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Ostenil plus injection of the knee – Rob Mast, Extended Scope Physio and MSK Sonographer

This was a very interesting case involving an Ostenil plus injection of the knee.

This patient had previously suffered several traumas to his left knee. When he was only 15 years of age 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. I guess these radical procedures were not unheard of in those days and at the time menisci were not seen as very important for appropriate function of the knee.

When he was older in his twenties 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.

Knee x-ray demonstrating OA changes
Figure 1: Knee x-ray demonstrating OA changes

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.

 Figure 2: Approach for this ultrasound guided injection
Figure 2: Approach for this ultrasound guided injection

 

The procedure was uneventful. I reviewed him one month post injection and he said that he was virtually pain free. He was again seen by one of my colleagues in September this year (one year later) and said that he had been pain free for at least 6 months post injection and then had a gradual worsening of symptoms and (stiffness and pain) but still not to its previous levels. He received another Ostenil plus injection from my colleague and opted to contact us if and when symptoms worsen. So far he has not contacted us.

As always, please provide feedback to [email protected]

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