Tendon Involvement Research Articles

Ultrasonographic Evaluation of Hand and Foot Tendons in Behçet's Disease

There have been few studies in the literature evaluating the effect of Behçet's disease (BD) on tendons. Thus, we planned to search for the involvement of hand and foot tendons in BD by using ultrasonography and to determine the relation of tendon involvement with clinical measurements. The study consisted of 33 randomly selected BD patients and 36 voluntary healthy controls matched by age and body mass index. Sonographic evaluations were performed from hands (flexor digitorum süperficialis (2-5), flexor digitorum profundus (2-5), flexor carpi radialis) and Achilles tendons of the nondominant extremities using an 8-10 MHz linear array probe. Grip strength and crepitation were also measured on the nondominant side. Mean hand and foot tendon thickness values of BD patients were significantly higher than in control group (p=0.00). Disease duration, age, and presence of crepitation were not correlated with tendon thickness in the BD group (all p values>0.05). Grip strength values were lower in the BD group than in control group but the difference was not statistically significant (p=0.344). Grip strength values were not correlated with hand tendon thicknesses in BD groups (all p values>0.05). Because tendons tears and thicknesses are associated with inflammation, awareness of tendon pathologies is very important in rheumatic diseases. It would be of value to investigate this relationship in future studies in order to determine if this increment in tendon thickness is an indicator of disease activity and affects prognosis. The physician should be on alert about tendon involvement even if the patient has no complaints.

Venous malformations: MR imaging features that predict skin burns after percutaneous alcohol embolization procedures

To examine the value of magnetic resonance (MR) imaging for predicting the occurrence of skin burns in patients with venous malformations who undergo percutaneous alcohol embolization was the objective of the study. Pre-procedural MR imaging at 1.5 T from 40 patients with venous malformations who had undergone percutaneous alcohol embolization was retrospectively reviewed by two observers for these features: anatomic location, definition (well-defined or ill-defined), and the presence of skin, subcutaneous tissue, muscle, tendon, bone, joint, and deep venous system involvement. One observer recorded the length of skin involvement and volume of the malformation. Univariate and multivariate analysis tests were used to determine whether an association between the occurrence of skin burns and MR imaging features existed. The anatomic locations of the venous malformations were the lower extremity (20 out of 40), upper extremity (11 out of 40), trunk (four out of 40), head/neck (three out of 40) and pelvis (two out of 40). Of the 40 subjects, 15% (six out of 40) experienced skin burns. There was a significant association between the absence of muscle involvement (p = 0.0198) as well as the length of skin involvement (p = 0.027), with the occurrence of skin burns. Malformation size and all other features were not significantly associated with skin burns. Skin burns in patients with venous malformations treated with alcohol embolization are associated with the length of skin involvement and with the absence of deeper tissue involvement, as depicted on MR imaging.

Radiologie osseuse : cheville et pied de l’adulte

The main views and indications in adult foot and ankle radiography are detailed. Among foot and ankle diseases, mechanical ones are most frequent, including usual podologic changes (commonly followed by peculiar involvement of certain bones, ligaments, joints, tendons and other soft tissues), synostoses, occult and stress fractures, sprains, and tendon changes. Although they are less frequently encountered in common clinical practice, the radiographic appearance of inflammatory, infectious, and tumoral diseases of foot and ankle are disclosed as well. The correlation existing between some subtle radiographic changes and their counterpart on US, CT, or MR examinations are also emphasized.

Tuberculous Tenosynovitis of Flexor Digitorum Longus Tendon

Extrapulmonary tuberculous involvement of musculoskeletal system accounts for approximately 1% to 5% of cases. Tuberculous involvement of the feet tendon is even rarer. We are reporting an extremely rare case of tuberculous tenosynovitis of flexor digitorum longus tendon in a 68-year-old man. A 68-year-old farmer from India presented with a painless swelling over medial aspect of left ankle for 3 months. Examination of left ankle and foot revealed non-tender, fluctuant swelling, anteroinferior to medial malleolus. Plain radiographs of the ankle and foot revealed no abnormality. Laboratory findings, including erythrocyte sedimentation rate, were within normal limits. When excision was attempted, purulent material came out on incising the subcutaneous tissue. Gram staining, acid fast bacilli staining and pyogenic culture detected no organism. Histopathological examination of the granulation tissue showed non-specific inflammation. The wound healed well with secondary intention over a 15-day period. Two months postoperatively, swelling recurred at the same site. Magnetic resonance imaging showed small hypointense collection in the tendon sheath of left flexor digitorum longus behind the left ankle joint and adjacent lower end of tibia on the T2-weighted, STIR, and gradient (T2 with fat saturation) images, which appeared hypointense on T1-weighted images, suggestive of tenosynovitis. Tenosynovectomy was performed. Mycobacterium tuberculosis was isolated on culture. Histopathological examination, this time revealed epitheloid granuloma. Patient recovered uneventfully after 5-drug antituberculous regime.

Distally Based Fasciocutaneous Sural Flap for Foot Reconstruction: A Retrospective Review of 10 Years Experience

The treatment of soft tissue defects of the foot is a problem mainly connected to the thickness of the coverage tissues, to the poor circulation, and to the frequent involvement of muscle, tendon, and bone. The authors present their experience with the sural flap, also in some particular cases. The authors treated 33 patients for small- and medium-size defects of the foot, caused by work, home, and road accidents, and by venous or diabetic ulcers. In all cases, the flap was cut in its fasciocutaneous variant; an extension of the sole portion of fascia was added in 5 patients. The flap was transferred under a subcutaneous tunnel in 10 cases, with an open incision in 20 cases, and in 3 cases the pedicle was kept external for 4 weeks, then resected. One patient showed a complete necrosis of the flap and another showed a superficial necrosis preserving the deep fascia; in the remaining 31 cases, the flap incorporated without any major complication. The flap provided proper coverage of the defects from both an aesthetic and functional point of view as evidenced clinically and through a baropedographic test. The advantages of this flap include: dissection is fast and easy, it is not necessary to sacrifice important arterial pedicle or muscular units as it can be used in traumatized limbs without further damage to main arteries, and a wide rotation arc is possible. Disadvantages include the sacrifice of the sural nerve and the covering of the donor region with skin grafts.

Nail Gun Injuries to the Hand

Aberdeen Royal Infirmary is a teaching hospital serving a population of over 500,000. A number of nail gun injuries to the hand prompted a review of our management of these injuries and a review of the literature. These are deep penetrating injuries, often contaminated by particles of skin, oil, paper or glue, or caused by nails that are barbed. Fifty-five cases of nail gun injury to the hand were reviewed in a retrospective study of injuries presenting to the hospital between January 2000 and June 2004. The population at risk is almost entirely men and involved in the construction industry. Twenty-five percent of cases were found to have tendon, nerve or joint involvement at operation. None of the injuries required anything more than meticulous wound toilet. To our knowledge, this is the first large study to clinically document the actual hand injuries caused by nail guns. An analysis of our treatment patterns suggests a low risk from surgical exploration with several potential benefits.

Achilles tendon problems: Not just an orthopaedic issue

Purpose. To review the current concepts on Achilles tendon involvement in various pathological conditions.Method. A literature search was conducted to trace relevant literature on Achilles tendon problems in general pathologies.Results. The Achilles tendon can be involved in inflammatory and autoimmune conditions, genetically determined collagen abnormalities, infectious diseases, tumours, and neurological conditions which are not of a primary surgical nature.Conclusions. Although Achilles tendon problems are classically considered frequent in active individuals from overuse or a single acute episode, problems in the Achilles tendon can be a consequence of several conditions.

Acute First-Time Hamstring Strains during Slow-Speed Stretching

Background Hamstring strains can be of 2 types with different injury mechanisms, 1 occurring during high-speed running and the other during stretching exercises. Hypothesis A stretching type of injury to the proximal rear thigh may involve specific muscle-tendon structures that could affect recovery time. Study Design Case series (prognosis); Level of evidence, 2. Methods Fifteen professional dancers with acute first-time hamstring strains were prospectively included in the study. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. The clinical follow-up period was 2 years. Results All dancers were injured during slow hip-flexion movements with extended knee and experienced relatively mild acute symptoms. All injuries were located proximally in the posterior thigh close to the ischial tuberosity. The injury involved the semimembranosus (87%), quadratus femoris (87%), and adductor magnus (33%). All injuries to the semimembranosus involved its proximal free tendon. There were no significant correlations between clinical or magnetic resonance imaging parameters and the time to return to preinjury level (median, 50 weeks; range, 30-76 weeks). Conclusion Stretching exercises can give rise to a specific type of strain injury to the posterior thigh. A precise history and careful palpation provide the clinician enough information to predict a prolonged time until return to preinjury level. One factor underlying prolonged recovery time could be the involvement of the free tendon of the semimembranosus muscle.

Management of a type II nasoethmoid orbital fracture and near-penetration of the intracranial cavity with transnasal canthopexy

Nasoethmoid orbital fractures are perhaps the most complicated aspect of craniomaxillofacial trauma. Involvement of the medial canthal tendon markedly increases the complexity of the repair. We report a case of type II nasoethmoid orbital fracture in a 32-year-old man that was managed without formal medial canthal tendon repair; instead, we used open reduction and internal fixation of the central fragment and the nasoethmoid complex. However, during the immediate postoperative period, we noted anterior and inferior displacement of the medial canthus. We took the patient back to the operating room to address the detachment. Revision surgery was successful, and at the 6-month follow-up, his medial canthi were completely symmetrical in all dimensions. We describe our intraoperative technique and measures to prevent complications that can help the surgeon intraoperatively. We also discuss an important point that has not been adequately addressed in the literature to date--that is, the fact that the use of the frontoethmoid suture line and the anterior ethmoid artery as a guide to the skull base can be inaccurate. Problems associated with this inaccuracy can be avoided by carefully reviewing preoperative computed tomography, which can help keep the surgeon from entering the intracranial cavity while fixing the medial canthal tendon during transnasal canthal repair.

Acute First-Time Hamstring Strains during High-Speed Running

Background Hamstring muscle strain is one of the most common injuries in sports. Still, knowledge is limited about the progression of clinical and magnetic resonance imaging characteristics and their association with recovery time in athletes. Hypothesis Knowing the anatomical location and extent of an acute first-time hamstring strain in athletes is critical for the prognosis of recovery time. Study Design Case series (prognosis); Level of evidence, 2. Methods Eighteen elite sprinters with acute first-time hamstring strains were prospectively included in the study. All subjects were examined, clinically and with magnetic resonance imaging, on 4 occasions after injury: at day 2 to 4, 10, 21, and 42. The clinical follow-up period was 2 years. Results All sprinters were injured during competitive sprinting, and the primary injuries were all located in the long head of the biceps femoris muscle. There was an association between the time to return to pre-injury level (median, 16; range, 6-50 weeks) and the extent of the injury, as indicated by the magnetic resonance imaging parameters. Involvement of the proximal free tendon, as estimated by MRI, and proximity to the ischial tuberosity, as estimated both by palpation and magnetic resonance imaging, were associated with longer time to return to pre-injury level. Conclusion Careful palpation during the first 3 weeks after injury and magnetic resonance imaging investigation performed during the first 6 weeks after injury provide valuable information that can be used to predict the time to return to pre-injury level of performance in elite sprinting.

Arthroscopic Rotator Cuff Repair With and Without Subacromial Decompression: A Prospective Randomized Study

Our purpose was to evaluate the role of subacromial decompression in the arthroscopic repair of full-thickness rotator cuff tears in a prospective randomized clinical study. Arthroscopic cuff repair was performed in 80 patients with a full-thickness rotator cuff tear. They were divided into 2 groups comprising 40 patients each. In group 1 arthroscopic rotator cuff repair was performed with subacromial decompression. In group 2 the repair was performed without decompression. Rotator cuff tears were repaired via metal suture anchors for tendon-to-bone repair, side-to-side repair, or a combination of the 2 techniques. Results were evaluated by use of the Constant score normalized for age and gender, as well as the Disabilities of the Arm, Shoulder and Hand (DASH) and Work-DASH self-administered questionnaires. On analyzing the results at 2 years' follow-up, we considered the following independent variables: age; gender; dominance; location, shape, area, retraction, and reducibility of cuff tear; fatty degeneration; involvement of subscapularis tendon; treatment of biceps tendon; rotator cuff repair technique; and type of acromion. A univariate and multivariate statistical analysis was performed to determine which variables were independently associated with the outcome. Comparison between the groups did not show significant differences for each variable considered. The overall results for the Constant score were 103.6 points in group 1 and 96.1 points in group 2; those for the DASH score were 18.2 points and 23.1 points, respectively; and those for the Work-DASH score were 23.7 points and 26.2 points, respectively. Univariate and multivariate analysis showed that the following variables significantly and independently influenced the outcome: age; shape, retraction, and reducibility of cuff tear; fatty degeneration; involvement of subscapularis; and repair technique. Subacromial decompression did not influence the outcome significantly for each scoring system considered. At short-term follow-up, subacromial decompression did not seem to significantly affect the outcome of arthroscopic rotator cuff repair. Longer follow-up studies will be necessary to confirm the clinical relevance of these observations. Level I, randomized controlled trial with no significant difference but narrow confidence intervals.

MR imaging of rectus femoris origin injuries

To describe the MR imaging findings of acute and chronic rectus femoris origin (RFO) injuries. A retrospective review of pelvic and hip MR imaging procedures was performed over a 4-year period for detection of cases with injuries to the RFO. Subjects were classified as having either acute or chronic symptoms. MR imaging studies, radiographs, CT scans, radiology reports, medical records, and operative notes were reviewed. Imaging analysis was directed to assess injuries affecting the direct and indirect heads of the RFO. Concurrent osseous, cartilaginous and musculotendinous injuries were tabulated. The incidence of RFO injuries on MR imaging was 0.5% (17/3160). With the exception of one case of anterior inferior iliac spine apophysis avulsion and partial tear of the direct head of RFO, all subjects had indirect head of RFO injuries (acute injury 8/9, chronic injury 8/8). Partial tear of the direct head of RFO was less frequently seen (acute injury 3/9, chronic injury 2/8). Partial tears of the conjoint tendon were least frequent (acute 1/9, chronic 2/8). No full-thickness tears of the RFO were noted. Associated labral tears were seen in only one case, with no other concomitant abnormality of the articular cartilage or surrounding soft tissues. All RFO injuries were treated non-operatively. Injuries of the RFO are uncommon on MR examinations of pelvis/hips and may occur in a sequence progressing from indirect head injury to involvement of direct head and conjoint tendon in more severe cases.

Hand Arthritis in Systemic Lupus Erythematosus: An Ultrasound Pictorial Essay

A small minority of systemic lupus erythematosus (SLE) patients may develop a deforming arthritis, typically with a non-erosive (Jaccoud's) pattern, although erosive features indistinguishable from rheumatoid arthritis may also occur. High-resolution ultrasonography (HRUS) allows detailed 'real time' imaging of joint and tendon morphostructural changes involving the hand in patients with several rheumatic diseases. The main aim of this pictorial essay is to provide the first descriptive HRUS and power Doppler (PD) findings of joint and tendon involvement of the hand and wrist in patients with SLE arthritis. Seventeen patients with SLE and hand involvement were examined. HRUS of the wrist, 2nd and 3rd MCP joints, 3rd PIP joint and 2nd, 3rd and 4th finger flexor tendons were studied in the dominant hand for each patient. Sixteen (94%) patients had joint effusion or synovial hypertrophy in the wrist. Twelve (71%) patients had joint effusion or synovial hypertrophy in 2nd or 3rd MCPJs. Eight (47%) patients had erosion at 2nd or 3rd MCPJs. In three cases erosions were not present radiologically. Eleven (65%) patients had evidence of tenosynovitis. In SLE, HRUS with PD detects a high prevalence of inflammatory pathology in the tendons and synovium of the hand and wrist, and a high prevalence of MCP joint erosions. HRUS offers a sensitive, real-time and readily repeatable assessment of soft-tissue, inflammatory and bony changes in SLE hands.

The distal radioulnar joint in rheumatoid arthritis

Rheumatoid arthritis (RA) often–up to 80%–involves the wrist; even up to 95% of the patients after 12 years of disease have signs of wrist arthritis. The distal radioulnar joint (DRUJ) is involvement in 31% of these patients in early rheumatoid arthritis and in 75% in late presentations. It is often the first compartment of the wrist involved. Only a few papers discuss the DRUJ problem in RA separately; usually, the whole wrist complex is discussed or described. The latter are right: it is practically impossible to distinguish the DRUJ problem from other arthritic changes in other compartments of the wrist or to ignore associated tendon involvement.

The Use of an Intra-Articular Depth Gauge In The Measurement of Partial Thickness Rotator Cuff Tears (SS-25)

It has been a long held belief that the amount of partial thickness damage to the rotator cuff correlates with the severity of symptoms and can be used to direct treatment. However, assessment of partial thickness rotator cuff tear (PT-RCT) size and thickness is difficult and imprecise. Despite this, several authors have recommended different treatment regimens for PT-RCTs based on the percentage of thickness of the tendon torn. The current method of measurement arbitrarily compares the amount of exposed bone in the rotator cuff footprint, to historic anatomic data to determine the percentage of tendon involvement. Considering the variability of footprint anatomy, this can lead to imprecise and improper decision making. The purpose of this study was to compare the current method of measurement to the use of an intra-articular depth gauge in the measurement of articular surface PT-RCTs of the supraspinatus tendon. Cadaveric Study: In eight fresh frozen cadaveric shoulders, PT-RCTs of various amounts were created in the supraspinatus tendon. Each tear was then evaluated arthroscopically and the amount of footprint exposed, the total tendon thickness and percentage of tendon thickness torn was measured by comparison to a shaver of known size and using an intra-articular depth gauge. Shoulders were then dissected and the true anatomic measures determined. Clinical Study: Over a 1 year period, patients with articular surface PT-RCTs of the supraspinatus tendon were evaluated arthroscopically using the intra-articular depth gauge and the amount of footprint exposed, the total tendon thickness and percentage of tendon thickness torn was measured. In the cadaveric study, the mean true amount of footprint exposed was 7mm (range: 5-10mm), the mean true total tendon thickness was 13mm (range:10-22mm), and the mean true percentage of tendon thickness torn was 54% (range: 33-70%). The intra-articular depth gauge was more accurate than comparison to/estimation to a known size. In particular, total tendon thickness and percentage of tendon thickness torn was more accurately determined using the intra-articular depth gauge. In the clinical study, 22 patients with PT-RCTs of the supraspinatus tendon were identified. Using the intra-articular depth gauge, the mean footprint exposed was 10mm (range:0-18mm), the mean total tendon thickness was 14mm (range: 10-19 mm) and the mean percentage of tendon thickness torn was 65% (range:0-95%). In 4 cases the treatment decision was altered by the measurement made by the intra-articular depth gauge (i.e. 1 patient repaired instead of debrided; 3 patients debrided instead of repaired.) Weber has recommended that PT-RCTs involving > 50% of the tendon thickness should be repaired. Despite his recommendations, which have become a standard of treatment, measuring tear thickness remains difficult. The intra-articular depth gauge provides a method of direct measurement of the amount of footprint exposed, total tendon thickness and percentage of thickness torn for accurate and precise documentation and decision making. In our clinical study use of the intra-articular depth gauge altered treatment 18% of the time. However, previous treatment recommendations should be scrutinized since these are based on comparisons/estimates and are likely inaccurate.

Flexor tendon synovectomy in rheumatoid arthritis

Rheumatoid hand deformities are often visible on the dorsal aspect of the hand and wrist. This explains why less attention has been given to the role of flexor tendon involvement in this condition. Swelling and joint distortions are also more visible on the dorsal aspect, although the sequences of movements, the major part of the joint and collateral ligaments, are volar. Hypertrophic synovitis is also more abundant and thicker volarly than dorsally.

Persistent joint swelling and borrelia-specific antibodies in Borrelia garinii-infected mice after eradication of vegetative spirochetes with antibiotic treatment

We wanted to study the pathogenesis and the long-term manifestations of Borrelia garinii infection in SJL and C3H/He mice. We report here that B. garinii Å218 causes a persisting infection in these mouse strains. Mice infected with intracutaneous inoculation of B. garinii at 4–5 weeks of age developed a disseminated infection and joint swelling within 2 weeks of inoculation and remained infected with joint symptoms until the end of follow-ups of up to 52 weeks. Treatment with ceftriaxone or ampicillin at 18 or 44 weeks of infection did not affect the joint swelling during the follow-ups of 19 and 8 weeks, respectively. However, B. garinii could not be cultured from any of the post mortem tissue samples of the treated mice, whereas the spirochete grew from samples of all untreated infected animals. borrelia-specific IgG antibodies were detectable after 2 weeks of infection, and in late infection, all mice had high anti-borrelia IgG levels. Antibiotic treatment had no effect on antibody levels. Histology showed only slight changes in the joints of the infected mice with occasional lymphocyte infiltration, synovial proliferation and slight involvement of the Achilles' tendon. No difference was seen in the findings between ceftriaxone-treated and untreated mice. The results suggest that the presence of vegetative spirochetes is no prerequisite for persisting joint symptoms and elevated anti-borrelia IgG levels in these B. garinii-infected mice.

Mycobacterium tuberculosis–Induced Carpal Tunnel Syndrome: Management and Follow-Up Evaluation

To determine the clinical characteristics of 12 patients with Mycobacterium tuberculosis-induced carpal tunnel syndrome. This article also presents our intraoperative findings and surgical treatment results. Twelve patients with tuberculosis-induced carpal tunnel syndrome who had surgery during a 10-year period that began in March 1991 were reviewed. The entrance criterion was a positive histologic report of tuberculosis for surgical specimens. The preoperative evaluation leading to diagnosis was reviewed for all patients. Transection of the transverse carpal ligament and complete synovectomy were performed for all patients. After surgery the patients were given an antituberculosis regimen for 1 year and were followed up for an average of 6 years. Twelve cases from a total of 1,180 patients with carpal tunnel syndrome were traced to M tuberculosis involvement of synovial tissue of the flexor tendons. Ten patients had large rice bodies in thick synovial membranes, and in the other 2 patients thick synovial tissue with yellow exudates were observed during surgery. In contrast to tendon involvement with rupture, no direct median nerve involvement was noted. Histopathologic study results of surgical specimens were positive for tuberculosis in all patients. Eight of 10 initial smears showed acid-fast bacillus and all 10 cultures of the specimens were positive for tubercle bacilli. Surgery and antituberculosis therapy were associated with a desirable outcome and sensory disturbance in the median nerve distribution resolved in all patients. Anterior wrist swelling disappeared and there has been no clinical or laboratory evidence of recurrence in all treated patients. Early diagnosis and surgical treatment combined with antituberculosis medical treatment are important in treating this condition. All patients treated were relieved of symptoms of synovial proliferation at the wrist, with no recurrence of the condition during the follow-up period. Therapeutic, Level IV.

Degenerative suspensory ligament desmitis as a systemic disorder characterized by proteoglycan accumulation

BackgroundDegenerative suspensory ligament desmitis (DSLD) is a debilitating disorder thought to be limited to suspensory ligaments of Peruvian Pasos, Peruvian Paso crosses, Arabians, American Saddlebreds, American Quarter Horses, Thoroughbreds, and some European breeds. It frequently leads to persistent, incurable lameness and need to euthanize affected horses. The pathogenesis remains unclear, though the disease appears to run in families. Treatment and prevention are empirical and supportive, and not effective in halting the progression of the disease. Presently, the presumptive diagnosis of DSLD is obtained from patient signalment and history, clinical examination, and ultrasonographic examination of clinically affected horses, and is confirmed at post mortem examination. Presently, there are no reliable methods of diagnosing DSLD in asymptomatic horses. The goal of this study was to characterize and define the disorder in terms of tissue involvement at the macroscopic and microscopic levels.ResultsWe examined tissues and organs from 28 affected horses (22 Peruvian Pasos, 6 horses of other breeds) and from 8 control horses. Histopathological examination revealed the presence of excessive amounts of proteoglycans in the following tissues removed from DSLD-affected horses: suspensory ligaments, superficial and deep digital flexor tendons, patellar and nuchal ligaments, cardiovascular system, and sclerae. Electron microscopy demonstrated changes in diameters of collagen fibrils in the tendon, and in smooth muscle cells of the media of the aorta compatible with increased cell permeability in DSLD-affected cells. Separation of tendon extracts by gel chromatography revealed the presence of additional proteoglycan(s) in extracts from affected, but not control extracts.ConclusionThis study demonstrates for the first time that DSLD, a disease process previously thought to be limited to the suspensory ligaments of the distal limbs of affected horses, is in fact a systemic disorder involving tissues and organs with significant connective tissue component. Abnormal accumulation of proteoglycans between collagen and elastic fibers rather than specific collagen fibril abnormalities is the most prominent histological feature of DSLD. Because of this observation and because of the involvement of many other tendons and ligaments beside the suspensory ligament, and of non-ligamentous tissue we, therefore, propose that equine systemic proteoglycan accumulation or ESPA rather than DSLD is a more appropriate name for this condition.

Ultrasound detection of entheseal insertions in the foot of patients with spondyloarthropathy

The aim of the study was to evaluate entheseal involvement in the foot of patients with spondyloarthropathy (SpA) by ultrasonographic (US) examination and compare the results with clinical and radiological findings. Forty-four patients (27 men, 17 women) with a diagnosis of SpA were recruited. Patient evaluation included physical examination (swelling and pain), Bath Ankylosing Spondylitis Radiological Index, Bath Ankylosing Spondylitis Disease Activity, Bath Ankylosing Spondylitis Metrological Index, and laboratory parameters (erythrocyte sedimentation rate, C-reactive protein). Foot x-rays of the patients were assessed and scored according to SpA Tarsal Radiographic Index (SpA-TRI). A high-resolution US was used to examine the tendon and ligament insertion sites in the foot, and the findings were scored according to Glasgow Ultrasound Enthesitis Scoring System (GUESS). The mean age and disease duration of the patients were 39.9+/-12.5 and 9+/-8.2 years, respectively. US revealed pathological findings in 25 of 44 (56.8%) patients, most of whom exhibited no clinical signs of foot involvement. Pain and swelling at entheseal insertions were detected in only 16 (37%) patients. The mean GUESS score and SpA-TRI score were 2.2+/-2.5 and 3.3+/-3.7, respectively. There was a correlation between the scores of GUESS and SpA-TRI, particularly at the Achilles and plantar fascia insertion sites. The mean score of SpA-TRI was higher in patients with enthesopathy, detected by US, than in patients without enthesopathy (4.6+/-4.4 vs 1.8+/-2.1). There was no significant correlation between the mean GUESS score and clinical and laboratory variables. In conclusion, involvement of tendon and entheses is not rare, and US is a valuable diagnostic method in detecting subclinical enthesopathic changes. The GUESS and SpA-TRI are suggested in quantifying US and radiological changes in the foot of patients with SpA.