[CT/MRI image characteristics of iliopsoas bursitis in avascular necrosis of femoral head]

OBJECTIVE

To investigate the spectrum of CT and MR imaging and surgical operation findings in iliopsoas bursitis in patients with avascular necrosis of femoral head so as to enhance the diagnostic ability.

METHODS

A total of 1,415 patients with avascular necrosis of the femoral head were analyzed retrospectively; of them, 15 patients were complicated by iliopsoas bursitis surgically or aspiration of synovial fluid between May 2005 and May 2007. Fifteen cases were all necrosis of the bilateral femoral head and 17 hips were combined with iliopsoas bursitis. There were 14 males and 1 female, aging 29-58 years. The course of disease was 1 month to 3 years. All 15 patients had limitation of ability of the hips and the "4" type sign was positive. The Harris score of hip's function was 54-78 (mean 62.7). Five patients of them can be touched a palpable cystic mass and tenderness in the inguinal area, and 3 of them associated with femoral neuropathy and 2 patients presented slight atrophy of the thigh muscle in suffering side. All these cases were taken X-ray films of positive and frog-leg lateral position, helical CT scan with 5 mm thinness, and MRI was performed in 6 patients with TlWI, T2WI, T2WI and fat-saturated inversion recovery sequence.

RESULTS

The radiographs were the primary basis evidences for diagnosis and degrees of the avascular necrosis of femoral head. According to the standards of Association Research Circulation Osseuse, there were 2 hips at stage II (II C 2), 6 hips at stage III ( II B 1, III C 5 and 9 hips at stage IV. The X-ray films showed the bulging of the fat pad and soft tissue swelling in 6 patients. CT analysis disclosed that the enlarged iliopsoas bursae appeared as hypodense, well-defined, thin-walled (< 2 mm) cystic structures. The content of the examined bursae was homogeneous with a CT density of ranging from 12.7 to 41.2 Hu, showing fluid collection. They were round or oval in shape medial to the iliopsoas, exhibiting inyvrted water-drop cystic shadow just inferior to the femoral head. Slight contrast enhancement of the bursal wall was seen after contrast agent administration in 3 cases. MRI demonstrated that the iliopsoas bursitis presented as low signal on T1WI and water-like high signal on T2WI and markedly higher signal on STIR in 6 cases. The demonstration of the extent, size, mass effects and its relation and subsequent affection to surrounding anatomical structures were clearly shown by MRI, and by the communications between the il opsoas bursa and the adjacent hip joint.

CONCLUSION

In the diagnosis of avascular necrosis of femoral head with imaging approaches, much attention should be paid to the abnormalities around the articular capsule to early identify iliopsoas bursitis for further management.

Ankle stiffness after Bosworth fracture dislocation of the ankle

PURPOSE

The purpose of this study is to review the result of patients with Bosworth fracture dislocation of ankle.

TYPE OF STUDY

Retrospective case series.

METHODS

Four patients with Bosworth fracture-dislocation of ankle are evaluated clinically and radiologically.

RESULT

All four cases have failed initial closed reduction of the ankle and open reduction is required. Three patients with delayed presentation suffered from post-traumatic ankle stiffness and subsequently developed ankle degeneration.

CONCLUSION

Early recognition and prompt reduction of the dislocated ankle is important in case of Bosworth fracture dislocation in order to prevent late complication. Closed reduction of dislocated ankle is usually not helpful and repeated attempts may be harmful. Emergency operation of open reduction and internal fixation is usually required to reduce the ankle joint without delay.

Ossification of the infraspinatus tendon-bursa in 13 dogs

Ossification of the infraspinatus tendon-bursa was diagnosed in 13 labrador retrievers, 12 of which were lame in one thoracic limb and the other in both. They ranged in age from 28 to 121 months (mean 69.4 months). The lameness developed gradually and was progressive in 11 of the 14 affected joints. Scapular muscle atrophy and signs of pain on direct pressure over the infraspinatus tendon of insertion were key clinical signs. Caudocranial radiographs revealed multiple mineralised masses lateral to the proximal humerus or glenohumeral joint in 11 of the 26 joints and single masses in 12. An arthroscopic examination revealed concomitant ligament or tendon abnormalities in six of seven shoulders. The dogs were followed up from one to 55 months (mean 20 months). Of five shoulders treated with non-steroidal anti-inflammatory drugs (nsaids), one resolved, two improved and two were managed surgically. Of six shoulders treated by the injection of long-acting intra-articular corticosteroid (five before and one after surgery), three resolved, two improved and one was unchanged. Of six shoulders treated by the surgical resection of the infraspinatus tendon and bursa (three before and two after treatment with nsaids, and one after treatment with a long-acting intra-articular corticosteroid), four improved, one was unchanged and one was managed with an intra-articular long-acting corticosteroid. One shoulder was managed by restricted exercise and the lameness resolved. Histological examination of the excised tissues revealed heterotopic bone within the infraspinatus tendon and/or bursa.

[Utility of joint distension during arthrography in treatment of adhesive capsulitis of the shoulder in a study of 20 patients]

AIM

The aim of our study is to evaluate the efficacy of joint distension during arthrography followed by an intra articular corticosteroid injection.

METHODS

This procedure associated to a physical therapy started immediately after joint distension and performed during 3 months in the treatment of 20 patients suffering from adhesive capsulitis of the shoulder were assessed.

RESULTS

Patients were evaluated on D 90:90 % of them have regression of pain, 70 % have an improvement of deficiency and ranges of motion of the shoulder. Adhesive capsulitis of the shoulder is a disabling pathology but, generally, with good evolution. It is a clinical diagnosis.

CONCLUSION

Joint distension associated to physical therapy has an interest in treatment because of therapeutic and antalgic effect and also restoration of range of movement.

Gallium scintigraphy in a case of tuberculous trochanteric bursitis

We report a 67-year-old woman with systemic lupus erythematosus and systemic disseminated tuberculosis affecting the femoral trochanteric bursae, a site rarely affected by tuberculosis. For quantification of the inflammation with gallium-67 scintigraphy, we calculated the radioisotope count ratio in the most inflamed areas, the right lateral thorax and bursa of the right greater trochanter. Systemic scanning with this modality allowed evaluation of the extent of lesions and simple quantitative determination of the severity of inflammation, yielding information useful for the follow-up of the patient during the course of tuberculosis treatment.

Septic Arthritis and Bursitis: Emergency Ultrasound Can Facilitate Diagnosis

This article reports the case of a 52-year-old woman with septic arthritis and bursitis of her shoulder. Due to a minor musculoskeletal injury and lack of fever, the diagnosis was missed on her first Emergency Department visit. Sonographic guidance of the shoulder arthrocentesis led to successful aspiration of the larger fluid collection in the subacromial bursa and allowed the diagnosis and treatment to proceed more rapidly. Septic arthritis is a challenging clinical diagnosis, and when it occurs in more difficult to aspirate joints, the diagnosis can become more challenging still. Ultrasound provides a means for the emergency physician to establish the diagnosis more readily.

Gallium-67 scintigraphy in polymyalgia rheumatica

A patient with atypical presentation of polymyalgia rheumatica is presented. Her major symptoms were mild weakness, pain on passive movement of the shoulder and hip girdles, with mild tenderness but no joint stiffness. Muscle enzymes were within the normal range. The diagnostic work-up included gallium-67 scintigraphy, which showed intense uptake in both shoulders, with remarkable improvement following steroid treatment. A prospective study may delineate the possible role of this imaging modality in establishing a diagnosis of polymyalgia rheumatica.

A sonographic enthesitic index of lower limbs is a valuable tool in the assessment of ankylosing spondylitis

BACKGROUND

Enthesitis is a remarkable feature of ankylosing spondylitis (AS) not specifically approached by the available measuring tools for the disease. Ultrasonography (US) has proved to be an excellent technique for the assessment of tendon pathology.

OBJECTIVE

To test a Sonographic Entheseal Index (SEI) of the lower limbs in a cohort of patients with AS, as a potential measuring tool.

METHODS

44 patients with AS and 10 healthy controls were enrolled. Bath Ankylosing Spondylitis Functional Index and Bath Ankylosing Spondylitis Disease Activity Index, pain at entheseal points, severity of symptoms, acute-phase reactants, Schober's test and stage of sacroiliitis were recorded. Patients underwent US examination of five entheseal regions from both lower limbs by two experts. Hypoechogenicity, increased tendon thickness, peritendinous oedema and bursitis were considered signs of active inflammation. Insertional bone erosions, intratendinous calcifications, decreased thickness and tears were considered signs of chronic injury. Each alteration independently scored one point. Data were analysed with Spearman's correlation method.

RESULTS

A significant interobserver correlation in SEI scores (p<0.001) and a fine discriminative power between controls and patients were observed. Acute entheseal lesions predominated (63% vs 37%), the most frequent alteration being tendon hypoechogenicity (43%). 72% of all lesions were located at the foot. The SEI correlated with reduction of Schober's test (p<0.02), but not with other activity or severity parameters.

CONCLUSIONS

A scoring method such as the SEI may be of help in characterising entheseal injury in AS, and for decision making in these patients.

Ultrasonographic findings in patients with olecranon bursitis

BACKGROUND

Musculoskeletal ultrasonography (U.S.) is an important imaging technique in the diagnosis of olecranon bursitis, especially for early manifestation. It allows sensitive detection of small fluid collections as well as for differentiation between soft tissue and bone lesions. U.S. examination allows detection of effusions, synovial proliferation, calcifications, loose bodies, rheumatoid nodules, gout tophi and septic processes.

AIM

To assess the role of ultrasonography in the diagnosis and management of patients with olecranon bursitis.

METHODS

Ultrasound was used in 34 patients with swelling above the olecranon. The opposite asymptomatic side served as a control group.

RESULTS

20 patients demonstrated increased fluid collection in the olecranon bursa. 5 had synovial proliferation, 2 cases showed loose body, 5 patients revealed markedly increased blood flow consistent with inflammation, 2 patients had triceps tendonitis with calcifications.

CONCLUSIONS

Sonography is an extremely effective tool for the diagnosis of soft tissue lesions in the olecranon area.

Atypical extraspinal musculoskeletal tuberculosis in immunocompetent patients: part II, tuberculous myositis, tuberculous bursitis, and tuberculous tenosynovites

Tuberculosis involving the soft tissue from adjacent bone or joint is well recognized. However, primary tuberculous pyomyositis, tuberculous bursitis, and tuberculous tenosynovitis are rare entities constituting 1% of skeletal tuberculosis. Tuberculous tenosynovitis involves most commonly the tendon sheaths of the hand and wrist, and tuberculous bursitis occurs most commonly around the hip. The greater trochanteric bursa and the greater trochanter are the most frequent sites of tuberculous bursitis. Cases of primary tuberculous pyomyositis and tenosynovitis of the tendons of the ankle and foot are seldom reported in the radiology literature. All imaging modalities-plain radiography, bone scan, computed tomography, and magnetic resonance imaging (MRI)--provide information that is helpful in determining therapy. MRI in particular, with its multiplanar capabilities and superb contrast of soft tissue, can demonstrate the extent of the soft tissue mass and access the adjacent bones and joints. However, MRI has no diagnostic specificity in regard to tuberculosis, and in nonendemic areas, biopsy is strongly recommended. All patients in this review were permanent residents of North America or Western Europe and were immunocompetent. Examples of atypical presentations of the above entities are demonstrated.

Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool?

OBJECTIVE

To determine the accessibility of the coracohumeral ligament (CHL) by ultrasound (US) and to determine CHL thickness in adhesive capsulitis of the shoulder.

DESIGN AND PATIENTS

US examinations were carried out in 498 consecutive shoulders of 306 individuals (194 women and 112 men), mean age 47.4 years (range 15-92 years), in order to identify and measure the maximum thickness of the CHL. The patients were divided into three study groups: asymptomatic shoulders (n=121), painful shoulders (n=360) and shoulders with arthrographic evidence of adhesive capsulitis (n=17). The mean maximal thickness of CHL was compared among the 3 study groups (non-parametric test of Kruskal-Wallis, p<0.05).

RESULTS

The CHL was visualized in 92 out of 121 shoulders in the asymptomatic group (76.0%), in 227 out of 360 shoulders in the painful shoulder group (63.0%), and in 15 out of 17 shoulders in the adhesive capsulitis group (88.2%). The average thickness of the CHL was significantly greater in adhesive capsulitis (3 mm) than in the asymptomatic (1.34 mm) and painful (1.39 mm) shoulders. No significant difference was found between asymptomatic and painful shoulders.

CONCLUSION

CHL depiction can be achieved in a reasonable proportion of shoulders. A thickened CHL is suggestive of adhesive capsulitis. More studies are needed for clinical validation of these data.

Intra-tendinous ossification with concomitant tendonitis and bursitis--ultrasound grey-scale and colour Doppler findings

A case report of a 62-year-old man with a 20-year history of tendon problems, who presented with a swollen and tender left Achilles tendon. Ultrasound (US) revealed a 2 x 1 x 0.9 cm intra-tendinous substance with acoustic shadowing. On a radiogram, ossification was found. Colour Doppler activity was present in both the bursa and the tendon. A US-guided injection of 40 mg Depomedrol was applied into the retrocalcaneal bursa. On follow-up two months later, the patient had no symptoms and US showed total regression of Doppler activity. The ossification was unchanged. US colour Doppler may be recommended for guidance and monitoring of treatment.

Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip

OBJECTIVE

The purpose of this study was to compare sonographic evaluations of patients referred with suspected snapping of their iliopsoas tendon with the pain relief achieved from anesthetic injection of the iliopsoas bursa, and with the subsequent surgical outcome. This study also assessed the effectiveness of Kenalog injection into the iliopsoas bursa for long-term pain relief.

PATIENTS AND METHODS

Dynamic and static sonography was performed in 40 patients with clinically diagnosed snapping hips. The iliopsoas bursa was injected with Bupivicaine and Lidocaine in the first 22 patients, and an additional 1 ml Kenalog-40 was added to this mixture in the last 18 patients. We compared the static and dynamic sonographic findings with change in the patients' level of pain at 2 days after anesthetic injection. The sonographic findings and response to anesthetic injection were also compared to the response to Kenalog injection and the results of any subsequent surgery.

RESULTS

Static sonography of the iliopsoas tendon was normal in 38 patients, and detected iliopsoas bursitis in one patient and iliopsoas tendinopathy in another. Snapping of the iliopsoas tendon was observed using dynamic sonography in 9 of the 40 patients. Following anesthetic injection of the iliopsoas bursa, 29 patients had complete or partial pain relief, and 11 patients had no pain relief. Eight of the nine patients with a snapping iliopsoas tendon had complete or partial pain relief from the bursal injection. Twelve of the 29 patients with pain relief after anesthetic injection later had an arthroscopic iliopsoas tendon release, and all of these 12 patients had a good postoperative result. Of the 18 patients who had Kenalog-40 injected into the iliopsoas bursa and did not have iliopsoas surgery, 16 had sustained pain relief following the injection.

CONCLUSIONS

Patients with groin pain and a clinically suspected snapping iliopsoas tendon can benefit from injection into the iliopsoas bursa even if the snapping tendon is not visualized sonographically. The use of a corticosteroid may provide long-term pain relief, and pain relief after injection is a predictor of good outcome after surgical release of the iliopsoas tendon.

Adhesive capsulitis of the shoulder: the rate of manipulation following distension arthrogram

To determine the rate of manipulation under anaesthesia (MUA) following distension arthrogram for adhesive capsulitis of the shoulder. Thirty-nine patients (42 shoulders) between 1998 and 2004 were treated with distension arthrogram for adhesive capsulitis diagnosed by the clinical picture of progressive pain and stiffness. Capsular disruption into the subscapular bursa was demonstrated in 40 of the 42 shoulders (95%). Thirty-seven of 42 (88%) shoulders were painfree following distension arthrogram. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram for stiffness although 10 of these (67%) were painfree. Prior to distension arthrogram, the range of external rotation (ER) was no different between those that had MUA and those that did not (P = 0.36). The improvement in ER was 33% (P = 0.28) in those that had MUA and 50% (P = 0.001) in those that did not. The only complication was a vasovagal episode during the procedure. Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the majority of adhesive capsulitis and decrease the rate of MUA of the shoulder.

Shoulder distension arthrography in adhesive capsulitis

Capsular retraction of the shoulder often occurs as a solitary pathological process; half of the cases are of primitive nature. In the past 10 years or more, distension of the shoulder joint has proven to be an efficient percutaneous treatment, and various techniques have been proposed. We report on our technique, which was performed on a series of 200 patients, and on the results observed in 27 patients with a precise evaluation of progressive changes in movements of the joint.

Ultrasonography of the lower extremity

Ultrasonography is a useful imaging tool for various soft tissue and joint pathologies affecting the lower extremity. This article reviews the normal sonographic appearance of muscles, tendons, ligaments, nerves, bone, and cartilage. The ultrasound imaging appearance of various pathologic conditions affecting the hip, thigh, knee, lower leg, ankle,and foot are illustrated. The advantages of ultrasonography are highlighted.

Ultrasound-Guided Shoulder Injections in the Treatment of Subacromial Bursitis

OBJECTIVE

To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis.

DESIGN

A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study. These patients were divided into blind and ultrasound-guided injection groups. The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups.

RESULTS

The shoulder abduction range of motion before injection in the blind injection group was 71.03 +/- 12.38 degrees and improved to 100 +/- 18.18 degrees 1 wk after the injection treatments. However, the improvement did not reveal significant statistical differences (P > 0.05). The shoulder abduction range of motion before injection in the ultrasound-guided injection group was 69.05 +/- 14.72 degrees and improved to 139.29 +/- 20.14 degrees 1 wk after the injection treatments (P < 0.05).

CONCLUSIONS

Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa. The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis.

MRI appearance of retrocalcaneal bursitis and rheumatoid nodule in a patient with rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis and sometimes multisystem involvement. Rheumatoid nodules have been reported in as many as 20-30% of patients with rheumatoid arthritis; however, they are not commonly seen in the feet. We present magnetic resonance (MR) findings of a rarely seen case of rheumatoid bursitis in the retrocalcaneal bursa associated with a subcutaneous rheumatoid nodule inferior to the calcaneus which histologically confirmed the rheumatoid arthritis. To the best of our knowledge, this is the first case that rheumatoid bursitis in the retrocalcaneal bursa associated with the rheumatoid nodule in the foot was revealed by MR imaging.