Severe Adverse Effect after Intra-articular Injection of Hyaluronate in Osteoarthritis: A case report

Osteoarthritis of the knee is a common cause of disability in the aging population. Traditional nonoperative treatment options include exercise, physical therapy, weight reduction, nonsteroidal antiinflammatory drugs, analgesics and corticosteroid injection. In recent years, intra-articular injection of hyaluronate-derived products has gained popularity as a palliative modality for the treatment of osteoarthritis of the knee. The common adverse reaction are mild pain or swelling at the site of injection that may occur up to 20% of patients. Severe local inflammation, warmth and joint effusion are rare and no systemic complication have been reported, to our knowledge. We presented one case in which synovial inflammation was observed following intra-articular injection of the knee.

The Changes of Markers of Bone Metabolism and Bone Mineral Densities in Patients with Spinal Cord Injury

OBJECTIVE: In patients with spinal cord injury, it is more susceptible to osteoporosis because bone resorption is more prominent than bone formation. Thus we evaluated the change of biochemical markers and bone mineral densities (BMDs) according to the duration of injury, the spinal cord injury level, and the injury severity. METHOD: The subjects were included 26 patients with spinal cord injury and 22 healthy men. We measured serum osteocalcin and urine deoxypyridinoline (DPYD) in 2 hours after awakening and measured BMDs in lumbar vertebrae, femur, and distal forearm in patients and control group. The patients were 21 men, 5 women, mean age 43.2+/-14.3 years, and mean duration 28.3+/-45.0 months, who were divided by injury level and injury severity respectively. RESULTS: The biochemical markers of bone metabolism in patients group had significant differences comparing to control group (p<0.05). The urine DPYD and BMDs in femur showed significantly negative correlation with the duration of spinal cord injury (p<0.05). CONCLUSION: In patients with spinal cord injury, urine DPYD and BMDs in femur had significant correlation with the duration of injury. But, the injury level and injury severity had no significant correlation with the markers of bone metabolism and BMDs.

The Abnormal Ultrasonographic Findings of Carpal Tunnel in Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to find out what was the diagnostic usefulness of ultrasonography in carpal tunnel syndrome METHOD: Subjects included 30 hands of 25 carpal tunnel syndrome patients and 20 hands of 17 healthy adults with no electrophysiologic evidence of carpal tunnel syndrome. All subjects were examined with real-time ultrasonography. The ultrasonography was evaluated quantitatively with regard to the cross-sectional area and the flattening ratio of the median nerve and the palmar displacement of the flexor retinaculum. The analysis of difference between normal control group and carpal tunnel syndrome group was done by independent t-test. RESULTS: The carpal tunnel syndrome patients group had significantly increased cross-sectional area of the median nerve at distal radio-ulnar joint, pisiform and hamate. The carpal tunnel syndrome patients group had significantly increased flattening ratio of median nerve at hamate. The carpal tunnel syndrome patients group had significantly increased palmar displacement of the flexor retinaculum. CONCLUSION: Based on the result of this study, the ultrasonography is useful in the diagnosis of the carpal tunnel syndrome.

The Effect of an Epidural Corticosteroid Injection on the Early Stage of Bone Metabolism

OBJECTIVE: The purpose of this study is to find out what is the effect of epidural corticosteroid injection on bone metabolism. METHOD: We have assessed the systemic effects of a single epidural triamcinolone acetonide injection on biochemical indices of bone formation and resorption in patients with lumbosacral radiculopathy. Twenty patients who had lumbosacral radiculopathy and free from exposure to corticosteroid for at least 6 weeks were selected for this study. Patients were classifed as two groups; 1) epidural block with 2% lidocaine 3 ml and 0.9% normal saline 15 ml (4 men, 5 women; mean age 47.2+/-7.6 years) and 2) combination of triamcinolone acetonide 40 mg (5 men, 6 women; mean age 49.6+/-8.2 years). Fasting serum and the second voided urine were collected at 0, 1, 3, 7 and 14 days after the single epidural injection for bone-related biochemicalmarkers measurements. RESULTS: 1) Level of serum osteocalcin showed a significant time trend in the epidural corticosteroid injection group. Osteocalcin decreased dramatically from 11.2+/-3.4 ng/ml on day 0 to 5.9+/-2.8 ng/ml on day 1, 6.1+/-1.5 ng/ml on day 3 (p<0.05). After the initial drop, the level recovered to 9.8+/-3.7 ng/ml by day 7, and returned to preinjection level on day 14, at 10.9+/-4.1. 2) Urinary deoxypyridinoline levels did not show any significant changes. CONCLUSION: According to the above results, the epidural injection of corticosteroid may be a better therapeutic mode, with less potential for harmful effects to bone metabolism, in providing effective relief of symptoms to patients with lumbosacral radiculopaties.

Spontaneous Intraperitoneal Hemorrhage in a Cervical Spinal Cord Injured Patient with Warfarin Therapy: A Case Report

Spontaneous intraperitoneal hemorrhage in the patient who has cervical spinal cord injury and been treated by warfarin, is rarely reported. In general, adverse drug reactions of warfarin were reported as bleeding, cutaneous microvascular thrombosis. A 46-year-old C4 tetraplegia (ASIA A) patient had been treated by warfarin for a treatment and prevention of pulmonary embolism after cardiopulmonary resuscitation. Suddenly, the patient complained dyspnea and abdominal distension and we noticed that his hemoglobin count was very much lower than usual. So, we had the patient to take the abdominal CT and find out there was a bleeding in intraperitoneal area. We did angiography trying to find out the bleeding focus but in vain. We concluded that it was the spontaneous intraperitoneal hemorrhage due to warfarin therapy and we finally made an improvement with the conservative treatment.