Nonsteroidal anti-inflammatory drugs for at least three weeks (Requirement is waived if NSAIDS are not tolerated or contraindicated, or if condition worsens while under treatment.)
Activity modification or physical therapy if appropriate
The reader is referred to VIDEOS IN CLINICAL MEDICINE Schraeder, Teresa L., Terek, Richard M., Smith, C. Christopher Clinical Evaluation of the Knee N Engl J Med 2010 363: e5;for a good discussion of the examination of the knee/
Failed conservative management
Surgery contemplated if positive
Not responding to conservative managment
X-ray imaging not diagnostic
Joint Pain not responsive to conservative managemnet
Decreased ROM Locking of joint Pain
Padhraig F. O’Loughlin, Benton E. Heyworth, and John G. Kennedy Clinical Sports Medicine Update: Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle Am J Sports Med February 2010 38:392-404;
SCHENCK, ROBERT C., JR., GOODNIGHT, JON MARC Current Concept Review – Osteochondritis Dissecans J Bone Joint Surg Am 1996 78: 439-56
Osteochondritis Dissecans See Loose body.
Residual or recurrent meniscal tears following meniscal surgery.
ACR Appropriateness Criteria® Nontraumatic Knee Pain
Lynne S. Steinbach, William E. Palmer, and Mark E. Schweitzer Special Focus Session: MR Arthrography Radiographics September 2002 22:1223-1246
1.1 Joint instability
1.2.1 Suspect Loose Body
1.3.1 X-ray and/or ultrasound nondiagnostic
1.4.1 Failed Conservative Management
1.4.2 Known Malignancy Elsewhere, suspect metastasis (Conservative Management NOT required)
1.5.1 Failed Conservative Management
2.1.1 Alcoholism
2.1.2 Cushing’s disease
2.1.3 History of pancreatitis
2.1.4 Sickle Cell disease
2.1.5 Steroid use in recent past (up to one year)
2.1.6 Systemic Lupus (SLE)
2.2.1 X-rays non diagnostic on two occasions
2.3 Joint mouse See loose body
2.4.1 Decreased ROM
2.4.2 Locking of joint
2.4.3 Pain
2.4.4.1 Padhraig F. O’Loughlin, Benton E. Heyworth, and John G. Kennedy Clinical Sports Medicine Update: Current Concepts in the Diagnosis and Treatment of Osteochondral Lesions of the Ankle Am J Sports Med February 2010 38:392-404;
2.4.4.2 SCHENCK, ROBERT C., JR., GOODNIGHT, JON MARC Current Concept Review – Osteochondritis Dissecans J Bone Joint Surg Am 1996 78: 439-56
2.5.1.1 Decreased ROM
2.5.1.2 Occasional joint locking
2.5.1.3 Positive McMurray test
2.6 Osteochondritis Dissecans See Loose body.
2.7.1.1 C reactive Protein elevated
2.7.1.2 Elevated ESR
2.7.1.3 Fever
2.7.1.4 Leukocytosis
2.7.1.5 Positive Blood Cultures
2.7.2.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.
2.7.2.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.
2.7.2.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.
2.7.2.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.
2.7.2.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.
2.7.2.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.
2.7.2.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.
2.7.2.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.
2.8 Pain in Joint AVN Suspected SEE Avascular Necrosis
2.9.1 Known Malignancy Elsewhere
2.10.1.1 Fever, Leukocutosis, Edema
2.11.1 Localized pain, nondiagnostic repeat x-ray >7 days of symptoms
2.12.1 Failed Conservative Management
2.12.2 Pain with motion
2.13.1.1 Failed Conservative Management
2.13.2 Palable gap in tendon
2.13.3 Evidence of tendon abnormality on Ultrasound
2.14.1 X-ray and/or ultrasound nondiagnostic
3.1 Crepitus, Failed conservative management
3.2 Effusion, Failed Conservative Management
3.3 Joint instability
3.4 Joint line tenderness, Failed conservative management
3.5.1 X-ray, CT or Ultrasound nondiagnostic
4.1 Abnormality on Plain Film, suspecious for tumor, metastasis, infection (osteomyelitis), for avascular necrosis
5.1.1 Evaluation of joint prior to aggressive therapy, and interval follow up.
5.2.1 For treatment planning
5.3.1 Interval follow up during and after treatment
5.3.2 Preoperative
5.3.3 Worsening clinical situation
5.3.4.1 Parsonnet Jeffrey, “Chapter 120. Osteomyelitis” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2893649.
5.3.4.2 Alok Kapoor, Stephanie Page, Michael LaValley, Daniel R. Gale, and David T. Felson Magnetic Resonance Imaging for Diagnosing Foot Osteomyelitis: A Meta-analysis Arch Intern Med, Jan 2007; 167: 125 – 132.
5.3.4.3 J. Herman Kan, Melissa A. Hilmes, Jeffrey E. Martus, Chang Yu, and Marta Hernanz-Schulman Value of MRI After Recent Diagnostic or Surgical Intervention in Children with Suspected Osteomyelitis Am. J. Roentgenol., Nov 2008; 191: 1595 – 1600.
5.3.4.4 Kuo-Chen Lee, Yi-Ting Tsai, Chih-Yuan Lin, and Chien-Sung Tsai Vertebral osteomyelitis combined streptococcal viridans endocarditis Eur. J. Cardiothorac. Surg., Jan 2003; 23: 125.
5.3.4.5 D Allen, S Ng, K Beaton, and D Taussig Sternal osteomyelitis caused by Aspergillus fumigatus in a patient with previously treated Hodgkin’s disease J. Clin. Pathol., Aug 2002; 55: 616 – 618.
5.3.4.6 M Ida, H Watanabe, A Tetsumura, and T Kurabayashi CT findings as a significant predictive factor for the curability of mandibular osteomyelitis: multivariate analysis Dentomaxillofac. Radiol., Mar 2005; 34: 86 – 90.
5.3.4.7 Jyri K. Koort, Tatu J. Mäkinen, Juhani Knuuti, Jari Jalava, and Hannu T. Aro Comparative 18F-FDG PET of Experimental Staphylococcus aureus Osteomyelitis and Normal Bone Healing J. Nucl. Med., Aug 2004; 45: 1406 – 1411.
5.3.4.8 Susan A. Connolly, Leonard P. Connolly, Laura A. Drubach, David Zurakowski, and Diego Jaramillo MRI for Detection of Abscess in Acute Osteomyelitis of the Pelvis in Children Am. J. Roentgenol., Oct 2007; 189: 867 – 872.
5.4.1 Includes Anakinra, Enbrel, Humiria, Kineret, MabThera, Rituxan, Rituximab and methotrexate.
5.5.1.1 Effusion
5.5.1.2 Limited ROM
5.5.1.3 Pain
5.5.1.4 Swelling
5.6.1 Staging, restaging or interval follow up