and joint pain is a frequent presenting complaint in PM&R clinics. It is important for physiatrists to consider Cushing’s disease in patients with osteoporotic fractures or recurrent stress fractures without known secondary causes of osteoporosis and a suggestive clinical picture. Although Cushing’s disease is rare, it is a treatable condition. Screening of Cushing’s disease is relatively easy and inexpensive. Early diagnosis can prevent the significant morbidity and mortality associated with delay in diagnosis.

Poster 162 Sonographically Assisted Diagnosis of Left Rectus Femoris Tendon Tear in a Patient with a Total Knee Arthroplasty: A Case Report

Childhood Experience (ACE) Module asks about abuse (physical, sexual, emotional) and family dysfunction (exposure to domestic violence, living with mentally ill, substance abusing, or incarcerated family member). Setting: Six U.S. States: Arkansas, Louisiana, New Mexico, Tennessee, Washington, Wisconsin. Participants: Community-dwelling adults ages 18 (n 30,059). Interventions: Not Applicable. Main Outcome Measures: Self-reported musculoskeletal (MSK) disorder prevalence; MSK-disorderrelated disability measured as: activity limitations, work and social participation restrictions. Results: The prevalence of any ACE was 59% and of 4 ACEs was 15%. The age-adjusted MSK-disorder prevalence increased from 21% for those with no ACEs to 36% for those with 4 ACEs. In those with MSK-disorders (n 9354), the percent reporting activity limitations increased from 46% (no ACEs) to 59% (4 ACEs.). The percent reporting work and social restrictions increased from 25% (no ACEs) to 44% (4 ACEs) and from 40% (no ACEs) to 57% (4 ACEs) respectively. In logistic regression analyses adjusting for demographic factors (sex, age, education, marital status, income), those reporting 1, 2, 3, and 4 ACEs had an increased OR (95% confidence interval) of MSK disorders of 1.14 (1.05-1.24), 1.53 (1.33-1.76), 1.84 (1.58-2.13), 2.43 (2.15-2.74) respectively, compared to those reporting no ACEs. Those with MSK-disorders and 4 ACEs also had an increased adjusted odds of MSK-related activity limitations [1.6 (1.4-2.0)], work [1.9 (1.5-2.4)] and social [1.6 (1.3-2.0)] participation restrictions compared to those with no ACEs. Conclusions: Adverse childhood experiences have a graded effect on musculoskeletal disorder prevalence and also magnify the disability associated with these disorders. A better understanding of this link will help physicians improve functioning in those affected by childhood adversity and musculoskeletal disorders.

Poster 325 Use of Platelet-rich Plasma for Nonoperative Management of Bicipital Tendinopathy in Spinal Cord Injury: A Case Series

times during the examination due to severe pain in the lateral neck. Physical examination results revealed minimal pain reproduction with opening and closing the mouth. The musculoskeletal and neurologic examination of the head, neck, and upper extremities, as well as HEENT examination, were unremarkable. Magnetic resonance imaging of the brain and cervical spine with and without contrast revealed no space-occupying or demyelinating lesions, normal-appearing spinal cord, and mild degenerative changes within the cervical spine. Electromyography revealed no evidence of left superior or recurrent laryngeal mononeuropathy, left spinal accessory or left C2-3 neuropathy. Laboratory tests, including complete blood cell count, complete metabolic profile, thyroid stimulating hormone, hemoglobin A1c, lyme titer, vitamin B12, and methylmalonic acid, were normal. Setting: Tertiary care hospital. Results: The patient was diagnosed with left glossopharyngeal neuralgia (GN) based on the above history, clinical examination, and workup. Symptoms have improved with the initiation and titration of carbamazepine and baclofen. Magnetic resonance imaging FIESTA and evaluation for surgical decompression are pending and will be discussed. Discussion: This case report presents a case of GN, a rare pain syndrome, presenting as lateral neck pain. Pain from GN is typically felt around the base of tongue, throat, ears, jaw, and/or larynx. GN primarily affects the elderly and occurs more often in men. Conclusions: Cranial neuralgias should be considered in the differential for atypical neck pain.

Poster 207 Effectiveness of Tenotomy With Platelet-rich Plasma Seeding in a Biceps Tendon Tear Under Ultrasound Guidance. A Case Report

knee amputation (AKA). Program Description: The patient was involved in a motorcycle accident in which she sustained a pelvic ring fracture, an unstable left femoral neck fracture, and a left AKA. The patient underwent a hemiarthroplasty to repair the femoral neck fracture. However, she subsequently developed left hip septic arthritis which necessitated a resection arthroplasty with excision of the femoral head and neck (ie, Girdlestone arthroplasty) to eradicate the infection. Setting: Prosthetic clinic. Results: The patient currently wears an above knee prosthesis 6-10 hours daily and ambulates pain free while using a single-point cane. The components of the AKA prosthesis include a microprocessor knee to aid with stability, a dynamic response heel-height adjustable foot with a soft heel and firm toe, and a umbrella liner suspension system. Discussion: We were not able to find a case in the literature that describes a patient who had undergone a Girdlestone arthroplasty and an AKA, and been able to ambulate with an above knee prosthesis. This procedure has been fairly beneficial in eradicating septic arthritis after total hip arthroplasty, improving pain after infection, aseptic component loosening, and several additional very specific indications. Ambulation after this procedure is generally difficult due to shortening, with a resultant leg-length discrepancy that has been documented as up to 10 cm. Patients who have undergone bilateral procedures have done relatively well by using double supports because their leg length discrepancy is less than patients undergoing a unilateral procedure. In this case, the height of the patient’s AKA prosthesis was adjusted to accommodate the leg-length discrepancy. Conclusions: A Girdlestone arthroplasty does not preclude ambulation after an AKA and may help decrease the effect of a known procedural complicating factor, leg-length discrepancy.

Poster 232 Ultrasound-guided Diagnosis of Tophaceous Gout Mimicking Rheumatoid Arthritis: A Case Report

Disclosures: M. Skeels, none. Patients or Programs: A healthy 21-year-old right-hand dominant man. Program Description: The patient was attempting to perform an iron cross, which is a gymnastic maneuver in which someone holds onto the still rings with the arms extended away from the body. After a month of attempting this move, he noticed that he was no longer able to adduct the fifth digit of his right hand. He was not aware of any trauma or inciting incident. He had no any sensory loss or paresthesias of his hand. Setting: An outpatient clinic. Results: The patient was a healthy 6 ft 1 in., 170 lb man with normal gross appearance of his right hand. Light touch sensation and 2-point discrimination were intact in the ulnar, median, and radial nerve distributions of the right hand. The patient had a positive Wartenberg sign, negative Froment sign, no clawing of the hand, and other than adduction of the fifth digit; the muscle strength of his hand demonstrated no weakness. The flexor and extensor tendons were intact, there was no instability at the wrist, and he had full range of motion of his wrist and fingers. Electrodiagnostic testing revealed increased latency and decreased amplitude to the first dorsal interosseous muscle on motor nerve conduction testing and motor unit loss on needle electromyography. Magnetic resonance imaging revealed contusion or compression, with soft-tissue swelling surrounding the ulnar nerve at the hamate hook, with the nerve signal slightly edematous, without enlargement or disruption of the ulnar nerve. The patient was treated with rest and discontinuation of provoking activity, and his symptoms resolved after 1 month. Discussion: This is the first case report of ulnar neuropathy at the wrist that was caused by attempting to perform the gymnastic maneuver of the iron cross. Conclusions: The case represents an unusual cause of ulnar neuropathy at the wrist.