This patient had previously suffered several traumas to his left knee. When he was a teenager he had some knee pain which he attributed to playing football. The Orthopaedic surgeon at the time felt it was due to a meniscal tear and recommended complete removal of the menisci in his knee. He agreed and he had open surgery to remove both menisci.
When he was older he was also involved in an RTA and fractured this same leg. He recovered well but always had some restriction and intermittent pain in the knee. He was a fairly stoic type of person and also believed that exercise was important in maintaining good knee function. He started attending the gym in order to keep the knee as strong as possible. He regularly ran short distances on the treadmill. Perhaps surprisingly given the degree of osteoarthritis as shown on X-ray (Figure 1) he was still fairly functional and relatively speaking his pain was manageable.
He had no pain at rest. His range of motion was very limited with flexion being not much more than 90 degrees and extension was -15 degrees. He was keen to avoid a knee replacement which had been suggested to him many times before.
On the face of it he would be an unlikely candidate for hyaluronic acid injections as most of the evidence for its efficacy is for its use in mild to perhaps moderate osteoarthritis. Synovial fluid, which is viscoelastic due to the presence of hyaluronic acid, is found in all synovial joints, particularly the large weight bearing joints, where it ensures normal, painless movement due to its lubricating and shock-absorbing properties. It is also responsible for the nutrition of the cartilage. In degenerative joint disorders such as osteoarthritis, the viscoelasticity of the synovial fluid is markedly reduced thereby decreasing its lubricating and shock-absorbing functions. However as his function was more of a problem (stiffness of the knee and reduced walking distance etc) rather than the pain it was worth a try, prior to considering surgical options
I performed the injection of Ostenil Plus with the use of ultrasound guidance (see below) with a Sonosite M-Turbo with beam steer. The injection was in itself less than straight forward due to the obstruction of the medial access point to the knee due to large osteophytes at the medial patello-femoral joint. The only way to effectively gain access to the joint was through the effusion which was visible in supra-patellar recess and then point the needle in the distal direction over the medial condyle (see Figure 2) towards the centre of the knee. This demonstrates the benefit of using ultrasound to help ensure a comfortable and effective injection. It also often leads to a quicker procedure.
The procedure was uneventful. I reviewed him one month post injection and he said that he was virtually pain free.
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