Vertebral Endplate

A great review of vertebral endplate
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16816945#CR15

Introduction and conclusion From Bone. 2009 Feb;44(2):372-9. Epub 2008 Nov 11

The cranial endplate of thoracolumbar vertebrae is injured more often than the caudal [1], [2], [3], [4], [5] and [6], and anterior wedge fractures in elderly patients usually involve the cranial rather than caudal endplate [7] and [8]. Schmorl's nodes, which represent a bony reaction to endplate defects, are also more common in the cranial endplate [4]. Mechanical experiments on cadaveric spines suggest that the cranial endplate is more vulnerable to compressive damage than either the caudal endplate or the intervertebral disc [9], and indentation experiments on isolated endplates suggest that cranial are weaker than caudal [10] even though there is little difference in their bone density [11]. These curious facts have been reported, but not explained. Cranial and caudal endplates of adjacent vertebrae are subjected to the same compressive loading by the intervertebral disc that lies between them, and cranial endplates tend to fail in-vitro even if specimens are tested upside down [9]. Therefore this asymmetry in fracture pattern suggests an underlying structural asymmetry in the vertebrae.

In the human thoracolumbar spine, pedicles join the vertebral body at above mid-height. Bone mineral density (BMD) is higher in the pedicles than in the vertebral body [1], and trabecular arcades from the pedicles appear to reinforce the lower endplates more than the upper, at least at some spinal levels [12]. However, the neural arch largely resists axial rotation [13] and [14] and shear [15] B.M. Cyron and W.C. Hutton, Articular tropism and stability of the lumbar spine, Spine 5 (2) (1980), pp. 168–172. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (35)[15] acting on the spine, and there is no obvious reason why trabeculae from the neural arch should be deployed to enhance the compressive strength of the vertebral body.

Structural asymmetry may lie in the endplate itself rather than in its trabecular support. A vertebral endplate consists of perforated cortical bone with a layer of hyaline cartilage bonded to its disc surface. The cortical bone layer contains a radiating anastomosing network of small marrow cavities [16] which allow bone marrow to lie adjacent to calcified hyaline cartilage for approximately 10% of the central endplate area [17], and this is widely regarded as an important route for metabolite transport into the avascular intervertebral discs [18]. Certainly, calcification and blocking of the endplate route is associated with disc degeneration [6] and [19]. It seems reasonable to suppose that the nutritional demands of the discs, which are the largest avascular structures in the body, ensure that vertebral endplates are as thin and porous as possible. This may explain why endplate fracture is so common, but it does not explain why cranial endplates should be more vulnerable than caudal.

This is an important clinical problem because endplate fractures and Schmorl's nodes are associated with back pain [20], [21] and [22], even though both lesions often go unidentified so that the scale of the problem may be underestimated [21], [23], [24], [25] and [26]. Typical recovery periods from acute episodes of back pain are consistent with bony injury, as are the protective and accelerated recovery effects of exercise [27] and [28]. Endplate fracture may cause chronic as well as acute back pain because it can lead to disc degeneration, both in humans [29] and [30] and in experimental animals [31]. In elderly people, damage to vertebral endplates and their supporting trabeculae is so common [23] that it largely explains why old endplates develop a concave deformity facing the disc [32]. Damaged endplates decompress the nucleus pulposus of the disc [33] and [34], lead to abnormally-high load-bearing by the annulus fibrosus and neural arch [33] and [34], and probably contribute to pain and disability in patients with senile kyphosis [35]. A greater understanding of the factors that contribute to the increased fragility of the cranial endplate may help to reduce the risk of injury, and to optimise treatments such as vertebroplasty.
...

Vertebral compressive failure usually affects the cranial endplate because it is thinner and supported by less-dense trabecular bone. This relative weakness may reflect the fact that most spinal compression arises from muscle tension [37], which is transmitted to the vertebral body via the pedicles. This causes compressive loading to increase down the spine in stepwise fashion, at the level of each pedicle. Each cranial endplate is compressed by the disc above it, whereas the caudal endplate of the same vertebra is also compressed by muscles attached to its pedicles. Hence the structural asymmetry. Unfortunately, this fine match between loading and strength is lost if the spine is compressed by external forces, such as in a fall on the buttocks with the spine flexed, because then the same force passes through both endplates, damaging the weaker (cranial) one. This could explain the preponderance of cranial endplate fractures in the present experiment, where the same compressive force passed through both endplates. It could also explain their preponderance in life, because falls contribute greatly to vertebral fractures [55].

Reduced thickness and density in the central regions of vertebral endplates (Fig. 6) may reflect the precarious supply of nutrients to the adjacent intervertebral discs. Discs rely on the thinness and porosity of endplates for the transportation of metabolites from blood vessels within the vertebral body [18] J.P. Urban, S. Smith and J.C. Fairbank, Nutrition of the intervertebral disc, Spine 29 (23) (2004), pp. 2700–2709. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (57)[18], and nutritional demands are greatest in the disc nucleus [18]. Impairment of this supply is associated with disc degeneration [19] and [56]. Cranial endplates may not thicken in lumbar vertebrae (as caudal endplates do) as a concession to the nutritional demands of the largest discs. Cranial endplates could possibly be singled out for this “sacrifice” because of asymmetries in blood supply to the vertebral bodies although information on this is lacking. Low optical density in the central endplate probably represents a greater concentration of marrow contact channels in the region which is known to be most porous [39]. In the cervical spine, where discs are thinner and have less acute metabolite transport problems, cranial and caudal endplates are equally thick [57].

The apparent weakness of endplates compared to intervertebral discs may have carried little evolutionary disadvantage when average lifespans were short. Longevity in modern humans exaggerates sarcopaenia and osteopaenia, which appear to reduce vertebral strength more than disc strength [58]. Longevity also increases disc degeneration which intensifies focal loading on vertebral endplates [52] and may facilitate fracture. The need to resist focal loading from degenerated discs may explain why BMD in older spines is greater in trabecular bone adjacent to the endplates compared to central regions of the vertebral body [59] and why BMD is greater in the posterior vertebral body, opposite the high stress concentrations which are commonly found in the posterior annulus of the disc [46].

Shoe inserts and PFS

1. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

2. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: A randomised clinical trial
3. http://d-med.com/orthaheel/Knee_Pain.html#

• secrets of medical success: this was a great set of advice that may seem obvious.
• Slower recovery after 2-incision surgery

Hyperdense bones can be the result of

• osteopetrosis
  
• hypervitaminosis D,
  
• hypoparathyroidism,
  
• myelofibrosis,
  
• Paget disease,
  
• lead toxicity,
  
• diffuse skeletal metastasis of breast or prostate cancer,
  
• pseudohypoparathyroidism,
  
• fluoride toxicity,
  
• beryllium toxicity,
  
• sickle cell disease,
  
• leukemia.
  
• 1 case report describes abnormal bone modeling and increased bone density, with histologic features of drug-induced osteopetrosis, in a 12-year-old boy treated with bisphosphonates.

Completely unrelated to medicine are
hulk vs wolverine
chevelle
folliculitis (eeewwww)

Uhthoff's phenomenon

Thanks to dr. patel for pointing this out.

C7 to Flexor Carpi Ulnaris?

According to Dumitru, there are two "communicating branches" in the majority of brachial plexi. One of them is a connection between the medial and lateral pectoral nerves. The second is referred to as "lateral root of the ulnar nerve" which is present in 43 to 92% of brachial plexus dissections. This suggests that it is not an anomaly but a major portion of the brachial plexus ignored in standard descriptions. This arises from the lateral cord, communicates with the medial branch of the medial cord to the median nerve, and the continuation of this connection to the ulnar nerve itself. This is an explanation for the contribution from C7 to the ulnar.

NESS L300

Effects of a New Radio Frequency–Controlled Neuroprosthesis on Gait Symmetry and Rhythmicity in Patients with Chronic Hemiparesis

Claimed to have improved gait rhythm and symmetry over 5 years after the stroke. Could be effective for our patients?

Primary Arthroscopic Stabilization for a First-Time Anterior Dislocation of the Shoulder

"Following a first-time anterior dislocation of the shoulder, there is a marked treatment benefit from primary arthroscopic repair of a Bankart lesion, which is distinct from the so-called background therapeutic effect of the arthroscopic examination and lavage of the joint. However, primary repair does not appear to confer a functional benefit to patients with a stable shoulder at two years after the dislocation."

Bisphosphonate Therapy Linked to Risk for Severe Musculoskeletal Pain

January 8, 2008 — Temporary or permanent discontinuation of bisphosphonate therapy should be considered in patients who present with severe musculoskeletal pain, the US Food and Drug Administration (FDA) warned healthcare professionals yesterday. Overlooking bisphosphonate therapy as a causal factor may delay diagnosis, thereby prolonging pain and/or impairment and the use of analgesics. In contrast with the acute-phase response that sometimes accompanies initial exposure to bisphosphonate therapy, some patients experience severe and sometimes incapacitating bone, joint, and/or muscle pain that begins months or years later.

Autoimmune effects of medications.

It's common medical knowledge that autoantibodies are associated with the use of certain medications. We memorize the small list of board relevant meds that cause lupus-like symptoms. More have been reported and they're common: minocycline, tnf alpha biologics, aromatase inhibitors, sulfasalazine and statins.

Although many patients develop autoantibodies, only a minority develop autoimmune-like diseases. The development of autoantibodies alone is not sufficient reason to discontinue the medication. Patients treated with medications such as tumor necrosis factor inhibitors and minocycline who develop an apparent 'flare' of the disease should be evaluated for the possibility of drug-related lupus. Rechallenge with minocycline might be useful in order to confirm a diagnosis of minocyclinerelated lupus. Clinical trial data indicate that patients who receive aromatase inhibitors can develop arthralgias and arthritis, although no data regarding the development of autoantibodies have been reported. Patients with pre-existing thyroid autoantibodies are more likely to develop autoimmune thyroid disease when treated with interferon-α than patients with no pre-existing condition.

Memories of Jim (Off topic)

It's now 1:30 a.m. on January 21, 2008. I received two phone calls from my buddy Gary. I missed both of them. Maybe it was fortunate. The voicemail said that Jim McLean had passed this weekend during the snowboarding accident in Colorado. I saw that Jim's brother Justin had also left a message so I called him back. I actually started to get just a slight bit of emotion coming through my voice. I told him that I would be available at any time to help the family and to pass on the information to his residents and programs.

Jim and brother Justin. I came upstairs and replayed Gary's voicemail on speakerphone. Monica began sobbing loudly. I comforted her and then walked away so that I could talk Gary and clear my head. Gary sounded a little lost in his voice. It seemed he had all this emotion and intention but no clear outlet with which to produce something. We spoke in tones and inflections as if nothing had happened. But the content was clearly corrupted by the news we had just taken in. Gary had taken care of calling all of Jim’s co-residents etc. At this point he was trying to figure out how to pay tribute to Jim McLean as an outlet. I figured I would try to do the same.

Jim's residency-class picture. I first was aware of Jim during residency when he was approaching the insurance reps during our Kessler resident lunch hour. I heard him say that he lives in the same town as me and in no time we became study partners. He had become habituated to studying at Starbucks so I honored his request the first time. He was determined to read the Braddom textbook from cover to cover within his first year. He was working on understanding/memorizing the anatomy of the limbs. I was studying an article by Asa Wilbourne on radiculopathy. In order to understand something I have to be able to teach it, and he was soaking up every bit of what I was telling him. I think he was sold on the idea of studying with me and therefore respected my wishes to try studying at my parents house.

What really sealed the deal for our studying there, were the endless bountiful meals offered by my parents. Even they were impressed with the frequency and amplitude of portions ingested by Jim with a huge grin on his face. My parents used to love feeding him. It seemed to all of us that his gut was an inexhaustible infinite receptacle of food. His classmate Gary, was known to be a competitive eater in his pre-medical life. It was widely accepted that everyone should get their food from the buffet table before Gary and Jim had a chance to deplete the resources. (I suppose he had to eat like a champ in order to do the training of a champ.)

Whatever we studied that first day in my basement, required that I printed out my notes. Jim found this to be a bit excessive and he did not hesitate to tell me so. I showed him the process that I went through and he was doubly sure that this was not something he was going to explore. To him, it just did not seem to justify the time spent. The next day he showed me what he had studied in a handout format. He had completely co-opted my style and was taking it to the next step. He went handout crazy after that and served as the source of positive competitive spirit for me.

He took in all of my advice but was very careful not to let any of the negative aspects of it slow him down. I remember being amazed at how diplomatically he could get me to do things without my knowledge of it at the time for example, it is well known that I am physically quite lazy. But somehow he got me to help him move out of his apartment with two other people who clearly were not averse to physical activity. I still can’t believe that happened in retrospect.

Jim and Sally at an event (photo by Casey ODonnell).

I remember one day when we were studying in my parents basement and he sat down at my drum kit. He started to play something that caught my attention. He had played percussion in his middle school band. I immediately saw the potential rock drummer in him. By treating rock drumming as a math problem, I was able to teach him enough to play a few songs at the program's graduation party. He attacked this task with the same intensity, drive, and comprehensiveness that he did everything else. No one could believe that he was holding his own on a stage with a bunch of musicians with years of experience.

Jim drumming at Kessler graduation (photo by Jenfu Cheng)

Jim was an excellent multitasker. He simultaneously participated in a number of potentially publishable research projects, trained for the Ironman competition, set up the Ironman as a fundraiser for children, worked on a curriculum to teach electrodiagnostic evaluation to residents, tutored medical students and still made the time to talk on the phone with friends, have a relaxed dinner with my family, and keep his dating life active. He somehow did all of this without spreading himself too thin. His reputation was so ingrained among the people who knew him that it was not uncommon to hear people say "Look, I'm no Jim McLean" when trying to imply that a specific task or number of tasks seemed potentially overwhelming.

I designed this cover for the last of many manuals/study guides created by Jim.
It's hard to explain to people outside our field what it means to be prolific
in this way. Most of us don't even read a full manual, let alone write more than one.

I remember one day that he rang my doorbell and was soaking wet. I remarked that I didn't realize how torrentially it must've been raining. He corrected me, told me it was beautiful outside, the dripping wetness was actually his perspiration after riding his bike from four towns over. He then laid down on my new microfiber sofa which now has a Jim McLean body sized discoloration where he had lain. J

Jim Mclean displaying an impressive hematoma after a biking accident
(ie sliding at god knows how many mph on a metal grate bridge).

He was truly fearless. To call him a gentle soul would be a mischaracterization. He had a gentle aura which contrasted his aggressive physique and assertive ambition. We had very different backgrounds and aesthetics yet he was able to see beyond those things when dealing with me. In that way I was able to gain a strong friendship in my life.

Jim and I were very close for two years. This is the kind of closeness that one rarely finds in adulthood... it's the kind that requires many hours a week spent in the same room, with the same goals, and the same urgency to achieve them. People knew this. One friend joked when he saw our new house "which of these is Jim's bedroom?" I enjoy the guilty vice of taunting my friends to the point of aggravation. Jim never let this get to him. There was only one time that I was really able to get under his skin but I can't count it as a victory because we later found out that he was severely hypoglycemic at that moment.

Happy smiling Jim AFTER the hypoglycemia was sated by
chocolatey goodness (yes, those are girlscouts cookies)
BEFORE it he was going to unleash on me
the wrath of his front headlock!

Right now I'm a little numb. It hit me very very hard when I heard of his passing but seconds later it was gone. His life was already packed with twice the experiences and accomplishments at the end of most people's lives. Despite this, there was so much more that Jim had left to give to the world. This is the definition of tragic. I'm really going to miss him.

2 noteworthy articles:

• Daily Record.com
  
• Video from Fox
  

Other Links to the Story:

• Link to first Local Newspaper Announcement in Rocky Mountain News
• Denverpost.com
• Kansas City.com
• Summit Daily
  
• Kansas.com
• NJ.com
• Denverpost.com
• KJCT8.com
• 9news.com
• thedenverchannel.com
• gazette.com
• vaildaily.com
• bnd.com
• gazetteoutthere.blogspot.com
• kake.com
• hdnews.net
• msnbc.msn.com
• ksn.com
• Kansas.com
  
• Rutgers
• Flow Wrestling
  

• In England they found advice and manual therapy or advice alone to be more cost effective than ultrasound (duh!)
• Hemiarthroplasty was found to have better outcome compared to internal fixation in 222 femoral neck fractured patients in Norway.
• Radial contrast-enhanced CT can detect acetabular labrum injury almost as well as MRI (confirmed by arthroscopy). So go ahead and use it when MRI is contraindicated.
• Vitamin D Deficiency in Residents of Academic Long-Term Care Facilities Despite Having Been Prescribed Vitamin D. Elovic and Heath reviewed the link between Vit D deficiency and musculoskeletal pain.

Shoulder adhesive Capsulitis

I wish I could read this article in its entirety. I can't tell if there is any appreciable benefit or not.
I'm going to need to review this at some point.

Random Stuff: Lasers, Vitamins, and worthless PT

Zoledronic acid
A bisphosphonate used for hypercalcemia of malignancy.
NEJM recommends infusion to improve morbidity and mortality after hip fracture.
Has a well established safety profile.

Meta Analysis of Ca Vit D to prevent fractures and bone loss in age 50 and over:
"Evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, in the preventive treatment of osteoporosis in people aged 50 years or older. For best therapeutic effect, we recommend minimum doses of 1200 mg of calcium, and 800 IU of vitamin D (for combined calcium plus vitamin D supplementation).

"Vitamin C reduces the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended."
Vitamin C reduces lipid peroxidation, scavenges hydroxyl radicals, protects the capillary endothelium, and inhibits vascular permeability. They assert that Complex regional pain syndrome type I or reflex sympathetic dystrophy which is treated symptomatically, and the clinical focus is on prevention. Major trauma can overwhelm homeostasis, lead to systemic inflammatory response syndrome and multiple-organ distress syndrome. This may parallel burn wounds and the development of CRPS because of the inflammatory reaction and the involved microangiopathy involving a cascade of deterioration and exaggeration of a similar process. High dose Vit C in early burn resuscitation has reportedly significantly reduced resuscitation fluid volume requirements, wound edema, severity of respiratory dysfunction, vascular permeability. This stuff reminds me of Jack's "molecular helmet."

Low level laser therapy for nonspecific low-back pain.6 reasonalbe quality RCTs showed some short-term and intermediate-term evidence of pain relief with LLLT, compared to sham therapy for subacute and chronic low-back pain. No difference disability and insufficient evidence for lumbar range of motion. Relapse rate was significantly lower than control.

Bracing after ACL reconstruction: "This study represents a systematic review of the Level I evidence (12 RCTs) to determine if appropriate evidence exists to support brace use. We found no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use..."

Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial: "As compared with no therapy, physiotherapy following first-time disc herniation operation is effective in the short-term. Because of the limited benefits of physiotherapy relative to "sham" therapy, it is open to question whether this treatment acts primarily physiologically in patients following first-time lumbar disc surgery, but psychological factors may contribute substantially to the benefits observed." This is quite a claim.

Jones Fx, RFA, Knee Bursae, Diabetic Amyotrophy

Jones Fracture is a frx at base of fifth metatarsal at metaphyseal-diaphyseal junction not to be confused with the much more common 5th metatarsal styloid avulsion, os peroneum, or stress fracture (chronic jones). Conservatively treat (if minimally displaced, is 3 months old, and radiographs show frx w/o evidence of non-union) with non-wt-bearing cast for 6-8 wks .

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Pes Anserine bursitis good ol emedicine does an okay job. They mention some of the 12 bursae i always talk about.
See my document about Knee Bursae

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Radiofrequency neurotomy for neck pain: an excellent study in N Engl J Med. 1996 Dec 5;335(23):1721-6. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. This paper tells you about the procedure as well.

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Diabetic Amyotrophy: One of the best reviews of this is the podcast with Dr. Dyck where he discusses his article "Diabetic and Nondiabetic Lumbosacral Radiculoplexus Neuropathies: New Insights into Pathophysiology and Ttreatment." Muscle & Nerve. 2002 Apr;25(4):477-91. It is a usually monophasic & unilateral lumbosacral radiculoplexus neuropathy associated with weight loss, begins focally with pain (excruciating in thigh, hip, buttocks muscles) but evolves into widespread, bilateral paralytic disorders. There may be prolonged pain and weakness leading to wheelchair-dependence. Nerve injury and microvasculitis seen (motor>autonomic and sensory ischemic injury). Immune-modulating therapies may be beneficial.

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Can you say Articularis Genus?

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Other Topics from Today

Parkinson's Disease:
Spinal Stenosis:
Spondylolisthesis:
Crossed Adductor Reflex:
Fibromyalgia
Proprioception
Sciatica vs. sciatic nerve injury vs. common peroneal nerve injury

Calcium and friggin Iron absorption

In an effort to understand a vegetarian family member's persistent anemia and osteopenia, i came to suspect that they could be inter-related. Nutrition was defiinitely an under-represented component in my training.

Calcium supplementation in clinical practice: a review of forms, doses, and indications.
"Most Americans do not meet the adequate intake (AI) for calcium; calcium supplements can help meet requirements...Calcium carbonate, the most cost-effective form, should be taken with a meal to ensure optimal absorption. Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine-2 blockers or protein-pump inhibitors...The maximum dose of elemental calcium that should be taken at a time is 500 mg. U.S. ..Absorption from calcium-fortified beverages varies and in general is not equal to that of milk...The risk of advanced and fatal prostate cancer has been associated with calcium intakes from food or supplements in amounts >1500 mg/d."

The inhibitory effect of dietary calcium on iron bioavailability: a cause for concern?"high intakes of dietary calcium can inhibit iron absorption if both are present in the same meal. The mechanism for the calcium-iron interaction is not known. A recent study has demonstrated that separating foods high in calcium from meals high in iron can prevent some of the calcium-induced inhibition of iron absorption."

Effect of tea and other dietary factors on iron absorption.
Several dietary factors can influence this absorption. Absorption enhancing factors are ascorbic acid and meat, fish and poultry; inhibiting factors are plant components in vegetables, tea and coffee (e.g., polyphenols, phytates), and calcium.

Pigmented Villonodular Synovitis

Recently a friend was diagnosed with PVNS as a cause of knee pain. It's a fascinating disease. I have compiled and plagerized some of my readings. References at the end.

• Epidemiology: Uncommon but not necessarily rare (1.8 cases per 1 million people per year). Affects synovial lined joints, bursae, and tendon sheaths. The knee is the most commonly affected joint, followed by the hip, ankle, small joints of the hands and feet, shoulder and elbow. more often in patients aged 20-50 years the knee (approximately 80%),usually is monoarticular. localized form occurs most frequently in the fingers—in particular, in the volar aspect of the first 3 fingers. It is the most common soft-tissue tumor of the hand.
  

• Etiology controversial, several theories based on histology (Localized lipid metabolic derangement, Repeated nontraumatic inflammation, A benign neoplastic process, A response to blood or blood products within the joint)
  

  "For unknown reasons, some or all of the synovial lining tissue of a joint occasionally undergoes a change and becomes diseased, wherein the joint lining tissue becomes thick and overgrown and accumulates a rust-colored, iron pigment known as hemosiderin. Strange, foamy cells and large (so-called "giant") cells with many nuclei also appear. The overgrowth of the joint lining tissue can occur diffusely throughout a joint by way of a generalized thickening of the entire lining membrane, or a localized area of synovial membrane can overgrow and form a discrete nodule (tissue mass) that remains attached to the rest of the internal joint lining by way of a stalk."ref

• 2 forms:
  
• Diffuse joint involvement: affects the entire synovial lining of a (typically involves the large joints) joint, bursa, or tendon sheath,
  
• The rare localized form of the disease usually has a female predominance and presents as a pain-free, slowly enlarging mass most frequently occurring on the flexor aspect of the fingers. rare focal localized form typically occurs around the small joints of the hands and feet. Often appears around tendon sheaths, in which case it is termed giant cell tumor of the tendon sheath. Rarely, the localized form may develop around large joints. (The term PVNS is used when the condition, in either diffuse or localized form, affects a joint.)
  

• History: insidious onset, slow progression, nonspecific presentation (Intermittent swelling and stiffness, diffuse discomfort rather than severe focal pain, usually not preceded by trauma, occasionally a "popping" sensation). The swelling is disproportionate to the degree of pain. Acute pain may occur with nodular torsion and/or infarction. Most common incorrect working diagnoses were patellofemoral syndrome and meniscal lesion (also inflammatory arthritis, ligament instability).

• Exam: 96% have distention of the suprapatellar pouch and a large warm tender effusion. 40% have a diffuse palpable synovial mass, one or more palpable nodules. Slightly decreased ability to flex and extend the joint. mild to moderate tenderness, mainly over the medial patellofemoral area. Arthrocentesis usually yields blood-tinged synovial fluid without preceding traum.


• Imaging: plays an important role in the diagnosis, treatment, and follow-up monitoring of the disorder.

• Xray is often normal and can not determine the extent of disease.
  
• may see effusion (Occasionally dense from hemosiderin).
• may see periarticular soft tissue density
• expansion of the suprapatellar pouch and patellofemoral osseous changes (abnormal tracking as synovial mass lifts/stretches extensor mech)
• sometimes osteopenia and secondary degenerative changes may occur later (concentric cartilage space narrowing, subchondral cyst, and osteophyte formation)
• Calcifications are NOT a usual feature. Rarely, foci of dystrophic calcification. Differentiating calcifications from hemosiderin-laden foci may be difficult on MRI, XRAY should be used in this setting to confirm or deny.
  
• Well-corticated pressure erosions (saucerization) and cysts may occur on either side or both sides of the joint.
• Nodular form most commonly results in localized swelling of the palmar aspect of a finger.
  
• Arthrography demonstrates multiple, irregular, nodular filling defects of variable sizes. These produce the typical cobblestone appearance of the synovium.
  
• bone scan is not very helpful. Hypervascularity and areas of erosion may result in increased radionuclide uptake. Soft-tissue masses often demonstrate increased uptake on blood-pool images.
• CT does not completely show extent of disease and other pathology around or within the joint. Useful for needle biopsy guidance and for preoperative planning. Findings invariably are diagnostic:
• lesions appear hyperdense due to the presence hemosiderin,
  
• valuable in delineating bone cysts and erosions.
• Affected synovium is hypervascular and generally enhances following administration of radiographic contrast.
  
• MRI is imaging modality of choice in the evaluation of synovial and soft-tissue lesions. Variable appearance, depending on relative composition proportions of hemosiderin, lipid, fibrous tissue, cyst formation, and cellular elements. MRI findings are diagnostic >95% of patients. Rarely, confused with synovial osteochondromatosis (xrays can help). MRI findings:
• nodular intra-articular masses Low signal intensity (T1-, T2-, and proton density) due to hemosiderin deposits within the affected tissue and is accentuated on T2.
• lipid-laden macrophages, resulting in focal regions of high T1 and intermediate T2.
• Hyperplastic and hypervascular synovium enhances with gadolinium.
• Bony erosions (when present) and extra-articular extension of the lesion are well demonstrated on MRI.

• 

• Differential Diagnosis: Osteoarthritis, Inflammatory arthritis, Rheumatoid arthritis, Psoriatic arthritis, tuberculosis, hemophilic arthropathy, synovial hemangioma, amyloid arthropathy, Systemic lupus erythematosus, Septic arthritis, Synovial chondromatosis, Pigmented villonodular synovitis, Benign or malignant bone tumor
• Definitive Diagnosis: synovial biopsy

• Pathology: Grossly, large effusions, bony erosions, proliferative hyperplastic synovium with brownish villonodular fronds. Two types of villi are present in the diffuse form of PVNS, including coarse villi with a "shag carpet" appearance, and fine or fernlike villi. The nodular component is seen predominantly in tendinous or extra-articular lesions. The nodules are well demarcated and may be sessile or pedunculated, although they lack a true capsule. Histologically, mononuclear/histiocytic infiltrate in fibrous stroma of synovial membrane Hemosiderin-laden macrophages give the characteristic brown color; also lipid-laden foam cells and multinucleated giant cells. Hemosiderin lends the tissue a characteristic pigmented appearance. The lesions tend to be hypervascular and demonstrate synovial hyperplasia.

• Treatment: Synovectomy. Curettage/bone grafting as necessary.. high rate of local recurrence. Synovectomy may not relieve all symptoms in patients with significant destructive changes in the joint. In these situations, arthrodesis or total joint replacement should be considered. Radiotherapy can be considered in patients with previous adequate resection of disease who experience local relapse and in patients with a large amount of disease in whom complete resection is not possible.(13 of 14 were disease-free at a mean follow-up period of 69 months).
  

"Clinicians should always keep in mind the possibility of PVNS when presented with a patient who is suffering from unexplained, recurrent fluid accumulations in one of their joints, especially when the joint fluid has a slightly more orange-brown color to it than normal." ref

References:

1. Emedicine
2. AAFP
3. Kneeandshoulder
4. Interesting patient experiences

Most Patients Prefer Their Physicians to Greet Them With a Handshake and Introduction

Arch Intern Med. 2007;167:1172-1176.

"Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior," the authors write. "Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names. Greetings create a first impression that may extend far beyond what is conventionally seen as 'bedside manner.'"...More women than men and African Americans than whites preferred that the physicians use both first and last names when introducing him or herself...Other physician characteristics of value to patients interviewed by telephone included smiling, being friendly, being warm and respectful, and being attentive and calm.

Intervertebral Disk Transplantation Shows Promise in Spine Disease

Lancet. 2007;369:993-999, 968-967.

March 22, 2007 — Preliminary experience in 5 patients with degenerative spine disease suggests that transplantation of fresh-frozen intervertebral disks preserved motion and stability of the spinal unit, despite some signs of mild degeneration in the disks over follow-up. Neurologic symptoms in all patients were also improved compared with before-surgery levels...The authors report that by the end of 3 months after surgery, good union of the graft end plates was seen in all patients...One patient with incomplete paraplegia caused by trauma, for example, improved to Frankel Grade D at final follow-up, from Grade B prior to surgery....No patient had any signs of immunoreaction to the graft. There was no olisthesis, but some mild degenerative changes were seen in the transplanted disks, they note..."I think this is a feasible surgical alternative to spinal fusion or artificial disk replacement," Dr. Luk told Medscape. "In a fusion, the motion of the segment will be lost. For artificial disk replacement, the major concern is the long-term outcome and the difficulties and risks with revision surgery. This biological approach enables the body to remodel the graft according to biomechanical laws."

Introduction to EOVA Geek Club

People participate in journal clubs or book clubs. Geek Club is my affectionate term for documenting summaries of all the geeky stuff I read.

I work at the East Orange VA hospital in NJ. This may also serve as a resource for the residents who rotate through there.

I hope you will enjoy.