S220 S290
Poster 278:
Treatment of Femoral Osteonecrotic Lesion
Following Failed Subchondroplasty with Bone Marrow
Aspirate Concentrate Loaded Allograft: A Case Report
Paul S. Chirichella (Rutgers University-New Jersey Medical School,
Newark, NJ, USA), Gerald Malanga, MD
Disclosures:
Paul Chirichella: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 61-year-oldwomanwith chronic left knee
pain secondary tomoderate to severemedial compartment osteoarthritis
with bone marrow lesion (BML) within the medial femoral condyle. She
underwent subchondroplasty (SCP) which was complicated by extrava-
sation of the methyl methacrylate and persistence of pain symptoms. She
was referred for non-surgical management of her pain which did not
improve with bracing, home exercise program, nonsteroidal anti-in-
flammatory drugs (NSAID), platelet rich plasma (PRP) injection and hy-
aluronic acid injection series. MRI showed a focal sclerotic lesion
indicative of avascular necrosis in themedial femoral condyle. This lesion
was then targeted for injection using amixture of harvested bonemarrow
aspirate concentrate (BMAC), platelet poor plasma (PPP) and micro-
particulated allograft to serve as a scaffold using an 11 g Jamshidi needle
under fluoroscopic guidance. Concurrently BMAC was injected intra-
articularly and into the medial meniscus at site of previous tear. She was
instructed to avoid NSAID use and minimize weight bearing using crutches
for 1 week, then weight bearing as tolerated. Three weeks post proced-
ure, PRP injection was performed under ultrasound guidance to the knee
joint as well as the medial knee overlying location of BMC injection.
Setting:
Outpatient musculoskeletal private practice.
Results:
At 7 week follow up, the patient noted significant overall
improvement of pain with resolution of pain on ambulation.
Discussion:
SCP is a procedure that has increasingly been performed
without clear scientific evidence for its efficacy. This patient suffered
a complication from the procedure and had concomitant degenerative
changes of the joint and wished to avoid partial or total knee
replacement. She was provided both intraosseous as well as intra-
articular BMAC in effort to heal her bone necrosis and facilitate
decreased pain related to her knee OA.
Conclusions:
Injected BMC combined with allograft is a treatment
option for osteonecrosis after failed SCP.
Level of Evidence:
Level V
Poster 279:
1st Metacarpophalangeal Joint (MCP) Dislocation with
Associated UCL and Volar Plate Injury Diagnosed with
Ultrasound: A Case Report
Ryan Woods, MD (Mayo Clinic of Rochester, Rochester, MN, United
States), Shawn C. Oxentenko, MD
Disclosures:
Ryan Woods: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Patient presented to local emergency
department following acute trauma to the left thumb. A painful pop
was felt after catching a fastball from his adolescent son. Removal of
his catcher’s glove revealed a deformity of the left thumb which was
immediately self-reduced.
Setting:
Tertiary Academic Medical Center.
Results:
Plain films were negative for a fracture. Patient was immo-
bilized in a splint and follow up was scheduled. Hand clinic examina-
tion revealed severe laxity with ulnar collateral ligament (UCL)
stressing. A diagnostic ultrasound demonstrated partial thickness
tearing and distraction of the ulnar margin of the MCP joint during
valgus stressing. The adductor aponeurosis remained intact. There was
no sonographic evidence of a complete left UCL tear or Stener lesion.
Small fracture fragments compatible with a volar plate avulsion injury
were seen. He was placed in a left radial forearm based thumb orthosis
for 6 weeks and prescribed occupational hand therapy.
Discussion:
Acute injury to UCL of the thumb results from a forced hy-
perextension and hyperabduction moment. In addition to MCP joint pain
and swelling, laxity during valgus stress testing further increases the
clinical suspicion of UCL injury. Prompt imaging is vital to assist in treat-
ment planning. Complete ligament ruptures with retraction proximal to
the adductor aponeurosis (Stener lesion) require surgical intervention.
MRI is the modality of choice to assess for a UCL injury. However, sono-
graphic evaluation is capable of providing real time high resolution dy-
namic imaging. Recent reviews suggest the sensitivity and specificity
rates for identifying UCL injury under ultrasound ranges from 81-100%.
Conclusions:
Sonographic imaging is a safe, quick and cost effective
method that allows for dynamic assessment of thumb UCL integrity
following an acute injury. In experienced hands it is a reliable method
to assess for complete UCL tears and associated injuries such as a
Stener lesion or volar plate injury.
Level of Evidence:
Level V
Poster 280:
Neuralgic Amyotrophy (NA) in a 15-Year-Old with Neurapraxic
Block: A Case Report
Nicholas C. Kinback, MD (Temple Univ Hospital/Moss Rehab, Wilmore,
PA, United States), Ziva Petrin, MD, Channarayapatna R. Sridhara, MD
Disclosures:
Nicholas Kinback: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
Patient is a 15-year-old healthy female
swimmer who awoke with severe pain 4 months ago in the right
shoulder and arm without numbness, tingling, inciting events or neck
pain. After 1 week pain resolved and she noted weakness of right
shoulder with scapular prominence. The right scapula was elevated
and protracted with depressed glenoid and winging of the medial
border with shoulder flexion. Scapular retraction and other shoulder
muscles were normal.
Setting:
Tertiary Care Outpatient Electrodiagnostic Center.
Results:
The right long thoracic latency to the serratus anterior was
insignificantly prolonged compared to the left, with symmetric CMAPs.
Right median sensory and motor conduction studies were normal. The
H latency of right median to FCR was normal. There were no abnor-
malities of insertional or spontaneous activity. There was relative
increased duration and polyphasicity of MUPs in serratus anterior,
deltoid and rhomboid. There was reduced recruitment in rhomboid,
but otherwise normal in other muscles.
Discussion:
This patient’s history and clinical picture is typical of NAwith
preferential involvement of some of C5-innervated muscles with findings
of old axon loss. Typical electrodiagnostic findings in NA is patchy
demyelination and axonal degeneration. Conduction block in NA is rare.
The patient’s young age is atypical for idiopathic NA with no family his-
tory. She lacks the typical dysmorphic features of hereditary NA, but
genetic mutation (SEPT9 gene) should be considered due to young age of
onset. A mild C5 root pathology cannot be excluded based on electro-
diagnostic findings, but lacks neck pain or inciting event. The clinical and
electrodiagnostic examination of scapular winging with no evidence for
acute axon loss suggests neurapraxic block proximal to Erb’s point.
Conclusions:
This is an atypical case of NAwith unusual electrodiagnostic
presentation of conduction block with possible genetic mutation.
Level of Evidence:
Level V
Poster 281:
Vertebral Artery Dissection and Stroke in a Female
Marathon Runner: A Case Report
Stephen Schaaf, MD (University of Pittsburgh Medical Center,
Pittsburgh, PA, United States), Beth Stepanczuk, MD, FAAPMR
Disclosures:
Stephen Schaaf: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 48-year-old female marathon runner
with no significant past medical history developed right sided neck
S220
Abstracts / PM R 9 (2017) S131-S290