Tendon Calcification Research Articles

Incidence and risk factors for postoperative Achilles tendon calcifications after percutaneous repair

Numerous publications are dealing with acute Achilles tendon rupture. To our knowledge, no systematic trial has been published analyzing the incidence, risk factors and the potential clinical impact of postoperative tendon calcifications (PTC) after percutaneous Achilles tendon repair. Therefore, the aim of this study was to analyze these relevant aspects. Between March 2003 and November 2010, a total of 126 patients with an acute, complete Achilles tendon rupture were treated with a percutaneous technique according to Ma and Griffith at a single university-based trauma department. The follow-up included a detailed clinical and sonographic examination. To assess the functional outcome and possible impact of PTC after percutaneous Achilles tendon repair, the Thermann and AOFAS scores were used. 81 patients (65 men and 16 women) with a median age of 46years (range 24-76) were available for a follow-up examination. The median time of follow-up was 64months (range 15-110months). PTC occurred in nine out of 81 patients (11.1%). All patients with PTC were male with a median age of 52years (range 26-76years). In the group of patients with PTC, the median overall Thermann score was 94 (range 68-100) and the median overall AOFAS score was 97 (range 85-100). In the group of patients without PTC, the median overall Thermann score was 88.5 (range 60-100) and the median overall AOFAS score was 97 (range 85-100). No significant differences were detected between the group of patients with PTC and the group of patients without PTC and the clinical outcome according to the Thermann (p=0.21) and the AOFAS scores (p=0.37). None of the patients with PTC sustained a re-rupture. The overall re-rupture rate was 4.9%. PTC was no risk factor for wound and neurological complications. The incidence of PTC after percutaneous Achilles tendon repair was 11.1%. Male gender and advanced age seem to be risk factors for PTC. In this study, PTC had no negative impact on the postoperative clinical outcome.

Infraspinatus and Teres Minor Tendon Calcification with Severe Pain

Calcific tendinitis is an extremely common shoulder disorder which affects 2.7 to 10.3% of the adult population. However, clear details regarding the formation of calcific tendinitis have only been found recently, and its pathology still under debate. In this report, we present a case of calcific tendinitis affect both the infraspinatus and the teres minor tendon with both X-ray and ultrasound findings. Calcific tendinitis at the infraspinatus is rare (around 8.4% in all rotator cuff calcific tendinitis), and no separate case report on calcific tendinitis has been reported in the teres minor region in the preceding several years, therefore, the rarity of reporting this case was considered.4 We assume that additional case reports can help to further improve our understanding regarding infraspinatus and teres minor tendon calcification.

Calcium pyrophosphate dihydrate and hydroxyapatite crystals in a patient with rheumatoid arthritis: a case report

The association between rheumatoid arthritis (RA) and calcium pyrophosphate dihydrate (CPPD) crystal deposits can now be easily identified by MSUS, which is a noninvasive technique that can be applied to patients with painful joints and enthesis that are unexplained by rheumatoid activity. In this paper, we report an Egyptian case of a 51-year-old man who had rheumatoid arthritis since 7 years and developed bilateral knee and heel pain of 1.5 months’ duration with gradual onset and progressive course. Radiography revealed features of RA in both hands, as well as features of severe osteoarthritis in both knees with no signs of chondrocalcinosis. Ultrasonography of the joints, Achilles tendon, and plantar fascia detected knee, Achilles tendon, and plantar fascia calcifications, which are characteristic of CPPD, and supraspinatus calcification, which is characteristic of hydroxyapatite (HA) deposition. Further investigations revealed no evidence of metabolic disorders. CPPD and HA crystals were identified in his synovial fluid. Subclinical affection with CPPD and HA crystals in RA can be easily detected by ultrasonography, which allows early management to prevent future attacks in RA patients that could lead to exacerbation of joint symptoms that may be missed as rheumatoid disease activity. Diet control and colchicine treatment may be more effective if started early before exacerbation.

Sonography of the Achilles Tendon After Complete Rupture Repair: What the Radiologist Should Know.

This review aims to provide the radiologist with simple and systematic guidelines for evaluation of the Achilles tendon after complete rupture repair. Currently, there is a plethora of nonsurgical and surgical treatments, but sonographic examination has shown no significant differences between them. A systematic analysis of several parameters (morphologic characteristics, structure, color Doppler vascularization, and mobility) should be undertaken. Morphologically, the repaired tendon is larger, wider, or both. The loss of the fibrillary structure, inhomogeneity, and the surgical material in the context of the tendon are "normal" aspects after a repaired rupture. The presence of fluid collections when affecting greater than 50% of the surface of the tendon and extensive calcifications should be considered pathologic aspects. In the immediate postoperative period, there is the absence of vascularization detectable by color Doppler imaging. During the first 3 months, there is an increase in intratendinous vascularization with hypervascularization. From 3 to 6 months, stabilization and regression of the vascularization occur. Beyond the first 6 months, the hypervascularization is pathologic. The pattern of motion is, generally, reduced considerably more often in surgically treated tendons than in non-surgically treated ones. Elastography generally shows a hard appearance, with only a relatively heterogeneous pattern. In conclusion, a treated tendon will never regain a normal sonographic appearance, and the operator must distinguish between normal posttreatment changes and real pathologic characteristics.

AIUM Practice Parameter for the Performance of Selected Ultrasound‐Guided Procedures

AIUM Practice Parameter for the Performance of Selected Ultrasound‐Guided Procedures

AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures

AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures

Magnesium inhibits the calcification of the extracellular matrix in tendon-derived stem cells via the ATP-P2R and mitochondrial pathways

Tendon calcification has been widely regarded by researchers to result from the osteogenic differentiation of Tendon-Derived Stem Cells (TDSCs) and ectopic mineralization caused by the calcification of cellular matrix. Recent studies have revealed a correlation between the Mg2+/Ca2+ balance and the degeneration or calcification of tendon tissues. Furthermore, the ATP–P2X/P2Y receptor pathway has been shown to play a decisive role in the process of calcification, with calcium exportation from mitochondria and calcium oscillations potentially representing the cohesive signal produced by this pathway. Our previous study demonstrated that matrix calcification is inhibited by magnesium. In this study, we examined the effects of extracellular Mg2+ on the deposition of calcium phosphate matrix and cellular pathways in TDSCs. The suppression of the export of calcium from mitochondria has also been detected. We found that a high concentration of extracellular Mg2+ ([Mg2+]e) inhibited the mineralization of the extracellular matrix in TDSCs and that 100 μM ATP reversed this inhibitory effect in vitro. In addition, the spontaneous release of ATP was inhibited by high [Mg2+]e levels. A high [Mg2+]e suppressed the expression of P2X4, P2X5 and P2X7 and activated the expression of P2Y1, P2Y2, P2Y4 and P2Y14. The interaction between Mg2+ and Ca2+ is therefore contradictory, Mg2+ inhibits mitochondrial calcium concentrations, meanwhile it reverses the opening of mPTP that is induced by Ca2+. JC-1 staining verified the protective effect of Mg2+ on mitochondrial membrane potential and the decrease induced by Ca2+. Taken together, these results indicate that high [Mg2+]e interferes with the expression of P2 receptors, resulting in decreased extracellular mineralization. The balance between Mg2+ and Ca2+ influences mitochondrial calcium exportation and provides another explanation for the mechanism underlying matrix calcification in TDSCs.

Current research on tendon calcification

Tendon calcification, a common clinical disease, is often complicated after tendon injury or surgery, or as a special manifestation of tendinopathy. It is also one manifestation of acquired heterotopic ossification. However, there are no preventive measures for tendon calcification in clinical treatment as its pathogenesis is still unclear. In addition, the domestic orthopedic surgeons have paid little attention to this issue yet. To enhance understanding of tendon calcification, we have summarized the relevant literature published in recent years. Key words: Tendon calcification; Pathogenesis; Epidemiology; Treatment

Rapamycin Attenuates Age-associated Changes in Tibialis Anterior Tendon Viscoelastic Properties.

Rapamycin extends mouse life span, but the extent to which rapamycin prevents aging-associated changes in specific tissues remains unclear. Stiffness increases and collagen turnover decreases in mouse tendon with aging; thus, our aim was to determine the effect of long-term rapamycin treatment on the mechanical and structural properties of tendons from old mice. Tendons were harvested from female UM-HET3 mice maintained on a standard chow diet for 4 (adult) or 22 (old) months or fed chow containing polymer-encapsulated rapamycin (eRAPA) from 9 to 22 months of age (old RAPA). Stiffness was twofold higher for tendons of old compared with adult mice, but in old RAPA mice, tendon stiffness was maintained at a value not different from that of adults. Additionally, expression of collagen decreased, expression of matrix metalloproteinase-8 increased, and total hydroxyproline content trended toward decreased levels in tendons of old eRAPA-fed mice compared with controls. Finally, age-associated calcification of Achilles tendons and accompanying elevations in expression of chondrocyte and osteoblast markers were all lower in old eRAPA-fed mice. These results suggest that long-term administration of rapamycin alters the molecular pathways responsible for aging of tendon extracellular matrix, resulting in tissue that is structurally and mechanically similar to tendons in adult mice.

Ten weeks of treadmill running decreases stiffness and increases collagen turnover in tendons of old mice.

Increased tendon stiffness in response to mechanical loading is well established in young animals. Given that tendons stiffen with aging, we aimed to determine the effect of increased loading on tendons of old animals. We subjected 28-month-old mice to 10 weeks of uphill treadmill running; sedentary 8- and 28-month-old mice served as controls. Following training, plantaris tendon stiffness and modulus were reduced by approximately half, such that the values were not different from those of tendons from adult sedentary animals. The decrease in plantaris tendon stiffness was accompanied by a similar reduction in the levels of advanced glycation end-product protein adducts in tibialis anterior tendons of trained compared with sedentary old mice. In Achilles tendons, elevated mRNA levels for collagen type 1, matrix-metalloproteinase-8, and lysyl oxidase following training suggest that collagen turnover was likely also increased. The dramatic mechanical and structural changes induced by training occurred independent of changes in cell density or tendon morphology. Finally, Achilles tendon calcification was significantly reduced following exercise. These results demonstrate that, in response to exercise, tendons from old animals are capable of replacing damaged and dysfunctional components of extracellular matrix with tissue that is mechanically and structurally comparable to adult tissue.

Retrospective study of sonographic findings in bone involvement associated with rotator cuff calcific tendinopathy: preliminary results of a case series

ObjectiveThe present study was aimed at investigating bone involvement secondary to rotator cuff calcific tendonitis at ultrasonography.Materials and MethodsRetrospective study of a case series. The authors reviewed shoulder ultrasonography reports of 141 patients diagnosed with rotator cuff calcific tendonitis, collected from the computer-based data records of their institution over a four-year period. Imaging findings were retrospectively and consensually analyzed by two experienced musculoskeletal radiologists looking for bone involvement associated with calcific tendonitis. Only the cases confirmed by computed tomography were considered for descriptive analysis.ResultsSonographic findings of calcific tendinopathy with bone involvement were observed in 7/141 (~ 5%) patients (mean age, 50.9 years; age range, 42-58 years; 42% female). Cortical bone erosion adjacent to tendon calcification was the most common finding, observed in 7/7 cases. Signs of intraosseous migration were found in 3/7 cases, and subcortical cysts in 2/7 cases. The findings were confirmed by computed tomography. Calcifications associated with bone abnormalities showed no acoustic shadowing at ultrasonography, favoring the hypothesis of resorption phase of the disease.ConclusionPreliminary results of the present study suggest that ultrasonography can identify bone abnormalities secondary to rotator cuff calcific tendinopathy, particularly the presence of cortical bone erosion.

An Investigation of the Asymptomatic Limb in Unilateral Lateral Epicondylalgia.

Musculoskeletal ultrasound (MSUS) imaging is used to investigate features of tendinosis. Recent studies have reported tendon pathology not only in the symptomatic tendon but also in the contralateral asymptomatic tendon of animals and humans with unilateral Achilles tendinopathy. This study assessed the symptomatic and contralateral asymptomatic tendon in unilateral lateral epicondylalgia (LE) for features of tendinosis and compared with a pain-free control. Twenty-nine participants with clinically diagnosed unilateral LE and 32 pain-free controls (matched for age, sex, and arm dominance) underwent a blinded bilateral MSUS examination of the common extensor tendon using a standardized protocol. Grayscale features, including tendon thickening, hypoechoic region, fibrillar disruption and calcification, as well as neovascularity, were scored using separate ordinal scales. Tendon thickness and hypoechoic volume were also measured. The contralateral asymptomatic tendon did not differ from the tendons of the pain-free controls. The symptomatic tendon of participants with LE revealed a significantly greater score for the following: tendon thickening (mean difference, 0.76 (95% confidence interval, 0.22-1.30)), hypoechoic changes (0.58 (0.05-1.11)), fibrillar disruption (0.97 (0.52-1.42)), and neovascularity (1.53 (0.9-2.2)) than controls. Hypoechoic volume was greater in the symptomatic arm (33.0 mm3 (8.4-57.6)), than that in the controls. Unlike Achilles tendinopathy, MSUS examination did not reveal features of tendinosis in the contralateral asymptomatic limb beyond those present in tendons of pain-free controls.

Sonography of chondral print on humeral head.

The aim of this study is to determine the diagnostic accuracy of sonography in order to identify the chondral print on the humeral head. In total, 44 patients who had already been candidates for arthroscopic surgery were prospectively studied with ultrasound to assess the presence of humeral subchondral erosion at the level of the biceps pulley; no patient had undergone previous surgery or radiographic calcification of rotator cuff tendons. Using arthroscopy as the reference standard the sensitivity, specificity, positive predictive, negative predictive and diagnostic accuracy values were calculated. Of the 44 patients, arthroscopy showed the humeral chondral print in 30 patients. Of the 30 arthroscopy proven humeral chondral prints, ultrasound identified 28 subchondral erosions at the same level, with two false negatives. One of the 14 patients without arthroscopic humeral chondral print was positive for subchondral erosion at ultrasound. The sensitivity, specificity, positive predictive, negative predictive, and diagnostic accuracy values of ultrasound were respectively of 93, 93, 96, 87 and 93%. Ultrasound has a good diagnostic accuracy in identifying the chondral print sign.

Assessment of implant position after total knee arthroplasty by dual-energy computed tomography.

Correct alignment of prosthetic components is the most important factor for the success of total knee arthroplasty (TKA). Dual-energy computed tomography (DECT) may be a reliable method in determining implant position after TKA. To evaluate the accuracy and reproducibility of DECT in determining implant position after TKA. Institutional review board approval was obtained. Forty-five patients (age 75.2 ± 6.4 years) prospectively underwent TKA at our institution between May and December 2012. DECT was performed 1 year after surgery, using an alignment similar to a standing position and generating images at an extrapolated energy of 120 kVp, in order to reduce metal artifacts. Implant position was evaluated by two independent readers. Intra- and inter-observer agreements were calculated. DECT measurements on implant position were compared with the preoperative planning based on radiographs. Additional clinical and DECT findings were taken into account. Metal artifact reduction was judged satisfactory in all cases. Regarding implant position assessed with DECT, good to excellent intra-observer (k: 0.74-0.87 and k: 0.75-0.88, respectively), and inter-observer agreement (k: 0.72-0.82) were found. In the comparison with preoperative planning, the widest limits of agreement were within 3.9° for the sagittal orientation of tibial component. A single patient with postoperative knee pain and stiffness had periprosthetic osteopenia, quadriceps femoris tendon calcifications, articular effusion, and excessive intrarotation of the femoral component. DECT is an accurate and reproducible tool for determining implant position after TKA.

Calcific Tendinitis Of The Longus Colli Muscle

HISTORY: A 43 year old Arabic speaking female with history of chronic headaches presented to the Emergency Department with a 2 day history of left sided neck pain, odynophagia and urinary symptoms. She was diagnosed with strep pharyngitis and a UTI and treated with Amoxicillin, Ciprofloxacin, Phenazopyridine, and mouthwash. While on antibiotic therapy, she noted an improvement in her urinary symptoms but her head, neck and throat pain and fevers continued to worsen. Ibuprofen caused mild improvement in her symptoms. She was seen in our clinic two days after her Emergency Department visit. PHYSICAL EXAMINATION: Pharynx non-erythematous, no tonsil hypertrophy, no cervical lymphadenopathy. Head tilted to right, unable to open mouth widely or turn head/neck due to pain. Tenderness to palpation over mastoid as well as entire left side of neck. Increased tone to left side of head/neck musculature. DIFFERENTIAL DIAGNOSIS: 1. Infectious spondylitis 2. Mastoiditis 3. Retropharyngeal abscess 4. Torticollis 4. Calcific tendinitis TEST AND RESULTS: Neck Soft Tissue Computerized Tomography with and without contrast — No abscess/signs of pharyngitis, visible fluid collection, or inflammation. — C1-C2 calcification of the longus colli tendon. — Multiple indeterminate lymph nodes FINAL/WORKING DIAGNOSIS: Calcific tendinitis of the longus colli muscle TREATMENT AND OUTCOMES: 1. Conservative management was started with anti-inflammatory medications 2. Patient returned 3 weeks later and was symptom free 3. If symptoms are severe, a course of oral corticosteroids can be considered

Ultrasonographic Evaluation of Patients Suspected of Rotator Cuff Tears

Objective: Partial thickness rotator cuff tears are often difficult to detect. Therefore, many patients are referred for ultrasonographic evaluation. The purpose of this study was to evaluate patients suspected of having rotator cuff tears by musculoskeletal ultrasonography. Methods: We analyzed 283 patients referred by orthopedic surgeons for musculoskeletal ultrasonography between January 2013 and April 2014. All electronic medical records, reasons of referral, images, and ultrasonographic reports were reviewed. Results: The study comprised 171 women and 112 men (mean age: 56.0 years). A total of 102 patients (36.0%) were confirmed to have rotator cuff tears by ultrasonography, including 90 cases of partial tear (88.2%) and 12 cases of complete tear (11.8%). The most frequent torn tendon was the supraspinatus, which was also the most frequent calcified rotator cuff tendon. There was no statistical gender differences in supraspinatus tendon tears or in calcified supraspinatus tendon. Conclusion: Among patients with suspected rotator cuff tears, supraspinatus tendon tear and calcification were most common ultrasonographic findings.

Case-based session: cardiac masses: Wednesday 3 December 2014, 11:00-12:30 * Location: Agora

Case-based session: cardiac masses: Wednesday 3 December 2014, 11:00-12:30 * Location: Agora

Rectus Femoris Tendon Calcification: Arthroscopic Excision in 6 Top Amateur Athletes.

Background:Since it was developed, hip arthroscopy has become the favored treatment for femoroacetabular impingement. Due to recent considerable improvements, the indications for this technique have been widely extended. Injuries of the rectus femoris tendon origin, after an acute phase, could result in a chronic tendinopathy with calcium hydroxyapatite crystal deposition, leading to pain and loss of function. Traditionally, this condition is addressed by local injection of anesthetic and corticosteroids or, when conservative measures fail, by open excision of the calcific lesion by an anterior approach.Purpose:To assess whether arthroscopic excision of calcification of the proximal rectus is a safe and effective treatment.Study Design:Case series; Level of evidence, 4.Methods:Outcomes were studied from 6 top amateur athletes (age range, 30-43 years; mean, 32.6 years) affected by calcification of the proximal rectus who underwent arthroscopic excision of the calcification. Patients were preoperatively assessed radiographically, and diagnosis was confirmed by a 3-dimensional computed tomography scan. To evaluate the outcome, standardized hip rating scores were used pre- and postoperatively (at 6 and 12 months): the Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score, and Modified Harris Hip Score. Moreover, visual analog scales (VAS) for pain, sport activity level (SAL), and activities of daily living (ADL) were also used.Results:One year after surgery, all patients reported satisfactory outcomes, with 3 of 6 rating their return-to-sport level as high as preinjury level, and the remaining 3 with a percentage higher than 80%. Five patients ranked their ability to carry on daily activities at 100%. Statistical analysis showed significant improvement of the Oxford Hip Score, the Modified Harris Hip Score, and all 3 VAS subscales (pain, SAL, and ADL) from pre- to latest postoperative assessment (P < .05).Conclusion:Arthroscopic excision of rectus femoris tendon calcification yields satisfying results with few risks to the patient as well as rapid recovery.Clinical Relevance:The recent improvements in hip arthroscopy give the opportunity to address an increasing number of hip conditions effectively and safely, with rapid recovery for the patient. Arthroscopic excision of rectus femoris tendon calcification can be considered a feasible option, with few risks to the patient, rapid recovery, and satisfying outcomes.

Uniaxial repetitive mechanical overloading induces influx of extracellular calcium and cytoskeleton disruption in human tenocytes.

Tendon calcification is common in the Achilles tendon, and injuries affect not only athletes, but also the general population. However, the underlying cellular mechanisms are not yet fully understood. In this study, we isolated healthy human tenocytes and subjected them to uniaxial mechanical stretching (at 1.0 Hz) for various stretch times (4 h, 8 h, 12 h) or magnitudes (0%, 4%, 8%, 12%). The extracellular calcium chelator EGTA, calcium channel inhibitor MnCl2, nifedipine, or various doses of exogenous calcium were administered to these cells with or without mechanical overloading. The intracellular calcium concentration was determined by using a Fluo-3/AM fluorescence probe, and the cytoskeleton was revealed by F-actin Phalloidin staining. The intracellular calcium concentration increased in a magnitude- and time-dependent manner following stretching. These increases were suppressed by EGTA, MnCl2, or nifedipine. Additionally, cytoskeleton F-actin was disrupted significantly by stretching in a time-dependent manner. When extracellular calcium was applied, the intracellular calcium concentration increased, and F-actin was disrupted dramatically under mechanical stretching compared with non-stretched cells. Thus, repetitive mechanical overloading induces the accumulation of abnormally high concentrations of intracellular calcium resulting from extracellular calcium influx mediated, at least in part, by membrane calcium channels and finally causes cytoskeleton disorganization and tenocyte dysfunction. These findings provide novel experimental evidence for the pathology of tendon calcification and indicate that the blockade of calcium influx is a potential target for the prevention and treatment of calcific tendinopathy.

Running on time: the role of circadian clocks in the musculoskeletal system.

The night and day cycle governs the circadian (24 hourly) rhythm of activity and rest in animals and humans. This is reflected in daily changes of the global gene expression pattern and metabolism, but also in the local physiology of various tissues. A central clock in the brain co-ordinates the rhythmic locomotion behaviour, as well as synchronizing various local oscillators, such as those found in the musculoskeletal system. It has become increasingly recognized that the internal molecular clocks in cells allow a tissue to anticipate the rhythmic changes in their local environment and the specific demands of that tissue. Consequently, the majority of the rhythmic clock controlled genes and pathways are tissue specific. The concept of the tissue-specific function of circadian clocks is further supported by the diverse musculoskeletal phenotypes in mice with deletions or mutations of various core clock components, ranging from increased bone mass, dwarfism, arthropathy, reduced muscle strength and tendon calcification. The present review summarizes the current understanding of the circadian clocks in muscle, bone, cartilage and tendon tissues, with particular focus on the evidence of circadian rhythms in tissue physiology, their entrainment mechanisms and disease links, and the tissue-specific clock target genes/pathways. Research in this area holds strong potential to advance our understanding of how circadian rhythms control the health and disease of the musculoskeletal tissues, which has major implications in diseases associated with advancing age. It could also have potential implications in sports performance and sports medicine.