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Acute knee effusions: A systematic approach to diagnosis
Abstract
Knee effusions may be the result of trauma, overuse or systemic disease. An understanding of knee pathoanatomy is an invaluable part of making the correct diagnosis and formulating a treatment plan. Taking a thorough medical history is the key component of the evaluation. The most common traumatic causes of knee effusion are ligamentous, osseous and meniscal injuries, and overuse syndromes. Atraumatic etiologies include arthritis, infection, crystal deposition and tumor. It is essential to compare the affected knee with the unaffected knee. Systematic physical examination of the knee, using specific maneuvers, and the appropriate use of diagnostic imaging studies and arthrocentesis establish the correct diagnosis and treatment.
... Therefore, diagnosis of knee joint disorders is widely based on X-ray images [12]. One critical condition of knee joint disorders is effusion, which occurs outside the bones of the knee and can indicate other abnormalities within the joint [40]. However, visually identifying effusion in X-ray images is challenging, especially in the early stages, making it particularly difficult for non-orthopedic physicians [41]. ...
... Results with five fold cross-validation. References [27,[29][30][31][32][33][34]40,46,47] Informed Consent Statement: Written consent was waived for all subjects involved in the study. ...
Knee effusion, a common and important indicator of joint diseases such as osteoarthritis, is typically more discernible on magnetic resonance imaging (MRI) scans compared to radiographs. However, the use of radiographs for the early detection of knee effusion remains promising due to their cost-effectiveness and accessibility. This multi-center prospective study collected a total of 1413 radiographs from four hospitals between February 2022 to March 2023, of which 1281 were analyzed after exclusions. To automatically detect knee effusion on radiographs, we utilized a state-of-the-art (SOTA) deep learning-based classification model with a novel preprocessing technique to optimize images for diagnosing knee effusion. The diagnostic performance of the proposed method was significantly higher than that of the baseline model, achieving an area under the receiver operating characteristic curve (AUC) of 0.892, accuracy of 0.803, sensitivity of 0.820, and specificity of 0.785. Moreover, the proposed method significantly outperformed two non-orthopedic physicians. Coupled with an explainable artificial intelligence method for visualization, this approach not only improved diagnostic performance but also interpretability, highlighting areas of effusion. These results demonstrate that the proposed method enables the early and accurate classification of knee effusions on radiographs, thereby reducing healthcare costs and improving patient outcomes through timely interventions.
... causes synovial fluid accumulation inside the knee joint. Eventually, it leads to knee effusion and consequently changing the knee's physical size and its dielectric properties [15,16]. The early detection of the ligament tear reduces the risk of developing a severe injury, which can only be cured to some degree using intrusive surgery. ...
... Three quantitative metrics are used to evaluate the accuracy of the constructed images presented in [32,75], (15)(16)(17). The first quantitative parameter is the average intensity of the tear region ( ) compared to the surrounding clutter in the rest of the knee domain ( ). ...
The high rate of knee injuries among athletes and other people and the need for early onsite detection to avoid severe ligament tear highlights the necessity of a portable knee imaging tool. Thus, an electromagnetic system based on a multi-static radar to image knee injuries is introduced. The system includes an antenna array of eight printed biconical elements, which have wide operational bandwidth of 103.4%, covering the band 0.7-2.2 GHz, and unidirectional radiation with a high front to back ratio for improved imaging. The antenna array is placed on movable holders around the knee to ensure equal distances from its boundaries. The antenna is assessed in terms of simulated and measured near and far fields, along with electromagnetic wave penetration into the knee. The complete system is built and experimentally validated on in-house built durable, realistic knee phantoms, which emulate normal and injured cases. To reconstruct knee images, a modified multi-static confocal algorithm is used. Since the left and right knees of humans are mirror-symmetrical, the modified algorithm uses a differential approach to remove signal clutters, muti-static coherence factor to improve the quality of channels, and applies dielectric mapping to reduce detection error. The images indicate the ability of the system to detect different types of ligament tears with an accurate localization.
... Risk factors for these diseases include a history of renal stones, increased alcohol consumption, a high purine diet, and the use of diuretics. 11 Hypersensitivity to penicillin or sulfa-containing drugs can cause a response similar to that of serum sickness. Fever, lymphadenopathy, rash, proteinuria, and arthralgia are more common symptoms, but knee effusion may occur. ...
... Vasculitis (notably Henoch-Schönlein purpura and Wegener granulomatosis), bleeding disorders, and vascular fragility caused by a vitamin C deficiency can cause hemarthrosis. 10,11 In the setting of effusion with a hematologic origin, the joint is typically painful and warm, similar to a septic joint. Synovial hemangiomas and pigmented villonodular synovitis can recur as a nontraumatic hemarthrosis of the suprapatellar pouch. ...
Musculoskeletal complaints, which are frequently associated with Lyme disease, often prompt patients to see a physician. In particular, transient episodes of spontaneous knee effusion are common early in the progression of Lyme disease, and, if left untreated, 60% of patients diagnosed with the disease develop Lyme arthritis. This disease is easily treated with antibiotics; therefore, inclusion of Lyme disease in the differential diagnosis as a potential cause of a spontaneous knee effusion can prevent the development of more severe symptoms associated with the disease. However, the time required to receive test results and the inconsistencies between serum and synovial tests can complicate diagnosis of the disease.
... However, the DNN with clinical data and a fine-tuning model for PD did not show a significant difference in TMJ effusion prediction performance. Diagnosis of joint effusion may involve physical examination, imaging tests, and laboratory evaluation of the fluid in the joint 47 . In addition, clinicians obtain pain characteristics, medical history, current health, and other systemic symptoms from the patients to narrow the judgment of effusion 48 . ...
This study investigated the usefulness of deep learning-based automatic detection of temporomandibular joint (TMJ) effusion using magnetic resonance imaging (MRI) in patients with temporomandibular disorder and whether the diagnostic accuracy of the model improved when patients’ clinical information was provided in addition to MRI images. The sagittal MR images of 2948 TMJs were collected from 1017 women and 457 men (mean age 37.19 ± 18.64 years). The TMJ effusion diagnostic performances of three convolutional neural networks (scratch, fine-tuning, and freeze schemes) were compared with those of human experts based on areas under the curve (AUCs) and diagnosis accuracies. The fine-tuning model with proton density (PD) images showed acceptable prediction performance (AUC = 0.7895), and the from-scratch (0.6193) and freeze (0.6149) models showed lower performances (p < 0.05). The fine-tuning model had excellent specificity compared to the human experts (87.25% vs. 58.17%). However, the human experts were superior in sensitivity (80.00% vs. 57.43%) (all p < 0.001). In gradient-weighted class activation mapping (Grad-CAM) visualizations, the fine-tuning scheme focused more on effusion than on other structures of the TMJ, and the sparsity was higher than that of the from-scratch scheme (82.40% vs. 49.83%, p < 0.05). The Grad-CAM visualizations agreed with the model learned through important features in the TMJ area, particularly around the articular disc. Two fine-tuning models on PD and T2-weighted images showed that the diagnostic performance did not improve compared with using PD alone (p < 0.05). Diverse AUCs were observed across each group when the patients were divided according to age (0.7083–0.8375) and sex (male:0.7576, female:0.7083). The prediction accuracy of the ensemble model was higher than that of the human experts when all the data were used (74.21% vs. 67.71%, p < 0.05). A deep neural network (DNN) was developed to process multimodal data, including MRI and patient clinical data. Analysis of four age groups with the DNN model showed that the 41–60 age group had the best performance (AUC = 0.8258). The fine-tuning model and DNN were optimal for judging TMJ effusion and may be used to prevent true negative cases and aid in human diagnostic performance. Assistive automated diagnostic methods have the potential to increase clinicians’ diagnostic accuracy.
... Diagnosis of joint effusion may involve physical examination, imaging tests, and laboratory evaluation of the uid in the joint 41 . In addition, clinicians obtain pain characteristics, medical history, current health, and other systemic symptoms from the patients to narrow the judgment of effusion 42 . ...
This study investigated the usefulness of deep learning-based automatic detection of temporomandibular joint (TMJ) effusion using magnetic resonance imaging (MRI) in patients with temporomandibular joint disorder (TMD) and whether the diagnostic accuracy of the model improved when patients’ clinical information was provided in addition to MRI images. The sagittal MR images of 2,948 TMJs were collected from 1,017 women and 457 men (mean age 37.19 ± 18.64 years). The TMJ effusion diagnostic performances of three convolutional neural networks (scratch, fine-tuning, and freeze schemes) were compared with those of human experts based on areas under the curve (AUCs) and diagnosis accuracies. The fine-tuning model with proton density (PD) images showed acceptable prediction performance (AUC = 0.7895), and the from-scratch (0.6193) and freeze (0.6149) models showed lower performances (p < 0.05). The fine-tuning model had excellent specificity compared to the human experts (87.25% vs. 58.17%). However, the human experts were superior in sensitivity (80.00% vs. 57.43%) (all p < 0.001). In Grad-CAM visualizations, the fine-tuning scheme focused more on effusion than on other structures of the TMJ, and the sparsity was higher than that of the from-scratch scheme (82.40% vs. 49.83%, p < 0.05). The Grad-CAM visualizations agreed with the model learned through important features in the TMJ area, particularly around the articular disc. Two fine-tuning models on PD and T2-weighted images showed that the diagnostic performance did not improve compared with using PD alone (p < 0.05). Diverse AUCs were observed across each group when the patients were divided according to age (0.7083–0.8375) and sex (male:0.7576, female:0.7083). The prediction accuracy of the ensemble model was higher than that of the human experts when all the data were used (74.21% vs. 67.71%, p < 0.05). A deep neural network (DNN) was developed to process multimodal data, including MRI and patient clinical data. Analysis of four age groups with the DNN model showed that the 41–60 age group had the best performance (AUC = 0.8258). There was no significant difference between the prediction performances of the fine-tuning model and the DNN (p > 0.05). The fine-tuning model and DNN were optimal for judging TMJ effusion and may be used to prevent true negative cases and aid in human diagnostic performance. Assistive automated diagnostic methods have the potential to increase clinicians’ diagnostic accuracy.
... Background Knee joint effusion is the excessive aggregation of synovial fluid (SF) intra-articularly [1]. It can be caused by traumatic or non-traumatic factors such as knee osteoarthritis (KOA) [2]. The pathology of KOA involves the whole joint, including the synovial membrane [3]. ...
Background
To assess the diagnostic performance of clinical examination and ultrasound (US) assessment of knee effusion in primary knee osteoarthritis (KOA) patients. Furthermore, the success rate for effusion aspiration and the factors related to it were investigated.
Methods
This cross-sectional study included patients diagnosed with primary KOA-induced knee effusion clinically or sonographically. The affected knee of each patient was subjected to clinical examination and US assessment using the ZAGAZIG effusion and synovitis ultrasonographic score. Patients with confirmed effusion and consented to aspiration were prepared for direct US-guided aspiration under complete aseptic techniques.
Results
One hundred and nine knees were examined. During visual inspection, swelling was detected in 80.7% of knees and effusion was confirmed by US in 67.8% of knees. Visual inspection was the most sensitive at 90.54% while bulge sign was the most specific at 65.71%. Only 48 patients (61 knees) consented to aspiration procedure; 47.5% had grade III effusion, and 45.9% had grade III synovitis. Successful aspiration was achieved in 77% of knees. Two needle types were used; a 22 gauge / 3.5-inch spinal needle in 44 knees and an 18 gauge/ 1.5-inch needle in 17 knees, with a success rate of 90.9% and 41.2%, respectively. Aspirated amount of synovial fluid correlated positively with effusion grade (rs=0.455, p < 0.001) and negatively with synovitis grade on US (rs = − 0.329, p = 0.01).
Conclusions
The superiority of the US over clinical examination in detecting knee effusion suggests that US should be used routinely to confirm the presence of effusion. Long needles (spinal needle) may have a higher success rate of aspiration than shorter needles.
... Acute knee pain may be caused by a traumatic mechanism of injury, resulting in ligament sprains, tendon strains or fractures. Some systemic disorders can cause an acute onset of knee pain such as seen with gout, rheumatoid arthritis or infection (Johnson, 2000). Several decision rules and clinical tests, including: American College of Radiology Appropriateness Criteria; Ottawa Knee Rule (OKR); Pittsburgh Knee Rules; red flag screening; and percussion tests with the use of a stethoscope exist to help determine if a condition requires referral for imaging in the presence of knee pain (Adams, Yarnold, and Mathews, 1988;Bachmann et al., 2003;Borgerding, Kikillus, and Boissonnault, 2007;Emparanza et al, Emparanza and Aginaga, 2001;Jenkin, Sitler, and Kelly, 2010;Konan, Zang, Tamimi, and Haddad, 2013;Smeets et al., 2018;Williams et al., 2013). ...
Background:
Evidence supports direct referral for imaging by physical therapists. Accuracy and self-efficacy for imaging decisions have not been investigated in entry-level doctor of physical therapy (DPT) students.
Objective:
The purpose of this study was to understand the relationship between entry-level DPT instruction and accuracy and self-efficacy for imaging referral due to acute knee trauma. A second purpose was to identify relationships between accuracy and self-efficacy.
Methods:
An online survey was sent via e-mail to program directors in accredited DPT programs in the United States with an invitation to forward the survey to DPT students. The survey captured demographic information and included five questions that assessed the respondent's ability to apply the Ottawa Knee Rules (OKR). Self-efficacy was assessed using the Physiotherapist Student Self-Efficacy (PSE) questionnaire, a self-rated 5-point Likert scaled tool.
Results:
Of 240 surveys, DPT students who completed imaging coursework had greater accuracy and higher self-efficacy (68.0% correct (95% CI, 63.6-72.5), PSE = 3.67, P < .001) compared to students who had not (45.8% correct (95% CI, 40.8-50.7), PSE = 2.67, P < .001). Conclusion: Accuracy by DPT students who completed imaging coursework was significantly improved and comparable to values from autonomous providers.
... The posterior capsule of the knee is described as the primary passive restraint to terminal knee extension with the hamstrings, popliteus, and gastrocnemius as adaptive contributors 13,15,37) . While all causes described for an active lag may cause a passive lag, the assumed position of comfort of knee flexion in a painful knee 38) and the avoidance of terminal knee extension in individuals who present with ACL deficient knees are other causes 39,40) . ...
[Purpose] This study aimed to determine the diagnostic utility of the sitting active and prone passive lag test in identifying terminal extension lag in unilaterally symptomatic knees. The lack of full extension at the knee leads to greater force of quadriceps activation, overloading of the weight bearing joints, abnormal gait mechanics, resulting in pain and dysfunction. [Participants and Methods] Participants were randomly assigned and evaluated by two blinded examiners, to determine the presence of extension lag at the knee. The reproducibility of test results between examiners was determined, for reliability. In addition, the ability of the test to identify the presence of extension lag in symptomatic knees and absence of extension lag in asymptomatic knees was assessed, for validity. [Results] The results revealed the test to possess an ‘almost perfect’ inter-rater reliability, high sensitivity, and moderate specificity. [Conclusion] The sitting active and prone passive lag test may be incorporated as a reliable and valid test to determine the presence of terminal knee extension lag in a unilaterally symptomatic knee population.
... However, radiographic suprapatellar effusion is nonspecific for diagnosing oTPF since it is also present in patients with overuse syndrome as well as posttraumatic ligamentous and meniscal injuries. [8] In many low-resource settings, this radiograph "normality" usually results in a discontinuation of any further radiological evaluation, despite ultrasonography being a cheap and widely available modality for further assessment. Ultrasonography may readily suggest intra-articular Jarraya et al. [2] also observed increased T2 signal intensity in the adjacent collateral ligament (associated with sprain), none of the reviewed cases reported tear, abnormal signal intensity, or protrusion in the menisci. ...
We describe a case of posttraumatic lateral tibial plateau fracture that was not demonstrated by conventional radiography. Knee joint ultrasound showed mild lateral meniscal protrusion suggestive of an intra-articular injury, which was confirmed at magnetic resonance imaging to represent an occult lateral tibial plateau fracture. A high index of suspicion for occult fractures should be maintained in posttraumatic patients with ultrasound findings of meniscal protrusion, in spite of apparently normal X-ray findings.
... Compression, instead of a distraction, follows a repetition of the process. A meniscus tear is diagnosed when a decreased rotation is associated with a more painful knee when the knee is rotated and compressed [13]. The fibrocartilaginous meniscus is essential for the musculoskeletal stability of the knee joint [14]. ...
Meniscus tears are a common orthopedic pathology and planning a single, effective treatment is challenging. The diagnosis of meniscal tears requires detailed history-taking, physical examinations, special diagnostic tests, and most likely magnetic resonance imaging (MRI) to confirm the lesion. A good understanding of the meniscal structure including vascularity, zones, function, and affected movements with associated symptoms plays a crucial role in establishing an optimal management plan. A careful assessment of the patient's characteristics, comorbidities, post-repair rehabilitation, and patient's overall function and satisfaction are also important for ideal management. While conservative management is commonly implemented and the only option for certain patients, partial meniscectomy remains to be the most performed treatment procedure. However, partial meniscectomy is no longer the first-line therapy due to the limitation of certain patient characteristics and side effects in the long run. Instead, meniscal repair has been shown to have better long-term outcomes and is therefore recommended for all tears, especially for young patients with acute traumatic lesions. Tissue engineering has been of high interest in the current research with promising therapeutic results. This review critically evaluates and compares the management of meniscal tears with surgical versus comprehensive management using the current literature.
... In the knee joint, causes of synovitis such as trauma, overuse, infections, gout, systemic causes, or changes in osteoarthritis, may cause the effusion [2,3]. However, tumors and tumor-like affections (such as chondroblastoma, osteoid osteoma, osteochondroma, synovial sarcoma, or metastatic processes) should not be overlooked [4]. Synovial fluid laboratory testing is an important part of a diagnostic evaluation of patients with joint diseases. ...
Joint effusions are most frequently caused by osteoarthritis, trauma, an infection process or an autoimmune disease. The development of joint effusion due to a tumor process is rare but should be taken into consideration in the diagnostics. Joint effusions are examined mostly by means of microbiology to rule out or confirm pyogenic synovitis. These standard processes may take up to several days. The article presented here describes a unique case of a 74-year-old female diagnosed with a generalized malignant process according to a cytological-energy analysis and an immunocytochemical examination of a malignant joint effusion caused by femoral condyle metastasis. Other widely-used imaging methods such as X-ray, full-body CT scan and also laboratory examinations confirmed the malignancy and the origin. A cytological-energy analysis and an immunocytochemical examination can expedite the diagnostic process, can outline the processes happening in the joint and can indicate further examinations and subsequent therapy. The use of these laboratory methods appears to be a helpful diagnostic option to obtain additional information about a joint effusion, including the information about an ongoing malignant process. In our case report, they helped to confirm the typing of the tumor within three days, without the need for a metastasis biopsy. In appropriate cases, synovial fluid can play a role in tumor diagnostics.
... Алгоритм дифференциального диагноза при синовите КС представлен во многих работах [9,10], в том числе в недавно опубликованной статье группы международных экспертов, одним из авторов которой является ведущий специалист по изучению ОА в России Л.И. Алексеева (см. ...
One of the primary tasks for a doctor when meeting a patient for the first time is to gain his affection and trust. It is not always possible during the first visit to make an accurate diagnosis and prescribe pathogenetic therapy, because this often requires a deep additional examination. However, it is imperative to demonstrate knowledge and confidence, provide psychological support and alleviate the suffering of the patient, especially in the case of rheumatic disease accompanied by severe pain. Such a patient should be immediately prescribed adequate analgesic therapy. The main tool for controlling pain in diseases of the joints and spine are non-steroidal anti-inflammatory drugs. Moreover, their prescription should be deliberate and balanced, taking into account the clinical picture and comorbid pathology.
The article presents two clinical observations, illustrating the formation of a diagnostic and therapeutic concept at an outpatient appointment.
... For knee injuries, when the ligament/tendon tear happens, the synovial fluid increases inside the knee joint. Specifically, it is a haematomaa mixture of blood and synovial fluid, leading to knee effusion and changes in its dielectric properties [23,24]. Therefore, EMI is investigated here as a tool that may overcome the limitations of current modalities. ...
A wearable textile brace is introduced as an electromagnetic imaging system that breaks hospital boundaries to real-time onsite scanning for knee injuries. The proposed brace consists of a 12-element textile slot loop antenna array, which is designed to match the human knee for enhanced electromagnetic wave penetration. Wool felt and conductive fabric are used to fabricate the antenna array thanks to their flexibility and proper dielectric properties. Each antenna element has a compact footprint of
and achieves unidirectional radiation, high front-to-back ratio of 14 dB, wide bandwidth of 81% at 0.7–1.7 GHz, and safe SAR levels. A modified double-stage delay, multiply, and sum (DS-DMAS) algorithm is used to process the collected signals from the antenna array based on differential left/right knee imaging. The reconstructed images numerically and experimentally on realistic phantoms demonstrate the potential of the brace system for onsite detection of different types of ligaments/tendon tears.
... Bis zu einer Leukozytenzahl von 500/μl scheinen keine klinischen Zeichen einer Arthritis vorzuliegen [13]. Allgemein wird akzeptiert, dass ab einer Leukozytenzahl von 2000/μl eine Arthritis besteht [6]. ...
Zusammenfassung
Gelenkschmerzen gehören zu den häufigsten Symptomen in der Medizin. Um Gelenkschmerzen diagnostisch einordnen zu können, ist eine Kategorisierung des Schmerzes in einen entzündlichen, nichtentzündlichen oder neuropathischen Schmerz hilfreich. Zudem muss der Schmerz einer anatomischen Struktur zugeordnet werden, da nur bei einem Schmerz, der von der Synovialmembran ausgeht, von einem Gelenkschmerz gesprochen werden kann. Für die Einordnung des Schmerzes in einen entzündlichen oder nichtentzündlichen Schmerz stehen uns methodisch die Schmerzanamnese, als bildgebende Methoden der Ultraschall und die Magnetresonanztomographie und die Entzündungsparameter zur Verfügung. In unklaren Situationen und zur Sicherung eines entzündlichen Geschehens sind eine Synoviaanalyse und eventuell die Biopsie erforderlich. Um den Ort des Schmerzgeschehens zu lokalisieren, können wir die funktionelle Untersuchung, die Sonographie, die Magnetresonanztomographie und eventuell die Röntgenuntersuchung heranziehen.
... The key factor that has a direct effect on the accuracy of any EMI system is the changes in the properties of tissues during/after injuries. For the knee, when the ligament tear happens, knee effusion occurs, the synovial fluid accumulates, changes the physical size of the knee, and its dielectric properties [31,32]. ...
A knee phantom with realistic dielectric and anatomical properties has been fabricated using proper molds and equivalent mixtures. The fabricated phantom is based on a composite material of polymer and additive materials such as aluminium-oxide, and graphite. These materials are selected to achieve high dielectric properties and realistic distribution of knee tissues in addition to long-life stability. A positive mold of muscle tissue and a negative mold of skin tissue are extracted from MRI data, whilst the positive molds for bones, tendons, ligaments, and tibia are extracted from a 1:1 commercial knee joint model. Due to a lack of data about dielectric properties of human knee ligaments in microwave frequency (0.5-10 GHz), dog's ligament tissues are characterized. The fabricated tissues of the knee phantom are stable and accurately match the dielectric properties of knee tissues across the wideband 0.5 GHz to 10 GHz. The phantom will open the door for a portable, low cost, and onsite electromagnetic imaging techniques to detect knee injuries.
... Additionally, a high index of suspicion for PJI is warranted when symptoms such as pain, redness, and swelling arise in the setting of prior total joint replacement. However, these clinical symptoms can also be seen in other conditions such as rheumatoid arthritis, gonococcal arthritis, gout, and pseudogout [11]. ...
We present a case of an 82-year-old female with a history of right total knee arthroplasty 11 years prior. She was admitted after a ground-level fall and developed progressive pain and swelling of her right knee. She had no history of complications with her total knee replacement. Radiographs of the knee and hip were negative for acute fracture, dislocation, or hardware malalignment. Knee aspiration was performed and revealed inflammatory exudate, synovial fluid consistent with crystal arthropathy, and no bacterial growth. She was diagnosed with an acute gout flare, and her symptoms significantly improved with steroids and anti-inflammatory treatment. Orthopedic surgeons should be aware of the potential for crystal arthropathy in the setting of total joint arthroplasty and evaluate for crystals before treating a presumed periprosthetic joint infection.
... 14,26 Swelling that occurs immediately (minutes to a few hours) after injury suggests a ligament rupture, intra-articular fracture, or patellar dislocation; swelling that appears within hours to a few days suggests a meniscal tear. 15,19 Atraumatic swelling with erythema or palpable warmth implies gout or pseudogout, arthritic flare, or infection. Swelling that is limited to the borders of the patella suggests prepatellar bursitis. ...
Knee pain affects approximately 25% of adults, and its prevalence has increased almost 65% over the past 20 years, accounting for nearly 4 million primary care visits annually. Initial evaluation should emphasize excluding urgent causes while considering the need for referral. Key aspects of the patient history include age; location, onset, duration, and quality of pain; associated mechanical or systemic symptoms; history of swelling; description of precipitating trauma; and pertinent medical or surgical history. Patients requiring urgent referral generally have severe pain, swelling, and instability or inability to bear weight in association with acute trauma or have signs of joint infection such as fever, swelling, erythema, and limited range of motion. A systematic approach to examination of the knee includes inspection, palpation, evaluation of range of motion and strength, neurovascular testing, and special (provocative) tests. Radiographic imaging should be reserved for chronic knee pain (more than six weeks) or acute traumatic pain in patients who meet specific evidence-based criteria. Musculoskeletal ultrasonography allows for detailed evaluation of effusions, cysts (e.g., Baker cyst), and superficial structures. Magnetic resonance imaging is rarely used for patients with emergent cases and should generally be an option only when surgery is considered or when a patient experiences persistent pain despite adequate conservative treatment. When the initial history and physical examination suggest but do not confirm a specific diagnosis, laboratory tests can be used as a confirmatory or diagnostic tool.
... Knee effusion can be classified into traumatic and non-traumatic. Non-traumatic aetiologies include degenerative arthritis, inflammatory arthritis, infection, crystal deposition and tumour [4]. There is obvious reason for knee effusion in cases of inflammatory, infectious, crystal deposition diseases and tumour cases. ...
... With a thorough history and physical examination, particularly with a history of trauma, infectious and inflammatory causes can often be ruled out. The time course of a traumatic knee effusion is also important to incorporate, as an effusion evolving within four hours of injury increases the likelihood of major osseous, ligamentous, or meniscal injury [1]. Morel-Lavallée lesions (MLL) is a rare condition presenting with superficial fluid collection between subcutaneous tissue and the superficial fascia or bone mainly caused by direct trauma. ...
Traumatic swelling/effusion in the knee region is a relatively common presenting complaint among athletes and nonathletes. Due to its broad differential diagnosis, a comprehensive evaluation beginning with history and physical examination are recommended. Knee joint effusion can be differentiated from other types of swelling by careful physical examination. Imaging, including plain radiography, ultrasound, and magnetic resonance imaging (MRI), is preferred modality. Aspiration of a local fluctuating mass may help with the diagnosis and management of some of these conditions. We present a case of a 26-year-old gentleman with superomedial Morel-Lavallée lesion (MLL) of the knee with history of a fall during a Frisbee game. His MLL was successfully treated with therapeutic aspiration and compression wrap without further sequelae. MLL is a rare condition consisting of a closed degloving injury caused by pressure and shear stress between the subcutaneous tissue and the superficial fascia or bone. Most commonly, MLL is found over the greater trochanter and sacrum but in rare cases can occur in other regions of the body. In most cases, concurrent severe injury mechanisms and concomitant fractures are present. MLL due to sports injuries are very rare. Therapeutic strategies may vary from compression wraps and aspiration to surgical evacuation.
... Areas of bone contusion in MRI that help to understand the mechanism of injury, predict and confirm the presence of capsule ligamentous injuries 9 . The most common traumatic causes of knee effusion are ligamentous, osseous and meniscal injuries, and overuse syndromes 14 . As much as the Authors know, there isn't any research about the association between fracture around knee joint, joint effusion on one hand and pattern of injury to the menisci and ligaments on the other hand. ...
Background:
magnetic resonance imaging (MRI) as a noninvasive diagnostic tool may help clinicians in the evaluation of injuries to menisci and ligaments.
Purpose:
this study assessed the associations between type of trauma to knee joint, bone bruise, fracture and pathological joint effusion with injuries to menisci and ligaments of knee joint.
Methods:
we reviewed knee joint MRI of 175 patients aged less than 45 years old who were referred to MRI center of our University.
Results:
statistical analysis showed that tearing of medial meniscus (MM) is significantly more common in sport related trauma (p= 0.045) but tearing of medial collateral ligament (MCL) is significantly more common in non-sport related trauma (p= 0.005). Existence of bone bruise in knee MRI is negatively associated with tearing of medial meniscus (MM) (p=0.004) and positively associated with tearing of anterior cruciate ligament (ACL) (p=0.00047) and medial collateral ligament (MCL) (p = 0.0001). Existence of fracture is associated with decreased risk of the tearing of ACL and MM (p=0.04, p=0.001 respectively). Pathologic joint effusion is significantly more common in ACL and MCL tearing (p=0.0001, p=0.004 respectively).
Conclusions:
as diagnostic clues, bone bruise, fracture and joint effusion may help radiologists for better assessment of injury to menisci and ligaments in MRI of patients with knee trauma.
... Joint effusion is the presence of increased intra-articular fluid 3 , which has been positively associated with knee pain in knee OA patients 4 . Joint effusion is known to be related to joint inflammation 5 and a recent study showed that occurrence of joint effusion is a strong predictor for development of incident radiographic OA 6 . ...
Objective:
To identify molecular biomarkers for early knee osteoarthritis (OA), we examined whether joint effusion in the knee associated with different gene expression levels in the circulation.
Materials and methods:
Joint effusion grades measured with magnetic resonance (MR) imaging and gene expression levels in blood were determined in women of the Rotterdam Study (N=135) and GARP (N=98). Associations were examined using linear regression analyses, adjusted for age, fasting status, RNA quality, technical batch effects, blood cell counts, and BMI. To investigate enriched pathways and protein-protein interactions, we used the DAVID and STRING webtools.
Results:
In a meta-analysis, we identified 257 probes mapping to 189 unique genes in blood that were nominally significantly associated with joint effusion grades in the knee. Several compelling genes were identified such as C1orf38 and NFATC1. Significantly enriched biological pathways were: response to stress, gene expression, negative regulation of intracellular signal transduction, and antigen processing and presentation of exogenous pathways.
Conclusion:
Meta-analyses and subsequent enriched biological pathways resulted in interesting candidate genes associated with joint effusion that require further characterization. Associations were not transcriptome-wide significant most likely due to limited power. Additional studies are required to replicate our findings in more samples, which will greatly help in understanding the pathophysiology of OA and its relation to inflammation, and may result in biomarkers urgently needed to diagnose OA at an early stage.
... 19 The effusion values observed in our volunteers were between 10 and 11 mm which indicate suspicion of pathological joint effusion. 37,38 Although no statistically significant differences were observed between the groups, an effusion reduction tendency of −5.35% (in mm) was shown after RCE intervention indicating that RCE could also have a beneficial effect on this parameter. ...
Preliminary results suggested that oral-administration of rooster comb extract (RCE) rich in hyaluronic acid (HA) was associated with improved muscle strength. Following these promising results, the objective of the present study was to evaluate low-fat yoghurt supplemented with RCE rich in HA on muscle function in adults with mild knee pain; a symptom of early osteoarthritis. Participants (n=40) received low-fat yoghurt (125 mL/d) supplemented with 80 mg/d of RCE and placebo group (n=40) consumed the same yoghurt without the RCE, in a randomized, controlled, double-blind, parallel trial over 12 weeks. Using an isokinetic dynamometer (Biodex System 4), RCE consumption, compared to control, increased affected knee peak torque, total work and mean power at 180º/s, at least 11% in men (p<0.05) with no differences in women. No dietary differences were noted. These results suggest that long-term consumption of low-fat yoghurt supplemented with RCE could be a dietary tool to improve muscle strength in men, with attendant possible clinical significance. However, further studies are needed to elucidate reasons for these sex difference response observed, and may provide further insight into muscle function.
Background
Traumatic knee injuries are challenging to diagnose accurately through radiography and to a lesser extent, through CT, with fractures sometimes overlooked. Ancillary signs like joint effusion or lipo-hemarthrosis are indicative of fractures, suggesting the need for further imaging. Artificial Intelligence (AI) can automate image analysis, improving diagnostic accuracy and help prioritizing clinically important X-ray or CT studies.
Objective
To develop and evaluate an AI algorithm for detecting effusion of any kind in knee X-rays and selected CT images and distinguishing between simple effusion and lipo-hemarthrosis indicative of intra-articular fractures.
Methods
This retrospective study analyzed post traumatic knee imaging from January 2016 to February 2023, categorizing images into lipo-hemarthrosis, simple effusion, or normal. It utilized the FishNet-150 algorithm for image classification, with class activation maps highlighting decision-influential regions. The AI's diagnostic accuracy was validated against a gold standard, based on the evaluations made by a radiologist with at least four years of experience.
Results
Analysis included CT images from 515 patients and X-rays from 637 post traumatic patients, identifying lipo-hemarthrosis, simple effusion, and normal findings. The AI showed an AUC of 0.81 for detecting any effusion, 0.78 for simple effusion, and 0.83 for lipo-hemarthrosis in X-rays; and 0.89, 0.89, and 0.91, respectively, in CTs.
Conclusion
The AI algorithm effectively detects knee effusion and differentiates between simple effusion and lipo-hemarthrosis in post-traumatic patients for both X-rays and selected CT images further studies are needed to validate these results.
Purpose of Review
Acute knee injuries are commonly encountered in both the clinical and sideline setting and may be treated operatively or non-operatively. This article describes an evidence-based approach to non-operative acute knee injury. This includes history, physical exam, imaging, and initial management. In addition, the non-operative management of three such injuries—ligament injury, meniscus injury, and patellar dislocation injury—will be discussed via a case-based practical approach.
Recent Findings
Aside from grade III ACL tears, most acute knee ligament injuries, especially in the absence of other concurrent injuries, can be treated non-operatively. There is new evidence that acute traumatic meniscus tears in those younger than 40 can be successfully treated non-operatively and can do equally, as well as those that undergo surgery, at 1 year out from injury. Based on the current literature, a short period of knee bracing in extension with progression to weightbearing to tolerance is recommended after initial patellar dislocation.
Summary
Many of the most common acute knee injuries, including MCL tears, meniscus tears, and patellar dislocations, can be managed non-operatively. A detailed systemic approach to initial evaluation, including pertinent history, physical exam, and appropriate imaging, is essential and complementary to the subsequent non-operative treatment algorithm.
Osteoarthritis (OA) is a degenerative disease that causes severe pain and reduces the range of motion of the joint, decreasing the quality of life for millions of individuals in the United States. Electromyography (EMG) sensors have been widely studied in biomechanics, showing applications in prosthetics, robotics, and control. While complex musculoskeletal models have been well established, the attempt of directly correlating EMG with kinematics and kinetics is still quite limited. Particularly, little work has been conducted on OA patients. In this work, we propose a method for estimating lower body joint angles (JAs) and ground reaction forces (GRFs) from surface-EMG sensors during a step-down task for individuals diagnosed with OA. The JAs and GRFs were measured by a Vicon motion capture system and force plates, respectively. EMG, JAs, and GRFs were used to train an echo state network (ESN) which afforded JAs with relative errors of 3.78% and 3.71% and the GRFs with relative errors of 3.619% and 4.596% for training and testing datasets, respectively. This study suggests the high fidelity of the ESN in automatically predicting full lower body kinematics and kinetics from the EMG signals. The results of this work promote the development of an EMG-controlled lower limb rehabilitation robot system for patients with OA.
Aim
Complete arthrocentesis of the effusive knee ameliorates patient pain, reduces intra-articular and intraosseous pressure, removes inflammatory cytokines, and has been shown to substantially improve the therapeutic outcomes of intra-articular injections. However, conventional arthrocentesis incompletely decompresses the knee, leaving considerable residual synovial fluid in the intra-articular space. The present study determined whether external pneumatic circumferential compression of the effusive knee permitted more successful arthrocentesis and complete joint decompression.
Methods
Using a paired sample design, 50 consecutive effusive knees underwent conventional arthrocentesis and then arthrocentesis with pneumatic compression. Pneumatic compression was applied to the superior knee using a conventional thigh blood pressure cuff inflated to 100 mm Hg which compressed the suprapatellar bursa and patellofemoral joint, forcing fluid from the superior knee to the anterolateral portal where the fluid could be accessed. Arthrocentesis success and fluid yield in mL before and after pneumatic compression were determined.
Results
Successful diagnostic arthrocentesis (≥3 mL) of the effusive knee was 82% (41/50) with conventional arthrocentesis and increased to 100% (50/50) with pneumatic compression (P = .001). Synovial fluid yields increased by 144% (19.8 ± 17.1 mL) with pneumatic compression (conventional arthrocentesis; 13.7 ± 16.4 mL, pneumatic compression: 33.4 ± 26.5 mL; 95% CI: 10.9 < 19.7 < 28.9 mL, P < .0001).
Conclusions
Conventional arthrocentesis routinely does not fully decompress the effusive knee. External circumferential pneumatic compression markedly improves arthrocentesis success and fluid yield, and permits complete decompression of the effusive knee. Pneumatic compression of the effusive knee with a thigh blood pressure cuff is an inexpensive and widely available technique to improve arthrocentesis outcomes.
Purpose
Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy.
Methods
Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention.
Results
A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis.
Conclusion
The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6–12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases.
Level of evidence
IV.
Purpose
The purposes of this study were as follows: (1) to evaluate the diagnostic testing performance of synovial WBC count, PMN%, synovial glucose, synovial protein, synovial LDH and synovial CRP levels, as diagnostic markers for diagnosis of septic arthritis after ACL reconstruction; (2) to define the ideal thresholds of the aforementioned tests, leading to the optimal sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy; (3) to define sensitivity of synovial fluid culture and synovial tissue sample culture, and if previous antibiotic treatment may affect the accuracy of these tests.
Methods
A retrospective analysis of all patients readmitted from January 2009 to September 2019 with suspicious signs of septic arthritis and undergoing a knee aspiration for synovial fluid analysis and culture was performed. ,. The receiver operating characteristic (ROC) curves and the associated area under the curve (AUC) were constructed for the aforementioned synovial markers. Sensitivity, specificity, PPV, (NPV) and accuracy were calculated for the obtained optimal values. Sensitivity was also calculated for synovial fluid culture and synovial tissue samples culture, and the influence of previous antibiotic treatments on culture sensitivity was evaluated.
Results
Out of 3,408 cases of ACL reconstruction, after excluding 13 patients not meeting the inclusion criteria, 24 infected and 14 non-infected patients were reviewed and included in the analysis. Diagnosis was confirmed by the presence of two positive cultures with the same isolated microorganism, or by at least 3 out of 4 of the following criteria: elevated serum CRP and ESR, positive histological analysis of synovial tissue, macroscopic evidence of purulence, one positive culture. The ROC curve analysis demonstrated that the most reliable marker for the diagnosis of septic arthritis after ACL reconstruction was the synovial WBC count (AUC = 0.89). A cutoff value of 28,100 cells/ml presented the highest accuracy (0.85), the highest PPV (0.94) and the highest NPV (0.76); moreover, with the threshold set at 40,000 cells/mL, postoperative infection could be diagnosed with 100% specificity. The sensitivity of synovial fluid culture was significantly lower than the sensitivity of synovial tissue samples culture (0.63 vs 0.96, p =0.0045); moreover, the sensitivity further reduced if patient took antibiotics before aspiration (0.44 vs 0.73), although this decrease was not statistically significant .
Conclusions
Synovial WBC count is the most reliable test for diagnosis of septic arthritis after ACL reconstruction. While the sensitivity of synovial fluid culture is affected by previous antibiotic treatment, synovial WBC count is not influenced, and proved to be useful in the diagnosis of this uncommon complication.
Although medical complications are rare following anterior cruciate ligament reconstruction, their impact can be significant. The two most common medical complications are postoperative infection or sepsis and thrombolic events such as deep venous thromboembolism and pulmonary embolism. The incidence of, risk factors for, and clinical course of these complications following anterior cruciate ligament reconstruction are detailed in this chapter to guide diagnosis, treatment, and prevention.
: Arthrocentesis of an acute hemarthrosis in hemophilia remains a controversial issue. The purpose of this study is to define the role that joint aspiration can play in the recovery from acute hemarthrosis in patients with hemophilia. The study sample included 33 hemophilic patients (55 joints) with acute elbow, knee, and ankle hemarthrosis as confirmed by ultrasonography. Patients were distributed into a treatment group and a control group. Patients in the first group were subjected to joint aspiration, whereas patients in the second were not. Arthrocentesis was carried out immediately after diagnosis of acute hemarthrosis in liquid phase. Patients were infused with the deficient coagulation factor and were instructed to observe relative rest until resolution of hemarthrosis. The following parameters were analyzed: time to full resolution of hemarthrosis (determined by ultrasonography), duration of treatment with the deficient coagulation factor, time to pain relief, time to recovery of prebleed range of motion, and time to resumption of school/work (all of these measured in days). The joints treated with joint aspiration exhibited a significantly faster resolution of bleeding (fewer days). In addition, this group required fewer days of pharmacological treatment, with faster achievement of functional recovery and resumption of school/work activities. No complications were observed. This study shows that joint aspiration under hemostatic cover and in strictly aseptic conditions is a well-tolerated technique that makes the recovery of acute hemarthrosis of hemophilic patients faster.
We hypothesized that constant compression of the knee would mobilize residual synovial fluid and promote successful arthrocentesis. Two hundred and ten knees with grade II–III osteoarthritis were included in this paired design study: (1) conventional arthrocentesis was performed with manual compression and success and volume (milliliters) determined; and (2) the intra-articular needle was left in place, and a circumferential elastomeric brace was tightened on the knee to provide constant compression. Arthrocentesis was attempted again and additional fluid volume was determined. Diagnostic procedural cost-effectiveness was determined using 2017 US Medicare costs. No serious adverse events were noted in 210 subjects. In the 158 noneffusive (dry) knees, sufficient synovial fluid for diagnostic purposes (≥ 2 ml) was obtained in 5.0% (8/158) without compression and 22.8% (36/158) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis fluid obtained without compression was 0.28 ± 0.79 versus 1.10 ± 1.81 ml with compression (293% increase, p = 0.0001). In the 52 effusive knees, diagnostic synovial fluid (≥ 2 ml) was obtained in 75% (39/52) without compression and 100% (52/52) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis without compression was 14.7 ± 13.8 versus 25.3 ± 15.5 ml with compression (72.1% increase, p = 0.0002). Diagnostic procedural cost-effectiveness was 387/sample with compression. The new technique of constant compression via circumferential mechanical compression mobilizes residual synovial fluid beyond manual compression improving the success, cost-effectiveness, and yield of diagnostic and therapeutic arthrocentesis in both the effusive and noneffusive knee.
Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.
Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health's PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/-nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.
Knee arthrocentesis is a relatively benign and quick procedure, commonly performed in emergency departments. There are many indications, either as a diagnostic tool (synovial fluid appearance and analysis) or as a therapeutic procedure (aspiration of tense or infected effusion, injection). There are very few contraindications to knee joint aspiration and if arthritis is suspected, arthrocentesis will play a critical role in the management of this medical emergency. Three major portals of approach to the knee joint for its aspiration or injection have been classically described: suprapatellar, midpatellar, and inferopatellar. Each peripatellar approach has a lateral or medial portal with symmetric landmarks. Among these portals of approaches, the superolateral approach seems to be the most common technique used by physicians for aspiration of knee joint effusion. This technique is simple, painless, and safe. Nevertheless, it is necessary to perform the other technique if there are local or technical contraindications.We present here the indications, the landmarks, the benefits of ultrasound guidance and the various techniques of this medical procedure.
Knee trauma and effusion are common Emergency Department presentations. This article outlines the clinician's sonographic approach to knee effusion detection and localisation. A case where lipohaemarthrosis was detected with ultrasound is demonstrated, and the characteristic appearance of this pathology discussed. The sonographic detection of the associated tibial fracture is also demonstrated.
Synovitis, presenting as a synovial effusion is common. The most common cause include tuberculosis, osteoarthritis. Here with, presenting
a rare case of monoarticular synovitis with synovial fluid and peripheral blood eosinophilia of unknown aetiology in an 18-year-old male.
We review the clinical and pathological features and impress the need for synovial fluid examination in all cases.
REVIEW Aspiration in injections: should we continue or abandon the practice? Abstract Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health's PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/-nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well. 1,2 1,3 4,5 2
Primary care physicians are being called on more frequently to treat patients who have musculoskeletal injuries. This article discusses mechanisms of injury, diagnosis, and treatment, with emphasis on determining when to refer patients to an orthopedist. Discussed here are several types of knee injuries that require referral, including extensor mechanism injuries, most subluxations and dislocations, ligament injuries, and meniscus injuries.
There are many questions concerning knee effusions and the basic diagnostic approach to them. The case of a young female with gonococcal arthritis presenting to the Emergency Room with an isolated knee effusion is discussed. From the errors in diagnosis of this case, a basic outline in the approach and work-up of a knee effusion is detailed, including history and physical examination, and the use of synovial fluid analysis as a further diagnostic aid. Procedural instructions and contraindications for knee arthrocentesis are given, as well as data related to interpretation of pertinent laboratory findings of synovial fluid in disease states.
The knee is frequently injured and affected by a variety of diseases. A precise history of injury or onset of symptoms is essential. The joint is ideally examined as soon after injury as possible. Examination should include observation of swelling, palpation of bony prominences, determination of the presence of effusion, recording of range of motion and evaluation of joint stability. Although x-ray studies constitute an important part of overall assessment, they only augment and not supplant thorough physical examination. Aspiration of joint effusion should be performed for diagnostic purposes, or to relieve pain. Arthrocentesis is indicated when effusion of uncertain etiology is present.
Findings of an early arthroscopy performed in 108 consecutive hemarthrotic and clinically stable knees were analyzed. The patients were young conscripts, the mean age being 19.9 years. Fifty-seven of the knees were injured during military training, 36 in different sports activities, 9 at falls, and 6 in motorbike accidents. The lesions were divided into "primary" (lesions needing operative treatment or the supposed most common lesions in incidence) and "secondary" (other lesions). An average of 1.6 lesions were observed per knee. Dislocation of the patella was the most common diagnosis in 38 (35%) cases. Dislocation of the patella was associated with military exercise (p < 0.001). Lesions of the anterior cruciate ligament (ACL) were observed in 37 (34%) cases. ACL ruptures were related to sport activities (p < 0.0001).
We describe the case of a patient with breast cancer who developed bilateral malignant knee effusions, and review the English language literature. Patients with solid tumors who develop malignant joint effusions are rare; 27 cases have been reported (including our patient). The knee is the predominant site of joint involvement (p < 0.001). Synovial fluid (SF) analysis often demonstrates noninflammatory bloody effusion. Synovial biopsy was positive in 11 of 16 cases in which it was performed. SF cytology was positive in one half of cases in which it was obtained. Arthritis secondary to metastasis is a poor prognostic finding. A strong clinical suspicion is necessary to make the diagnosis; SF cytology or synovial biopsy can confirm it.