Intramuscular vascular malformations: a rare cause of exertional leg pain and a novel treatment approach with ultrasound-guided doxycycline sclerotherapy

Intrabursal Doxycycline Sclerotherapy for Recurrent Olecranon Bursitis of the Elbow: A Case Control Study

Purpose

This study aimed to determine the efficacy and safety of intrabursal injection of doxycycline sclerotherapy to treat olecranon bursitis (OB) refractory to conservative management.

Methods

We retrospectively reviewed 27 patients with recurrent OB who were treated over 11 years with intrabursal injections of doxycycline. They were compared with a control group of 18 patients with recurrent OB who underwent surgical bursectomy. Patients were re-evaluated by the treating physician for recurrence of bursitis and treatment complications and completed a questionnaire to assess satisfaction, pain, and other patient-reported outcomes.

Results

Eight patients (29.6%) undergoing doxycycline sclerotherapy had recurrence, requiring one more doxycycline lavage within the first 4 weeks of initial doxycycline treatment. Three patients (16.7%) undergoing surgery had recurrence after surgery, requiring repeat aspiration. There were no patients in either doxycycline or surgical groups with recurrence of bursitis at the final follow-up (median = 195 and 1,055 days, respectively). No patients in the doxycycline group ultimately required surgical bursectomy, and no patients undergoing surgery required repeat surgeries. A regression model controlling for covariates did not find a significant difference between groups in the likelihood of physician-identified complication or repeat aspiration after doxycycline lavage or surgical bursectomy. Of patients undergoing doxycycline sclerotherapy, 85.7% of patients reported high satisfaction (Likert score: 8-10), and 95.2% reported that they would pursue this treatment again.

Conclusions

Use of intrabursal doxycycline as a sclerosing agent for recurrent OB was safe and effective, with high patient satisfaction and no ultimate recurrence of bursitis at the final follow-up. This may be an effective alternative to surgical bursectomy for patients with recurrent OB refractory to conservative management.

Type of study/level of evidence

Therapeutic IV.

Operative management of equinus associated with lower limb venous malformations

OBJECTIVES

Functional impairment is a common complaint in patients with venous malformations. Equinus can occur when the venous malformation involves the lower limb, a challenging condition with only a few studies to guide treatment choices. This study was aimed to investigate the operative management of equinus associated with lower limb venous malformations.

METHOD

Between August 2015 and September 2017, a total of 12 patients presented with equinus associated with lower limb venous malformations and underwent surgical correction. Preoperative and postoperative clinical symptoms, physical examination and orthopaedic evaluation were retrospectively reviewed. 8 patients who experienced pain underwent percutaneous sclerotherapy prior to the operation. Surgical management included gastrocnemius intramuscular aponeurotic recession, Z-lengthening of the Achilles tendon, Hoke technique and Taylor Spatial Frame external fixation.

RESULTS

There were eight female and four male patients with a mean age of 14.3 ± 5.9 years. The mean follow-up period was 34.8 ± 9 months. The range of motion of ankle dorsiflexion (with knee extended) improved for each patient (mean, 25.4 degrees; standard deviation, 8.5 degrees). No neurovascular complications were observed.

CONCLUSION

Operative correction of equinus associated with lower limb venous malformations is safe and effective. Selective preoperative sclerotherapy is necessary for optimal outcomes.

Risk factors associated with pain in patients with venous malformations of the extremities

Pain is a common symptom and the major complaint in patients with venous malformations of the extremities, which may lead to joint dysfunction and even walking disabilities. Therefore, this study aimed to investigate determined independent risk factors for pain in these patients. We retrospectively collected data for 168 patients with venous malformations of the extremities from January 16, 2013 to August 13, 2015. They were categorized into painful and painless groups according to the symptom and pain scores. Associations between pain and candidate factors were determined using univariate and multivariate analyses. A total of 125 (74.4%) patients with an average pain score of 4.4 were included in the painful group. In univariate analysis, age, lesion size, tissue involvement, and phleboliths were associated with pain. In the multivariate analysis, only type-II tissue involvement (adjusted odds ratio 4.57; p = 0.001) and phleboliths (adjusted odds ratio 2.44; p = 0.039) were identified as the independent risk factors. In conclusion, this study revealed that prevalence of pain in patients with venous malformations of the extremities was high. Patients who presented with type-II tissue involvement and phleboliths are more likely to suffer from pain.

Joint dysfunction associated with venous malformations of the limbs: Which patients are at high risk?

Objectives Joint dysfunction occurs frequently in patients with venous malformations of the extremities. This study aims to describe the risk factors of joint dysfunction in these patients. Method We retrospectively collected clinical and radiological aspects of 168 patients with extremity venous malformations from January 2013 to August 2015. Patients were categorized into "with joint dysfunction" or "without joint dysfunction" groups according to the symptoms. Results Forty-four (26%) patients were assigned into with joint dysfunction group. Univariate analysis showed that the significant variables were age (P = 0.008), location (P = 0.005), size (P < 0.001), involved tissue (P < 0.001), visual analogue scale scores of pain (P = 0.004), pain duration (P = 0.018), and therapy history (P < 0.001). Multivariate analysis showed that the factors associated with joint dysfunction were age below 10 years (adjusted odds ratio = 2.70, P = 0.004), lower limb (adjusted odds ratio = 2.72, P = 0.042), pain duration over 1 year (adjusted odds ratio = 3.47, P = 0.001) and therapy history (yes) (adjusted odds ratio = 3.71, P = 0.004). Conclusion This study provides preliminary evidence indicating which patients are at high risk for joint dysfunction associated with limb venous malformations.