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Poster 217 Treatment of Avascular Necrosis of the Proximal Femur with Core Decompression and Stem Cell Injection: A Case Report
PM&R
total injectate of 5 mL of PRP obtained from 30 mL antecubital blood draw was delivered to the site. There was no blood loss and the patient tolerated the procedure well with no complaints. Setting: Outpatient Physical Medicine and Rehabilitation Clinic at an Academic Medical Center. Results or Clinical Course: Patient had previously had nearly 3 years of continual pain. At 2 weeks post PRP injection followed by relative rest, patient noted improvement in pain. Patient currently undergoing a strengthening program with PT and is noted be making good improvements without adverse event. Further developments will be discussed. Discussion: This is the first reported case, to our knowledge, of the use of PRP to the distal bicep insertion site. Conclusions: The use of platelet-rich plasma therapy is an effective treatment for biceps tendon tear at the distal insertion site. Use of ultrasound guidance allowed accurate delivery of the injectate to maximize optimal results. Poster 216 Bifurcated Distal Bicep Tendon with an Isolated Rupture of the Distal Long Head Tendon at Insertion Site: A Unique Anatomical Variant and Injury Pattern. Emilia Ravski, DO (New York University Medical Center -RUSK, New York, NY, United States); Shan Babeendran, DO; Amit K. Bansal, DO. Disclosures: E. Ravski, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 35-year-old man with no significant past medical history presented with a 10-week history of left arm pain. The pain started while pulling a lat-pull bar in a flexed-elbow position followed by a fast eccentric contraction. He felt sudden pain in the left antecubital fossa that persisted for 10 weeks and was associated with weakness. Physical examination revealed pain and weakness with resisted forearm supination and flexion. Hook test and “Popeye” deformity were negative. Setting: Tertiary Care Center. Results or Clinical Course: MRI showed a full thickness tear at the distal insertion of the long head bicep tendon with an intact short head bicep tendon. The patient underwent surgical repair followed by physical therapy and regained full bicep strength with return to pre-injury exercise. Discussion: Bicep tendon ruptures most commonly occur in males between ages 40 to 60 with incidence of 1.2 per 100,000. Mechanism of injury involves eccentric contraction of a flexed forearm, followed by pain and significant weakness in forearm flexion and supination. The two bicep brachii typically unite into one tendon that inserts onto the radial tuberosity. Additional anatomical variations include bifurcation of the distal short and long head tendons at insertion site. Several injury patters at the insertion site have been reported and most commonly include ruptures of the short head tendon with or without a concomitant rupture of the long head bicep tendon. Literature on distal long head rupture with an intact short head component in the setting of a bifurcated bicep tendon is limited. Conclusions: This case demonstrates a patient with a unique anatomical variant at the distal bicep tendon insertion site who sustained a rare injury involving a complete tear of the distal long head bicep tendon with an intact short head component. This was a rather challenging diagnosis to make as this patient presented late
Vol. 6, Iss. 9S, 2014
S261
after initial injury and did not have typical physical examination findings of a ruptured distal bicep tendon. He also had functional limitations secondary to pain rather than true weakness as would be expected in a full bicep rupture. When a distal bicep tear is suspected, it is important to consider the anatomical variant of a splint distal bicep tendon and associated variety of possible injury patterns as part of differential diagnosis. Poster 217 Treatment of Avascular Necrosis of the Proximal Femur with Core Decompression and Stem Cell Injection: A Case Report. Pegah Dehghan (Montefiore, Bronx, NY, United States); Shane Drakes; Mark Thomas, MD; Farshad Adib. Disclosures: P. Dehghan, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 30-year-old woman on hemodialysis for chronic renal failure who presented with bilateral hip pain, progressive over 3 months. The pain was aggravated by weight bearing and limited ambulation. Examination was notable for pain and restricted range of motion (ROM) of both hips. MRI revealed extensive bilateral avascular necrosis (AVN) of the femoral head without collapse. After review of treatment options, she elected bilateral core decompression and bone marrow aspiration with stem cell injection. Setting: Tertiary care outpatient orthopedic surgery service. Results or Clinical Course: The procedure was performed uneventfully and she began physical therapy uniquely for training in walker use on post-operative day (POD) 1. She was discharged to home on POD 2 and instructed to resume physical therapy after 2 weeks, all the while limiting hip flexion to maximum of 70 degrees. Restrictions included walker (short distances) or wheelchair (longer distances) use for 6 weeks. Her course has been notable for improvement in pain, ROM and ambulation. Discussion: Painful femoral head AVN affects people with such risk factors as corticosteroid use or alcohol abuse. It can lead to femoral head collapse requiring total hip replacement. As most patients are young, an initial hip replacement might not last throughout the patient’s lifetime. Core decompression with injection of bone marrow stem cells in an attempt to save the femoral head prior to collapse may be a valuable strategy in the early stages of osteonecrosis. Conclusions: Implantation of autologous bone-marrow cells might be a safe and effective treatment in the early stages of femoral head osteonecrosis and eliminate or delay the need for total hip replacement. No postoperative rehabilitation protocol exists for this procedure, but protected weight bearing and limitation of hip flexion appeared to provide a safe and effective program for our patient. Physiatrists should be aware of this treatment option and be involved in the judicious application of post-operative physical therapy. Poster 219 Medial and Lateral Plantar Nerve Hydrodissection in Tarsal Tunnel Syndrome: A Case Report. Patrick Buchanan, MD (UMDNJ, Hoboken, NJ, United States); Suneil Kumar, MD; Todd P. Stitik, MD. Disclosures: P. Buchanan, No Disclosures: I Have No Relevant Financial Relationships to Disclose.
total injectate of 5 mL of PRP obtained from 30 mL antecubital blood draw was delivered to the site. There was no blood loss and the patient tolerated the procedure well with no complaints. Setting: Outpatient Physical Medicine and Rehabilitation Clinic at an Academic Medical Center. Results or Clinical Course: Patient had previously had nearly 3 years of continual pain. At 2 weeks post PRP injection followed by relative rest, patient noted improvement in pain. Patient currently undergoing a strengthening program with PT and is noted be making good improvements without adverse event. Further developments will be discussed. Discussion: This is the first reported case, to our knowledge, of the use of PRP to the distal bicep insertion site. Conclusions: The use of platelet-rich plasma therapy is an effective treatment for biceps tendon tear at the distal insertion site. Use of ultrasound guidance allowed accurate delivery of the injectate to maximize optimal results. Poster 216 Bifurcated Distal Bicep Tendon with an Isolated Rupture of the Distal Long Head Tendon at Insertion Site: A Unique Anatomical Variant and Injury Pattern. Emilia Ravski, DO (New York University Medical Center -RUSK, New York, NY, United States); Shan Babeendran, DO; Amit K. Bansal, DO. Disclosures: E. Ravski, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 35-year-old man with no significant past medical history presented with a 10-week history of left arm pain. The pain started while pulling a lat-pull bar in a flexed-elbow position followed by a fast eccentric contraction. He felt sudden pain in the left antecubital fossa that persisted for 10 weeks and was associated with weakness. Physical examination revealed pain and weakness with resisted forearm supination and flexion. Hook test and “Popeye” deformity were negative. Setting: Tertiary Care Center. Results or Clinical Course: MRI showed a full thickness tear at the distal insertion of the long head bicep tendon with an intact short head bicep tendon. The patient underwent surgical repair followed by physical therapy and regained full bicep strength with return to pre-injury exercise. Discussion: Bicep tendon ruptures most commonly occur in males between ages 40 to 60 with incidence of 1.2 per 100,000. Mechanism of injury involves eccentric contraction of a flexed forearm, followed by pain and significant weakness in forearm flexion and supination. The two bicep brachii typically unite into one tendon that inserts onto the radial tuberosity. Additional anatomical variations include bifurcation of the distal short and long head tendons at insertion site. Several injury patters at the insertion site have been reported and most commonly include ruptures of the short head tendon with or without a concomitant rupture of the long head bicep tendon. Literature on distal long head rupture with an intact short head component in the setting of a bifurcated bicep tendon is limited. Conclusions: This case demonstrates a patient with a unique anatomical variant at the distal bicep tendon insertion site who sustained a rare injury involving a complete tear of the distal long head bicep tendon with an intact short head component. This was a rather challenging diagnosis to make as this patient presented late
Vol. 6, Iss. 9S, 2014
S261
after initial injury and did not have typical physical examination findings of a ruptured distal bicep tendon. He also had functional limitations secondary to pain rather than true weakness as would be expected in a full bicep rupture. When a distal bicep tear is suspected, it is important to consider the anatomical variant of a splint distal bicep tendon and associated variety of possible injury patterns as part of differential diagnosis. Poster 217 Treatment of Avascular Necrosis of the Proximal Femur with Core Decompression and Stem Cell Injection: A Case Report. Pegah Dehghan (Montefiore, Bronx, NY, United States); Shane Drakes; Mark Thomas, MD; Farshad Adib. Disclosures: P. Dehghan, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 30-year-old woman on hemodialysis for chronic renal failure who presented with bilateral hip pain, progressive over 3 months. The pain was aggravated by weight bearing and limited ambulation. Examination was notable for pain and restricted range of motion (ROM) of both hips. MRI revealed extensive bilateral avascular necrosis (AVN) of the femoral head without collapse. After review of treatment options, she elected bilateral core decompression and bone marrow aspiration with stem cell injection. Setting: Tertiary care outpatient orthopedic surgery service. Results or Clinical Course: The procedure was performed uneventfully and she began physical therapy uniquely for training in walker use on post-operative day (POD) 1. She was discharged to home on POD 2 and instructed to resume physical therapy after 2 weeks, all the while limiting hip flexion to maximum of 70 degrees. Restrictions included walker (short distances) or wheelchair (longer distances) use for 6 weeks. Her course has been notable for improvement in pain, ROM and ambulation. Discussion: Painful femoral head AVN affects people with such risk factors as corticosteroid use or alcohol abuse. It can lead to femoral head collapse requiring total hip replacement. As most patients are young, an initial hip replacement might not last throughout the patient’s lifetime. Core decompression with injection of bone marrow stem cells in an attempt to save the femoral head prior to collapse may be a valuable strategy in the early stages of osteonecrosis. Conclusions: Implantation of autologous bone-marrow cells might be a safe and effective treatment in the early stages of femoral head osteonecrosis and eliminate or delay the need for total hip replacement. No postoperative rehabilitation protocol exists for this procedure, but protected weight bearing and limitation of hip flexion appeared to provide a safe and effective program for our patient. Physiatrists should be aware of this treatment option and be involved in the judicious application of post-operative physical therapy. Poster 219 Medial and Lateral Plantar Nerve Hydrodissection in Tarsal Tunnel Syndrome: A Case Report. Patrick Buchanan, MD (UMDNJ, Hoboken, NJ, United States); Suneil Kumar, MD; Todd P. Stitik, MD. Disclosures: P. Buchanan, No Disclosures: I Have No Relevant Financial Relationships to Disclose.