The value of combined ultrasound contrast arthrography and subacromial-subdeltoid bursography for detecting and differentiating the rotator cuff tear subtypes in patients with the uncertain rotator cuff tear

OBJECTIVES

In this study, ultrasound (US) contrast arthrography and subacromial-subdeltoid bursography with the contrast agent of SonoVue were performed to evaluate their value for detecting and differentiating the rotator cuff tear (RCT) subtypes in patients with the uncertain RCT.

METHODS

A total of 102 patients with the clinically suspected RCTs in the orthopedic clinic were prospectively recruited and underwent conventional high-frequency US for the category of undoubted full-thickness RCT, uncertain RCT, and intact rotator cuff. Among these patients, the patients with uncertain RCT underwent the subsequent US contrast arthrography and subacromial-subdeltoid bursography. The arthroscopic findings were used as the gold standard in this study.

RESULTS

After the conventional US screening, 62 patients with uncertain RCT underwent the subsequent US contrast arthrography and subacromial-subdeltoid bursography. All the US contrast arthrography and subacromial-subdeltoid bursography were successfully performed and no severe side effects were observed in all the patients. For full-thickness tears, the sensitivity and specificity of the combined US contrast arthrography and subacromial-subdeltoid bursography were 94.7% (CI: 0.72-1.0) and 81.4% (CI: 0.66-0.91), respectively, and for articular-side tears 100% (CI: 0.51-1) and 100% (CI: 0.92-1), respectively, and for the bursal-side tears 84.6% (CI: 0.54-0.97) and 97.9% (CI: 0.88-1.0), respectively. The main inconsistency between the contrast-enhanced US and arthroscopy was that 7 patients with arthroscopic proved concurrent articular- and bursal-side tears were indicated as full-thickness RCTs on contrast-enhanced US.

CONCLUSIONS

Combined US contrast arthrography and subacromial-subdeltoid bursography are useful for detecting the RCT subtypes in patients with the uncertain RCTs.

CLINICAL RELEVANCE STATEMENT

When conventional high-frequency US has some difficulty in differentiating the full-thickness from partial-thickness RCTs, combined US contrast arthrography and subacromial-subdeltoid bursography could be used to improve the detection accuracy of RCT subtypes.

KEY POINTS

• This is the first study by injection of the US contrast agent SonoVue into the shoulder joint cavity and subacromial-subdeltoid bursa for the detection and differentiation of the RCT subtypes among the people with the uncertain RCT by conventional US screening. • The SonoVue was injected into the glenohumeral joint cavity under US guidance to differentiate the full-thickness RCTs from partial-thickness RCTs. • Combined US contrast arthrography and subacromial-subdeltoid bursography are useful for detecting the RCT subtypes in patients with the uncertain RCTs.

Calcific bursitis of the Gruberi bursa: a case report

BACKGROUND

Bursitis is the inflammation of a synovial bursa, a small synovial fluid-filled sac that acts as a cushion between muscles, tendons, and bones. Further, calcific bursitis results from calcium deposits on the synovial joint that exacerbates pain and swelling. The Gruberi bursa is located dorsolaterally in the ankle, between the extensor digitorium longus and the talus. Despite limited literature on its pathophysiology, the aim of this case is to discuss the bursa's association with calcific bursitis and its management via a case presented to our clinic.

CASE PRESENTATION

A 47-year-old Caucasian female with no past medical or family history presents with acute right ankle pain following a minor injury 3 months prior with no improvement on analgesic or steroid therapy. Imaging demonstrated incidental calcium deposits. The day prior to presentation, the patient stated she used 1-pound ankle weights that resulted in mild swelling and gradual pain to the right dorsoanterior ankle. Physical exam findings displayed a significant reduction in the range of motion limited by pain. Imaging confirmed calcification within the capsule of the talonavicular joint, consistent with Gruberi bursitis. Initial management with prednisone yielded minimal improvement, requiring an interventional approach with ultrasound-guided barbotage that elicited immediate improvement.

CONCLUSION

The presented case report highlights a rare and unique instance of acute ankle pain and swelling caused by calcific Gruberi bursitis in a young female. Although the Gruberi bursa is a relatively new discovery, it contains inflammatory components that may predispose it to calcification and should be considered in the differential of ankle swelling. Therefore, utilizing a systematic approach to a clinical presentation and considering all differential diagnoses is essential.

[CME-Sonography 106: Subacromial Bursa - A Myth]

CME-Sonography 106: Subacromial Bursa - A Myth Abstract. In everyday clinical practice, we frequently encounter bursitis. It can occur in practically any joint region, for example in local mechanical overload situations, after a trauma or in the context of an inflammatory systemic disease. In this review we focus on the location of bursitis in the shoulder region and would like to contribute to get away from the "myth" called subacromial bursitis.

Ultrasound Guidance Is Not Superior in Subacromial Bursa and Intraarticular Injections but Superior in Bicipital Groove: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To perform a meta-analysis comparing the clinical and functional outcomes of ultrasound-guided (USG) and blind injections for shoulder pain.

METHOD

The Embase, Cochrane Library, and PubMed databases were searched from database inception to April 7, 2021. Clinical and functional outcomes included the visual analog scale (VAS) pain score, abduction, flexion, American Shoulder and Elbow Surgeons Assessment Form (ASES) score, Constant-Murley Shoulder (CMS) score, Shoulder Pain and Disability Index (SPADI), Shoulder Disability Questionnaire (SDQ) score, and Shorted Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Dichotomous outcomes were assessed with mean differences (MDs) and 95% confidence intervals (95% CIs).

RESULTS

Fifteen studies that compared USG and blind injections were included. No significant difference was found in the VAS score between the blind group and USG group (MD 0.41 [-0.02, 0.84]; I2 = 79%; P = .06). Subgroup analysis of the brachial bicipital groove indicated that the USG group had less pain than the blind group (MD 1.50 [0.54, 2.46]; I2 = 64; P = .002). The USG injection patients had better postoperative abduction (MD -3.08 [-5.19, -0.98], I2 = 0, P = .004) and flexion (MD -3.36 [-5.56, -1.16]; I2 = 0; P = .003) than the blind group. Additionally, the USG injection patients had better CMS scores than the blind injection patients (MD -12.95 [-25.60, -0.29]; I2 = 96; P = .04). However, subgroup analysis showed no significant difference in the subacromial bursas and glenohumeral joints of CMS score (MD -13.22 [-29.93, 3.94]; I2 = 97; P＜.0001). No significant difference was found in the SPADI, ASES score, or SDQ score between the groups.

CONCLUSIONS

Ultrasound guidance is not superior in the subacromial bursa and glenohumeral joint injections in pain or function. However, injection in the brachial bicipital groove, is still superior to blind injection of pain relief.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

The role of grey-scale ultrasound in the diagnosis of adhesive capsulitis of the shoulder: a systematic review and meta-analysis

AIMS

In this systematic review and meta-analysis, we discuss the value of grey-scale ultrasonography (US) in diagnosing adhesive capsulitis of the shoulder (ACS).

MATERIAL AND METHODS

We retrieved relevant studies from PubMed, Cochrane Library, and Embase before 8 April 2019. We selected 7 studies concerning 446 patients (490 shoulders) that used grey-scale US to diagnose ACS and magnetic resonance imaging (MRI) or arthroscopy as the reference standard. We assessed the diagnostic accuracy of US on the basis of combined sensitivity, specificity, likelihood ratio (LR), and the area under the summary receiver operating characteristic (SROC) curve (AUC).

RESULTS

The combined sensitivity, specificity, positive LR and negative LR were found to be 88% (95%CI: 74-95), 96% (95%CI: 88-99), 23.89 (95%CI: 6.31-90.51) and 0.12 (95%CI: 0.05-0.29), respectively. The AUC was 0.97 (95%CI: 0.96-0.98). ACS was diagnosed on the basis of four US features: coracohumeral ligament thickening, inferior capsule/axillary recess capsule thickening, rotator interval abnormality, and restriction of the range of motion. The corresponding sensitivities were 64.4 (95%CI: 48.8-78.1), 82.1 (95%CI: 73.8-88.7), 82.6 (95%CI: 74.1-89.2) and 94.3 (95%CI: 84.3-98.8), respectively, and specificities were 88.9 (95%CI: 76.0-96.3), 95.7 (95%CI: 90.3-98.6), 93.9 (95%CI: 89.8-96.7), and 90.9 (95%CI: 75.7-98.1), respectively.

CONCLUSIONS

Our meta-analysis showed that grey-scale US plays a significant role in the diagnosis of ACS. Because of its high sensitivity and specificity, US can be added to the existing clinical diagnosis program.

Ultrasound Microflow Imaging Technology for Diagnosis of Adhesive Capsulitis of the Shoulder

OBJECTIVES

To assess the diagnostic accuracy of Superb Microvascular Imaging (SMI; Canon Medical Systems, Otawara, Japan) at the subcoracoid triangle for adhesive capsulitis of the shoulder, to compare the diagnostic value of SMI with that of conventional ultrasound (US) and power Doppler ultrasound (PDUS) findings, and to investigate the correlation between vascular flow on SMI with clinical features.

METHODS

Our study included 39 patients with a diagnosis of adhesive capsulitis and 35 healthy patients as a control group. The echogenicity in the rotator interval and coracohumeral ligament thickness were assessed with conventional US. Vascular flow in the subcoracoid fat triangle was evaluated with SMI and PDUS (SMI and PDUS areas). A receiver operating characteristic curve analysis was performed to evaluate diagnostic accuracy. The correlation between US findings and the range of motion, pain intensity, and duration of symptoms was also evaluated.

RESULTS

The SMI area was higher in the adhesive capsulitis group than in the control group (2.95 versus 0 mm² ; P < .01). The visualization of vascular flow at the subcoracoid fat triangle was superior with SMI compared with PDUS (P < .01). In the receiver operating characteristic analysis, the SMI area showed higher diagnostic performance, with an area under the curve of 0.90 compared with other US findings. The area of SMI vascular flow was also negatively correlated with external rotation and forward flexion (P < .05) in the adhesive capsulitis group.

CONCLUSIONS

Measurement of vascular flow at the subcoracoid fat triangle using SMI facilitated the diagnosis of adhesive capsulitis. Superb Microvascular Imaging was superior to PDUS in diagnostic performance. Vascular flow was negatively correlated with the range of motion of external rotation and forward flexion.

Influenza Vaccine-related Subacromial/Subdeltoid Bursitis: A Case Report

Serious side effects of vaccinations are not common, though rare complications can occur. We present a case of one such uncommon side effect, influenza vaccine-related subacromial/subdeltoid bursitis. A 72-year-old female presented with severe shoulder pain following influenza vaccination. The pain persisted for up to two months despite conservative measures, and MRI demonstrated moderate subacromial/subdeltoid bursitis. Vaccine-related shoulder dysfunction includes a range of pathology, from osteonecrosis to bursitis, which will be reviewed in this report. Recognition of infrequent vaccine-related musculoskeletal pathology is important to prevent delay of diagnosis.

Accuracy and efficacy of ultrasound-guided pes anserinus bursa injection

PURPOSE

To compare the accuracy and efficacy of ultrasound (US)-guided versus blind pes anserinus bursa (PAB) injection in patients with pes anserinus tendinobursitis (PATB).

METHODS

Forty-seven patients with clinically diagnosed PATB were randomly assigned to a US-guided group or a blind group of steroid injection. In the US-guided group, the injectate was delivered under sonographic visualization. In the blind group, the conventional technique was used without any visual guidance. After the PAB injection, the injectate location was identified using US in both groups. Treatment effects were assessed using the visual analogue scale (VAS) of knee tenderness. Outcomes were measured before, 1 week and 4 weeks after the injection.

RESULTS

Both groups showed pain relieving at 1 week and 4 weeks after the injection. The injectate in the US guided group were found to be accurately at the PAB in all subjects, whereas blind group were found to be just in 4 of 22 subjects. The US-guided group showed significant improvement of both of VAS scores compared to the blind group at 1 week and 4 weeks after the injection (P < .05).

CONCLUSION

Our results suggest that US-guided PAB injection is more accurate and effective than blind injection in patients with PATB.

Clinical efficacy of ultrasound-guided injection in the treatment of olecranon subcutaneous bursitis

BACKGROUND

Recent studies have shown that ultrasound-guided injection of glucocorticoids is superior to blind puncture methods.

OBJECTIVE

To evaluate clinical efficacy of ultrasound-guided drug injection in the treatment of olecranon subcutaneous bursitis.

METHODS

From June 2016 to September 2018, 45 patients diagnosed with obvious synovial effusion and treated with ultrasound-guided injection therapy for olecranon bursitis were included in this study. Under the guidance of ultrasound, the synovial effusion aspiration was performed and 2 ml of the compound betamethasone mixture was injected into the bursae and dressed under pressure. Ultrasound examination was performed 2 weeks after operation and the secondary fluid aspiration and drug injection treatment were performed. The depth of synovial effusion, the thickness of synovial hyperplasia and the blood flow signal were measured 4 weeks after operation to evaluate the therapeutic effect.

RESULTS

After first treatment, the recurrence rate of the olecranon mass were 40%. After secondary treatment, recurrence of olecranon mass occurred in 6 of the 45 patients with a recurrence rate of 13.3%. After 4 weeks of follow-up, the depth of olecranon synovial effusion, the average thickness of synovial hyperplasia and the blood flow signal decreased significantly after treatment (P < 0.05).

CONCLUSIONS

Ultrasound-guided drug injection is safe and effective in treating olecranon subcutaneous bursitis. Although the recurrence rate is high after the first treatment, the second treatment is simple and can reduce the recurrence rate. The patients have a high acceptance rate, which is worthy of clinical promotion.

[A woman with swollen shoulders]

A 65-year-old woman, who had been suffering from erosive rheumatoid arthritis, presented with swollen shoulders. Also, she experienced a weary feeling in her left arm. An MRI scan of the left shoulder showed multiple nodules ('rice bodies') in the subacromial-subdeltoid bursa. We extracted the nodules via a deltopectoral approach, after which the symptoms disappeared.

Improving the Performance Time and Accuracy of Ultrasound-Guided Interventions: A Randomized Controlled Double-Blind Trial of the Line-of-Sight Approach and the "APPLES" Mnemonic

OBJECTIVES

To determine whether the line-of-sight approach improved the performance time and accuracy of ultrasound (US)-guided needle placement targeting the subdeltoid bursa in a cadaver among novice operators compared to the side approach. A secondary objective was to determine whether participants thought the APPLES (angle, position, perpendicular, line up, entry, sweep) mnemonic was a helpful guide for performing the procedure.

METHODS

Medical students and residents were randomized into either a line-of-sight or side approach group and then crossed over to the other group. The procedure time was determined by 2 blinded reviewers. A survey was administered to determine which method participants preferred and whether they thought the APPLES mnemonic was helpful. A paired t test was used to compare the performance time, and the McNemar test was used to compare the accuracy of the methods.

RESULTS

Among the 110 participants, the performance time with the line-of-sight approach (mean, 14.4 seconds; SD, 9.95 seconds) was significantly decreased compared to the side approach (mean, 18.6 seconds; SD, 10.1 seconds; P = .00029). Additionally, participants who only hit the target using one method were more likely to hit the target in 30 seconds using the line-of-sight approach (P = .035). In total, 72.7% of participants preferred the line-of-sight approach over the side approach, and 88.2% of participants thought that APPLES mnemonic was useful.

CONCLUSIONS

This study highlights the finding that positioning of the operator is important in performing US-guided interventions, and the line-of-sight approach may improve the performance time and accuracy among novice operators. Furthermore, the APPLES mnemonic serves as a useful educational tool for teaching US-guided interventional procedures.

Utility of power Doppler ultrasonography for detecting forefoot bursae in early rheumatoid arthritis: A case report

RATIONALE

Power Doppler ultrasonography (PDUS) in musculoskeletal ultrasound (MSUS) is a sensitive and reliable method for the assessment of rheumatoid arthritis (RA). The association between ultrasound-detectable forefoot bursae and the development of RA has gained attention. However, a few studies have evaluated the utility of PDUS for examining forefoot bursae in early RA. We report the case of an RA patient who developed reduced foot mobility and had detectable intermetatarsal bursitis with remarkable power Doppler (PD) signals in MSUS at the onset of RA.

PATIENT CONCERNS

A 40-year-old Japanese woman diagnosed with palindromic rheumatism visited our department due to sustained forefoot pain and difficulty walking. The levels of both rheumatoid factor (RF) and anticitrullinated protein antibody (ACPA) were high. She had opening toes with swelling in metatarsophalangeal (MTP) joints. PDUS showed intermetatarsal bursitis with mild MTP synovitis.

DIAGNOSES

We diagnosed RA by comprehensive judgment based on the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for RA.

INTERVENTIONS

We administered 6.0 mg/wk of methotrexate (MTX) and 2.0 mg/d of prednisolone (PSL) followed by an increase of MTX to 10 mg/wk.

OUTCOMES

After those treatments, the patient's symptoms showed improvement. As of this writing, the patient's remission has been maintained for >2 months.

LESSONS

Her case suggests that PDUS is useful for the detection of forefoot bursitis, and the detection of forefoot bursitis by PDUS may provide the opportunity to make an early diagnosis of RA.

Increased expression of type 1 cannabinoid (CB1) receptor among patients with rotator cuff lesions and shoulder stiffness

BACKGROUND

Shoulder stiffness is a disease manifested by pain, limited range of motion, and functional disability. The inflammatory and fibrosis processes play a substantial role in the pathogenesis of shoulder stiffness. The CB1 receptor has been recognized to mediate the processes of pathologic fibrosis. This study investigated the role of the CB1 pathway in pathogenesis of rotator cuff lesions with shoulder stiffness.

METHODS

All of the patients undergoing repair surgery for rotator cuff lesions were recruited and subcategorized into subjects with and without shoulder stiffness. Reverse transcription-polymerase chain reaction assay was used to evaluate the expression level of CB1 and interleukin 1β (IL-1β) in the subacromial bursae, and enzyme-linked immunosorbent assay was used to measure the concentration of CB1 and IL-1β in the subacromial fluid. Tenocytes treated with CB1 agonists and antagonists were also studied for the relationship of CB1 and the inflammatory cytokine IL-1β.

RESULTS

The patients with shoulder stiffness had higher messenger RNA (mRNA) expression (P = .040) and immunohistochemistry staining (P < .001) of CB1 in the subacromial bursa and higher CB1 concentration in the subacromial fluid (P = .008). Tenocytes treated with the CB1 agonist WIN 55,212-2 and antagonist AM251 showed increased expression of IL-1β mRNA (P = .049) and suppressed expression of IL-1β mRNA (P = .001), respectively.

DISCUSSION

The CB1 pathway is involved in the pathogenesis of shoulder stiffness. It may be a promising target for the treatment of rotator cuff lesions with shoulder stiffness.

Bilateral Lower-Extremity Edema Caused by Iliopsoas Bursal Distention after Hip Arthroplasty

Lower-extremity edema is encountered by internists, nephrologists, vascular specialists, and many others. We report a case of an elderly woman who presented with a painful, swollen left leg. Without a clear diagnosis, she had been taking diuretics for the past 8 years for swelling in both legs. After extensive investigation, we found that her lower-extremity edema was due to bilateral iliopsoas bursal distention secondary to degeneration of her hip prostheses. Chronic breakdown of the polyethylene component of the hip prostheses had led to a communication between the artificial joints and the iliopsoas bursae. With the aid of ultrasonographic guidance, she underwent drainage, followed by clinical and radiographic improvement. Although case reports have described leg swelling arising from extravascular compression by enlarged iliopsoas bursae, we think that this is the first case of clinically significant bilateral lower-extremity edema arising from that cause. More important than the novelty is the inappropriate use of diuretics to treat lower-extremity edema without first establishing a diagnosis.

CORR® ORS Richard A. Brand Award: Clinical Trials of a New Treatment Method for Adhesive Capsulitis

BACKGROUND

Conservative and even surgical management of adhesive capsulitis often is prolonged and painful. Management of adhesive capsulitis is lacking evidence-based controlled clinical trials.

QUESTIONS/PURPOSES

We asked: (1) Does a collagenase clostridium histolyticum (CCH) injection lyse shoulder capsule collagen in adhesive capsulitis and at what dose? (2) Can a shoulder capsule injection be administered extraarticularly? (3) Do CCH injections result in better scores for pain and function than can be achieved with physical therapy among patients with adhesive capsulitis?

METHODS

First, 60 patients with adhesive capsulitis were evaluated by clinical examination. To make the diagnosis of adhesive capsulitis, a patient had to have restricted active ROM of at least 60° in total active ROM in the affected shoulder compared with the unaffected contralateral shoulder; with the scapula stabilized, external rotation with the elbow at the side was a very important determinant. Patients were randomized to receive a single injection of 0.5 mL placebo or 0.145, 0.29, or 0.58 mg CCH. All 60 patients were followed up at 30 days. After that, if patients did not attain treatment thresholds they were eligible for up to five open-label 0.58-mg collagenase injections. For the longer-term followup in the open-label phase, 53 patients (83%) were followed to 12 months, 46 (77%) for 24 months, 36 (60%) for 36 months, 37 (62%) for 48 months, and 25 (42%) for 60 months. The extraarticular injection was directed at the anterior shoulder capsule with the patient in the supine position. To prove that these injections could be delivered reliably to the anterior shoulder capsule extraarticularly, the next study involved volunteers without adhesive capsulitis, in which 10 volunteers received a 10-mL injection of normal saline under ultrasound guidance. Finally, to determine the efficacy and dosing of CCH, four cohorts of 10 patients received up to three ultrasound-guided injections separated by 21 days. These injections were administered at one of four dose-volume levels. A fifth cohort of 10 patients was used as a control group and performed standardized home shoulder exercises only. All patients performed standardized home shoulder exercises three times daily. For Study 3, followup was at 22, 43, 64, and 92 days. No patients were lost to followup.

RESULTS

In the first study, a single CCH injection did not provide clinically important improvements from baseline in active ROM, passive ROM, and function and pain scores compared with patients who received placebo. Ultrasound guidance confirmed extraarticular injection of the shoulder capsule in Study 2. The CCH injection was more effective than exercise therapy alone at 0.58 mg/1 mL and 0.58 mg/2 mL compared with exercise only in the primary measure of efficacy (active forward flexion) as shown in Study 3. For active forward flexion the mean in degrees in the 0.58 mg/2 mL group was 38° compared with 12° in the exercise-only group (p = 0.03). For active forward flexion the mean in the 0.58 mg/1mL group was 43° compared with 12° in the exercise-only group (p = 0.01).

CONCLUSIONS

Extraarticular injections of CCH for treatment of adhesive capsulitis were well tolerated and seem effective compared with exercise therapy. Future FDA-regulated clinical trials must verify CCH injection therapy for adhesive capsulitis.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Imaging of benign complications of exostoses of the shoulder, pelvic girdles and appendicular skeleton

Exostoses are the most common benign bone tumors, accounting for 10 to 15% of all bone tumors. They develop at the bone surface by enchondral ossification and stop growing when skeletal maturity has been reached. At first, exostoses are covered by a smooth cartilage cap that progressively ossifies with skeleton maturity. Then they may regress, partly or even completely. Osteochondromas may be solitary or multiple, with the latter associated with hereditary multiple exostoses (HME). Exostoses develop during childhood and become symptomatic during the third decade of life in the case of solitary exostoses, or earlier, in case of HME. They stop growing after puberty, when the epiphyseal plates close. Most exostoses remain asymptomatic. Local complications, usually benign, may occur, such as fractures or mechanical impingements upon nearby structures. In rare cases, sarcomatous degeneration occurs. Most of these complications have been described in case reports. This article describes the imaging features of benign complications of exostoses of the shoulder, pelvic girdles and appendicular.

Factors Associated with the Outcome of Ultrasound-Guided Trochanteric Bursa Injection in Greater Trochanteric Pain Syndrome: A Retrospective Cohort Study

BACKGROUND

Trochanteric bursa injections of corticosteroids and local anesthetics have been shown to provide pain relief for the treatment of greater trochanteric pain syndrome (GTPS). However, symptom recurrence and incomplete symptom relief are common. The reason for the variation in response is unclear but may be related to disease-, treatment-, or patient-related factors.

OBJECTIVE

To determine whether there are factors related to patient, treatment, or disease that can predict either the magnitude or duration of response to ultrasound-guided trochanteric bursa injections for GTPS.

STUDY DESIGN

Retrospective evaluation.

SETTING

A university hospital outpatient center.

METHODS

Potential study participants were patients who underwent ultrasound-guided trochanteric bursa injection at an outpatient rehabilitation department. Follow-up interviews were performed in a hospital visit at 1, 3, and 6 months after injection. The Harris Hip Score and the Verbal Numeric Pain Scale were used to evaluate clinical effectiveness of pain reduction and functional improvement at baseline, 1, 3, and 6 months after treatment. Clinical data and ultrasound findings were obtained to assess the possible predictive factors for a good and durable response to ultrasound-guided trochanteric bursa injection.

RESULTS

Patients receiving ultrasound-guided trochanteric bursa injections had a statistically significant improvement in pain and hip function at 1, 3, and 6 months after the last injections. Of the 137 patients, 110 (80.3%), 95 (64.9%), and 77 (56.2%) patients achieved successful outcomes according to their 1, 3, and 6-month follow-up evaluations, respectively. Univariate analysis showed that patients with knee osteoarthritis and lumbar facet joint or sacroiliac joint pain experienced less therapeutic effect than those without the conditions at 6 months post-injection. Logistic regression analysis showed that the significant outcome predictors at the 6-month follow-up were facet joint or S-I joint pain (odds ratio = 0.304, P = .014) and knee osteoarthritis (odds ratio = 0.329, P = .021). Age, gender, body mass index, and pain duration were not independent predictors of a clinically successful outcome. There was no statistically significant association between effective treatment and the ultrasound findings of tendinosis, bursitis, partial or full-thickness tear, and enthesopathic changes.

LIMITATIONS

Retrospective chart review without a control group.

CONCLUSIONS

This study suggests that knee osteoarthritis and lower back pain might be associated with a poor outcome of ultrasound-guided trochanteric bursa injection for GTPS. Assessment of these clinical factors should be incorporated into the evaluation and counseling of patients with GTPS who are candidates for ultrasound-guided trochanteric bursa injection.

KEY WORDS

Bursa injection, corticosteroid, greater trochanteric pain syndrome, knee osteoarthritis, lower back pain, lumbar facet joint, ultrasonography, S-I joint pain.

Synovial osteochondromatosis in the subacromial bursa mimicking calcific tendinitis: sonographic diagnosis

Synovial osteochondromatosis is an idiopathic benign metaplasia of the synovial membrane rarely found in an extra-articular bursa. We describe the case of a 55-year-old woman with synovial osteochondromatosis in the subacromial bursa mimicking calcific tendinitis. Plain radiographs showed a radiopaque mass over the middle facet of the greater tuberosity, suggesting calcific tendinitis. Sonography, however, showed a loose body in the subacromial bursa, and no evidence of calcification inside the rotator cuff.

Ultrasound changes after rotator cuff repair: is supraspinatus tendon thickness related to pain?

BACKGROUND

Little is known about the morphology of healing rotator cuffs after surgical repair. This investigation aimed to determine whether there are changes in tendon thickness, subacromial bursa, anatomical footprint, tendon vascularity, and capsular thickness after rotator cuff repair, and whether supraspinatus tendon thickness correlates with pain.

METHODS

Fifty-seven patients completed a validated pain questionnaire. Using a standardized protocol, their shoulders were scanned by the same ultrasonographer at 1 week, 6 weeks, 3 months, and 6 months postarthroscopic repair by a single surgeon. The contralateral shoulders, if uninjured, were also scanned.

RESULTS

Of 57 patients, 4 re-tore their tendons at 6 weeks and 4 retore at 3 months. Sixteen of the remaining 49 patients had intact contralateral supraspinatus tendons. The repaired supraspinatus tendon thickness remained unchanged throughout the 6 months. Compared to week 1, at 6 months, bursal thickness decreased from 1.9 (0.7) mm to 0.7 (0.5) mm (P < .001); anatomical footprint increased from 7.0 (2.0) mm to 9.3 (1.5) mm; tendon vascularity decreased from mild to none (P < .001); posterior capsule thickness decreased from 2.3 (0.8) mm to 1.3 (0.6) mm (P < .001). Frequency and severity of pain and shoulder stiffness decreased (P < .001). There was no correlation between tendon thickness and pain.

CONCLUSION

After rotator cuff repair, there was an immediate increase in subacromial bursa thickness, tendon vascularity, and posterior glenohumeral capsular thickness. These normalized after 6 months. Tendon thickness was unchanged while footprint contact was comparable with the contralateral tendons. There was no correlation between tendon thickness and pain.

Ultrasound imaging for the rheumatologist XLV. Ultrasound of the shoulder in psoriatic arthritis

OBJECTIVES

The aims of this study were to investigate the prevalence of ultrasound (US) pathologic abnormalities in the shoulders of psoriatic arthritis (PsA) patients and to compare them with the main clinical findings.

METHODS

Ninety-seven PsA patients were enrolled in the study. The subacromial/subdeltoid bursa, the sheath of the long biceps tendon, the glenohumeral joint and the acromion-clavicular joint were examined for the presence of synovial effusions and synovial hypertrophy. Rotator cuff tendons (supraspinatus, subscapularis, infraspinatus) were imaged for tendinosis, calcifications and total or partial tears, while deltoid enthesis were evaluated for local enthesitis and the lesser and greater tuberosity of the humerus for the presence of enthesophytes.

RESULTS

Tendinosis represented the most frequent abnormal finding. Supraspinatus tendinosis was detected more often than subscapularis and infraspinatus tendinosis. When considering tendon tear, supraspinatus was also the most frequently involved anatomical structure. Clinical examination frequently failed to detect abnormalities in patients in whom US examination showed pathological findings. This is particularly true for tendon involvement, i.e. effusion within the sheath of the biceps tendon was imaged in 43 shoulders but clinical assessment reported abnormalities only in 22 shoulders (p<0.0001).

CONCLUSIONS

US examination appears to be a useful and sensitive imaging technique, specifically in identifying joint and tendon involvement of the shoulder.

Achilles enthesis ultrasound: the importance of the bursa in spondyloarthritis

OBJECTIVES

This paper aims to assess the prevalence and relevance of the bursa-synovial lesion in spondyloarthritis (SpA).

METHODS

A transversal blind and controlled two-dimensional (2D) and three-dimensional (3D) ultrasound (US) study of Achilles enthesis bursa in early SpA was undertaken. Clinical outcome measures were collected.

RESULTS

Bilateral Achilles enthesis of 66 early SpA patients (34 women) and 46 control patients (23 asymptomatic healthy subjects and 23 rheumatoid arthritis [RA] patients) were analysed. Mean BASDAI, BASFI and BASRI-spine were 4.55±2.08, 2.16±1.95 and 0.65±0.77, respectively. Mean erythrocyte sedimentation rate (ESR) was 10.93±12.35 mm/h and C-reactive protein (CRP) was 6.46±10.09 mg/l. The κ-values for intra-reader agreement for 2D and 3D images and bursa measurement were 0.82 and 0.98, respectively. Bursas were visualised in 89/132 SpA enthesis (67.4%) vs. 27/46 enthesis (58.7%) of healthy controls (p<0.01), and 10/46 enthesis (21.7%) of RA controls (p<0.01). When the thicknesses of the bursas were analysed, the SpA group had a mean of 1.52±1.47 mm versus 0.76±0.76 mm in the healthy control group (p<0.0001), and 0.38±0.62 mm in the RA control group (p<0.0001). A positive likelihood ratio of 4.6 with a cut-off point of bursa >2 was found. No Doppler signal was detected in controls, but 6.6% of SpA Achilles enthesis had Doppler bursitis. Heel pain was more frequent when bursa was present (p<0.05). When Doppler was present, male predominance, HLA B27 positive, heel pain, and higher number of swollen joints, CRP levels, disease activity by the patient and BASDAI questions 2 and 3 achieved statistical significance (p<0.01).

CONCLUSIONS

The presence of bursa and Doppler signal at retrocalcaneal bursa level could have a relevant contribution to differentiate SpA patients, and were correlated with clinical outcomes of SpA disease activity.

Sonographically guided obturator internus injections: techniques and validation

OBJECTIVES

The primary purpose of this investigation was to describe and validate sonographically guided techniques for injecting the obturator internus (OI) muscle or bursa using a cadaveric model.

METHODS

A single experienced operator completed 10 sonographically guided OI injections in 5 unembalmed cadaveric pelvis specimens (4 female and 1 male, ages 71-89 years with body mass indices of 15.5-24.2 kg/m2). Four different techniques were used: (1) OI tendon sheath (4 injections), (2) OI intramuscular (2 injections), (3) OI bursa trans-tendinous (2 injections), and (4) OI bursa short-axis (2 injections). In each case, the operator injected 1.5 mL of diluted yellow latex using direct sonographic guidance and a 22-gauge, 87.5-mm (3½-in) needle. Seventy-two hours later, study coinvestigators dissected each specimen to assess injectate placement.

RESULTS

All 10 OI region injections accurately placed latex into the primary target site. Two of the 4 OI tendon sheath injections produced overflow into the underlying OI bursa. Both OI intramuscular injections delivered 100% of the latex within the OI. All 4 OI bursa injections (2 trans-tendinous and 2 short-axis) delivered 100% of the latex into the OI bursa, with the exception that 1 OI bursa trans-tendinous injection produced minimal overflow into the OI itself. No injection resulted in injury to the sciatic nerve or gluteal arteries, and no injectate overflow occurred outside the confines of the OI or its bursa.

CONCLUSIONS

The results of this investigation demonstrate that sonographically guided injections into the OI or its bursa are feasible and, therefore, may play a role in the diagnosis and management of patients presenting with gluteal and "retrotrochanteric" pain syndromes.

Ultrasonography of the hip

A complete physical examination of the hip is often difficult due to its size and deep position. During the last two decades, ultrasonography (US) of the hip has been widely accepted as a useful diagnostic tool in patients with hip pain and /or limited range of motion. It is commonly used in both adults and children. This technique allows evaluation of different anatomical structures and their pathological changes, such as joint recess (joint effusion, synovial hypertrophy), changes within the bursae (bursitis), tendons and muscles (tendinopathy, ruptures, calcifications), as well as changes in the bony profile of the joint surfaces, ischial tuberosity, and greater trochanter (erosions, osteophytes, calcific deposits). US is very useful for guided procedures in hip joint and periarticular soft tissues under direct visualization. The needle aspiration of synovial fluid and steroid injections are commonly-applied activities in daily rheumatology practice. The relatively limited acoustic windows available to the US beam are the principal limitations to hip US. Therefore, conducting a detailed examination of some important structures together with the interpretation of Doppler signal (sometimes undetectable) is not easy, requiring good knowledge of the modality. The aim of this review is to analyze the current literature about US of the hip and to describe the most frequently-observed normal and pathological findings.

Dynamic ultrasound of the subacromial-subdeltoid bursa in patients with shoulder impingement: a comparison with normal volunteers

OBJECTIVE

The purpose of the study was to determine if the thickness of the subacromial-subdeltoid (SASD) bursa during dynamic ultrasound and on static views differs between patients with shoulder impingement syndrome and healthy volunteers.

MATERIALS AND METHODS

Twenty-two patients with a clinical diagnosis of shoulder impingement syndrome and 23 healthy volunteers were recruited. A subset of patients showing an immediate symptom response following intrabursal injection was identified as "injection responders". Ultrasound of the shoulder was performed on all participants using three standard static views and two dynamic views (before and after arm abduction). The thickness of both the intrabursal fluid and the superficial peribursal fat was measured on all views. The bursal thickness measurements in the two groups were compared using a t test for significance.

RESULTS

The mean increase in SASD bursal fluid thickness following arm abduction was not statistically different among all patients (0.39 ± 0.41 mm) and controls (0.35 ± 0.32 mm), p = 0.72. The same was true comparing injection responders (0.46 ± 0.49 mm) with controls, p = 0.41. On static views, greater bursal fluid thickness was found in patients (1.01 ± 0.48 mm) compared with controls (0.67 ± 0.32 mm) when using the short axis view of the supraspinatus, p = 0.006. No statistically significant difference was found between injection responders and controls when measuring peribursal fat thickness on any view.

CONCLUSIONS

Gathering of the SASD bursa demonstrated during dynamic ultrasound does not necessarily indicate painful impingement of the bursa as it is found to a similar degree in patients with a clinical diagnosis of impingement and healthy volunteers.

Relationship between width of greater trochanters and width of iliac wings in tronchanteric bursitis

Trochanteric bursitis is a common disorder that is characterized by inflammation of the bursa, superficial to the greater trochanter of the femur, leading to pain in the lateral hip, and often occurs because of acute trauma or repetitive friction involving the iliotibial band, the greater trochanter, and the bursa. In the study reported here, we hypothesized that the increased incidence of bursitis may be the result of the increased prominence of the trochanter in relation to the wings of the iliac crest. Distances between the outermost edges of trochanters and iliac wings were measured in 202 patients from the University of North Carolina Health Care System-101 without a known diagnosis and 101 with a clinical diagnosis of trochanteric bursitis. To determine significance, t tests for nonpaired data were used. Mean (SD) difference between trochanter and iliac wing widths was 28 (20) mm in the group diagnosed with trochanteric bursitis and 17 (18) mm in the control group. The difference between the groups in this regard was significant (P<.00005). In addition, mean (SD) ratio of trochanter widths to iliac wing widths was 1.09 (.06) in the bursitis group and 1.05 (.06) in the control group. The difference between these groups was significant (P<.0005) in this regard as well. Having trochanters wider in relation to iliac wings was associated with the diagnosis of trochanteric bursitis.

Comparison of 2 methods of centesis of the bursa of the biceps brachii tendon of horses

REASONS FOR PERFORMING STUDY

Centesis of the bicipital bursa using an 8.9 cm long spinal needle has been reported but the alternative of employing a 3.8 cm long hypodermic needle requires validation.

OBJECTIVE

To compare the efficacy of 2 different methods of centesis of the bicipital bursa and to evaluate the usefulness of ultrasonographic imaging to determine the location of solution administered when centesis of the bursa is attempted.

METHODS

For Trial 1, 6 clinicians, who had no previous experience of centesis of the bicipital bursa, attempted to inject a solution composed of an aqueous radiopaque contrast medium and physiological saline solution (PSS) into the bicipital bursae of 2/12 horses using the previously described distal approach to inject one bursa and a proximal approach to inject the contralateral bursa. The bicipital tendon and bursa were examined ultrasonographically before and after injection; and both shoulders were examined radiographically to identify the location of the medium. In Trial 2, another 6 clinicians, also with no previous experience of centesis, repeated Trial 1, using 6 horses, but the radiopaque contrast medium was mixed with air instead of PSS.

RESULTS

Accuracy of centesis using the proximal approach was 39% and that of the distal approach 28%. Ultrasonographic examination of the shoulder allowed the location of solution and air to be accurately predicted in all 12 shoulders examined.

CONCLUSIONS

Clinicians who have had no previous experience performing centesis of the bicipital bursa are unlikely to be successful in centesis using either approach. Radiographic examination after injecting a radiopaque contrast medium may be necessary to assess the success of centesis especially if bursal fluid is not obtained during centesis. Injecting air along with the radiopaque contrast medium provides more accurate ultrasonographic confirmation of centesis and better radiographic definition than does injection without air.

Pes anserine bursitis - an extra-articular manifestation of gout

While hospitalized with polymyositis, a medically complex 56-year-old male experienced an acute exacerbation of gout. Both ultrasound and magnetic resonance imaging cross-sectional modalities were used to detect, localize, and characterize a soft tissue mass. The tumor was ultimately found to be secondary to gouty inflammation of the pes anserine bursa, a previously unrecognized manifestation of acute gout.

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.

Lipoma arborescens of the suprapatellar bursa and extensor digitorum longus tendon sheath: report of 2 cases

OBJECTIVE

Lipoma arborescens (diffuse articular lipomatosis) is a rare intra-articular lesion consisting of subsynovial villous proliferation of mature fat cells. The usual clinical presentation is painless swelling. The aim of this series was to emphasize the importance of gray scale and color Doppler sonography through the investigation of chronic joint swelling.

METHODS

Lipoma arborescens of the knee and extensor digitorum longus tendon sheath at the ankle region are described. The latter is extremely rare. We examined 2 patients with sonography before using cross-sectional modalities.

RESULTS

Gray scale sonography revealed hyperechoic irregular villous and frondlike projections within prominent joint effusion. A wavelike motion of the projections was shown by dynamic compression and manipulation of the effusion. We observed moderate vascularity on color Doppler sonography. Spectral analysis revealed a low-resistance arterial waveform.

CONCLUSIONS

Gray scale sonography is a useful diagnostic modality that can be performed to evaluate chronic joint swelling before the use of cross-sectional and more expensive modalities.

The prepatellar bursa: cadaveric investigation of regional anatomy with MRI after sonographically guided bursography

OBJECTIVE

The purpose of this study was to use MRI and anatomic correlation in cadavers to show the macroscopic anatomic configuration of the prepatellar bursa.

MATERIALS AND METHODS

MRI of the prepatellar bursa of nine cadaveric knees was performed after sonographically guided bursography. The images were compared with those seen on anatomic sectioning. Histologic analysis was obtained in two specimens.

RESULTS

Mean dimensions of the prepatellar bursa in the craniocaudal, lateromedial, and anteroposterior planes were 39.7, 40.5, and 3.2 mm, respectively. A trilaminar aspect of the bursa was shown in seven of the nine knees (78%) and a bilaminar appearance in two of the nine knees (22%). Lateral extension of the bursa over the patella was observed in three knees (33%) and medial extension in one knee (11%). On histopathologic analysis, three potential bursal spaces were found.

CONCLUSION

The prepatellar bursa is most commonly a trilaminar structure, and variation in its relation to the patella can occur.

Injection of the subacromial-subdeltoid bursa: blind or ultrasound-guided?

BACKGROUND

Blind injection of the subacromial-sub-deltoid bursa (SSB) for diagnostic purposes (Neer test) or therapeutic purposes (corticosteroid therapy) is frequently used. Poor response to previous blind injection or side effects may be due to a misplaced injection. It is assumed that ultrasound (US)-guided injections are more accurate than blind injections. In a randomized study, we compared the accuracy of blind injection to that of US-guided injection into the SSB.

PATIENTS AND METHODS

20 consecutive patients with impingement syndrome of the shoulder were randomized for blind or US-guided injection in the SSB. Injection was performed either by an experienced orthopedic surgeon or by an experienced musculoskeletal radiologist. A mixture of 1 m'L methylprednisolone acetate, 4 mL prilocaine hydrochloride and 0.02 mL (0.01 mmol) Gadolinium DTPA was injected. Immediately after injection, a 3D-gradient T1-weighted magnetic resonance scan of the shoulder was performed. The location of the injected fluid was independently assessed by 2 radiologists who were blinded as to the injection technique used.

RESULTS

The accuracy of blind and US-guided injection was the same. The fluid was injected into the bursa in all cases.

INTERPRETATION

Blind injection into the SSB is as reliable as US-guided injection and could therefore be used in daily routine. US-guided injections may offer a useful alternative in difficult cases, such as with changed anatomy postoperatively or when there is no effective clinical outcome.

Detection of subacromial bursa thickening by sonography in shoulder impingement syndrome

BACKGROUND

Normally, the subacromial-subdeltoid bursa is thinner than 2 mm using ultrasound examination. The subtle thickening of the bursa could be an early sign of subacromial impingement and possibly a rotator cuff tear. The aim of this study was to compare the thickness of subacromial bursa measured using ultrasonography in the painful shoulder with normal side, and also to differentiate Neer stages I and II impingements in patients with unilateral shoulder pain.

METHODS

We performed bilateral shoulder sonography in 268 consecutive patients with unilateral shoulder pain and clinical suggestion of rotator cuff pathology. The study group consisted of 102 cases of Neer stage I and 166 cases of Neer stage II impingement syndrome. The bursa thickness was calculated from the superficial peribursal fat to the upper margin of the supraspinatus.

RESULTS

A statistically significant association was detected (p < .0001) between the symptomatic shoulder and asymptomatic side (mean thickness, 1.27 mm/0.75 mm). The thickness of bursa in patients with Neer stage I impingement had no statistically important link the results of the patients with Neer stage II impingement.

CONCLUSION

Increased bursa thickness in the symptomatic side may be an alternative sonographic indicator of subacromial bursitis and partial-thickness rotator cuff tears, even when measured to be less than 2 mm. Sonographic examination of subacromial bursa thickness is not an appropriate technique to differentiate the Neer stages I and II impingement. Further study is needed to quantify the echogenicity of the supraspinatus tendon and to show a level of accuracy in patients with rotator cuff tendinosis or partial tears.

Deep and superficial infrapatellar bursae: cadaveric investigation of regional anatomy using magnetic resonance after ultrasound-guided bursography

OBJECTIVE

To demonstrate the anatomy of the deep and superficial infrapatellar bursae using magnetic resonance (MR) imaging and anatomic correlation in cadavers.

DESIGN

MR imaging of the infrapatellar bursae of nine cadaveric knees was performed after ultrasound-guided bursography. The images were compared with those seen on anatomic sectioning. Histologic analysis was obtained in two specimens.

RESULTS

The deep infrapatellar bursa (DIB) was visualized in all specimens (n=9) and the superficial infrapatellar bursa (SIB) in five specimens (55%). The mean dimensions of the DIB in the craniocaudal, mediolateral, and anteroposterior planes were respectively 25, 28.7, and 6 mm, and for SIB 19.5, 21.2 and 2.2 mm. A fat apron dividing the DIB was depicted in eight knees (89%). Lateral extension of the DIB beyond the patellar tendon was observed in 100% of cases. Cadaveric analysis depicted a thin septum in the SIB in four of five cases (80%).

CONCLUSIONS

The DIB is generally present and extends beyond the lateral margin of the patellar tendon. A fat apron partially separating this structure is usual. The SIB is not an unusual finding and may have a septum separating its compartments.

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.

Radial and ulnar bursae of the wrist: cadaveric investigation of regional anatomy with ultrasonographic-guided tenography and MR imaging

OBJECTIVE

To demonstrate the anatomy of the radial and ulnar bursae of the wrist using MR and US images.

DESIGN

Ultrasonographic-guided tenography of the tendon sheath of flexor pollicis longus (FPL) and the common tendon sheath of the flexor digitorum of the fifth digit (FD5) of ten cadaveric hands was performed, followed by magnetic resonance imaging and gross anatomic correlation. Patterns of communication were observed between these tendon sheaths and the radial and ulnar bursae of the wrist.

RESULTS

The tendon sheath of the FPL communicated with the radial bursa in 100% (10/10) of cases, and the tendon sheath of the FD5 communicated with the ulnar bursa in 80% (8/10). Communication of the radial and ulnar bursae was evident in 100% (10/10), and presented an "hourglass" configuration in the longitudinal plane.

CONCLUSIONS

The ulnar and radial bursae often communicate. The radial bursa communicates with the FPL tendon sheath, and the ulnar bursa may communicate with the FD5 tendon sheath.

[Ultrasonic study of knee joint lesions in rheumatoid arthritis]

OBJECTIVE

To evaluate the effectiveness of ultrasonography in detecting Rheumatoid Arthritis through ultrasonographic image of suprapatellar bursa' fluid, synovium, and femoral condylar cartilage in the knee joints.

METHODS

The ultrasonographic image of suprapatellar bursa' fluid, synovium and femoral condylar cartilage was compared between people with and without Rheumatoid Arthritis. The changes of suprapatellar bursa' fluid and thickness, color flow grading, RI of synovium and femoral condylar cartilage in the patient with Rheumatoid Arthritis before and after therapy were measured. The correlations between suprapatellar bursa' fluid, thickness, color flow grading, RI of synovium and CRP/ESR were analyzed.

RESULTS

The suprapatellar bursa' fluid and synovium in the patients with Rheumatoid Arthritis before treatments were thicker than those without Rheumatoid Arthritis. After treatments for the patients with Rheumatoid Arthritis, the thickness of suprapatellar bursa' fluid and synovium decreased, the color flow of synovium reduced, whearaus the RI increased. The ESR/CRP were correlated with the thickness of suprapatellar bursa' fluid and synovium and color flow grading.

CONCLUSION

Ultrasonography is an auxiliary diagnostic instrument, which can be used in evaluating the therapeutic effect on Rheumatoid Arthritis.

Involvement of the Anterior Portion of the Subacromial-Subdeltoid Bursa in the Painful Shoulder

OBJECTIVE

The purpose of our study was to verify that increased widening of the anterior portion of the subacromial-subdeltoid bursa is associated with anteromedial shoulder pain.

MATERIALS AND METHODS

Bursography, sonography, and CT were performed in six cadaver shoulders and compared with anatomic sections in neutral position and while the humerus was extended and internally rotated. For the clinical study, the width of the anterior portion of the bursa was measured in both positions in both shoulders of 27 patients referred because of shoulder pain and in eight asymptomatic volunteers. Pain was coded as absent, experienced in the anteromedial portion of the shoulder, or experienced elsewhere but not anteromedially, and we compared the pain scores between shoulder positions.

RESULTS

In all cadaver shoulders, when compared with CT scans and anatomic sections, sonography showed the morphology of the bursa, its relationships with surrounding structures, and morphologic changes associated with position. In volunteers, the mean width of the bursa was 0.74 +/- 0.05 and 0.93 +/- 0.09 mm (p = 0.013), respectively, in neutral and stress position. In patients, the same values were 0.70 +/- 0.07 and 0.81 +/- 0.14 mm (p = 0.286) in the asymptomatic side and 1.20 +/- 0.11 and 1.75 +/- 0.23 mm (p < 0.001) in the symptomatic side, respectively. The bursa was wider in patients experiencing pain anteromedially than in those who experienced pain elsewhere and volunteers (p = 0.002 and < 0.001, respectively), and the bursa was wider in symptomatic shoulders than in asymptomatic shoulders (p < 0.001).

CONCLUSION

Widening of the anterior portion of the subacromial-subdeltoid bursa is associated with anteromedial shoulder pain and the clinical syndrome of coracoid impingement.

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.

Therapeutic arthrography and bursography

Arthrography and bursography as therapeutic venues have found their place in the musculoskeletal procedure armamentarium. Therapeutic arthrography not only rules in and rules out the origin of pain but can provide 6 to 9 months of pain relief in diseased joints. Therapeutic arthrography allows injections of anesthetic, corticosteroid, or alternatively hyaluronic acid to be delivered accurately to the source of pain. Corticosteroids have a long history of use in osteoarthritis. Alternative therapy with hyaluronic acid is anew procedure. This article reviews the technique of arthrography in different joints and bursae and discusses the pros and cons of the use of corticosteroids versus viscosupplementation in therapeutic arthrography.

Soft-tissue masses in the shoulder girdle: an imaging perspective

We discuss the radiological assessment of soft-tissue masses presenting in the shoulder girdle and emphasise the relative strengths and weaknesses of the different imaging modalities available. The appearances of the common benign and malignant soft-tissue tumours are presented together with conditions that present with specific imaging features around the shoulder region.

[Isolated synovial chondromatosis of the subacromial bursa: report of a new case and review of the literature]

Synovial chondromatosis is a rare metaplasia of the synovium of unknown etiology that may involve occasionally the subacromial bursa. We report a new case diagnosed by ultrasound in a 30-year-old man and we present pathogenetic, diagnostic and therapeutic features of this disease with a literature review.

Osteochondroma of the scapula associated with winging and large bursa formation

OBJECTIVE

To report a case of scapular osteochondroma associated with pain and winging that is rarely reported in the medical literature.

CASE PRESENTATION AND IDENTIFICATION

A 19-year-old male presented with pain and winging of the right scapula. CT scan revealed an osteochondroma of the medial border of the scapula with a large bursa between the chest wall and the tumour. Excision of the tumour relieved the symptoms. Pathological study showed osteochondroma of the scapula. In a follow-up 1 year later he was free of pain with no clinical or radiological sign of recurrence.

CONCLUSION

A case of scapular osteochondroma associated with pain and winging treated by excision and follow-up showed no sign of clinical or radiological recurrence.

Ultrasound of the Ankle: Anatomy of the Tendons, Bursae, and Ligaments

Ankle tendon and ligament disorders are commonly encountered in everyday orthopedic practice. Whereas tendons can be affected by traumatic, degenerative, and inflammatory conditions, ligaments are mostly involved by tears. Ultrasonography (US) has been accepted worldwide as an efficient, ready, dynamic, and noninvasive tool in assessing ankle tendons and ligaments. The recent technological advances in software and hardware of US equipment have improved the possibilities of US in ankle assessment, and modern equipment allows an accurate depiction of ankle structures. As with all imaging modalities, knowledge of the scanning technique and knowledge of normal US anatomy are prerequisites for a successful examination. In this article we briefly review the normal anatomy of ankle tendons and main ligaments relevant to the US examination. Then we present the routine US technique of examination for the anterior, posterolateral, posteromedial, and posterior region followed by a description of the normal US appearance of tendons, bursae, and ligaments.

Case reports: ossified mass of the rotator cuff tendon in the subacromial bursa

Unlike calcification, ossification is infrequent in the rotator cuff. We describe the clinical, radiographic, and pathologic findings in 64-year-old man with an ossified mass arising from a calcified portion of the rotator cuff tendon within the subacromial bursa. Mechanical stress and ischemic events are possible causes of cartilage formation followed by endochondral ossification, producing a mass causing outlet impingement.

A cholesterol-containing foreign body granuloma presenting as an inter-metatarsal bursa

A 68-year-old man presented with progressive forefoot swelling which coincided with the onset of type 2 diabetes mellitus. Imaging revealed a cystic inter-metatarsal mass containing two foreign bodies, which had been present for many years. Following aspiration of the mass, cholesterol crystals were observed on polarised microscopy. It is postulated that the development of diabetes triggered the shedding of cholesterol crystals around a long-standing quiescent foreign body granuloma.