[Operative treatment of Haglund's deformity]

The paper presents results of the operative treatment of 22 heel in 18 patients mostly young women from 13 to 31 years old (average 20.6) with Haglund's exostosis. Operative technique consisted in partial resection of the heel with removal of the Achilles bursa. The most valuable was radiological examination for the diagnosis and assessment operative results. The ultrasound examination was helpful of estimation of Achilles tendon and calcaneal bursa. Good results achieved in 16 patients (20 heel) with follow-up from 4 to 20 years (average 9.5). Unsatisfactory results in 2 patients was connected with inadequate bone resection.

Hydrodilatation in the management of shoulder capsulitis

The aim of this study was to research the benefit of hydraulic arthrographic capsular distension (hydrodilatation) in the management of adhesive capsulitis of the shoulder. One hundred and nine shoulders with primary adhesive capsulitis were treated with hydrodilatation. Prior to the procedure, 93 shoulders were painful. Two months following the procedure, 31 continued to have some pain. In the 109 shoulders, the measured range of passive glenohumeral movement improved by approximately 30 degrees in all directions. The procedure was of similar benefit if carried out early or late in the disease process. The absolute improvement in movement range was similar in severe and mild cases. The severe cases in the long term, although improved, still had more restriction in movement and tended to have more pain than the other cases. There was considerable improvement in all the non-diabetic patients. The patients with diabetes responded less well in the long term to hydrodilatation and had an increased requirement for arthroscopic surgery. Effective treatment of adhesive capsulitis can be achieved in the majority of cases with an immediate hydrodilatation of the shoulder. Technically, it is important to achieve maximum distension, preferably with capsular rupture, and to utilize cortisone in the fluid injected.

Endoscopic decompression of the retrocalcaneal space

BACKGROUND

Pain in the retrocalcaneal space can be incapacitating. Patients who do not respond to nonoperative treatment may seek a surgical solution. The first purpose of this paper was to describe and evaluate the efficacy of a minimally invasive procedure to address retrocalcaneal pain caused by retrocalcaneal bursitis, a Haglund spur, and impingement. The second purpose was to compare the endoscopic technique with a standard open technique.

METHODS

Our prospective study included thirty-three heels in thirty consecutive patients with chronic pain in the retrocalcaneal space for which nonoperative treatment had failed and endoscopic decompression was performed. The mean age was forty-nine years (range, nineteen to seventy-nine years). This group was compared with a group of seventeen heels in fourteen patients with the same diagnostic criteria who were treated with an open technique. Both groups of patients were evaluated preoperatively and postoperatively with the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale, and the patients treated with the endoscopic procedure were also evaluated postoperatively with the University of Maryland 100-point Painful Foot Center Scoring System.

RESULTS

In the endoscopic group, the AOFAS scores averaged 61.8 points preoperatively and 87.5 points postoperatively (p < 0.001). The endoscopic procedures yielded nineteen excellent, five good, three fair, and three poor results at an average of twenty-two months postoperatively. (Three patients were excluded from the study.) In the open-treatment group, the AOFAS scores averaged 58.1 points preoperatively and 79.3 points at an average of forty-two months postoperatively (p = 0.006). The scores after the endoscopic procedures were numerically, but not significantly (p = 0.115), better than those after the open procedures. The time to recovery was the same in the two groups. The endoscopic procedures were performed more quickly than the open procedures (forty-four compared with fifty-six minutes) and were associated with fewer complications (a 3% compared with a 12% rate of infection, a 10% compared with an 18% rate of altered sensation, and a 7% compared with an 18% rate of scar tenderness).

CONCLUSIONS

Endoscopic decompression is a feasible and efficient procedure for the treatment of retrocalcaneal disorders. It produces final results equal to or better than those of an open technique, with a similar recovery time, fewer complications, and a better cosmetic appearance.

Ultrasonography for assessment of subcutaneous nodules

OBJECTIVE

To characterize a variety of subcutaneous lesions by their ultrasonographic (US) appearance, and establish these images as a starting point to measure changes with treatments.

METHODS

Twenty-six patients with 48 subcutaneous nodular swellings of various types were imaged using a portable US machine equipped with a 10 MHz linear transducer. All patients had a known diagnosis of a rheumatic disease. We used US to examine subcutaneous lesions and the underlying cortical surface of the bone or joint. Two measurements of some tophi and rheumatoid nodules were done on different dates to examine reproducibility of the measurements.

RESULTS

Nodular lesions included 20 tophi and 20 rheumatoid nodules, 2 sarcoid nodules, 2 lipomas, and 4 synovial cysts. Tophi most often appeared as heterogeneous masses; hypoechoic areas in 2 tophi were decreased after aspiration of chalky liquid tophaceous material. Occasionally tophi had calcifications appearing hyperechoic with acoustic shadowing. Cortical bone erosions could be seen adjacent to some tophi. The nodules in patients with rheumatoid arthritis were often attached closely to the bone surface and less erosive to bone, allowing the cortical bone to be seen easily. The nodules were more homogeneous. Some showed a central sharply demarcated hypoechoic area, possibly corresponding to necrosis inside the rheumatoid nodules. Nodules were easily measured. The repeated measurements of both tophi and rheumatoid nodules showed excellent reproducibility. Lipomas had different echogenic patterns depending on composition of the associated connective tissue and position of the mass. They could be hypoechogenic, hyperechogenic, or mixed, but were easily distinguished by oval shapes with well demarcated capsules. Synovial cysts seen in this study had a characteristic hypoechoic pattern.

CONCLUSION

Subcutaneous nodules examined by sonography show characteristics and patterns that, although not diagnostic, can be used to help distinguish their etiology. Tophi and rheumatoid nodules can be easily measured and these measurements used to help follow disease progression or response to therapy.

Rice-body formation in atypical mycobacterial tenosynovitis and bursitis: findings on sonography and MR imaging

OBJECTIVE

This article describes rice bodies found in patients with atypical mycobacterial tenosynovitis and bursitis, emphasizing the sonographic and MR imaging appearances of these small bodies.

CONCLUSION

Rice bodies occur in patients with atypical mycobacterial tenosynovitis and bursitis. When small, rice bodies are better visualized on MR imaging than on sonography, allowing the radiologist to consider appropriate diagnoses.

Atypical retroperitoneal extension of iliopsoas bursitis

We report two rare cases of iliopsoas bursitis extending into the retroperitoneal space. The first lesion contained much gas, mimicking a retroperitoneal abscess, and the second was responsible for atypical inguinal pain. The diagnosis was made by contrast-enhanced CT in both cases and arthrography in the first case. Iliopsoas bursitis in these two patients, it is hypothesized, extended into the retroperitoneum, at least in part, by way of intraneural or perineural structures.

Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis

OBJECTIVE

Musculoskeletal ultrasonography allows real-time imaging of joint structures and may be used to complement clinical examination in rheumatological practice. We compared ultrasonography (US) with clinical examination (CE) in the detection of effusion, suprapatellar bursitis, and Baker's cyst of the knee in rheumatoid arthritis (RA) in order to determine whether US provided additional clinical information.

METHODS

A total of 22 patients with RA (ACR criteria) underwent independent clinical and US examination of both knees for suprapatellar bursitis, knee effusion, and presence of Baker's cyst. US was performed using an ATL HDI 3000 machine with L7-4 MHz and CL10-5 MHz probes. Clinical examination was performed using standard techniques by an experienced rheumatologist. Patients with previous knee surgery were excluded from the study.

RESULTS

A total of 44 knees were examined at a total of 130 sites (one patient was unable to lie prone for US of popliteal fossae). US detected soft tissue abnormality (suprapatellar bursitis, knee effusion, or Baker's cyst) at 54/130 (42%) sites, while CE detected soft tissue abnormality at 36/130 (28%) sites. US detected 17 (39%) cases of suprapatellar bursitis in 44 knees, 7 (16%) of which were detected on CE. US detected 27 (61%) knee joint effusions in 44 knees, 16 (36.36%) of which were detected on CE. US detected 10 (23.81%) Baker's cysts in 42 knees, 2 (4.76%) of which were detected on CE. Taking US of the knee as the gold standard, CE was specific but not sensitive in the detection of soft tissue abnormality of the knee in RA.

CONCLUSION

US is more sensitive than CE in the detection of suprapatellar bursitis, knee effusion, and Baker's cyst in RA. CE underestimates knee inflammation in RA. This has implications for the use of CE as a component of standardized disease activity scores and in guiding knee joint aspiration.

[Impingement of the iliopsoas muscle after revision of a loosened acetabular cup with an acetabular reinforcement ring]

Impingement of the iliopsoas muscle due to a protruding acetabular component is an uncommon cause of pain after total hip arthroplasty. We report the case of a 59 year old female patient who developed groin pain one year after revision arthroplasty and reconstruction of the acteabular defect with an acetabular reinforcement ring due to a loosened cup. THERAPY AND FOLLOW UP: After revision of the right hip via an anterior approach we used bone cement to smooth the anterior edge of the acetabular reconstruction ring and created a smooth rim for the iliopsoas tendon. At follow up 2 years later the patient was satisfied with the result, she complained about very rare recurrent groin pain, without any need for further treatment.

US of the shoulder: non-rotator cuff disorders

The most common indication for shoulder ultrasonography (US) is the diagnosis of rotator cuff disease. However, there is a spectrum of non-rotator cuff abnormalities that are amenable to US examination, including instability of the biceps tendon, glenohumeral joint, and acromioclavicular joint; arthropathies and bursites (inflammatory diseases, degenerative and infiltrative disorders, infections); nerve entrapment syndromes; and space-occupying lesions. Many of these conditions may be overlooked clinically or can even mimic rotator cuff tears, and US can help redirect the diagnosis if a complete shoulder examination rather than a simple rotator cuff assessment is performed. In addition, US can be remarkably helpful in guiding either needle aspiration procedures or local injection therapy in patients with synovial processes. Although radiography, magnetic resonance (MR) imaging, and computed tomographic and MR arthrography are effective modalities for the evaluation of non-rotator cuff disorders, US is both less costly and less invasive and will likely be used more frequently in this setting as experience increases. Once adequate radiographs have been obtained to exclude apparent bone disorders, high-resolution US should be the first-line imaging modality in the assessment of non-rotator cuff disorders of the shoulder, assuming the study is performed with high-end equipment by an experienced examiner.

Ultrasonographic evaluation of pes anserinus tendino-bursitis in patients with type 2 diabetes mellitus

OBJECTIVE

To assess musculoskeletal ultrasonographic (US) findings in patients with type 2 diabetes mellitus (DM) with and without pes anserinus (PA) tendinitis or bursitis syndrome; and to determine possible etiologic factors such as systemic diabetic microvascular disease complications in these patients.

METHODS

The knee joints were examined with an ultrasound real-time scanner using a 10 MHz electronic linear transducer in 48 patients with type 2 DM and 25 controls. The presence of systemic diabetic microvascular disease complications was evaluated.

RESULTS

On examination 23 (23.9%) knees of the 14 (29.1%) patients with type 2 DM were found to have PA tendinitis or bursitis syndrome. US revealed that only 4 (8.3%) of the diabetic patients with PA tendinitis or bursitis syndrome had PA tendonitis findings. There were no significant differences in the thickness of PA tendons between the diabetic patients with bilateral knee PA tendinitis or bursitis syndrome (9 patients) and controls, or between the asymptomatic and symptomatic knees in patients with unilateral PA tendinitis or bursitis syndrome (5 patients). The prevalence of morphologic changes of the medial meniscus, effusion and synovitis in the suprapatellar recess, popliteal cyst, and radiographic osteoarthritis (OA) in the diabetic patients with PA tendinitis or bursitis syndrome was found to be increased.

CONCLUSION

The prevalence of PA tendinitis or bursitis syndrome is not uncommon on examination in patients with type 2 DM. However, patients with clinically diagnosed PA tendinitis or bursitis syndrome less frequently have morphologic US changes of the PA tendons. Our results also suggest that structural changes such as meniscus lesions that occur in consequence of OA might have a role in the etiology of medial knee pain in diabetic patients.

Isolated suprapatellar bursitis: Computed tomographic and arthroscopic findings

A rare case of compartmentalized suprapatellar bursitis in the left knee of an 80-year-old man is presented. Computed tomographic (CT) scans following intravenous administration of contrast media showed a cystic mass between the quadriceps tendon and the anterior surface of the femur. Multiplanar reconstruction CT scans showed a mass superior to the patella, the wall of which was enhanced. Arthroscopic examination of the knee revealed a complete suprapatellar septum that separated the suprapatellar bursa from the knee joint cavity. Surgical excision of the bursa was curative. To our knowledge, multiplanar reconstruction CT and arthroscopic features of the isolated suprapatellar bursitis have not been illustrated previously.

Hydroxyapatite Crystal Deposition Disease

Hydroxyapatite (HA) crystal deposition disease (HADD) is a well-recognized systemic disease of unknown etiology that is caused by para-articular and/or intra-articular deposition of HA crystals. The disease is clinically manifested by localized pain, swelling, and tenderness about the affected joint along with variable limitation of joint motion, although not all patients are symptomatic. Plain radiographs may show calcifications of varying size and shape in the para-articular tendons, bursae, and capsule. The disease may be mono- or polyarticular in distribution. The shoulder is most commonly involved with calcification in the supraspinatus tendon. When intra-articular, HA crystals can cause joint destruction. Any joint can be involved; the shoulder is most commonly affected, resulting in "Milwaukee shoulder." Treatment of HADD usually requires use of analgesics, local heat, needling with or without aspiration of the calcific deposits, steroid injections, and, at times, even surgery for relief of pain.

Endoscopic treatment of calcific tendinitis of gluteus medius and minimus

Calcific tendinitis results from deposition of calcium hydroxyapatite crystals in periarticular muscle attachments. Although involvement of tendons around the hip is not uncommon, gluteus medius and minimus tendons are rarely affected. We present endoscopic treatment of calcific tendonitis of gluteus medius and minimus and associated trochanteric bursitis in a patient with 2-year history of lateral hip pain. This is the first reported case treated using an endoscopic approach, which is effective and minimally invasive.

Successful treatment of multiple bursal cysts in systemic sclerosis

BACKGROUND

Bursitis frequently occurs in the various conditions of autoimmune disorders including rheumatoid arthritis, but there have been few cases of effusive bursitis in systemic sclerosis.

OBJECTIVE

To present a case of systemic sclerosis with multiple bursitis on upper, lower extremities, and trunk with or without joint involvement.

METHODS

Case report and review of the literature.

RESULTS

Multiple asymptomatic cystic masses contained yellow and chalky sterile fluid, all of which were diagnosed as effusive bursitis. Most of them were treated with a surgical resection, a continuous drainage, and an injection of highly concentrated ethanol into their internal spaces. However, an intrabursal injection of emulsified triamcinolone acetonide was the only effective treatment for the giant mass that occurred on the right chest wall.

CONCLUSION

Successful treatment of multiple bursal cysts with systemic sclerosis was presented.

Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy

OBJECTIVE

To compare ultrasonography (US) with clinical examination in the detection of entheseal abnormality of the lower limb in patients with spondyloarthropathy (SpA).

METHODS

35 patients with SpA (ankylosing spondylitis 27; psoriatic arthritis 7; reactive arthritis 1) underwent independent clinical and ultrasonographic examination of both lower limbs at five entheseal sites-superior pole and inferior pole of patella, tibial tuberosity, Achilles tendon, and plantar aponeurosis. US was performed using an ATL (Advanced Technology Laboratories, Bothell, Washington, USA) high definition imaging 3000 machine with linear 7-4 MHz and compact linear 10-5 MHz probes to detect bursitis, structure thickness, bony erosion, and enthesophyte (bony spur). An enthesitis score was formulated from these US findings giving a possible maximum total score of 36.

RESULTS

On clinical examination 75/348 (22%) entheseal sites were abnormal and on US examination 195/348 (56%) sites were abnormal. In 19 entheseal sites with bursitis on US, only five were detected by clinical examination. Compared with US, clinical examination had a low sensitivity (22.6%) and moderate specificity (79.7%) for the detection of enthesitis of the lower limbs. There was no significant correlation between the US score of enthesitis and acute phase parameters such as erythrocyte sedimentation rate (ESR) or C reactive protein (CRP). The intraobserver kappa value for analysis of all sites was 0.9.

CONCLUSIONS

Most entheseal abnormality in SpA is not detected at clinical examination. US is better than clinical examination in the detection of entheseal abnormality of the lower limbs in SpA. A quantitative US score of lower limb enthesitis is proposed but further studies are required to validate it in SpA.

Arteriovenous fistula of the lateral superior and inferior geniculate arteries. A unique cause of a "recurrent prepatellar bursa

We report a previously undocumented case of an arteriovenous fistula of the superior and inferior lateral geniculate arteries presenting with what was thought to be a recurrent prepatellar bursa requiring repeated drainage and excision. The diagnosis was made by arteriography. Surgical exploration and ligation of the feeding and draining vessels, via a posterior approach, alleviated the symptoms. Vascular injury should be suspected in patients presenting with recurrent postoperative hematomas or hemarthroses following surgery on the knee.

Giant iliopsoas bursitis: sonographic findings with magnetic resonance correlations

We present the case of a 40-year-old man with rheumatoid arthritis who had a painless left inguinal mass. Sonographic examination revealed a large soft tissue mass with mixed internal echotexture and regular borders extending inside the pelvis and into the proximal portion of the thigh. Sonography also showed communication between the bursa of the iliopsoas muscle and the hip cavity, with intra-articular synovitis and erosion of the ileum. Giant iliopsoas bursitis secondary to hip involvement in rheumatoid arthritis was diagnosed on the basis of the sonographic findings. This diagnosis was confirmed by MRI.

[Technical aspects and value of arthrosonography in rheumatologic diagnosis. 4: Ultrasound of the elbow]

Musculoskeletal ultrasonography is an important imaging technique in the diagnosis of rheumatic diseases especially for early manifestation. It allows sensitive detection of small joint fluid collections as well as differentiation of soft tissue lesions and bone lesions. The following standard scans are suggested for sonographic evaluation of the elbow: 1) anterior humeroradial longitudinal scan, 2) anterior humeroulnar longitudinal scan to detect effusions, synovial proliferation, loose joint bodies, bone lesions (osteoarthritis/arthritis), 3) anterior transverse scan over the trochlea to evaluate these structures in an additional dimension, 4) posterior longitudinal scan and 5) posterior transverse scan of the olecranon fossa with flexed/extended elbow to evaluate the same objectives as the above mentioned scans and additionally to detect olecranon bursitis, and optional 6) distal dorsal longitudinal scan to differentiate soft tissue lesions such as rheumatoid nodules or gout tophi, 7) anterior transverse scan over the radius head to evaluate lesions of the radius head, tendopathy, calcinosis, 8) lateral humeroradial longitudinal scan to evaluate epicondylitis, 9) medial humeroulnar longitudinal scan to evaluate calcinosis, epicondylitis, signs of compression of the ulnar nerve. A linear transducer with a frequency of about 5-7.5 MHz is recommendable. The anterior distance between trochlea and the capitulum of the humerus between the bone and the joint-capsule of the elbow is > or = 2 mm in probable and > or = 3 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between the right and left elbow is 1 mm, and they are definite if the difference is > or = 2 mm.

Technetium-99m human immunoglobulin scintigraphy in patients with adhesive capsulitis: a correlative study with bone scintigraphy

Adhesive capsulitis (AC) is a disorder that is characterized by shoulder pain and progressive limitation of both active and passive shoulder motion. Although the underlying pathological mechanisms of the disease are not well understood, the inflammatory reactions depending on the stage have been demonstrated histologically. The purpose of the study is to investigate the inflammatory changes that can be demonstrated with Tc-99m HIG in AC, and to determine the presence of correlations between scintigraphic findings and the clinical assessment. Twenty-one patients (12 females and 9 males) with a mean age of 50.57+/-8.49 were included in the study. AC was diagnosed according to recognized criteria. The planar X-ray images of the affected shoulders of all patients were normal. The patients were evaluated with the Constant Scoring System, and the functional and pain assessment parts of the American Shoulder and Elbow Surgeons' Form (ASES). Three phase bone scans and Tc-99m HIG scintigraphy were performed at least two days apart. Bone scan and Tc-99m HIG scintigraphy were evaluated visually and HIG uptake was evaluated in comparison with the contralateral normal shoulder. Bone scan demonstrated hypervascularity in 9 of the 21 patients (43%), whereas increased osteoblastic activity was detected in 19 (90%) in the affected shoulder. Tc-99m HIG uptake was positive in 12 (57%), and negative in 9 (43%) patients. All patients with increased Tc-99m HIG accumulation in the affected shoulder, also had increased osteoblastic activity on Tc-99m bone scintigraphy. A significant correlation was found between HIG uptake and constant, functional and pain scores. The difference between these scores was also statistically significant in patients with HIG positive and negative uptake. This study indicates that there is a good correlation between Tc-99m HIG scan findings and clinical scores. Tc-99m HIG accumulation in the affected shoulder may be related to continuing inflammatory reaction to AC. Tc-99m HIG scan may be a noninvasive, complementary method for demonstrating continuing inflammatory changes and may help in staging the disease.

Calcific trochanteric bursitis: resolution of calcifications and clinical remission with non-invasive treatment. A case report

Calcific trochanteric bursitis, a common regional pain syndrome, is characterized by chronic, intermittent aching pain over the lateral aspect of the hip and limitation of function. Effective treatment is invasive, including infiltration therapy and surgical intervention. The therapeutic effects of conservative treatment modalities have not been proven. A 59-year-old woman presented at the department of physical medicine and rehabilitation with a 2-year history of pain in the right hip. She had been treated with several agents such as glucocorticoids and local anesthetics (via injection) for two years, but without success. Physical examination revealed the clinical diagnosis of bursitis trochanterica. Radiographic findings showed calcified rounded masses measuring about 1.5 cm in diameter around the greater trochanter; a calcific bursitis trochanterica was diagnosed. The patient presented for conservative treatment in order to avoid surgical intervention for removing the calcification and the bursal sac. A non-invasive treatment regimen including intensive pulsed ultrasound therapy, physiotherapy and iontophoresis was started. The conservative treatment led to a remission of both, symptoms as well as radiographic findings, which revealed complete resolution of calcifications. This case report shows that, in cases of calcific trochanteric bursitis (including those with extensive calcifications), a non-invasive conservative treatment regimen including intensive high-dosed pulsed ultrasound therapy should be attempted before more invasive treatment (injections, surgery) is considered.

Scintigraphy of cubital bursitis

A 50-year-old man with psoriatic arthropathy was examined for a painful mass in the left cubital fossa. The clinical findings indicated a tumor or infection. Computed tomographic scanning and bone scintigraphy also raised the possibility of a malignant lesion. Surgical exploration revealed that the mass was a chronically inflamed bicipitoradial bursa adherent to the biceps tendon. This is a rare condition, with only a handful of cases described in the literature. This is the first scintigraphic case reported. The imaging features of the bursa are discussed in terms of the anatomy.