Posted: Aug 1 2020 #(C101547)

Spontaneous Osteonecrosis of the Knee in a 63F

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HPI

She presented in office with consistent knee pain for the past 2 months, first occurred during the pandemic. She was diagnosed with osteoarthritis of the knee and was prescribed antiflamatory medications. Pain, limping, and severe nighttime pain continued despite NSAIDs.

PMH

No previous medical history

MSK - intra-articular effusion. Tenderness to palpation over the medial joint line. Range of motion limited by pain, with inability to extend the knee past 15-20 degrees of flexion. Antalgic gait. The clinical evidence drove me to the conclusion of a medial meniscal tear. I performed a typical meniscus reduction maneuver which improved the pain. She started walking with no or a little pain and minimal limping. A routine MRI in this cases was carried out. The patient was advised to avoid any pivot movement in every day living activities as well as bending the knee while bearing weight. In one week she returned with a non-antalgic gait, no pain whatsoever, and the clinical examination demosntrated no effusion with only some tenderness at the medial joint line. Range of motion was signficantly improved with the ability to achieve 120-130 degree of flexion with moderate pain at the extreme. The MRI returned with evidence of medial femoral condyle osteonecrosis with extensive bone marrow oedema. Non-weight-bearing of the knee was advised and bisphosphonates were prescribed. One month later, a new MRI was performed, showing reduced bone marrow edema and no progression of bony collapse despite only moderate compliance with non-weight-bearing. Clinical examination at that time was relatively benign with full painless range of motion from 0-130 degrees, no tenderness to the medial joint line, and no swelling or intra-articular effusion. Non-weight-bearing was advised for an additional month and a new MRI prescribed just prior to her return. One month later she returned with a new MRI, which showed continued resolution of the bony edema, no interval collapse of the lesion, and physical exam was completely benign at that time. She was progressed to weight-bearing and gradually return to her daily activities.

Poll

1 of 4

How would you manage the patient at this time?

1 Nonoperative

2 Operative

3 Outside my area of expertise - best if I don't vote

Other

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P: 118486

If you choose Nonoperative management, would you obtain follow-up imaging?

1 I would not choose Nonoperative management

2 No - it would not affect my management

3 Yes - only if her symptoms returned

4 Yes - at regular intervals

5 Outside my area of expertise - best if I don't vote

Other

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P: 118491

If you choose to Obtain follow-up imaging, how often would you do so?

1 I would not choose to Obtain follow-up imaging

2 Every 1 month

3 Every 2-3 months

4 Every 4-6 months

5 Every 7-12 months

6 Every 2-3 years

7 Outside my area of expertise - best if I don't vote

Other

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P: 118490

If you choose Operative management, what surgery would you perform?

1 I would not choose Operative management

2 Arthroscopic management only (includes meniscectomy, repair, and/or microfracture)

3 Osteotomy only

4 Osteotomy + Arthroscopic managment

5 Arthroplasty

6 Outside my area of expertise - best if I don't vote

Other

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P: 118381

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