Intratendinous Calcifications Research Articles

A Novel Tendon Injury Model, Induced by Collagenase Administration Combined with a Thermo-Responsive Hydrogel in Rats, Reproduces the Pathogenesis of Human Degenerative Tendinopathy.

Patellar tendinopathy is a common clinical problem, but its underlying pathophysiology remains poorly understood, primarily due to the absence of a representative experimental model. The most widely used method to generate such a model is collagenase injection, although this method possesses limitations. We developed an optimized rat model of patellar tendinopathy via the ultrasound-guided injection of collagenase mixed with a thermo-responsive Pluronic hydrogel into the patellar tendon of sixty male Wistar rats. All analyses were carried out at 3, 7, 14, 30, and 60 days post-injury. We confirmed that our rat model reproduced the pathophysiology observed in human patients through analyses of ultrasonography, histology, immunofluorescence, and biomechanical parameters. Tendons that were injured by the injection of the collagenase-Pluronic mixture exhibited a significant increase in the cross-sectional area (p < 0.01), a high degree of tissue disorganization and hypercellularity, significantly strong neovascularization (p < 0.01), important changes in the levels of types I and III collagen expression, and the organization and presence of intra-tendinous calcifications. Decreases in the maximum rupture force and stiffness were also observed. These results demonstrate that our model replicates the key features observed in human patellar tendinopathy. Collagenase is evenly distributed, as the Pluronic hydrogel prevents its leakage and thus, damage to surrounding tissues. Therefore, this model is valuable for testing new treatments for patellar tendinopathy.

Ultrasound Evaluation of Tendinopathy in Hemophiliac Patients for the Purpose of Rehabilitation Indications.

Hemophilia is a inherited bleeding disorder that is characterized by intra-articular bleeding (hemarthrosis). The aim of the study was to evaluate the state of the satellite tendons of the target joints in the patient with hemophilic arthropathy and propose rehabilitation treatment with eccentric exercises. The tendons of the joints mainly affected by hemophilic arthropathy were evaluated by ultrasound. The ultrasound evaluation is associated with the use of evaluation clinical scales, such as the Hemophilia Joint Health Score (HJHS), the Functional Independence Score in Hemophilia (FISH), the Hemophilia Activity List (HAL), the DASH, the VISA-A, the VISA-P, and the VAS scale. In 20 patients with hemophilic arthropathy, the thickness of the tendons that were examined was normal. In six subjects with severe joint damage, echostructural alterations were present, and signs of hyperemia and neo-vascularization were detected on color Doppler, as well as the presence of intratendinous calcifications. The tendons of the target joints in patients with hemophilic arthropathy are compromised by the indirect biomechanical damage caused by the joint disease, and rehabilitation treatment with eccentric exercises can be considered safe and effective in improving the tenso-elastic properties of the tendons.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review.

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.

Reinsertion of the Achilles Tendon with Bony Anchor in Insertional Achilles Tendinitis with Haglund’s Deformity

Haglund’s deformity is a common cause of hindfoot pain in adults and functional disability. Conservative treatment is effective often. Surgery is required only in intractable cases. Many surgical treatments in a Haglund deformity have been described. After resect and debridement, an anchor suture may use to reattach Achille’s tendon. This study aims to show the place of the suture anchor to improve the reinsertion of the Achilles tendon in an insertional Achilles tendinitis and Haglund’s deformity. We report a 54-year-old male complains of 2 years of chronic right heel pain while strength training. A focused exam of the left ankle showed a bump on the posterior heel with inflammation to the anterior and posterior Achilles tendon. A lateral X-ray and CT scan of the left ankle showed a bone spur and intratendinous calcification of the Achilles tendon with the Philip – Fowler angle at 87°. The Bohler’s ankle was at 27°. After the failure of at least 6 months of conservative treatment, surgical management was indicated. It has consisted of a midline incision. Bursectomy and, resection of the posterosuperior tuberosity of the calcaneus was performed. Then, debridement of necrotic tissue and calcifications in the tendon and any posterior osteophytes were carried out. The tendon had been reinserted at its central part with single-row anchor. The lower leg was immobilized in 20° plantar flexion, this was switched to a walking boot with adjustable plantar flexion. Partial support was allowed at the 6th postoperative week. Full rehabilitation was prescribed after the removal of the cast. At 2-year follow-up, the patient is very satisfied and had no pain when standing on the toes of the operated leg. Dorsiflexion was symmetric. The effective return to full-sport activities was at 6 months at the same level.

MRI or ultrasound-which imaging technique do we need?

Diagnostic imaging of epicondylitis is primarily performed using widely available, radiation-free ultrasound. The dynamic examination allows arapid point-of-care assessment. Typical imaging findings of epicondylitis include intratendinous hypoechogenic foci at the humeral origin, ossification at the enthesis, intratendinous calcifications, or (partial) rupture. In particular, Doppler sonography increases sensitivity by assessing possible neovascularization within the tendon. When sonographic findings are unclear or extensive, or when ultrasound machines or the required expertise in elbow examinations are not available, magnetic resonance imaging is indicated. Here, the use of proton density-weighted sequences is appropriate for assessing bone marrow and soft tissue edema and tendon tears, while ossifications are best delineated in T1weighted sequences. Projection radiography and computed tomography can be helpful for larger ossifications, although they are not part of the standard imaging protocol.

Severe insertional Achilles tendinopathy. Our experience with two different surgical techniques: surgical debridement and dorsal closing wedge calcaneal osteotomy according to modified Zadek’s technique

Introduction. This study is a retrospective analysis of two cohorts of patients treated for severe insertional Achilles tendinopathy (IAT) with two different surgical methods: surgical debridement and dorsal closing wedge calcaneal osteotomy according to modified Zadek’s technique. Materials and methods. We treated a total of 36 feet in 35 patients. Twenty five patients had surgical excision of intra-tendinous calcification with excision of posterior calcaneal prominence and reinforcement of insertion with either suture anchors or fibre tape. Ten patients (11 feet) had modified Zadek’s calcaneal osteotomy as an isolated intervention, without any other procedure to the Achilles tendon insertion or to the posterior part of the calcaneus. The mean age at operation was 52.6 years. (Range: 31 to 68 years in the debridement group and 18 to 64 years in the osteotomy group). There were 17 males and 18 females. 20 were right-sided procedures. Mean follow-up in the outpatient clinic for a clinical examination was 20 weeks. We expanded observation period with an up-to-date score based on Victoria Institute of Sport Assessment-Achilles Tendon (VISA-A) questionnaire and Manchester Oxford Foot Questionnaire (MOXFQ) making the maximum follow up in the debridement group up to 8 years and the osteotomy group of 4 years. Results. The open debridement group showed 76% (19 patients) to have a good to excellent outcome. The calcaneal osteotomy group showed 82% (9 patients) to have a good to excellent outcome. Osteotomies were united in all patients. We had no complications in either group until discharge. Conclusions. Both methods showed to be safe and efficient in bringing symptomatic relief to patients in short, medium and long-term observation.

Treatment of Achilles insertional calcific tendinosis using alongitudinal midline incision approach/central tendon splitting approach

Treatment of Achilles insertional calcific tendinosis through alongitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity). Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis. General medical contraindications to surgical interventions. Fracture, infection. Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of adorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity). Partial weight bearing 20 kg in 30° plantar flexion in along walker boot for 2weeks. Afterwards 2weeks of progressively weight bearing in 15° plantar flexion and another 2weeks in neutral ankle joint position in along walker boot. Atotal of 26feet of 26patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In10 (38%) feet, aprominent dorsal spur was resected, in 12feet (38%) retrocalcaneal bursa, and in24 (92%) feet acalcaneal tuberosity. Mean follow-up was 34.5months (range2-64months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.

Does intraoperative ultrasound help the surgeon in arthroscopic excision of rotator cuff tendon calcifications ?

Arthroscopic excision of rotator cuff tendon calcifications is a common procedure in cases where medical treatment has failed. The objective of this study was to evaluate how intraoperative ultrasound contributes to improving the interventional procedure. Our hypothesis was that through the use of ultrasonography the frequency of postoperative residual calcium deposits could be reduced without increasing operating time. In a non-randomized single-operator comparative study, 56 patients who underwent arthroscopic excision of calcification were retrospectively included: group 1 (n=20) without ultrasound guidance and group 2 (n=36) with guidance. Operating time was measured and localization failures noted. Radiological follow-up was carried out with x-ray images at conventional angles and ultrasound at 1.5, 3 and 6months postoperatively. Clinical follow-up was based on the Constant score (CS) at 6months. The mean operating time was 18min in group 1 (9-33±8.1) and 22min in group 2 (10-48 ± 7.7) (p=0.03). The rate of failure to identify calcifications was 8% and 2% in groups 1 and 2, respectively (p=0.22). At 6months, four calcifications were still visible on radiography in group 1 vs 1 in group 2 (20% vs 2.7%, p=0.03). The mean CS increased from 35 to 81 points in group 1 (p <0.001) and from 34 to 82 points in group 2 (p <0.001). Despite an increase in operating time, intraoperative ultrasound improves the process of excising rotator cuff intratendinous calcifications, prevents localization failures and enables a more complete extraction.

Interrater and Intrarater Reliability of Musculoskeletal Ultrasonographic Findings for the Common Extensor Tendon of the Elbow

Objectives: This retrospective case study evaluated the interrater and intrarater reliability of seven common extensor tendon pathologic features on musculoskeletal ultrasonography (MSK-US). Materials and Methods: A cohort of 50 patients were imaged due to presenting with atraumatic nonradicular lateral elbow pain. Three experienced and two novice readers rated the images on two separate occasions, and AC1 and kappa coefficients were calculated for each feature. Results: The interrater reliability was fair with respect to fascial thickening/scarring (AC1 = 0.26), tearing (AC1 = 0.35), tendon thickening (AC1 = 0.38), and intratendinous calcification (AC1 = 0.33); substantial for enthesophytes (AC1 = 0.80); and near complete for hyperemia (AC1 = 0.83) and hypoechogenicity (AC1 = 0.92). Intrarater reliability was moderate for fascial thickening/scarring (κ = 0.48), tearing (κ = 0.41), tendon thickening (0.47), intratendinous calcification (κ = 0.56), and hypoechogenicity (κ = 0.47); substantial for hyperemia (κ = 0.71); and almost perfect for enthesophytes (κ = 0.86). Conclusion: MSK-US may be a reliable tool to determine soft tissue changes in common extensor tendon pathology.

Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy

IntroductionNonoperative management of calcific insertional Achilles tendinopathy (CIAT) may fail in 10–30% of patients, and various operative procedures have been described to manage those. MethodsA modified Zadek (dorsal closing wedge) calcaneal osteotomy, without removing the calcific deposits and without detaching the insertion of the Achilles tendon, was performed between November 2016 and December 2017 in 25 consecutive patients (mean age 53.5 years), who were followed for at least 2 years. ResultsThe osteotomies had united at an average of 5 weeks. Two superficial wound infections (8%) were documented. Patients had returned to their normal activities at an average time of 23 ± 7.7 weeks. Three out of four patients, who practised recreational sport activity, returned to their pre-injury level. VAS and VISA-A scores had significantly improved at 3 months postoperatively (p < .001) and continued to improve for 24 months. ConclusionThe modified Zadek osteotomy, without excision of the intra-tendinous calcification, was safe, and significantly improved clinical outcome in patients with CIAT at 2 years after surgery.Level of evidence IV.

Retrocalcaneal Spur Removal and Achilles Tendon Reattachment for the Treatment of Haglund Deformity

Insertional Achilles tendinopathy frequently involves intratendinous calcification of the Achilles tendon insertion and a prominent superolateral calcaneus tuberosity known as a Haglund’s deformity. The incidence of insertional Achilles tendinopathy is up to 30%, affecting both recreational and elite athletes. The indications for surgical treatment of insertional Achilles tendinopathy is appropriate when a patient’s symptoms are recalcitrant to nonoperative therapies. Advancements in surgical treatment include the utilization of the midline longitudinal incision, improved soft tissue handling, and minimizing the detachment of the Achilles tendon insertion during surgery. Surgical treatment includes removal of the Haglund’s deformity, debridement of the Achilles insertion, and bone to tendon repair utilizing a double-row suture anchor construct. The authors are presenting a unique surgical technique for Haglund’s deformity excision, Achilles debridement, and repair without flexor hallucis longus augmentation. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Peripheral Enthesitis Detected by Ultrasonography in Patients With Axial Spondyloarthritis-Anatomical Distribution, Morphology, and Response to Tumor Necrosis Factor-Inhibitor Therapy.

Objectives: To investigate the anatomical distribution, morphological abnormalities and response to adalimumab therapy of ultrasound(US)-detected peripheral enthesitis in patients with axial spondyloarthritis (SpA).Methods: In a randomized, placebo-controlled, double-blinded, investigator-initiated trial (NCT01029847), patients with axial SpA according to the Assessment of Spondyloarthritis International Society criteria were randomized to subcutaneous adalimumab 40 mg every other week or placebo from baseline to week 6. From week 6 to 24, all patients received adalimumab 40 mg every other week. Of 49 patients enrolled, 21 patients participated in our observational US sub-study. US assessment applying the OMERACT US definitions for enthesitis of 10 peripheral entheseal regions of the upper and lower extremities and clinical examination were performed at baseline, weeks 6 and 24. US was performed by one experienced investigator. Hypo-echogenicity, increased thickness and Doppler activity of the enthesis were considered signs of active inflammation, whereas insertional bone erosions, intratendinous calcifications, and enthesophytes were regarded as signs of structural lesions.Results: Enthesitis on US was mostly present in the lower limbs, especially in the Achilles tendon (81%), the quadriceps tendon (62%), and the greater femoral trochanter (52%). Structural lesions were predominant (38 vs. 12% of examined entheses with inflammatory changes), particularly in the entheses of the lower limbs, and exhibited no change during treatment.Conclusion: US-detected structural lesions were common while inflammatory lesions were relatively rare in patients initiating adalimumab due to axial SpA. Structural lesions did not appear to change during 24 weeks follow-up, suggesting that these lesions may not be helpful outcome measures in short-term clinical trials.

Intra-articular echo-endoscopy during shoulder arthroscopy: an anatomical feasibility study

Background:The development of an ultrasound probe that can be used through an arthroscopic portal would provide direct access to the deep tissues of the shoulder. These structures are sometimes barely seen with an external ultrasound system and are also difficult to analyze under arthroscopy. Therefore, this intraoperative imaging technique could refine the diagnosis and surgical procedure and as a result provide more adequate therapy. The main objective of the study was to evaluate the feasibility of using an echo-endoscope to produce images during shoulder arthroscopy without causing secondary lesions. The secondary objective was to detect rotator cuff tears, calcific tendonitis, chondropathies, acromioclavicular arthropathy and labral tears.Methods:We used 6 shoulders of 3 anatomic subjects. The endo-ultrasound system used was the M15 probe developed by the society Cartimage Medical SAS® . The eleven structure of interest included in the principal objective of the study were: the tendon of the long head of the biceps, the glenoid and humeral cartilage surface, the gleno humeral ligament, the labrum, the rotator cuff tendon on their acromial and articular surfaces and the acromioclavicular joint. We noticed all lesions induced by the probe and we measured the acquisition time for the ultrasound images. The validation of the principles and secondary objectives were assessed by independent observer during the manipulations which were realized by one unique shoulder surgeon specialized in arthroscopic surgery.Results:We were able to produce ultrasound images of 68% of all the structures of interest.The inability to acquire certain images was partially due to the fact that the subjects were elderly (average age 90 years) and therefore, the structures of interest were no longer present.The secondary objective was partially fulfilled with the detection of complete tears of the supraspinatus tendon in 3 shoulders. We were also able to produce images of partial tears in the intra-tendinous cleavage. Intra-tendinous calcifications were explored in 1 shoulder. Humeral or glenoid chondropathy was identified in all the shoulders examined.Finally, no ultrasound-induced injuries were noted in any of the 6 shoulders in the study. The image acquisition time with the echo-endoscope was no more than 20 minutes for each shoulder, with an average time of 10 min 15 sec for shoulders with complete tissue evaluation.Conclusion:The echo-endoscope was easy and safe to use to acquire ultrasound images of the different glenohumeral or subacromial structures during shoulder arthroscopy. These results open the way for further explorations with the echo-endoscope.

Clinical and sonographic evaluation of Endobutton distal biceps brachii tendon repair: what constitutes normal post-operative appearances?

Distal biceps brachii tendon (DBBT) rupture is an uncommon but functionally significant injury given the loss of supination, flexion strength and pain that often result. Prompt surgical repair is preferred in most patients. Clinicoradiological post-operative follow-up is typically performed to assess DBBT repair integrity and function, frequently using ultrasound, though to date, no studies have described post-operative DBBT repair sonographic appearances. The purpose of this study was to evaluate post-operative DBBT sonographic appearances in the context of Endobutton repair with the following aims:i.Establish typical ultrasound appearances 12months post-surgeryii.Establish the relationship between ultrasound appearances and clinical/functional outcomes. Sixty patients between February 2016 and October 2017 undergoing DBBT repair were prospectively recruited, all undergoing clinical and sonographic assessment 12months post-surgery. Ultrasound data was collected on tendon integrity, tendon calibre and presence of intratendinous calcification, peritendinous fluid and peritendinous soft tissue/scarring. Clinical data was collected on active range of motion (ROM) (flexion, extension, supination, pronation) and strength (flexion and supination). A total of 57/60 patients had intact DBBT repairs identified sonographically and clinically at 12months. DBBT repairs had significantly increased cross-sectional area (mean 260%, 95% CI: 217%, 303%) compared with non-operated DBBT. Ninety-three percent of DBBT repairs were hypoechoic. Thirty percent contained intratendinous calcification. Peritendinous fluid/soft tissue was rarely observed. There was no significant correlation between DBBT calibre and strength/ROM parameters. Normal post-operative sonographic appearances of Endobutton DBBT repair comprise a hypoechoic tendon significantly increased in calibre compared with non-operated tendon ± intratendinous calcification. DBBT repair calibre varies greatly, but is not associated with any significant difference in strength/ROM.

Endo-échographie intra articulaire au cours d’arthroscopie d’épaule : étude anatomique de faisabilité

Background The development of an ultrasound probe that can be used through an arthroscopic portal allows direct access to the deep tissues of the shoulder. These structures are sometimes hardly seen with external ultrasound system and also difficult to analyze under arthroscopy. This intraoperative imaging technique can thus make possible the refine of the diagnosis, the surgical procedure and thus to propose a more adequate therapy. The main objective of the study is to evaluate the feasibility to use an endo-ultrasound probe, to realize images during shoulder arthroscopy on anatomical subjects without causing secondary lesions. The secondary objectives are the detection of rotator cuff tears, tendinous calcification, chondropathies, acromioclavicular arthropathy and labrum lesions. Results We were able to realize ultrasound images of 68% of all the structures of interest. A part of the missing acquisitions is due to the old age of the anatomical subjects (average age 90 years) where structures of interest were no longer present. The secondary objective was partially fulfilled with the detection of total tears of the supraspinatus tendon in 3 shoulders. We have also been able to produce partial rupture images of intra-tendon cleavage. Intra-tendinous calcifications were explored in 1 shoulder. Humeral or glenoid chondropathy were present on all the shoulders under study. Finally, we did not notice lesions induced by the ultrasound probe during our handling on all 6 shoulders. The acquisition time of the images with the endo-ultrasound probe was no more than 20 minutes for each of the shoulders, with an average time of 10 min 15s for shoulders with complete tissue state. Conclusion It was easy and safe to manipulate an endo-ultrasound probe and to acquire ultrasound images of the different glenohumeral or subacromial structures during shoulder arthroscopy. This result opens the way for further explorations using endo-ultrasound devices.

FREQUENCY OF PATHOLOGY ON DIAGNOSTIC ULTRASOUND AND RELATIONSHIP TO PATIENT DEMOGRAPHICS IN INDIVIDUALS WITH INSERTIONAL ACHILLES TENDINOPATHY

Insertional tendinopathy is likely caused by different pathologies. This variation could account for the recalcitrant nature of this condition to treatment. Ultrasound imaging may assist in identifying underlying pathology to inform patient management. The primary purpose of this study was to quantify the presence of underlying pathology using ultrasound in individuals with a clinical diagnosis of insertional Achilles tendinopathy. Secondarily, we sought to examine the relationship of abnormal ultrasound findings to age and body mass index (BMI). Cross-sectional study. Fifty-six individuals with insertional tendinopathy were included in this study. B-mode ultrasound imaging was used to descriptively and quantitatively describe tendon pathology. A greater proportion of bone defect (p<0.001), intratendinous calcifications (p = 0.01) and midportion tendinosis (p<0.001) were observed on the injured side compared to the uninjured side. Higher BMI was associated with presence of bone deformity, intratendinous calcifications and distal tendinosis (p = 0.001-0.04); adding age did not significantly improve the regression model. Patients with insertional tendinopathy present with multiple underlying pathologies. This may account for variable response to treatment. It may be helpful to include imaging to better identify underlying pathology when trying to determine an appropriate treatment strategy. Level 3.

Central Tendon-Splitting Approach and Double Row Suturing for the Treatment of Insertional Achilles Tendinopathy.

Background To assess the clinical outcomes of central tendon-splitting approach and double row anchor suturing for the treatment of insertional Achilles tendinopathy. Methods 28 patients (28 feet) diagnosed with insertional Achilles tendinopathy were included in this study. The inclusions were symptom of hindfoot pain around the insertion of the Achilles tendon, radiographic demonstration of calcification, or degeneration of the Achilles tendon, showing no symptom improvement even after standard nonsurgical treatment for more than six months. The X-ray revealed that patients had obvious posterior superior calcaneal exostosis with the possibility of friction with the Achilles tendon or intratendinous calcification. Surgical correction by the central tendon-splitting approach and double row Achilles tendon suturing was performed. The ankles were immobilized with plaster for four weeks postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue score (VAS) were assessed preoperatively and at 2 years postoperatively. At final follow-up, the Manchester-Oxford Foot Questionnaire (MOXFQ) as patient-reported outcome measures (PROMs) was also evaluated. Results No complication, including postoperative wound infection and tendon rupture, was not found. All the patients resumed their daily activities with no high level of daily activities, such as jumping and jogging after 6 weeks postoperatively. 27 patients were available for follow-up for at least 2 years, while only one patient was lost to follow-up. At postoperative 2 years, the postoperative AOFAS score increased significantly, while the VAS score decreased statistically when compared with preoperative values. At final follow-up, 24 patients had complete alleviation of pain, whereas the remaining 3 patients complained of mild heel pain after walking for a long time. The MOXFQ score showed obvious relief of previous symptoms for all included cases. Conclusions Central tendon-splitting approach and double row Achilles tendon suture provide excellent intraoperative visual field, larger tendon-bone contact area, and stronger pullout strength and, thus, facilitate early rehabilitation. It can be a safe and effective method for the treatment of insertional Achilles tendinopathy.

Modified Bunnell suture expands the surgical indication of the treatment of Haglund's syndrome heel pain with endoscope.

The aim of the present study was to develop a method which can solve the problem of partial tearing of the Achilles tendon insertion caused by the debridement for Haglund's syndrome using endoscopy-assisted percutaneous repair. Seven patients with Haglund's syndrome were prospectively recruited. All 7 patients (3 female, 4 male) had intratendinous calcifications. Preoperative diagnosis was made according to the clinical symptoms and diagnosis, medical examination results, plain film radiographs, and magnetic resonance imaging. The patients whose average age was 35.2 years, had experienced symptoms and were treated by conservative methods for 12–24 months (average 17.1 months). All 7 cases were treated with debridement of Achilles tendon insertion site with a standard 4.0 mm bur and underwent repair treatment with a modified Bunnell suture method under direct visualization using arthroscopy. The American Orthopaedic Foot and Ankle Society (AOFAS) score and the changes of the patient's parallel pitch lines were used to evaluate and assess the results. The follow-up period averaged 22 months. The lateral X-ray film after operation of all the heels of the patients showed that sufficient osseous planning of all the patients was completed. None of the patients converted to conventional open surgery. The average AOFAS scores of the 7 cases were improved significantly at final follow-up compared to pretherapy (P<0.005). The results of 5 of the 7 cases were excellent, 2, were good, and 0 was fair or poor. None of the cases had permanent nerve injuries, wound infections or Achilles tendon avulsion. Our study is a supplement of endoscopic repairing and strengthening of the Achilles tendon. The advantages and clinical significance of endoscopy during the treatment of Haglunds syndrome under the premise of strict control of operation indications were further verified.

Flexor carpi radialis tendon ultrasound pictorial essay

Disorders of the flexor carpi radialis tendon (FCRt) are often missed even though they are a relatively frequent cause of volar radial wrist pain. They can manifest as tenosynovitis, tendinopathy, synovial sheath cysts with or without scaphoid-trapezoid-trapezium (STT) joint pathology, and partial or complete rupture. Because FCRt disorders often present with non-specific symptoms and a non-diagnostic clinical examination, imaging is often necessary for accurate evaluation and therapeutic planning. Conventional radiography provides good visualization of the neighboring bones and joints, as well as rare intratendinous calcifications. MRI enables evaluation of the FCRt and adjacent anatomical structures with excellent tissue resolution. In comparison, ultrasound (US) evaluation of the FCRt is less commonly described in the radiology literature, despite its affordability, exquisite soft tissue resolution, and the advantages of quick, dynamic diagnostic imaging. This pictorial essay describes and demonstrates the normal anatomy of the FCRt, its US examination technique and normal US appearance, and US findings of clinically relevant FCRt disorders.

Ultrasound assessment of elbow enthesitis in patients with seronegative arthropathies

Enthesopathy is an evolving area for applied clinical research. MRI is the gold standard in the diagnosis of elbow joint pathology, but recent reports indicate that ultrasound imaging is more sensitive and accurate than MRI in detecting enthesopathy of the heels and knees. Too many patients are under-diagnosed and/or misdiagnosed because the early pathological changes of enthesitis in the different types of seronegative arthropathies are not detected. This study was undertaken to describe the ultrasound features of elbow enthesitis in patients with seronegative arthropathies. We studied 38 diseased elbows in 38 patients with spondyloarthropathies (26 men and 12 women, mean age 32years). All had elbow enthesopathy without typical conventional radiographic findings. Patients with histories of degenerative changes and/or local steroid injections were excluded. An HDI 3000 ATL ultrasound machine was used with a 5-12MHz linear transducer to examine the affected elbow joints. The elbows of 10 normal healthy individuals were examined as normal controls. The patients were examined in the supine position with the elbow flexed 30°-50°. Longitudinal and transverse scans were obtained of the radiohumeral joint, the ulnahumeral joint, and the olecranon fossa. Two independent observers unaware of the clinical diagnosis read the ultrasound images and assessed the collateral ligaments, intratendinous echogenicity, tendon calcification, tendon thickness, presence of fluid, synovial proliferation, and bony changes. The reliability of the sonographic images was assessed by review of video recordings of the ultrasound examinations. Ultrasound revealed loss of the fibrillar echopattern (100%), lack of a homogenous pattern with loss of the tightly packed echogenic dots (100%), peritendinous edema with flaring of the tendon margins (84.2%), irregular fusiform tendon thickening (100%), and hyperechoic intratendinous lesions with ill-defined focal defects (18.4%). Ultrasound also detected intratendinous calcifications of both the common extensor and common flexor tendons (52.6%). Bony erosions were seen at the tendon insertions into the lateral epicondyles (13.15%). Ultrasonographic features of elbow enthesitis differed from those described in knee and heel enthesitis. Ultrasound clearly showed early signs of tendon calcification, tendon edema, peritendinitis, and bony entheseal erosions. However, in elbow enthesitis the early bone erosion was associated with bone marrow edema, and the common extensor tendon was diffusely thickened. Ultrasound is a reliable, reproducible bedside imaging procedure. It improves the documentation of disease activity, progression, and treatment responses in patients with spondyloarthropathies. We recommend its use for the diagnosis and post-treatment follow-up of patients with enthesitis and seronegative spondyloarthropathies.