Superficial Vein Thrombosis After Intra-articular Particulate Steroid Injection for Knee Osteoarthritis

ABSTRACT

Intra-articular steroid injections for knee osteoarthritis are a routine procedure in musculoskeletal clinics. While their role in osteoarthritis care is debatable, they serve as an important therapeutic option to relieve osteoarthritis-associated pain. Potential risks are self-limited (increased pain flare, local skin irritation, flushing, insomnia) or severe (septic arthritis, intravascular medication placement, and the deleterious effect on cartilage and bone). In our experience, more serious adverse events are rare. In this case, we present a complication secondary to intra-articular steroid administration that has not previously been reported in the literature: superficial vein thrombosis. This will raise awareness among clinicians, improve the informed consent process, and provide an approach for the management of subsequent injections.

The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment

BACKGROUND

Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology.

METHODS

In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved.

RESULTS

The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment.

CONCLUSION

This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.

Standard of care for lipedema in the United States

Background

Lipedema is a loose connective tissue disease predominantly in women identified by increased nodular and fibrotic adipose tissue on the buttocks, hips and limbs that develops at times of hormone, weight and shape change including puberty, pregnancy, and menopause. Lipedema tissue may be very painful and can severely impair mobility. Non-lipedema obesity, lymphedema, venous disease, and hypermobile joints are comorbidities. Lipedema tissue is difficult to reduce by diet, exercise, or bariatric surgery.

Methods

This paper is a consensus guideline on lipedema written by a US committee following the Delphi Method. Consensus statements are rated for strength using the GRADE system.

Results

Eighty-five consensus statements outline lipedema pathophysiology, and medical, surgical, vascular, and other therapeutic recommendations. Future research topics are suggested.

Conclusion

These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals.

Trimers Conjugated to Fibrin Hydrogels Promote Salivary Gland Function

New strategies for tissue engineering have great potential for restoring and revitalizing impaired tissues and organs, including the use of smart hydrogels that can be modified to enhance organization and functionality of the salivary glands. For instance, monomers of laminin-111 peptides chemically conjugated to fibrin hydrogel (L_1pM-FH) promote cell cluster formation in vitro and salivary gland regeneration in vivo when compared with fibrin hydrogel (FH) alone; however, L_1pM-FH produce only weak expression of acinar differentiation markers in vivo (e.g., aquaporin-5 and transmembrane protein 16). Since previous studies demonstrated that a greater impact can be achieved when trimeric forms were used as compared with monomeric or dimeric forms, we investigated the extent to which trimers of laminin-111 chemically conjugated to FH (L_1pT-FH) can increase the expression of acinar differentiation markers and elevate saliva secretion. In vitro studies using Par-C10 acinar cells demonstrated that when compared with L_1pM-FH, L_1pT-FH induced similar levels of acinar-like cell clustering, polarization, lumen formation, and calcium signaling. To assess the performance of the trimeric complex in vivo, we compared the ability of L_1pM-FH and L_1pT-FH to increase acinar differentiation markers and restore saliva flow rate in a salivary gland wound model of C57BL/6 mice. Our results show that L_1pT-FH applied to wounded mice significantly improved the expression of the acinar differentiation markers and saliva secretion when compared with the monomeric form. Together, these positive effects of L_1pT-FH warrant its future testing in additional models of hyposalivation with the ultimate goal of applying this technology in humans.

Diagnostic approach to lower limb edema

Patients with lower limb edema are frequently referred to vascular specialists for evaluation. Multiple etiologies must be considered and often more than one cause may be present. Notably, the role of lymphatic system regardless of the underlying pathology has been underestimated. A thorough history and physical examination and a carefully considered laboratory and imaging evaluation are critical in differentiating causes. In this opinion article, we propose a diagnostic algorithm that incorporates a systematic approach to the patient with leg swelling and provides an efficient pathway for the differential diagnosis for this problem.

Cutaneous Manifestations of Chronic Vascular Disease

In the contemporary era of medical diagnosis via sophisticated radiographic imaging and/or comprehensive serological testing, a focused physical examination remains paramount in recognizing the cutaneous manifestations of chronic vascular disease. Recognition of the unique cutaneous signs of lymphatic and venous hypertension assists in the diagnosis as well as the staging and classification of both lymphedema and chronic venous insufficiency. Awareness of explicit dermatologic vasomotor manifestations aids not only in the identification of acrocyanosis, Raynaud phenomenon, pernio, and erythromelalgia but also mitigates confusion related to their clinical overlap. Although the clinical signs of peripheral artery disease are not necessarily specific or sensitive, a knowledge of suggestive dermatologic findings is helpful in recognition of severe limb ischemia. A brief review of the epidemiology, etiology, pathogenesis, and therapy of cutaneous related chronic vascular disease follows including an emphasis on characteristic clinical features supported by illustrative photographs.

Pseudocellulitis Need Not be Benign: Three Cases of Superficial Migratory Thrombophlebitis with "Negative" Venous Duplex Ultrasonography

Trousseau syndrome is a rare phenomenon in cancer patients characterized by superficial migratory thrombophlebitis. In this brief report, the authors describe three recent case presentations of patients without a prior history of cancer who were treated for cellulitis prior to be admitted to the hospital. All three patients were found to have "negative" testing on venous duplex scanning. Communication with the technicians and additional clinical and laboratory evaluations confirmed Trousseau syndrome as well as an underlying hematologic cancer in each patient. Dermatologists should be aware of the diagnostic limitations in the venous duplex scanning, especially when evaluating superficial veins or areas overlying pain, and should recognize the importance of communicating with the technician performing the procedure.

Acute right lower extremity iliofemoral deep venous thrombosis secondary to an anomalous inferior vena cava: a report of two cases

A congenital anomaly of the inferior vena cava is an increasingly identified risk factor for iliocaval deep venous thrombosis in young patients. We present two cases of acute right lower extremity iliofemoral deep venous thrombosis in 16 and 18-year-old patients that were ultimately diagnosed with an underlying anomalous iliocaval venous system. In one patient, the inferior vena cava was congenitally absent and the right iliac vein was diffusely stenotic with a proximally located high-grade stricture. In the other subject, the infrarenal inferior vena cava and right iliac vein were diffusely hypoplastic. Compensatory venous flow in both subjects was via large perilumbar venous collateral veins and a prominent azygous system. Both patients were successfully treated with a combination of initial catheter-directed thrombolysis followed by balloon angioplasty and venous stent placement.

Livedo reticularis and related disorders

OPINION STATEMENT

Livedo reticularis is a violaceous mottling of the skin with a "fishnet" reticular appearance. Primary and secondary etiologies exist, including a pathologic variant termed livedo racemosa. No evidence-based medicine exists to guide therapy for this disorder, but most patients with primary and secondary livedo reticularis are asymptomatic and do not require treatment. In the rare instance that a patient with primary livedo reticularis experiences mild symptoms such as episodic numbness and tingling, avoidance of cold and vasoconstricting substances should be encouraged. Lastly, judicious dosing of a vasodilator such as a calcium channel blocker can be prescribed. Patients with secondary livedo reticularis or livedo racemosa may benefit from these same therapeutic suggestions; however, treating the proximate cause of livedo with a systemic association is encouraged and is most likely to yield cutaneous improvement. Although antiplatelet and/or anticoagulant therapy is often required when treating a patient with the antiphospholipid antibody syndrome or Sneddon's syndrome, the attendant livedo racemosa typically remains unchanged or progresses despite this treatment.

A Second Case of Sunitinib-associated Pyoderma Gangrenosum

Pyoderma gangrenosum is a painful, noninfectious, ulcerative, cutaneous disorder that most commonly affects the lower extremities. The diagnosis is made by recognizing the characteristic clinical manifestations in the setting of a causative systemic disease and excluding other causes of similar-appearing ulcerations. Pyoderma gangrenosum often evolves in the setting of systemic illnesses, such as inflammatory bowel disease, rheumatological disorders, and hematological conditions. However, several medications have rarely been linked to pyoderma gangrenosum. The authors report the second case of sunitinib-associated pyoderma gangrenosum in a 61-year-old patient with recurrent renal cell carcinoma.

Atypical ischemic lower extremity ulcerations: a differential diagnosis

Severe peripheral artery disease (PAD) is the predominant cause of ischemic ulcerations involving the lower extremities. PAD-associated ulcerations are typically distally located involving the feet, toes, and sometimes the calves. In contradistinction, atypical ischemic ulcerations of the lower extremity are often non-atherosclerotic in etiology, involve the proximal leg (thigh/buttocks), can evolve despite palpable distal pulses, and may coexist with other cutaneous aberrations (e.g. macules, purpura, nodules, and livedo reticularis). A differential diagnosis of atypical ischemic ulcerations involving the legs is presented.

Pharmacologic treatment for intermittent claudication

In contradistinction to chronic critical limb ischemia, the peripheral arterial disease patient with intermittent claudication is at relatively low risk for limb loss. As a result, initial claudication management should employ non-interventional therapies rather than immediate catheter-based or surgical revascularization. Although exercise therapy is the most efficacious conservative treatment for claudication, supervised exercise programs are not widely available at present. Consequently, a pharmacologic agent can be utilized to lessen the symptoms and improve the function of the claudicant. This manuscript provides a comprehensive review of the various pharmacotherapies that have been investigated for improving walking distance in the setting of intermittent claudication. Cilostazol, a phosphodiesterase III inhibitor, appears to provide the greatest benefit, significantly improving not only walking distance but quality of life as well. Early trials indicate that propionyl-L-carnitine, oral prostaglandins, L-arginine, and therapeutic angiogenesis may eventually yield significant benefit in lessening the symptoms of intermittent claudication.

Successful pharmacologic treatment of lower extremity ulcerations in 5 patients with chronic critical limb ischemia

BACKGROUND

Ischemic ulcerations of the distal lower extremities are a manifestation of chronic critical limb ischemia. Without restoration of arterial flow, subsequent gangrene and limb loss can ensue. Unfortunately, revascularization is not always possible.

METHODS

A literature search of MEDLINE was performed and a case series of 5 patients with lower extremity ischemic ulcerations is described.

RESULTS AND CONCLUSION

Five patients with severe peripheral artery disease had nonhealing lower extremity ischemic ulcerations. Because 3 patients were not ideal candidates for percutaneous or surgical intervention, and 2 refused invasive therapy, they were treated with cilostazol. Between 7 and 24 weeks after beginning cilostazol therapy, the ulcerations healed in all 5 patients. Three of the patients experienced resolution of concurrent ischemic rest pain. One patient underwent a posttreatment noninvasive arterial study that documented improved large- and small-vessel perfusion. The antiplatelet, antithrombotic, and vasodilatory effects, in addition to possible unrecognized actions of cilostazol, appeared to promote wound healing in this small group of patients with chronic critical limb ischemia. When revascularization is not ideal therapy for ischemic ulcers, a pharmacologic approach with cilostazol might induce healing and obviate limb amputation.

Three cases of digital ischemia successfully treated with cilostazol

Three patients were evaluated for refractory digital ischemia. The first patient presented with chronic, post-traumatic, unremitting, cold, painful, right fourth and fifth fingers. The symptoms had failed to improve despite topical nitroglycerin and a calcium channel blocker. Baseline digital plethysmography documented impaired perfusion within the affected digits. Cilostazol (Pletal) was added to the medical regimen and at the 8-week follow-up the fourth and fifth fingers were warm with repeat plethysmography displaying normal perfusion. A second patient had CREST syndrome-associated painful bilateral index finger ulcerations that had evolved despite taking a calcium channel blocker. Consequently the patient was started on cilostazol and within 4 weeks the digital ulcerations and pain had resolved. The third patient with traumatic right fifth digital arterial thrombosis was seen for persistent pain and cyanosis in spite of undergoing thrombolysis and subsequent anticoagulation with vasodilator therapy. Digital plethysmography established fixed ischemia within the fifth finger; subsequently, cilostazol was prescribed. Four weeks later the digital pain and cyanosis had essentially resolved. A follow-up plethysmographic waveform documented restored perfusion. Although approved for the treatment of intermittent claudication, cilostazol was successfully utilized in the setting of severe digital ischemia.

Phenanthrene degradation in soils co-inoculated with phenanthrene-degrading and biosurfactant-producing bacteria

Contaminant sorption within the soil matrix frequently limits biodegradation. However, contaminant bioavailability can be species-specific. This study investigated bioavailability of phenanthrene (PHE) to two PHE-degrading bacteria (Pseudomonas strain R and isolate P5-2) in the presence of rhamnolipid biosurfactant and/or a biosurfactant-producing bacterium, Pseudomonas aeruginosa ATCC 9027. Pseudomonas strain R mineralized more soil-sorbed PHE than strain P5-2, but in aqueous cultures the rate and extent of PHE mineralization by P5-2 exceeded that by P. strain R. In Fallsington sandy loam (fine-loamy, mixed, active, mesic Typic Endoaquult) (high PHE-sorption capacity) the addition of rhamnolipid increased PHE mineralization by P. strain R. Phenanthrene mineralization in soils inoculated with P5-2 was minimal and no enhancement in PHE degradation was observed when biosurfactant was added. Co-inoculation of Fallsington sandy loam with the biosurfactant producer did not affect PHE mineralization by isolate P5-2, but significantly enhanced PHE mineralization by P. strain R. The enhancement of PHE mineralization could not be explained by P. aeruginosa-mediated PHE degradation. The addition of rhamnolipid at concentrations above the critical micelle concentration (CMC) resulted in enhanced PHE release from test soils. These results suggest that the PHE-degrading strains were able to access different pools of PHE and that the biosurfactant-enhanced release of PHE from soils did not result in enhanced biodegradation. The results also demonstrated that bacteria with the catabolic potential to degrade sorbed hydrophobic contaminants could interact commensally with surfactant-producing strains by an unknown mechanism to hasten the biodegradation of aromatic hydrocarbons. Thus, understanding interactions among microbes may provide opportunities to further enhance biodegradation of soil-bound organic contaminants.

Calciphylaxis: a favorable outcome with hyperbaric oxygen

A 66-year-old female with diabetes mellitus and end-stage renal disease presented with painful bilateral lower extremity livedo reticularis and necrotic ulcerations. Her distal lower extremity pulses were intact and plethysmographic studies confirmed relatively normal large vessel arterial perfusion. Extensive laboratory analysis was remarkable for an elevated calcium x phosphorous product and parathyroid hormone level. An ulcer biopsy revealed small vessel medial calcinosis, and calciphylaxis was subsequently diagnosed. Despite aggressive wound debridements, antibiotics and subtotal parathyroidectomy, her ulcers failed to improve significantly prompting a trial of hyperbaric oxygen therapy. After 7 weeks of hyperbaric treatments, her ulcers had essentially healed.

Ultrasound-guided compression closure of postcatheterization pseudoaneurysms during concurrent anticoagulation: a review of seventy-seven patients

PURPOSE

Data from our institution and elsewhere have demonstrated that ultrasound-guided compression closure (UGCC) is an effective method of treating postcatheterization pseudoaneurysms. Whereas patients receiving anticoagulation do not have as high a success rate as those not receiving anticoagulants, there have been no large series evaluating the factors associated with success or failure in patients receiving anticoagulation. The purpose of this study is to determine whether uninterrupted anticoagulation interferes with successful UGCC of pseudoaneurysms and to identify factors associated with success or failure.

METHODS

From May 1991 to September 1994, 238 cases of attempted UGCC of pseudoaneurysms were performed in our vascular laboratory. Only patients who received uninterrupted heparin, warfarin, or both at the time of pseudoaneurysm compression were eligible for inclusion into the study. Seventy-seven patients were identified who met the study criteria.

RESULTS

Successful pseudoaneurysm compression was obtained in 56 (73%) patients, whereas 21 (27%) patients had a failed UGCC. In the successfully treated group, seven (12.5%) required between two to three compression attempts to induce sustained thrombosis. There was no statistical difference in age, sex, sheath size, days after procedure, location of pseudoaneurysm, or number of chambers in the pseudoaneurysm between those patients who had a successful repair and those who did not. If the pseudoaneurysm was less than 4 cm in diameter, 51 of 65 patients (78%) had a successful repair compared with 5 of 12 patients (42%) with a pseudoaneurysm of 4 cm or greater (p = 0.013). There was no statistical difference between success and failure in patients receiving warfarin alone (3.73 mean international normalized ratio, 72% success rate), heparin alone (mean activated partial thromboplastin time of 63 seconds, 92% success rate), or heparin and warfarin (mean activated partial thromboplastin time of 70 seconds, mean international normalized ratio of 4, success rate of 67%). No arterial or venous thrombosis occurred during pseudoaneurysm compression.

CONCLUSION

Successful UGCC of pseudoaneurysms occurred in a large percentage of patients receiving full-dose, uninterrupted anticoagulation. The only factor influencing success was the size of the pseudoaneurysm.

Flashlamp-excited dye laser therapy of idiopathic vulvodynia is safe and efficacious

OBJECTIVE

The management of chronic vulvovaginal pain, not explicable on specific histologic grounds, presents a major problem in referral centers for lower genital tract diseases.

STUDY DESIGN

This article reports on a two-step protocol in a sample of 175 medical nonresponders, drawn from a 2-year cohort of 725 women with vulvovaginal pain. The first maneuver was the use of a flashlamp-excited dye laser to selectively photocoagulate symptomatic subepithelial blood vessels in 168 women; the second was the microsurgical removal of chronically painful Bartholin's glands in 52 women not responsive or not suited to flashlamp-excited dye laser photothermolysis.

RESULTS

Dye laser response rates were independent of whether patients manifested macroscopic foci of painful erythema ("vestibular adenitis") or just colposcopically apparent hyperemia-ectasia of the individual blood vessels ("pruritic papillomatosis") (56% vs 45% after a single surgical procedure; 76% vs 65% after serial retreatment; p not significant). Conversely, response rates were much lower among women in whom pressure on the Bartholin's glands produced sharp, lancinating pain (15% vs 66% after a single surgical procedure; 22% vs 93% after serial retreatment; p < 0.001). Forty-two (85%) of 50 patients with flashlamp-excited dye laser failure had deep pain; however, the impasse to progress was broken by gland removal. Final response rates were 92.5% (complete response 62%; partial response 30%) in the "surface-only" group and 80.3% in the "surface-plus-deep" group (chi 2 = 14.9; p < 0.001). The major complication was acute bacterial cellulitis, occurring in the first postoperative week. Modification of the treatment protocol to include topical antibiotics with an occlusive dressing reduced the cellulitis rate from 17.2% to 2.5%. In four women (1.8%) Koebner-like exophytic condylomas also developed within 1 month of flashlamp-excited dye laser surgery.

CONCLUSION

The availability of a safe, efficacious, and relatively noninvasive treatment should reduce the need for resective surgery in most patients with idiopathic vulvodynia.