General Practitioners

• Arthritis
  One thing that the diffuse form of PVNS has in common with the nodular form is that it is often misdiagnosed initially. The former may be even harder to diagnose than the latter because it does not have a discrete, nodular soft tissue mass as its calling card. Diffuse PVNS is almost always an entirely painless disease, at least in its early stages, and it most commonly presents itself as simple knee swelling caused by an excessive accumulation of synovial fluid within the joint. This excess fluid is secreted by the overgrown joint lining tissue. Unless the quantity of fluid in the joint becomes so great as to stretch the joint capsule and cause discomfort, patients often regard this as more of an annoying curiosity than a significant problem at first. Patients who present for medical evaluation find that their knee x-rays are almost always normal and that all of their blood tests are negative for diseases like rheumatoid arthritis, lyme disease, lupus, etc. Clinicians should always keep in mind the possibility of PVNS when presented with a patient who is suffering from unexplained, recurrent fluid accumulations in one of their joints, especially when the joint fluid has a slightly more orange-brown color to it than normal. Sometimes the delicate, overgrown joint lining tissue bleeds intermittently and thus even red joint fluid may be found at times. The presence of diffuse PVNS is verified by direct arthroscopic inspection of the interior of the joint and taking a synovial tissue biopsy. Microscopic tissue analysis is required to make a firm pathologic diagnosis. Once this has been confirmed, treatment must be planned.
• Cryotherapy
  NO ONE can completely remember complex verbal instructions regarding unfamiliar procedures and devices given in a recovery or hospital room! Traditional, rudimentary surgi-center and hospital instruction sheets have not kept pace with the complexities of advanced, orthopaedic home-care modalities such as C.P.M. machines, cryotherapy devices, and continuous local anesthetic infusion pump systems. Some surgeons solve this problem by simply not offering their patients any advanced home-care modalities, relying on just pain pills and the small, minimally effective ice packs dispensed in most recovery rooms. That is not our way of doing things at the Knee and Shoulder Centers.
• Medical Weight Loss
  Many cases of mild to moderate chondromalacia patella can be treated with just oral anti-inflammatory medication, weight loss and the proper type of therapeutic exercise. While nutritional supplements such as glucosamine and chondroitin have been shown to ease arthritic joint discomfort and slow down articular cartilage breakdown in some patients, there is no convincing proof yet that they totally halt or reverse chondromalacia. Viscosupplementation (Synvisc, Hyalgan, etc.) injection treatment does not seem to work as well on patellar arthritis pain as it does on symptoms caused by arthritic joint surfaces elsewhere in the knee.
• Primary Care
  Dr. Sidor presented the topic “The Primary Care of Adult Shoulder Disorders: An Orthopaedist’s Perspective” as part of the Orthopaedic Medicine section of the program.

Internists

• Internal Medicine
  December, 1993 "The Painful Shoulder: Intrinsic Disorders and Impingement Syndrome". Lankenau Hospital Department of Internal Medicine Subspecialty Medical Conference, Wynnewood, PA

Radiologist

• Ultrasound
  I asked Dr. Sapega if I could write this letter to help inform other patients with knee problems of my experience. I am a 25 year old, very active female who began developing knee problems in both knees about 3 1/2 years ago. I saw a specialist who was well known, highly recommended and a sports doctor for knees at a large institution in Philadelphia, for almost 3 years. At first I was having pain under the knee caps and slight pain in my patellar tendons. I tried physical therapy off and on and all sorts of other treatments for well over a year at multiple facilities. Before transferring my care to Dr. Sapega I tried stimulation, high volt, exercise, no exercise, strength building for my leg muscles, cortisone, topical cortisone, aqua therapy, McConnell taping, nerve blocks, knee braces, Synvisc shots and experimental calcium and dead tissue needle scrapings using ultrasound guidance. I have had 3 of these ultrasound procedures on my right knee and 2 on my left. Since my first one in January of '99 I went continually downhill. My patellar tendon pain went from a mere second thought behind the under-the-knee-cap pain to unbelievably excruciating pain. I was told I had arthritis, patellar tendonitis and R.S. D. Minor daily activities like walking up a flight of stairs or walking across a parking lot were unbearable. I had a tough time with any physical activity. The treadmill and the eliptical trainer were very tough and I couldn't even handle 2 minutes on the exercise bike. I became overmedicated several times orally, and following the needles I was temporarily not only a walking zombie but had no energy and became almost immune to nerve blocks. As time passed my spirit was diminishing. I was displeased and disheartened with the treatments, continued ultrasound-needle surgeries, shots, drugs, pain and how my daily life was miserable due to my knees. I also became more and more discouraged at the philosopshies of my physician and his practice. I was more like a number than an individual patient. As my Dad once said, it was like "McDonalds medicine". I began actively searching the New York and Philadelphia areas for a new knee specialist. I needed a new perspective and different treatment to restore my life to as close to pain-free as possible.
• MRI
  (see FIGURE 2a). It is usually painless and often does not become noticed until the tissue nodule reaches a size that causes swelling or some type of internal joint impingement symptoms to the patient. Obvious mechanical problems such as joint locking and snapping can occasionally occur, simulating a torn cartilage or other structural problem. On other occasions, the patient may simply feel a slowly growing soft tissue mass within their knee joint and/or their knee may become distended with excess synovial fluid (so-called "water on the knee"). MRI scanning is the best non-invasive means of identifying the presence of a synovial growth within a joint. Treatment is usually rendered both simply and effectively by way of either arthroscopic or "open"(access by way of a traditional incision) resection of the abnormal tissue
• Radiology
  May, 1994 "The Neer Classification of Proximal Humerus Fractures: Issues in Radiographic Evaluation and Classification" and "Magnetic Resonance Arthrography of the Shoulder". Temple University School of Medicine Department of Diagnostic Imaging Musculoskeletal Radiology Conference.
• X-Rays
• Iontophoresis
  Once diagnosed, and assuming that advanced tissue degeneration within the patellar tendon has not yet occurred, treatment is almost always initiated by non -operative means. A program of physical therapy may include quadriceps (frontal thigh muscle) stretching with special augmentation techniques, light conditioning exercise, multi-angle quadriceps isometrics, eccentric quadriceps strengthening, ice and friction massage to the tendon, dexamethasone iontophoresis, and sometimes ultrasound. Such therapy often proves effective, particularly when accompanied by oral anti-inflammatory medication. Obviously, avoiding the inciting stress or abnormal activity that caused the problem in the first place is helpful as well.
• Radiation Therapy
  Other means of treating pigmented villonodular synovitis include radiation beam therapy and radio isotope synovectomy. In the latter procedure a liquid, radioactive isotope is injected into the knee joint, subjecting the synovial lining to radiation treatment. This is an uncommon treatment that in the past has generally been reserved for difficult cases of PVNS that have recurred following a prior surgical synovectomy. Very few medical centers in the United States even offer such treatment, which is usually done under carefully controlled conditions in research protocols. Either form of radiation therapy can also be used as an adjuvant (additional or back-up) treatment following a surgical synovectomy.

Surgeons

• Orthopedics
  Orthopedics in their January/February 2016 issue, for his time and effort on their Review Panel. Dr. Sidor reviews submitted manuscripts concerning shoulder/general orthopedics topics, and critiques/edits/approves them in regards to publication suitability.
• Arthroscopy
  National Shoulder Surgical Technique Instructor, Cadaver Shoulder Laboratory and ALEX Shoulder Model Laboratory, Arthroscopy Association of North America.
• Minimally Invasive Surgery
  New Jersey Orthopaedic Society: “Electromagnetic “EM” Navigation in Minimally Invasive Surgery Total Knee Arthroplasty & “Quad Sparing” Minimally Invasive Surgery Total Knee Arthroplasty”
• Joint Replacement
  A severe case of arthrofibrosis can be an extremely difficult challenge for both patient and knee surgeon alike. In this author's experience, the comprehensive treatment program described above has met with good results in most circumstances, including cases of total knee joint replacement that still demonstrated a restricted range of motion despite one or more attempts at manipulation under anesthesia without arthroscopic intervention.
• Cyst Removal
• Arthritis Surgery
• Orthopedic Surgery
  For patients interested in the technical aspects of arthroscopic knee synovectomy, reprints of my illustrated surgical technique paper, published in Master Techniques in Orthopedic Surgery,can be obtained by either writing or e-mailing our Knee and Shoulder Centers office. Simply stated, the objective of arthroscopic synovectomy is to remove as much abnormal joint lining tissue as is technically feasible without damaging the patient's knee in the process. Properly and meticulously performed, it is a very lengthy and technically difficult surgical procedure. It requires mastery of almost every knee access technique ever devised by arthroscopic surgeons. All of the major internal regions of the knee joint, in sequence, must be both visualized and accessed by surgical re-section instrumentation, all the while keeping the number of access (arthroscope portal) incisions to a minimum and avoiding unintended neurovascular injury or damage to other internal joint structures. The surgeon must be comfortable working in the posteromedial and posterolateral knee compartments
• Arthroscopy
  2011 Arthroscopy Association of North America: Masters Surgical Techniques Course – Knee Cartilage Repair, Auto and Allograft Transplantation, Chicago, IL
• Hip Replacement
  April 29, 1994 "Hip Replacement for Fracture: Post-Operative Rehabilitation and Return of Activity Level". (re: Pope John Paul II's hip fracture). Healthcheck segment, Channel 6 Action News, WPVI Television.
• Knee Replacement
  If PVNS remains uncontrolled, over a period of years the patient's knee joint surfaces may gradually become destroyed, leading to a need for radical joint resection and replacement by prosthetic components ("total knee replacement" surgery). The initial radical resection stage of such a procedure allows relatively complete exposure inside the joint and thus an unusually complete surgical synovectomy. This often leads to a final cure of the disease, but the original knee joint has been lost forever.
• Knee Arthroscopy
  If a diagnostic knee arthroscopy is performed to assess the status of the ACL, great care should be taken because the visual appearance of a partially torn ACL can be very misleading. Sometimes an injured but still strong and stable ACL may look ominously lax and/or appear to have irregular, damaged fibers. Conversely, a severely compromised ACL that allows positive "pivot shift" joint instability to occur, will on occasion, be afflicted only with internal fiber disruption and generalized plastic deformation (permanent stretching), thus providing the appearance of merely being slack as opposed to being torn outright. This may cause a surgeon to underestimate the degree of ligament damage present.
• Reconstructive Surgery
  Tisme Engineering and its Use in Shoulder and Elbow Reconstructive Surgery: Basis Science and Early Clinical Experience

Dermatologists

• Cyst
• Lesions
  OCD lesions are uncommon and poorly understood joint surface defects that are found most frequently in the knees of children and young adults. While some OCD lesions heal on their own, many require surgical treatment. Unhealed or unsuccessfully treated OCD defects compromise the "ball-bearing" function of the knee's gliding surfaces (which are normally quite smooth and almost frictionless), leading to premature joint arthritis. The goal of surgical management is to preserve or restore a normally contoured, smooth, firm joint surface that will function properly in load-bearing throughout life. This goal is by no means easy to achieve.

Physical Therapists

• Sports Medicine
  1985-86 Post-graduate Fellowship in Arthroscopic and Athletic Trauma Surgery, Temple University Center for Sports Medicine and Science, Philadelphia, Pennsylvania
• Physical Therapy
  No matter how meticulous and thorough a scar tissue resection may be, and even if a full range of knee motion is successfully restored on the operating room table, the biggest challenge is maintaining that range of motion after surgery. New scar tissue may rapidly re-form within the joint unless comprehensive action is taken to avoid this. Unless special post-operative pain relief measures are taken, attempting to move the joint through its full range of motion immediately after surgery may simply be intolerable. Unfortunately, if the patient does not move their knee through a full arc of motion repeatedly and fairly continuously in the first 2 to 3 post-operative weeks, they are at risk of having their knee joint become "frozen" once again. Aside from knees where only joint extension is lacking (which are often best held in a maximally extended position in a full-leg cast for the first several post-op days), the key to better results following surgical procedures for arthrofibrosis is to perform them under epidural anesthesia and to maintain this or a supplemental regional, pain-relieving, anesthetic nerve block for a day or two post-operatively, so as to allow joint motion without the inhibiting effect of severe pain. I have been using this anesthetic method following arthrofibrosis surgery for well over a decade. Taking advantage of the ongoing pain relief afforded by the extended anesthetic block effect, a program of immediate post-operative physical therapy is begun and continued, utilizing special, passive stretching techniques at the extremes of the knee's range of motion. The patient is also taught how to do their own stretching therapy, to supplement their supervised treatment. A continuous passive joint motion (CPM) machine is used in between stretching sessions, beginning in the recovery room and then continuing at home. This device is a mechanical leg cradle that gently bends and straightens the knee while the patient is lying down in bed. Post-operative medication to inhibit recurrent fibrous scar tissue formation within the knee is also often helpful. Possibilities include intra-articular (injected into the joint) hyaluronate (a joint lubricant) and/or corticosteroid (cortisone) medication administered on one or more occasions in the first post-operative month or two. Faithful patient compliance with prescribed outpatient physical therapy treatment and diligent, self-administered stretching in the post-operative phase is critical. Supplemental treatment with an oral anti-inflammatory medication (if the patient's stomach can tolerate it) is helpful.
• Frozen Shoulder
  September, 1996 "Surgical Repair of Shoulder Instability" and "The Diagnosis and Treatment of the Stiff and Painful Shoulder: Adhesive Capsulitis vs. Frozen Shoulder." University of Pennsylvania Update 1996: Shoulder Disorders, Diagnosis, Treatment, and Rehabilitation Symposium, Philadelphia, PA.
• Tennis Elbow
  Patellar tendinitis can be thought of as the "tennis elbow of the knee". While surgery is only infrequently required for effective treatment, jumper's knee can be quite annoying and difficult to cure at times. It can appear in a variety of circumstances, many of which do not involve running or jumping at all! One common cause of patellar tendinitis is a direct contusion or impact blow, such as may occur when you fall down onto the frontal aspect of your knee, or if you strike the front of your knee on an unseen object while walking. Another common cause is altered gait and thigh muscle mechanics, as may occur during limping or partial weight-bearing while using crutches following knee injury or surgery. In my experience I have learned that over-use, abnormal use or occasionally even under-use of the knee can lead to this common knee condition!
• Manual Therapy
  FIGURE 1c - Arthroscopic view of the same patient's medial joint compartment at the conclusion of the case. The normal, internal joint space has been restored and the medial femoral condyle has been completely released from its enveloping scar tissue cocoon. Similar work has also been done in other knee compartments, in combination with a retinacular release. At this point, the knee is tested to see what free range of motion it has, and if necessary, joint manipulation and stretching are performed to restore the range of motion to normal. With almost all of the internal scar tissue that was formerly restricting the joint removed, the joint manipulation procedure will require significantly less applied force to regain the same range of motion, thus reducing the chance of an inadvertent femoral or tibial fracture.
• Orthotics and Prosthetic Therapy