The Ultrasound-guided Anteromedial Joint Line Approach: A Targeted Corticosteroid Injection Technique for Patients With Medial Knee Pain.

BACKGROUND: Medial knee pain is a common complaint in the adult population. When conservative measures fail, intraarticular knee corticosteroid injections are often offered through the superolateral approach into the suprapatellar recess to provide short-term relief. However, some patients fail to respond and require alternative approaches. The anteromedial joint line (AMJL) approach, which targets the medial compartment, may be more effective when pain-generating pathologies such as synovitis are located in the medial compartment. To date, there have been no dedicated studies evaluating ultrasound-guided (USg) corticosteroid injections through the AMJL approach to reduce medial knee pain. OBJECTIVES: The current study aims to assess the clinical characteristics, ultrasound findings, and clinical outcomes for patients with medial knee pain who received USg corticosteroid injections via the AMJL approach. STUDY DESIGN: Retrospective study. SETTING: This study took place at one academic musculoskeletal ultrasound clinic at an urban tertiary care center. METHODS: Sixty-five patients (76 knees; 11 patients with bilateral injections) with medial knee pain who had received USg-AMJL corticosteroid injections from January 2016 through  March 2020 were reviewed for inclusion. Baseline demographic information and clinical characteristics from one year prior to 6 months following USg-AMJL injection were analyzed for each patient. Responders were defined as those who reported pain relief, decreased usage of analgesic medications, or increased physical activity. Nonresponders  were defined as those not meeting any of the responder endpoints. RESULTS: Within one year prior to receiving a USg-AMJL injection, 51.3% (39/76 knees) had attempted superolateral knee injections without relief. Immediately following a USg-AMJL injection, 98.7% (75/76) experienced symptomatic relief. Follow-up visits took place on average at 11 weeks postinjection with 92.3% (60/65 patients) responding positively. In comparison to the responder group, the nonresponder group had a significantly older mean age (P = 0.009), lower mean body mass index (P = 0.007), and higher burden of morbidities as measured by the Charlson Comorbidity Index (P = 0.044). One patient reported a steroid flare within one week of injection. The most common diagnoses contributing to medial knee pain for these patients were osteoarthritis, medial meniscal injury, crystal arthropathy, and medial collateral ligament injury, which were supported by point-of-care ultrasound findings. LIMITATIONS: This study was limited by its sample size and retrospective observational design. CONCLUSIONS: USg AMJL injection is a safe and effective procedure for targeting medial knee pain, particularly in the settings of obesity and prior failed superolateral and suprapatellar knee injections. Further investigation is required to assess long-term clinical outcomes of this injection approach.

Similar Functional Gains Using Radial Versus Combined Shockwave Therapy in Management of Plantar Fasciitis.

Plantar fasciitis is a common condition that causes foot pain. While shockwave therapy has been shown to provide successful results, comparative outcomes from different forms of shockwave therapy have yet to be described for this condition. In this retrospective cohort study, we describe findings from a quality improvement initiative assessing safety and functional outcomes for patients with plantar fasciitis treated with radial shockwave therapy (n = 20) or radial and focused shockwave therapy (combined shockwave, n = 18). Most were runners (n = 31, 81.6%), mean age was 43.3 ± 12.9 years, and average symptom duration 12.1 ± 11.1 months. All patients were prescribed an exercise program focusing on foot intrinsic strengthening. We hypothesized both groups would have improvement in function using the foot and Ankle Ability Measure, with a similar safety profile. Both radial and combined groups received similar number of total treatments (4.9 ± 2.5 and 4.1 ± 2.4, respectively; p = .33). Within group score changes for the Activities of Daily Living and Sports subscales were observed for both the radial (16.5 ± 16.3, p < .001; 31.7 ± 23.1, p < .001) and combined groups (19.8 ± 10.8, p = .001; 26.0 ± 21.5, p = .003). There was no difference in proportion of patients meeting the minimal clinically important difference between radial and combined groups regarding the Activities of Daily Living (14 (70%) vs 14 (77.8%), p = .58) and Sports subscales (17 (85%) vs 12 (75%), p = .45). Collectively, these findings suggest that a majority of patients with chronic plantar fasciitis may achieve functional gains using either form of shockwave therapy.

Defining the Resident Continuity Clinic Panel Along Patient Outcomes: a Health Equity Opportunity.

BACKGROUND: Continuity clinics are a critical component of outpatient internal medicine training. Little is known about the population of patients cared for by residents and how these physicians perform. OBJECTIVES: To compare resident and faculty performance on standard population health measures. To identify potential associations with differences in performance, specifically medical complexity, psychosocial vulnerability, and rates of patient loss. SETTING AND PARTICIPANTS: Large academic primary care clinic caring for 40,000 patients. One hundred ten internal medicine residents provide primary care for 9,000 of these patients; the remainder are cared for by faculty. STUDY DESIGN: Descriptive analysis using review of the medical record and hospital administrative data. MAIN MEASURES: We compared resident and faculty performance on standard population health measures, including cancer screening rates, chronic disease care, acute and chronic medical complexity, psychosocial vulnerability, and rates of patient loss. We evaluated the success of resident transition by measuring rates of kept continuity visits 18 months after graduation. KEY RESULTS: Performance on all clinical outcomes was significantly better for faculty compared to residents. Despite similar levels of medical complexity compared to faculty patients, resident patients had significantly higher levels of psychosocial vulnerability across all measured domains, including health literacy, economic vulnerability, psychiatric illness burden, high-risk behaviors, and patient engagement. Resident patients experienced higher rates of patient loss than faculty patients (38.5 vs. 18.8%) with only 46.5% of resident patients with a kept continuity appointment in the practice 18 months after graduation. CONCLUSIONS: In this large academic practice, resident performance on standard population health measures was significantly lower than faculty. This may be explained in part by the burden of psychosocial vulnerability of their patients and systems that do not effectively transition patients after graduation. These findings present an opportunity to improve structural equity for these vulnerable patients and developing physicians.

Meta-analysis of the accuracy of termination of resuscitation rules for out-of-hospital cardiac arrest.

BACKGROUND: Our objective was to perform a systematic review of studies reporting the accuracy of termination of resuscitation rules (TORRs) for out-of-hospital cardiac arrest (OHCA). METHODS: We performed a comprehensive search of the literature for studies evaluating the accuracy of TORRs, with two investigators abstracting relevant data from each study regarding study design, study quality and the accuracy of the TORRs. Bivariate meta-analysis was performed using the mada procedure in R. RESULTS: We identified 14 studies reporting the performance of 9 separate TORRs. The sensitivity (proportion of eventual survivors for whom the TORR recommends resuscitation and transport) was generally high: 95% for the European Resuscitation Council (ERC) TORR, 97% for the basic life support (BLS) TORR and 99% for the advanced life support (ALS) TORR. The BLS and ERC TORR were more specific, which would lead to fewer futile transports, and all three of these TORRs had a miss rate of ≤0.13% (defined as a case where a patient is recommended for termination but survives). The pooled proportion of patients for whom each rule recommends TOR was much higher for the ERC and BLS TORRs (93.5% and 74.8%, respectively) than for the ALS TORR (29.0%). CONCLUSIONS: The BLS and ERC TORRs identify a large proportion of patients who are candidates for termination of resuscitation following OHCA while having a very low rate of misclassifying eventual survivors (<0.1%). Further prospective validation of the ERC TORR and direct comparison with BLS TORR are needed.