- Email: [email protected]
Poster 209 Failure of Platelet-Rich Plasma in the Treatment of Hip Osteoarthritis: A Case Report
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largest rates of increase. Importantly, opioid medications have demonstrated a generally rising rate of prescription for all body regions, except the elbow and the head (5-11% per year, P⬍.05). The largest increases in opioid prescription rate were for the hip (10% per year) and the neck (11% per year). Conclusions: We have described a rising incidence of regional body pain in the ED. The corresponding increasing trend of opioid medication prescriptions suggests that opioid medications may be relied on as a temporizing measure in the ED. Given the progressively important role of the ED in healthcare access and delivery, judicious pain management strategies are warranted. Poster 207 Gender and Racial Disparities in Opioid Medication Prescription for Regional Body Pain in the Emergency Department. Lyly Cao Minh, MD (Stanford University, Palo Alto, CA, United States); Salar Deldar, MD; Grace Y. Huang, MD; Ming-Chih J. Kao, PhD, MD; Matthew Smuck, MD; Jeffrey K. Teraoka, MD. Disclosures: L. Cao Minh, No Disclosures. Objective: To describe differences in the rate of opiate medication (OM) prescription by race and gender for regional body pain in Emergency Departments (EDs) in the United States (US). Design: ED data from National Hospital and Ambulatory Medical Center Survey (NHAMCS) from 1996-2008 were analyzed using SAS version 9.2 (Cary, NC, USA) and R (http://r-project.org). For variance estimation, masked “ultimate cluster” weights were used for 2002-06. Domain analysis was used in subset analyses. Weighted logistic regression was used to adjust for demographic factors. Setting: National multi-stage probability survey of U.S. EDs. Participants: Patients who presented at a set of randomly selected healthcare facilities on the days of data collection. Interventions: In silico. Main Outcome Measures: Rates of OM prescription for various regional body pains: axial (headache, neck, back, low back), upper extremity (shoulder, arm, elbow, wrist, hand), lower extremity (hip, leg, knee, ankle, foot) by race (African-American, Hispanic, white) and gender (male, female). Results: Controlling for age and gender, African-Americans were less likely to receive OM for head (OR⫽0.43, P⬍.001), back (OR⫽0.45, P⬍.001), hip (OR⫽0.46, P⫽.01), and arm pain (OR⫽0.47, P⫽.003) compared to white male controls. There appears to be a trend toward normalization of this disparity. Controlling for age and gender, Hispanics were less likely to receive OM for head (OR⫽0.41, P⬍.001) and back pain (OR⫽0.55, P⫽.001) compared to white male controls. Controlling for age and race, females were less likely to receive OM for headache (OR⫽0.64, P⫽.002) but more likely to receive OM for back pain (OR⫽1.48, P⬍.001), a trend that was normalizing at 4% per year. Conclusions: We describe robust 13-year trends on race and gender disparities in U.S. EDs showing statistically significantly different rates of OM prescription. We reveal African-Americans and Hispanics were not only less likely to receive OM for low back pain, but also for headache. These disparities have shown some recent changes, but not statistically significantly so. Females were also less likely to receive OM for headache. Interestingly, females
PRESENTATIONS
were historically more likely to receive OM for back pain before the year 2000; however, this trend demonstrated normalization in recent years, likely reflecting changes in practice patterns. Poster 208 Upper Extremity Deep Vein Thrombosis Following Air Travel: A Case Report. Mahmud M. Ibrahim, MD (Mount Sinai School of Medicine, New York, NY, United States); Joseph Herrera, DO. Disclosures: M. M. Ibrahim, No Disclosures. Case Description: Patient: A 70-year-old man with a history of gout presented for evaluation of a swollen hand after an overseas flight. Case Description: The patient presented for evaluation of a swollen right hand. About 2 weeks prior, he had flown from NYC to Italy. While in Europe, he noticed some minimal swelling of his right hand. The day after he flew back, the swelling significantly worsened. Physical examination revealed a severely swollen nondiscolored right hand. The swelling extended to approximately the middle of his forearm. There was venous distension along the forearm. There were no abnormal rashes, ulcerations, or evidence of insect bites along the extremity. There was no joint tenderness and the hand was warm to touch. Radial and ulnar pulses were detectable with good capillary refill. The remainder of the examination was unremarkable. Setting: Outpatient musculoskeletal office. Results or Clinical Course: The patient was sent for an upper extremity Doppler, which revealed a thrombus in a tributary vein of the right brachial vein. Discussion: The incidence of symptomatic DVT secondary to prolonged air travel has been estimated to occur at only 0.05% of all DVTs. DVT in the upper extremity is reported to account for only 1-2% of all venous thrombosis. Upper extremity DVTs usually develop in patients with cancer or those who underwent insertion of a central venous line. Prolonged air travel has been shown to be a risk factor for developing lower extremity DVT; however, there are no published reports of a correlation between prolonged air travel and upper extremity DVT. Passengers are often immobilized in cramped positions for hours and subjected to low air pressure with relative hypoxia and low humidity, which may cause dehydration and a subsequent hypercoagulable state. Conclusions: It is important to consider this rare diagnosis in individuals with these symptoms, especially in the setting of other medical problems, such as gout, which may have a similar presentation. Poster 209 Failure of Platelet-Rich Plasma in the Treatment of Hip Osteoarthritis: A Case Report. Mahmud M. Ibrahim, MD (Mount Sinai School of Medicine, New York, NY, United States); Joseph Herrera, DO. Disclosures: M. M. Ibrahim, No Disclosures. Case Description: A 46-year-old man with a history of left hip OA had previously received several intra-articular injections with steroids and hyaluronic acid derivatives with minimal lasting relief. He then underwent a series of 3 platelet-rich plasma (PRP) injections over a 4.5-month period. Setting: Musculoskeletal office. Results or Clinical Course: Initially, WOMAC scores im-
PM&R
proved by approximately 50%, but decreased to only 10% after the third injection. Discussion: Platelets contain a number of proteins, cytokines, and other bioactive factors that initiate and regulate basic aspects of wound healing. PRP causes the release a large pool of cytokines, chemokines, and growth factors into the joint capsule. These factors are involved in cell signaling and in the stimulation of intrinsic repair mechanisms. PRP has been shown to be efficacious in several in vitro studies in stimulating the proliferation of bone growth, enhancing and accelerating tendon repair, and in the healing of lower extremity ulcers. In addition, several in vivo studies have shown positive benefits to the use of PRP in lateral epicondylitis and Achilles tendinopathy. Studies by Sanchez et al. reported positive results with the use of PRP in the treatment of knee and hip OA. In addition, PRP has been used arthroscopically in the treatment of avascular necrosis. On the other hand, several authors have failed to observe a positive effect with the use of PRP. One study showed no effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic Achilles tendinopathy. Savarino et al. reported no functional or clinical difference in patients with bone grafted with bone chips and PRP. Furthermore, within the oral and maxillofacial surgery literature, there are several cases that show little benefit from using PRP to promote healing or osteogenesis. However, it is difficult to draw conclusions from many of the above studies as most are limited case series that may or may not have controls, have small sample sizes, and do not define a standardized preparation of PRP. Conclusions: The limited studies in the literature suggest there is potential in the treatment of cartilage lesions with PRP; however, to date, there are no large scale randomized, long-term studies providing reliable medical evidence that supports this claim; thus emphasizing the need for further research in this area. Poster 210 Genu Recurvatum in Adult Patients with Spastic Hemiparesis: Treatment Strategies: A Case Series. Malathy Appasamy, MD (The Hofstra North Shore Long Island Jewish Health System, Great Neck, NY, United States); Anthony Oreste, MD; Nisha M. Patel, MD. Disclosures: M. Appasamy, No Disclosures. Objective: Genu recurvatum (GR) is an acquired deformity occuring in nearly half of all stroke patients. Muscle imbalance and spasticity result in unopposed hyperextension moment at the knee. Our aim was to assess the effectiveness of our less cumbersome treatment strategies involving foot and ankle mechanisms to influence the ground reactive force at the knee in improvement or elimination of GR. Design: We retrospectively studied patients with GR secondary to spastic hemiparesis between 2005-2011. IRB approval was obtained and data collected include severity of GR, muscle strength, modified Ashworth score (MAS) for spasticity, presence of clonus, sensation and proprioception. Interventions included orthotics such as solid AFO, a hinged AFO with an adjustable posterior stop (APS: ability to place footplate in dorsiflexion); an AFO with a dual-channel ankle joint in the setting of quadriceps weakness (enable control of dorsiflexion or plantar flexion) and addition of heel lifts with AFO to provide pseudo-dorsiflexion. Outcome was recorded as elimination, improvement or non-improvement. Setting: Outpatient musculoskeletal clinic.
Vol. 4, Iss. 10S, 2012
S261
Results: Of 23 patients, 16 had mild GR, 4 had moderate and 3 had severe GR. Muscle agonist-antagonist strength imbalance was noted at the knee in all patients. Spasticity with MAS⬎1 were seen in 11 patients of which 10 patients had clonus. Botox was used in 9 patients who had significant plantar spasticity and/or clonus. Ankle/ foot orthotic interventions included solid AFO (n⫽7), hinged ankle joint with APS (n⫽12), dual-channel ankle joint (n⫽1) and KAFO for severe GR (n⫽1).Heel lifts were used by itself in one patient and in addition to AFO in 17 patients. On follow up, GR was completely eliminated in 8 patients (35%) and improved in 14 patients (61%). Conclusions: Muscle imbalance and spasticity vary widely and co-exist in patients with GR after spastic hemiparesis. Treatment should be individualized based on physical findings. Botox is a useful adjunct to orthotic devices in patients with severe spasticity. Influencing the ground reactive force at the knee using mechanisms at the ankle and foot like brace modifications with/without heel lifts could eliminate or improve GR. KAFO can be restricted to patients with severe GR resistant to simple measures. Poster 211 Recurrent Dislocation in Primary Total Knee Arthroplasty: A Case Report. Marissa H. Cohler, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Santiago D. Toledo, MD. Disclosures: M. H. Cohler, No Disclosures. Case Description: A 70-year-old woman with history of osteoarthritis and obesity was admitted for rehabilitation following bilateral total knee arthroplasties. The patient was progressing well until hospital day 10 (post-operative day 14) when she developed intense cramping pain in her left knee while performing independent bed mobility. Inspection of the knee was notable for a new deformity and a “step-off sign.” Plain radiographs revealed posterior dislocation of the left prosthetic knee. She was transferred to an acute care hospital and underwent closed reduction. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: Unfortunately, dislocation of the same prosthetic knee recurred 2 days later and she was referred to Orthopaedics for definitive management. Discussion: Dislocation is a rare complication following TKA. Incidence has been estimated at 0.2% in one retrospective analysis, and the literature on the topic is limited to case reports. Risk factors for dislocation include valgus deformity of the knee, malposition of the components, patellar instability and improper selection of prosthetic design. Although the exact mechanism that produced dislocation in this case remains unclear, our hypothesis is that the patient’s knee was being slightly flexed and internally rotated when she suffered her injury. In addition, her body habitus with the majority of her weight distributed centrally may have put more stress on her lower extremities and joints. Since she received simultaneous bilateral TKA, the functionality of both legs was compromised, rendering her unable to safely perform independent bed mobility. Conclusions: In presenting this occurrence of posterior dislocation of a TKA, we hope to highlight this rare but severe form of instability that can alter functional outcomes and overall recovery. Education of high-risk patients should emphasize techniques to avoid inappropriate physical movements. Certain patients may ben-
largest rates of increase. Importantly, opioid medications have demonstrated a generally rising rate of prescription for all body regions, except the elbow and the head (5-11% per year, P⬍.05). The largest increases in opioid prescription rate were for the hip (10% per year) and the neck (11% per year). Conclusions: We have described a rising incidence of regional body pain in the ED. The corresponding increasing trend of opioid medication prescriptions suggests that opioid medications may be relied on as a temporizing measure in the ED. Given the progressively important role of the ED in healthcare access and delivery, judicious pain management strategies are warranted. Poster 207 Gender and Racial Disparities in Opioid Medication Prescription for Regional Body Pain in the Emergency Department. Lyly Cao Minh, MD (Stanford University, Palo Alto, CA, United States); Salar Deldar, MD; Grace Y. Huang, MD; Ming-Chih J. Kao, PhD, MD; Matthew Smuck, MD; Jeffrey K. Teraoka, MD. Disclosures: L. Cao Minh, No Disclosures. Objective: To describe differences in the rate of opiate medication (OM) prescription by race and gender for regional body pain in Emergency Departments (EDs) in the United States (US). Design: ED data from National Hospital and Ambulatory Medical Center Survey (NHAMCS) from 1996-2008 were analyzed using SAS version 9.2 (Cary, NC, USA) and R (http://r-project.org). For variance estimation, masked “ultimate cluster” weights were used for 2002-06. Domain analysis was used in subset analyses. Weighted logistic regression was used to adjust for demographic factors. Setting: National multi-stage probability survey of U.S. EDs. Participants: Patients who presented at a set of randomly selected healthcare facilities on the days of data collection. Interventions: In silico. Main Outcome Measures: Rates of OM prescription for various regional body pains: axial (headache, neck, back, low back), upper extremity (shoulder, arm, elbow, wrist, hand), lower extremity (hip, leg, knee, ankle, foot) by race (African-American, Hispanic, white) and gender (male, female). Results: Controlling for age and gender, African-Americans were less likely to receive OM for head (OR⫽0.43, P⬍.001), back (OR⫽0.45, P⬍.001), hip (OR⫽0.46, P⫽.01), and arm pain (OR⫽0.47, P⫽.003) compared to white male controls. There appears to be a trend toward normalization of this disparity. Controlling for age and gender, Hispanics were less likely to receive OM for head (OR⫽0.41, P⬍.001) and back pain (OR⫽0.55, P⫽.001) compared to white male controls. Controlling for age and race, females were less likely to receive OM for headache (OR⫽0.64, P⫽.002) but more likely to receive OM for back pain (OR⫽1.48, P⬍.001), a trend that was normalizing at 4% per year. Conclusions: We describe robust 13-year trends on race and gender disparities in U.S. EDs showing statistically significantly different rates of OM prescription. We reveal African-Americans and Hispanics were not only less likely to receive OM for low back pain, but also for headache. These disparities have shown some recent changes, but not statistically significantly so. Females were also less likely to receive OM for headache. Interestingly, females
PRESENTATIONS
were historically more likely to receive OM for back pain before the year 2000; however, this trend demonstrated normalization in recent years, likely reflecting changes in practice patterns. Poster 208 Upper Extremity Deep Vein Thrombosis Following Air Travel: A Case Report. Mahmud M. Ibrahim, MD (Mount Sinai School of Medicine, New York, NY, United States); Joseph Herrera, DO. Disclosures: M. M. Ibrahim, No Disclosures. Case Description: Patient: A 70-year-old man with a history of gout presented for evaluation of a swollen hand after an overseas flight. Case Description: The patient presented for evaluation of a swollen right hand. About 2 weeks prior, he had flown from NYC to Italy. While in Europe, he noticed some minimal swelling of his right hand. The day after he flew back, the swelling significantly worsened. Physical examination revealed a severely swollen nondiscolored right hand. The swelling extended to approximately the middle of his forearm. There was venous distension along the forearm. There were no abnormal rashes, ulcerations, or evidence of insect bites along the extremity. There was no joint tenderness and the hand was warm to touch. Radial and ulnar pulses were detectable with good capillary refill. The remainder of the examination was unremarkable. Setting: Outpatient musculoskeletal office. Results or Clinical Course: The patient was sent for an upper extremity Doppler, which revealed a thrombus in a tributary vein of the right brachial vein. Discussion: The incidence of symptomatic DVT secondary to prolonged air travel has been estimated to occur at only 0.05% of all DVTs. DVT in the upper extremity is reported to account for only 1-2% of all venous thrombosis. Upper extremity DVTs usually develop in patients with cancer or those who underwent insertion of a central venous line. Prolonged air travel has been shown to be a risk factor for developing lower extremity DVT; however, there are no published reports of a correlation between prolonged air travel and upper extremity DVT. Passengers are often immobilized in cramped positions for hours and subjected to low air pressure with relative hypoxia and low humidity, which may cause dehydration and a subsequent hypercoagulable state. Conclusions: It is important to consider this rare diagnosis in individuals with these symptoms, especially in the setting of other medical problems, such as gout, which may have a similar presentation. Poster 209 Failure of Platelet-Rich Plasma in the Treatment of Hip Osteoarthritis: A Case Report. Mahmud M. Ibrahim, MD (Mount Sinai School of Medicine, New York, NY, United States); Joseph Herrera, DO. Disclosures: M. M. Ibrahim, No Disclosures. Case Description: A 46-year-old man with a history of left hip OA had previously received several intra-articular injections with steroids and hyaluronic acid derivatives with minimal lasting relief. He then underwent a series of 3 platelet-rich plasma (PRP) injections over a 4.5-month period. Setting: Musculoskeletal office. Results or Clinical Course: Initially, WOMAC scores im-
PM&R
proved by approximately 50%, but decreased to only 10% after the third injection. Discussion: Platelets contain a number of proteins, cytokines, and other bioactive factors that initiate and regulate basic aspects of wound healing. PRP causes the release a large pool of cytokines, chemokines, and growth factors into the joint capsule. These factors are involved in cell signaling and in the stimulation of intrinsic repair mechanisms. PRP has been shown to be efficacious in several in vitro studies in stimulating the proliferation of bone growth, enhancing and accelerating tendon repair, and in the healing of lower extremity ulcers. In addition, several in vivo studies have shown positive benefits to the use of PRP in lateral epicondylitis and Achilles tendinopathy. Studies by Sanchez et al. reported positive results with the use of PRP in the treatment of knee and hip OA. In addition, PRP has been used arthroscopically in the treatment of avascular necrosis. On the other hand, several authors have failed to observe a positive effect with the use of PRP. One study showed no effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic Achilles tendinopathy. Savarino et al. reported no functional or clinical difference in patients with bone grafted with bone chips and PRP. Furthermore, within the oral and maxillofacial surgery literature, there are several cases that show little benefit from using PRP to promote healing or osteogenesis. However, it is difficult to draw conclusions from many of the above studies as most are limited case series that may or may not have controls, have small sample sizes, and do not define a standardized preparation of PRP. Conclusions: The limited studies in the literature suggest there is potential in the treatment of cartilage lesions with PRP; however, to date, there are no large scale randomized, long-term studies providing reliable medical evidence that supports this claim; thus emphasizing the need for further research in this area. Poster 210 Genu Recurvatum in Adult Patients with Spastic Hemiparesis: Treatment Strategies: A Case Series. Malathy Appasamy, MD (The Hofstra North Shore Long Island Jewish Health System, Great Neck, NY, United States); Anthony Oreste, MD; Nisha M. Patel, MD. Disclosures: M. Appasamy, No Disclosures. Objective: Genu recurvatum (GR) is an acquired deformity occuring in nearly half of all stroke patients. Muscle imbalance and spasticity result in unopposed hyperextension moment at the knee. Our aim was to assess the effectiveness of our less cumbersome treatment strategies involving foot and ankle mechanisms to influence the ground reactive force at the knee in improvement or elimination of GR. Design: We retrospectively studied patients with GR secondary to spastic hemiparesis between 2005-2011. IRB approval was obtained and data collected include severity of GR, muscle strength, modified Ashworth score (MAS) for spasticity, presence of clonus, sensation and proprioception. Interventions included orthotics such as solid AFO, a hinged AFO with an adjustable posterior stop (APS: ability to place footplate in dorsiflexion); an AFO with a dual-channel ankle joint in the setting of quadriceps weakness (enable control of dorsiflexion or plantar flexion) and addition of heel lifts with AFO to provide pseudo-dorsiflexion. Outcome was recorded as elimination, improvement or non-improvement. Setting: Outpatient musculoskeletal clinic.
Vol. 4, Iss. 10S, 2012
S261
Results: Of 23 patients, 16 had mild GR, 4 had moderate and 3 had severe GR. Muscle agonist-antagonist strength imbalance was noted at the knee in all patients. Spasticity with MAS⬎1 were seen in 11 patients of which 10 patients had clonus. Botox was used in 9 patients who had significant plantar spasticity and/or clonus. Ankle/ foot orthotic interventions included solid AFO (n⫽7), hinged ankle joint with APS (n⫽12), dual-channel ankle joint (n⫽1) and KAFO for severe GR (n⫽1).Heel lifts were used by itself in one patient and in addition to AFO in 17 patients. On follow up, GR was completely eliminated in 8 patients (35%) and improved in 14 patients (61%). Conclusions: Muscle imbalance and spasticity vary widely and co-exist in patients with GR after spastic hemiparesis. Treatment should be individualized based on physical findings. Botox is a useful adjunct to orthotic devices in patients with severe spasticity. Influencing the ground reactive force at the knee using mechanisms at the ankle and foot like brace modifications with/without heel lifts could eliminate or improve GR. KAFO can be restricted to patients with severe GR resistant to simple measures. Poster 211 Recurrent Dislocation in Primary Total Knee Arthroplasty: A Case Report. Marissa H. Cohler, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Santiago D. Toledo, MD. Disclosures: M. H. Cohler, No Disclosures. Case Description: A 70-year-old woman with history of osteoarthritis and obesity was admitted for rehabilitation following bilateral total knee arthroplasties. The patient was progressing well until hospital day 10 (post-operative day 14) when she developed intense cramping pain in her left knee while performing independent bed mobility. Inspection of the knee was notable for a new deformity and a “step-off sign.” Plain radiographs revealed posterior dislocation of the left prosthetic knee. She was transferred to an acute care hospital and underwent closed reduction. Setting: Acute inpatient rehabilitation hospital. Results or Clinical Course: Unfortunately, dislocation of the same prosthetic knee recurred 2 days later and she was referred to Orthopaedics for definitive management. Discussion: Dislocation is a rare complication following TKA. Incidence has been estimated at 0.2% in one retrospective analysis, and the literature on the topic is limited to case reports. Risk factors for dislocation include valgus deformity of the knee, malposition of the components, patellar instability and improper selection of prosthetic design. Although the exact mechanism that produced dislocation in this case remains unclear, our hypothesis is that the patient’s knee was being slightly flexed and internally rotated when she suffered her injury. In addition, her body habitus with the majority of her weight distributed centrally may have put more stress on her lower extremities and joints. Since she received simultaneous bilateral TKA, the functionality of both legs was compromised, rendering her unable to safely perform independent bed mobility. Conclusions: In presenting this occurrence of posterior dislocation of a TKA, we hope to highlight this rare but severe form of instability that can alter functional outcomes and overall recovery. Education of high-risk patients should emphasize techniques to avoid inappropriate physical movements. Certain patients may ben-