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Fram BR, Rogero R, Fuchs D, Shakked RJ, Raikin SM, Pedowitz DI. Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection. Foot Ankle Int 2019; 40:888-894. [PMID: 31068007 DOI: 10.1177/1071100719847629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of symptomatic peroneal tendinopathy and tears traditionally begins with nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and immobilization, with surgery typically reserved for those failing nonoperative treatment. Ultrasound-(US)-guided peroneal tendon sheath (PTS) corticosteroid injection is an additional nonoperative modality, but limited data exist on its safety and efficacy. The purpose of this study was to assess clinical outcomes following US-guided PTS corticosteroid injection for chronic tendinopathy or tears. METHODS We retrospectively identified patients who had undergone US-guided PTS corticosteroid injection for pain due to peroneal tendinopathy, tears, or subluxation at our institution from 2012 to 2018. Underlying diagnosis was based on clinical examination, magnetic resonance imaging (MRI) results, and/or intraoperative findings, when available. Medical record data were supplemented by e-mail or telephone follow-up. Collected information included patient age, sex, body mass index (BMI), smoking status, workers' compensation status, prior surgeries about the foot and ankle, duration of symptoms prior to injection, perceived improvement in pain following injection and its duration, number of injections, progression to surgery, and any adverse outcomes of injection. We identified 96 patients (109 injections). Thirty-seven (38.5%) had previous foot and ankle surgery, with 17 (17.7%) having surgery specifically on the peroneal tendons. RESULTS Twenty-four of 96 (25%) progressed to have surgery on their peroneal tendons following injection. Following injection, 38/87 (43.7%) of patients reported 0-1 weeks of pain relief, 11/87 (12.6%) 2-6 weeks, 6/87 (6.9%) 7-12 weeks, and 32/87 (36.8%) greater than 12 weeks. Preinjection duration of symptoms was associated with postinjection duration of pain relief (P=.036). There were 2 reported complications (1.8%): 1 case of self-limited sural nerve irritation and 1 of peroneus longus tear progression. CONCLUSION Our study demonstrates US-guided PTS corticosteroid injection was safe and relatively effective in patients with symptomatic peroneal tendon tears or tendinopathy, including those who had undergone prior surgery, and may be considered in a comprehensive protocol of nonoperative management. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Ryan Rogero
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA.,2 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Daniel Fuchs
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Spang C, Chen J, Backman LJ. The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids. BMC Musculoskelet Disord 2016; 17:467. [PMID: 27832770 PMCID: PMC5105245 DOI: 10.1186/s12891-016-1328-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/04/2016] [Indexed: 12/13/2022] Open
Abstract
Background The use of corticosteroids (e.g., dexamethasone) as treatment for tendinopathy has recently been questioned as higher risks for ruptures have been observed clinically. In vitro studies have reported that dexamethasone exposed tendon cells, tenocytes, show reduced cell viability and collagen production. Little is known about the effect of dexamethasone on the characteristics of tenocytes. Furthermore, there are uncertainties about the existence of apoptosis and if the reduction of collagen affects all collagen subtypes. Methods We evaluated these aspects by exposing primary tendon cells to dexamethasone (Dex) in concentrations ranging from 1 to 1000 nM. Gene expression of the specific tenocyte markers scleraxis (Scx) and tenomodulin (Tnmd) and markers for other mesenchymal lineages, such as bone (Alpl, Ocn), cartilage (Acan, Sox9) and fat (Cebpα, Pparg) was measured via qPCR. Cell viability and proliferation was calculated using a MTS Assay. Cell death was measured by LDH assay and cleaved caspase-3 using Western Blot. Gene expression of collagen subtypes Col1, Col3 and Col14 was analyzed using qPCR. Results Stimulation with Dex decreased cell viability and LDH levels. Dex also induced a significant reduction of Scx gene expression and a marked loss of fibroblast like cell shape. The mRNA for all examined collagen subtypes was found to be down-regulated. Among non-tendinous genes only Pparg was significantly increased, whereas Acan, Alpl and Sox9 were reduced. Conclusions These results indicate a Dex induced phenotype drift of the tenocytes by reducing scleraxis expression. Reduction of several collagen subtypes, but not cell death, seems to be a feature of Dex induced tissue degeneration.
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Affiliation(s)
- Christoph Spang
- Department of Integrative Medical Biology, Anatomy, Umeå University, SE-901 87, Umeå, Sweden. .,Dr Alfen Orthopedic Spine Center, 97080, Würzburg, Germany.
| | - Jialin Chen
- Department of Integrative Medical Biology, Anatomy, Umeå University, SE-901 87, Umeå, Sweden
| | - Ludvig J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, SE-901 87, Umeå, Sweden
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van Dijk PAD, Lubberts B, Verheul C, DiGiovanni CW, Kerkhoffs GMMJ. Rehabilitation after surgical treatment of peroneal tendon tears and ruptures. Knee Surg Sports Traumatol Arthrosc 2016; 24:1165-74. [PMID: 26803783 PMCID: PMC4823352 DOI: 10.1007/s00167-015-3944-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/09/2015] [Indexed: 12/26/2022]
Abstract
PURPOSE The purpose of this study was to provide an overview of the available evidence on rehabilitation programmes after operatively treated patients with peroneal tendon tearsand ruptures. METHODS A systematic review was performed, and PubMed and EMBASE were searched for relevant studies. Information regarding the rehabilitation programme after surgical management of peroneal tendon tears and ruptures was extracted from all included studies. RESULTS In total, 49 studies were included. No studies were found with the primary purpose to report on rehabilitation of surgically treated peroneal tendon tears or ruptures. The median duration of the total immobilization period after primary repair was 6.0 weeks (range 0-12), 7.0 weeks (range 3.0-13) after tenodesis, 6.3 weeks (range 3.0-13) after grafting, and 8.0 weeks (range 6.0-11) after end-to-end suturing. Forty one percent of the studies that reported on the start of range of motion exercises initiated range of motion within 4 weeks after surgery. No difference was found in duration of immobilization or start of range of motion between different types of surgical treatment options. CONCLUSION Appropriate directed rehabilitation appears to be an important factor in the clinical success of surgically treated peroneal tendon tears and ruptures. There seems to be a trend towards shorter immobilization time and early range of motion, although there is no consensus in the literature on best practice recommendations for optimizing rehabilitation after surgical repair of peroneal tendon tears or ruptures. It is important to adjust the rehabilitation protocol to every specific patient for an optimal rehabilitation. LEVEL OF EVIDENCE Systematic Review, Level IV.
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Affiliation(s)
- Pim A. D. van Dijk
- />Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands , />Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands , />Amsterdam Collaboration on Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands , />Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Bart Lubberts
- />Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Claire Verheul
- />Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands , />Amsterdam Collaboration on Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands , />Orthopaedic Manual Therapy and (Sport)Physiotherapy, ManualFysion, Amsterdam, The Netherlands
| | - Christopher W. DiGiovanni
- />Foot and Ankle Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Gino M. M. J. Kerkhoffs
- />Department of Orthopaedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands , />Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam, The Netherlands , />Amsterdam Collaboration on Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
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Schade VL, Harsha W, Rodman C, Roukis TS. Peroneal Tendon Reconstruction and Coverage for Treatment of Septic Peroneal Tenosynovitis: A Devastating Complication of Lateral Ankle Ligament Reconstruction With a Tendon Allograft. J Foot Ankle Surg 2015; 55:406-13. [PMID: 26002675 DOI: 10.1053/j.jfas.2015.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Indexed: 02/03/2023]
Abstract
Septic peroneal tenosynovitis is a rare and significant challenge. A search of peer-reviewed published studies revealed only 5 case reports to guide treatment, none of which resulted in significant loss of both peroneal tendons necessitating reconstruction. No clear guidance is available regarding how to provide reliable reconstruction of both peroneal tendons after a significant loss secondary to septic tenosynovitis. In the present report, we describe the case of a young, active-duty soldier who underwent lateral ankle ligament reconstruction with a tendon allograft whose postoperative course was complicated by septic peroneal tenosynovitis resulting in significant loss of both peroneal tendons. Reconstruction was achieved in a staged fashion with the use of silicone rods and external fixation to maintain physiologic tension and preserve peroneal tendon function, followed by reconstruction of both peroneal tendons and the superior peroneal retinaculum with a tensor fascia lata autograft. Soft tissue coverage was obtained with an anterolateral thigh free tissue transfer and a split-thickness skin graft. The patient returned to full activity as an active-duty soldier with minimal pain and no instability of the right lower extremity. The muscle strength of both peroneal tendons remained at 5 of 5, and no objective findings of ankle instability were seen at 3.5 years postoperatively.
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Affiliation(s)
| | - Wayne Harsha
- Chief, Otolaryngology Service, Madigan Army Medical Center, Tacoma, WA
| | - Caitlin Rodman
- Staff, Adult Family Nurse Practitioner, South Sound Internal Medicine, Olympia, WA
| | - Thomas S Roukis
- President, American College of Foot and Ankle Surgeons, Chicago, IL; Attending Staff, Department of Orthopedics, Podiatry, and Sports Medicine, Gundersen Health System, La Crosse, WI
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Torricelli P, Fini M, Giavaresi G, Carpi A, Nicolini A, Giardino R. Effects of systemic glucocorticoid administration on tenocytes. Biomed Pharmacother 2006; 60:380-5. [PMID: 16928425 DOI: 10.1016/j.biopha.2006.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The effects of systemic administration of glucocorticoids (GC) on Achilles tendons of rats was studied. After the animal euthanasia, Achilles tendons were removed in sterile conditions from Sprague Dawley adult female rats to isolate tenocytes. Animals have been daily treated for 8 weeks with 4 mg/kg methylprednisolone or Sham-treated with saline solution. In vitro, cell proliferation (WST-1), extra-cellular matrix (ECM) synthesis (collagen type I, CICP; proteoglycans, PG; and fibronectin, FBN), and transforming growth factor (TGF-beta1) were evaluated at 3 and 7 days of culture. The effect of glucocorticoids (GC) on tenocytes was evident both at 3 and 7 days of culture, and caused a significant decreases in cell proliferation (P<0.01), CICP (P<0.01) and PG synthesis (P<0.01) as compared to NT tenocytes. In conclusion, GC systemic treatment seems to compromise the normal proliferation rate and synthetic activity of cultured tenocytes. This study was helpful in understanding the fundamental biological processes that occur during corticosteroid systemic administration and tenocyte cultures may be used to further study to improve knowledge of these cell behaviour also in the ambit of tendon tissue-engineered therapies.
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Affiliation(s)
- P Torricelli
- Laboratory of Experimental Surgery, Research Institute Codivilla-Putti, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, Bologna, Italy.
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Blanco I, Krähenbühl S, Schlienger RG. Corticosteroid-associated tendinopathies: an analysis of the published literature and spontaneous pharmacovigilance data. Drug Saf 2006; 28:633-43. [PMID: 15963008 DOI: 10.2165/00002018-200528070-00005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION AND OBJECTIVE Corticosteroids may cause tendinopathies, an adverse effect that is not well known and characterised, although it was initially described more than 40 years ago. This study was conducted in order to characterise the important aspects of this adverse reaction, such as the role played by routes of corticosteroid administration, therapy duration, comedication, cumulative corticosteroid dose and underlying disease. STUDY DESIGN AND METHODS Published case reports of tendinopathies that were associated with corticosteroid use were identified by a comprehensive literature search using the databases MEDLINE, Pharm-line, EMBASE, ToxFile, Adis Inpharma, International Pharmaceutical Abstracts, Drug Information Fulltext and PASCAL. The reference lists of all pertinent articles were cross-referenced to retrieve additional cases. Spontaneous reports were requested from the Uppsala Monitoring Centre (the WHO Collaborating Centre for International Drug Monitoring). Information of published and spontaneous reports was analysed with regard to age, sex, underlying disease, individual corticosteroids, equivalent corticosteroid dose, latency time, cumulative dose, route of administration, comedication and type of tendinopathy. RESULTS We included and analysed 73 published case reports and case series involving 133 patients and 191 spontaneous reports of corticosteroid-associated tendinopathies. The proportion of women with tendinopathies was 50.8% and 41.0%, respectively. The mean age (+/- standard deviation) of patients with a tendinopathy was 50 +/- 17 years and 61 +/- 16 years, respectively. The predominant routes of administration were oral (33% of published cases and 47% of spontaneous cases) and intra-articular (35% of the published cases or parenteral (7% of the spontaneous cases). There were isolated cases of tendinopathy after inhaled or topical (i.e. ocular, cutaneous, nasal) corticosteroid use. Tendinopathies that were reported in the literature cases consisted mainly of tendon ruptures (93%), predominantly of the Achilles tendon. Of the spontaneous cases, 31% had a rupture and the remaining cases had a tendinitis or an unspecified tendon disorder. CONCLUSION Oral and parenteral applications, especially intra-articular use, were the most prevalent routes of administration in cases with corticosteroid-associated tendinopathies. However, topical application has also been rarely associated with tendinopathies. Future pharmacoepidemiological studies should further address this issue to quantify the risk of corticosteroid-associated tendinopathies.
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Affiliation(s)
- Irene Blanco
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacy, University of Basel, Basel, Switzerland
| | - Stephan Krähenbühl
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacy, University of Basel, Basel, Switzerland
- Division of Clinical Pharmacology and Toxicology, University Hospital of Basel, Markgraflerhof Hebelstrasse 2, CH - 4031, Basel, Switzerland
| | - Raymond G Schlienger
- Department of Pharmaceutical Sciences, Institute of Clinical Pharmacy, University of Basel, Basel, Switzerland.
- Division of Clinical Pharmacology and Toxicology, University Hospital of Basel, Markgraflerhof Hebelstrasse 2, CH - 4031, Basel, Switzerland.
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Fitzgerald BT, Hofmeister EP, Fan RA, Thompson MA. Delayed flexor digitorum superficialis and profundus ruptures in a trigger finger after a steroid injection: a case report. J Hand Surg Am 2005; 30:479-82. [PMID: 15925155 DOI: 10.1016/j.jhsa.2004.10.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Revised: 10/22/2004] [Accepted: 10/25/2004] [Indexed: 02/02/2023]
Abstract
We report a case of delayed rupture of the flexor digitorum superficialis and profundus tendons after the use of local corticosteroid injections for trigger finger. The treatment involved the exploration, debridement, and placement of a silicone rod for planned flexor digitorum profundus staged reconstruction.
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Affiliation(s)
- Brian T Fitzgerald
- Department of Orthopedics, Naval Medical Center San Diego, San Diego, CA 92134-1005, USA
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Koenig MJ, Torp-Pedersen S, Qvistgaard E, Terslev L, Bliddal H. Preliminary results of colour Doppler-guided intratendinous glucocorticoid injection for Achilles tendonitis in five patients. Scand J Med Sci Sports 2004; 14:100-6. [PMID: 15043631 DOI: 10.1046/j.1600-0838.2003.00364.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND It is debated as to whether Achilles tendonitis (AT) has an inflammatory component. The intratendinous hyperaemia demonstrated with colour Doppler has been interpreted as neovascularisation. Glucocorticoid injection around the tendon is a common therapeutic procedure. HYPOTHESES The intratendinous hyperaemia seen with ultrasound (US) colour Doppler represents an inflammatory background. Glucocorticoid injections will be effective if administered inside the tendon where the inflammation seems to be. STUDY DESIGN An uncontrolled, prospective study with a minimum follow-up of 3 months. METHODS Six tendons in five patients were evaluated with grey-scale US and colour Doppler before and after US-guided intratendinous glucocorticoid injection. Pain at rest and at activity was evaluated on a visual analogue scale. RESULTS With colour Doppler all tendons had intratendinous flow. Pain and colour Doppler activity decreased during a mean follow-up of 182 days (range 92-309 days). One tendon relapsed after 199 days. CONCLUSION Intratendinous glucocorticoid injections seem to have a marked effect on both symptoms and colour Doppler findings, which may be taken as an indication of an inflammatory component in the disease. Colour Doppler adds significant information to grey-scale US with regard to diagnosis, location and follow-up of AT.
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Affiliation(s)
- M J Koenig
- The Parker Institute, Department of Rheumatology, Frederiksberg Hospital, Frederiksberg, Denmark
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Rodríguez Alonso J, Santos JG. Infiltraciones locales en Atención Primaria (III). Miembro inferior. Semergen 2003. [DOI: 10.1016/s1138-3593(03)74150-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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