超声引导下高容量注射与冲击波治疗慢性非止点跟腱腱病的比较

目的观察和比较超声引导下高容量注射治疗(HVUGI)与冲击波治疗(ESWT)慢性非止点跟腱腱病的临床疗效。方法选择2017年3月至2018年2月慢性非止点跟腱腱病保守治疗无效的患者52例,男21例,女31例,年龄35～70岁,BMI 18～35 kg/m~2。随机分为HVUGI组(H组)和ESWT组(E组),每组26例。H组在超声引导下将1%利多卡因10 ml及生理盐水40 ml注入到跟腱与跟腱前脂肪垫之间。E组采用瑞士STORZ医用放射式冲击波治疗仪MP100治疗跟腱疼痛部位,每周治疗1次,共3次。分别在治疗前、治疗后6周、3个月和6个月采用VAS评估疼痛程度,采用0～10分评估踝关节僵硬程度,采用维多利亚学院足踝运动功能评估评分(VISA-A)综合评估跟腱病变程度。观察注射部位有无出血、血肿、感染以及跟腱断裂等并发症。结果与治疗前比较,治疗后6周至6个月两组患者VAS疼痛评分均明显降低(P0.05),治疗后6周H组、治疗后6个月两组患者僵硬程度评分均明显降低(P0.05)。与治疗前比较,治疗后6周至6个月两组患者VISA-A评分均明显升高(P0.05)。两组VAS疼痛评分、僵硬程度评分和VISA-A评分差异均无统计学意义。两组患者治疗后均无出血、血肿、感染以及跟腱断裂等并发症。结论冲击波及超声引导下高容量注射治疗慢性非止点跟腱腱病具有良好效果,而高容量注射治疗在治疗后6周时僵硬程度的改善优于冲击波治疗。     

小腿肌肉离心训练联合体外冲击波治疗慢性跟腱止点腱病的疗效观察

目的观察小腿肌肉离心训练联合体外冲击波治疗慢性跟腱止点腱病的疗效。方法笔者自2015-02—2016-02诊治72例慢性跟腱止点腱病,按随机数字表进行分组,肌肉离心训练组25例,冲击波治疗组25例,小腿肌肉离心训练联合体外冲击波组(联合组)治疗22例。采用VISA-A跟腱病评分表评价疼痛和活动水平,6点Likert评分表评价2组主观满意度。结果所有患者均获得4个月的随访,肌肉离心训练组的VISA-A评分由(50.8±10.4)分提高到(72.5±18.0)分,冲击波治疗组由(50.6±9.8)分提高到(78.6±12.4)分,联合组由(50.2±10.6)分提高到(86.0±15.0)分,3组VISA-A评分均较治疗前有所改善,两两比较差异有统计学意义(P0.05);肌肉离心训练组对治疗满意14例,满意率为56%,冲击波治疗组对治疗满意17例,满意率为68%,联合组对治疗满意18例,满意率为81.8%,两两比较差异有统计学意义(χ2=3.65,P=0.031)。结论小腿肌肉离心训练结合体外冲击波治疗慢性跟腱止点腱病,能显著改善疼痛,提高患者满意率。     

拇长屈肌腱转位治疗顽固性跟腱止点病

目的探讨拇长屈肌腱转位治疗顽固性跟腱止点病的临床疗效。方法对30例顽固性跟腱止点病患者采用跟腱清创、拇长屈肌腱转位的术式进行跟腱重建。采用VISA-A评分评价疗效。结果患者均获得随访,时间25～43个月。VISA-A评分:术前为37. 50分±2. 70分,末次随访时为80. 80分±3. 10分,差异有统计学意义(P 0. 01)。1例因切口愈合不良行清创后重新缝合,其余患者无并发症发生。结论跟腱止点病的手术治疗不仅要去除跟腱腱体的病变,还要创造良好的腱周环境。拇长屈肌腱转位技术治疗顽固性跟腱止点病可获得满意的疗效。     

富血小板血浆在急性跟腱断裂治疗中的应用

目的探讨富血小板血浆(PRP)在急性跟腱断裂治疗中的应用。方法回顾性研究苏州大学附属第一医院自2018年1月至2019年1月治疗的21例跟腱断裂患者资料。根据患者是否注射PRP将21例患者分为PRP组(改良Kessler缝合法联合PRP注射治疗,15例)和对照组(单纯使用改良Kessler缝合法治疗,6例)。比较两组患者术后3、6、9个月的踝关节跖屈和背伸角度、疼痛视觉模拟评分(VAS)、Victorian运动学会评分(VISA)及美国足踝外科协会(AOFAS)的踝-后足评分。结果两组患者术前一般资料比较差异均无统计学意义(P>0.05),具有可比性。所有患者术后获9~12个月(平均11.3个月)随访。PRP组术后3、6、9个月跖屈角度(33.5°±1.8°、38.1°±1.2°、41.6°±1.6°)和背伸角度(10.3°、16.5°、21.5°)大于对照组[(26.9°±2.0°、31.5°±1.6°、35.6°±1.4°)和(5.3°、12.7°、18.2°)],PRP组术后3、6、9个月VISA评分[(41.2±6.5)、(78.7±10.4)、(91.0±4.1)分]和AOFAS的踝-后足评分[(75.5±5.4)、(88.6±5.2)、(95.2±3.5)分]高于对照组[(29.8±2.5)、(68.0±3.5)、(84.5±2.1)分和(66.8±4.8)、(82.8±3.6)、(90.7±1.1)分],PRP组术后3、6个月VAS评分[(1.7±0.9)、(1.3±0.4)分]低于对照组[(3.0±0.8)、(2.2±0.7)分],差异均有统计学意义(P<0.05)。结论PRP可以加速患者足及踝关节功能恢复,可以认为使用改良Kessler缝合法联合PRP是一种安全、实用、可靠的治疗方法。     

富血小板血浆联合间充质干细胞治疗膝骨关节炎的疗效

目的观察关节腔内联合注射富血小板血浆与脐带间充质干细胞治疗轻中度膝关节骨关节炎患者的近期疗效。 方法收集聊城市人民医院膝关节骨关节炎患者200例,纳入标准：Kellgren-Lawrence分级1～3级膝关节骨关节炎患者;排除标准：Kellgren-Lawrence分级4级骨关节炎患者及炎症性关节炎患者等。根据电脑产生的伪随机数字,将研究对象随机分为富血小板血浆(PRP)与脐带间充质干细胞(MSC)联合注射组(PRP＋MSC)、单纯PRP注射组(PRP组)、单纯脐带MSC注射组(MSC组)、玻璃酸钠(SH)注射组(SH组),每组各50例。PRP ＋ MSC组关节腔内注射5 ml富血小板血浆与脐带间充质干细胞混合液;PRP组关节腔内注射5 ml富血小板血浆;MSC组关节腔内注射5 ml脐带间充质干细胞;SH组关节腔内注射2.5 ml的SH及曲安奈德注射液。分别在治疗后1、3、6、12个月进行随访,通过视觉疼痛模拟评分(VAS),美国膝关节协会评分( AKS )评价治疗后膝关节功能的改善情况;采用酶联免疫吸附法检测治疗前后关节液中细胞因子的变化情况;利用MRI的T2 Map序列评价治疗前后关节软骨的变化情况。患者年龄、病程、VAS评分、AKS评分、细胞因子含量等计数资料分析采用单因素方法分析,患者性别比例、病情程度等计数资料分析采用卡方检验。 结果200例患者中,175例完成随访,PRP ＋ MSC组45例,PRP组44例,MSC组43例,SH组43例。4组患者治疗前VAS、AKS及关节液中细胞因子的表达无统计学意义(P >0.05)。治疗后1个月,4组患者的VAS评分均较前降低,AKS评分较前升高,组内差异具有统计学意义(t ＝6.45,P <0.01),组间差异无统计学意义(P >0.05)。3个月后,SH组VAS、AKS趋向于治疗前状态,其余3组未见反弹,PRP ＋ MSC联合注射组优于单纯PRP与MSC治疗组,4组间的差异具有统计学意义(F ＝7.84/4.35,P <0.01)。治疗后3周,SH组关节液中细胞因子未见明显改变,PRP ＋ MSC组关节液中细胞因子变化水平高于单纯PRP与MSC组,差异具有统计学意义(F ＝39.21,P <0.01)。治疗后6个月,MRI的T₂Map序列显示PRP＋MSC组、PRP组、MSC组、SH组的平均软骨T2值分别为(54.07±2.64)ms、(56.59±1.40)ms、(56.40±1.57)ms、(57.98±1.95)ms,差异具有统计学意义(F＝30.63,P<0.05)。 结论关节腔内联合注射富血小板血浆与脐带间充质干细胞明显改善膝关节骨关节炎患者的症状,延缓骨关节炎的进展。     

不同手术方式对跟腱中段腱病的疗效

[目的]评估不同手术方式对跟腱中段腱病的疗效。[方法]66例跟腱中段腱病患者采用手术治疗,根据手术方式不同将患者分成A组微创手术治疗组、B组传统开放手术治疗组,对比两组手术的疗效、手术时间、术中出血量、术后并发症、住院天数。分别在治疗前、治疗后即刻、治疗后4、12个月时用VISA-A跟腱腱病评分表进行评分,并在治疗后12个月时采用Likert评分进行患者主观满意度评价。[结果](1)微创手术治疗组在手术时间、术中出血量、住院天数等方面具有明显优势;(2)VISA-A评分:两组患者在治疗前评分无差异,(P>0.05)。A组治疗后即刻、治疗后4个月及治疗后12个月分别为(85.55±12.11)、(94.58±13.11)、(96.55±10.11),B组则分别为(68.63±7.40)、(78.63±6.58)、(82.38±6.65)。A组治疗后各时间点与治疗前的VISA-A评分差值与B组相比,差异有统计学意义(P<0.05);(3)Likert评分:A组中4例非常满意,25例满意,2例不满意,满意率达到93.8%。B组中没有非常满意者,28例满意,6例不满意,满意率为82.4%。微创手术组满意度明显高于传统开放手术组。[结论]微创手术较传统开放手术在治疗跟腱中段腱病上,围手术期有显著优势,具有更良好的长期临床结果,能够更好地提高病人整体的满意度。     

血小板裂解液与富血小板血浆治疗膝骨关节炎的临床研究

目的比较血小板裂解液(PL)与富血小板血浆(PRP)关节腔内注射治疗膝骨关节炎(KOA)的临床疗效。 方法采用前瞻性随机对照研究的方法,选取2012年4月至2015年9月山东省文登整骨医院收治的150例KOA患者的150膝,通过随机数字表法分为血小板裂解液(PL)组、富血小板血浆(PRP)组和玻璃酸钠(HA)组(每组50例),3组关节腔注射PL、PRP和HA频次为每周1次,连续5周。选择治疗前、治疗后1、3、6个月为时间观察点,西安大略和麦克马斯特大学(WOMAC)疼痛评分、Lequesne肿胀评分及WOMAC综合评分评价治疗前后关节疼痛、肿胀情况及综合功能等方面的区别,同时记录3组病例在治疗过程中不良反应发生情况并进行比较。Fisher精确检验、方差分析或t检验用于数据分析比较。 结果PL组49例,PRP组48例,HA组47例成功完成治疗及6个月以上随访。3组患者在治疗后1个月时WOMAC疼痛评分最低;治疗后3及6个月比较,PL组与PRP组低于HA组(3个月：t＝1.115,P<0.01;t＝2.343,P<0.05;6个月：t＝0.463,P<0.05;t＝1.983,P<0.01),PL组与PRP组比较,差异无统计学意义(t＝3.123、2.983,均为P>0.05)。Lequesne肿胀评分在治疗后3个月时PL组低于PRP组与HA组(t＝3.132,P<0.05;t＝1.545,P<0.01),PRP组低于HA组(t＝2.654,P<0.05)。治疗后6个月时,PL组与PRP组均低于HA组(t＝2.513,P<0.05;t＝3.313,P<0.01),PL组与PRP组比较差异无统计学意义(t＝2.343,P>0.05)。3组治疗完成后WOMAC综合评分比较：治疗后3个月PL组低于PRP组与HA组(t＝2.442,P<0.05;t＝2.415,P<0.01),PRP组低于HA组(t＝1.324,P<0.01);治疗6个月比较,PL组与PRP组低于HA组(t＝1.613,P<0.05;t＝2.913,P<0.01),PL组与PRP组比较差异无统计学意义(t＝3.413,P>0.05)。不良反应发生率的比较中,PL组不良反应发生率(2.0%)低于HA组(8.5%)(P<0.05);PL组低于PRP组(P>0.05),PRP组低于HA组(P>0.05),但差异均无统计学意义。 结论血小板裂解液治疗膝骨关节炎能够取得与富血小板血浆同样的治疗效果,均优于玻璃酸钠,同时不良反应发生率低。     

微骨折术联合关节腔内注射富血小板血浆治疗小面积距骨骨软骨损伤

目的探讨微骨折术联合关节腔内注射富血小板血浆(platelet-rich plasma,PRP)治疗小面积距骨骨软骨损伤(osteochondral lesion of the talus,OLT)的临床疗效。方法以2014年9月-2017年10月收治且符合选择标准的43例小面积OLT患者为研究对象,采用随机数字表法将其分为两组,微骨折组(21例)行单纯微骨折术治疗,联合组(22例)采用微骨折术联合关节腔内注射自体PRP治疗。两组患者性别、年龄、病程、侧别、损伤部位、病损面积、Mintz分型、术前疼痛视觉模拟评分(VAS)及美国矫形足踝协会(AOFAS)踝与后足评分比较,差异均无统计学意义(P>0.05)。治疗后采用MRI评价OLT恢复情况,VAS评分及AOFAS踝与后足评分评价踝关节疼痛及功能。结果术后两组切口均Ⅰ期愈合,无静脉血栓形成、踝关节内感染等并发症发生。两组患者均获随访,随访时间12~18个月,平均15.6个月。术后6、12个月两组患者VAS评分及AOFAS踝与后足评分均较术前显著改善,术后12个月较6个月时进一步改善,差异均有统计学意义(P<0.05)。术后6、12个月,联合组VAS评分及AOFAS踝与后足评分均显著优于微骨折组,差异有统计学意义(P<0.05)。MRI复查示术后12个月两组患者OLT处均填充良好。结论与单纯微骨折术相比,微骨折术联合关节腔内注射自体PRP治疗小面积OLT可有效减轻疼痛、改善踝关节功能,具有良好临床疗效。     

双排缝合桥固定技术治疗Haglund综合征的临床疗效分析

背景:保守治疗后疼痛症状缓解不明显的Haglund综合征患者可考虑手术治疗。缝合桥技术已广泛应用于肩袖损伤的修复。目的:评价双排缝合桥固定技术治疗Haglund综合征的临床疗效。方法:回顾性分析2013年6月至2016年7月,应用双排缝合桥固定技术治疗的22例(30足)Haglund综合征患者的病例资料。其中男13例(18足),女9例(12足),年龄22~48岁,平均(37.6±8.3)岁。术前主要临床表现为足跟后方疼痛及肿胀,跟腱止点及周边压痛,撞击试验阳性;负重位X线片见跟骨后上结节突起,超出平行间距线;MRI示跟腱末端病变及跟骨后滑囊炎。术中行跟腱止点病灶清除后使用双排缝合桥固定技术重建跟腱止点,术后定期随访。采用疼痛视觉模拟(VAS)评分,美国足踝外科协会(AOFAS)足踝功能评分、维多利亚运动学会跟腱(VISA-A)评分评估治疗结果。同时测量负重侧位X线片上跟骨倾斜角(CPA)、跟骨后角(FPA)、平行间距线(PPL)。结果:本组患者平均随访时间(38.9±9.2)个月,术后切口均一期愈合,随访期间无后跟肿胀、疼痛复发,无锚钉松动及移位、移植物取出、跟腱断裂等并发症发生。平均VAS评分、跟骨倾斜角、跟骨后角、平行间距线阳性率分别由术前的(5.1±1.2)分、18.6°±1.8°、72.9°±2.4°、100%减少为末次随访的(1.8±0.7)分、15.1°±2.1°、45.3°±5.0°、6.67%,差异均有统计学意义(P<0.01)。末次随访时AOFAS踝与后足评分、VISA-A跟腱评分较术前明显改善[(84.9±4.9)分vs(42.5±4.0)分,(88.7±6.0)分vs(47.6±4.2)分,P<0.01]。结论:双排缝合桥固定技术治疗Haglund综合征临床疗效良好,术中对病灶彻底清创、增加肌腱跟骨足迹及腱骨接触面积是影响手术疗效的关键。     

体外冲击波结合下肢洗伤方治疗踝部陈旧性软组织损伤

目的观察体外冲击波联合下肢洗伤方治疗踝部陈旧性软组织损伤的临床疗效。方法笔者自2014-06—2016-10将87例患者随机分成联合组、冲击波组和中药熏洗组。分别予体外冲击波联合下肢洗伤方(联合组)、体外冲击波(冲击波组)、下肢洗伤方熏洗(中药熏洗组)治疗。比较治疗前和治疗后2周、1个月、3个月、6个月VAS评分和AOFAS踝-后足评分。结果所有患者获得6个月随访。3组治疗后VAS评分均明显下降,AOFAS踝-后足评分均有提高,治疗后2周、1个月、3个月、6个月,联合组VAS评分、AOFAS踝-后足评分均优于冲击波组、中药组,冲击波组优于中药熏洗组,差异均有统计学意义(P0.05)。结论体外冲击波联合下肢洗伤方治疗踝部陈旧性软组织损伤短期疗效好。     

Evidence for the use of PRP in chronic midsubstance Achilles tendinopathy: A systematic review with meta-analysis

BackgroundPlatelet-rich plasma (PRP) injections have been proposed as an additional therapy in the treatment of chronic midsubstance Achilles tendinopathy (AT). The use of PRP injections as pharmacological treatment added to a conservative approach has gained growing interest, but the efficacy remains highly debated. The varying methodological quality of the available studies may contribute to these contradictory results. The aim of this systematic review with meta-analysis was to establish the existing evidence of PRP injections for chronic midsubstance AT on the functional outcome, with a risk of bias assessment of each included study.MethodsAccording to the PRISMA guidelines systematic searches were performed in Embase, the Cochrane library and Pubmed on June 12, 2020 for relevant literature. Only clinical trials comparing PRP injections with placebo, additional to an eccentric training program, in midsubstance AT were included. The primary outcome was Victorian Institute of Sport Assessment - Achilles (VISA-A) score at 3, 6 and 12 months post-injection. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials (Rob 2). As secondary outcome we assessed reported changes in tendon structure after PRP injections.ResultsA total of 367 studies were identified with the initial database search. Finally, four randomized controlled trials (RCTs) met inclusion criteria for systematic review and meta-analysis with data of 170 patients available for pooling. Results showed no difference in clinical outcome between the PRP and placebo group at different points in time using the VISA-A score as outcome parameter (3 months 0.23 (CI -0.45, 0.91); 6 months 0.83 (CI -0.26, 1.92); 12 months 0.83 (CI -0.77, 2.44)). The bias analysis showed a low or intermediate risk of bias profile for all studies which supports the good methodological quality of each included article. Finally, it is unclear whether PRP injections cause an improvement in tendon structure. However, no direct relationship between tendon structure and clinical presentation of AT could be found.ConclusionPRP has no clear additional value in management of chronic midsubstance Achilles tendinopathy and therefore should not be used as a first-line treatment option.     

Extrakorporale Stoßwellentherapie zur Behandlung der Achillessehnentendinopathie

PURPOSE: The purpose of this study was to determine the efficacy of extracorporeal shock wave therapy (ESWT) for the treatment of adults with chronic insertional Achilles tendinopathy. METHODS: 68 patients with chronic insertional Achilles tendinopathy were enrolled in this study. A total of 35 patients were treated with a single dose of ESWT (3000 shocks of 0.20 mJ/mm(2), ESWT group), while 33 patients were treated with traditional non-operative measures (control group). RESULTS: At 3 months post treatment, the mean VAS for the control and ESWT groups were 2.9 and 7.2 respectively. Using the Roles and Maudsley scale, 39% of the control patients and 51% of the ESWT patients were assigned an excellent or good result. CONCLUSIONS: ESWT as applied is a safe and effective treatment for chronic insertional Achilles tendinopathy.     

Clinical presentation and surgical management of chronic Achilles tendon disorders — A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon

Background

Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups.

Achilles tendoscopy for non insertional Achilles tendinopathy. A case series study

BackgroundAchilles non-insertional tendinopathy is usually treated with conservative means. If resistant to a rehabilitation protocol surgical treatment could be proposed. The aim of this research is to report the mid-term clinical results of endoscopic assisted surgery for patients suffering from recalcitrant painful non-insertional Achilles tendinopathy.MethodsA consecutive series of 11 patients (6 men and 5 women), median age of 54 (range 40–67) years, with chronic recalcitrant painful non-insertional Achilles tendinopathy were included. All patients completed at least 20 physical therapy sessions and 6 months of no sports activities before surgery. All underwent Achilles tendoscopy, without tendon excision or transfer with a median follow-up of 87 (27–105) months. We report the preoperative symptoms duration, treatment before surgery, complications and satisfaction after surgery, return to previous sport level, and postoperative VISA-A score.ResultsMean preoperative symptoms duration was 1 year, having all performed at least 20 physical therapy sessions. No postoperative complications were reported, achieving a complete satisfaction in 10 of 11 patients. All patients returned to their preoperative sports level with a median postoperative VISA-A functional score of 100 (30–100) points.ConclusionsThe mid-term results of Achilles tendoscopy in patients with chronic painful non-insertional Achilles tendinopathy are satisfactory with a rapid rehabilitation. This procedure is safe and has a low complication rate.Level of Evidence: IV. Retrospective case series.     

A novel technique of minimally invasive calcaneal osteotomy for intractable insertional Achilles tendinopathy associated with Haglund deformity

BackgroundTo date, minimally invasive surgery (MIS) involving calcaneal osteotomy for Haglund deformity associated with intractable insertional Achilles tendinopathy has not been reported. This study presents the radiographic and clinical outcomes of our novel MIS-dorsal closing wedge calcaneal osteotomy (DCWCO) technique compared to open Haglund resection. We hypothesized that earlier clinical improvement after MIS-DCWCO could be achieved by leaving the Achilles tendon insertion site untouched.MethodsWe retrospectively reviewed and compared the clinical and radiographic parameters of patients who underwent MIS-DCWCO (11 cases) or open Haglund resection (14 cases) between January 2012 and June 2019. The minimum duration of follow-up for inclusion was 18 months. We measured the calcaneal pitch, Meary’s, Fowler-Philip, and Böhler’s angles. Clinical outcomes were evaluated using the visual analogue scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores measured preoperatively and at 3, 6, 9, 12, and ≥18 months, postoperatively.ResultsIn both groups, the Meary’s and calcaneal pitch angles did not change significantly, whereas the Fowler-Philip and Böhler’s angles were significantly changed postoperatively. Significant improvements in VAS and VISA-A scores were observed in both groups (P < 0.001). The extent of correction of the four radiographic and two clinical parameters were not significantly different between the two groups. However, VAS and VISA-A scores at postoperative 6 months were significantly different, whereas these parameters were not significantly different at all other time points.ConclusionBoth techniques provided similar postoperative clinical and radiographic improvement. However, MIS-DCWCO achieved earlier clinical improvement than open Haglund resection.Level of evidenceLevel III, comparative series.     

六步手法联合体外冲击波治疗膝骨关节炎

目的：观察六步手法联合体外冲击波治疗膝骨关节炎的临床疗效。方法：2016年12月至2018年6月就诊的KOA患者76例,分为对照组和治疗组,每组各38例。对照组患者予口服药物结合体外冲击波疗法治疗,治疗组予六步手法联合冲击波疗法。分别比较两组治疗前及治疗后1 d、1个月及6个月VAS评分、WOMAC评分,以及临床疗效观察的变化。结果：两组患者治疗前VAS评分及WOMAC评分比较,差异均无统计学意义（P>0.05）;治疗后1 d及1、6个月,治疗组患者VAS评分及WOMAC评分较对照组均明显下降,差异有统计学意义（P<0.05）。结论：六步手法联合体外冲击波疗法,能明显缓解膝骨关节炎患者疼痛程度及改善膝关节功能,临床疗效较明显。     

Ultrasound-guided hyaluronic acid injection for the treatment of insertional Achilles tendinopathy: A prospective case series

BackgroundHeel pain is a common condition and often involves the Achilles tendon and is classified as insertional or non-insertional. Several operative and non-operative treatments have been described, but there is no consensus on the most effective therapy. The aim of this study is to evaluate a case series of patients with insertional Achilles tendinopathy refractory to conservative treatment submitted to a single-dose ultrasound-guided injection of hyaluronic acid (40 mg/2.0 mL).MethodsWe prospectively included 25 patients (29 feet) who underwent a single ultrasound-guided injection of hyaluronic acid after conservative treatment failure. Clinical outcomes such as pain (using the Visual Analog Scale – VAS), function (using the American Orthopedic Foot & Ankle Society – AOFAS score), personal satisfaction, and complications were evaluated. Statistical analysis was performed using the R software.ResultsMost patients were female (80%) and there was a right-side predominance (55%). The median VAS was 8 points [range 4–10] at baseline, decreasing to 3 points [range 0–8] at the six-month follow-up, with statistical significance (p < .001). The median AOFAS score was 71 points [range 38–87] at baseline, increasing to 90 points [range 48–100] at the six-month follow-up (p < .001). The personal satisfaction level was 69%, and 48% of patients considered the result excellent. There were no Achilles tendon ruptures, infections, or allergic reactions post injection.ConclusionSingle-dose injection of hyaluronic acid is a safe treatment option, improving function and reducing pain for six months in patients with insertional Achilles tendinopathy after conservative treatment failure.Level of evidenceIV, case series.     

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft

BackgroundTo determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up.MethodsWe reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications.ResultsMean follow-up period was 15 ± 3 months (range, 12–18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients’ mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes.ConclusionEndoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.     

Three-year followup study of topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy

BACKGROUND: Topical glyceryl trinitrate treatment has demonstrated short-term efficacy in chronic noninsertional Achilles tendinopathy. No long-term followup is reported. We aimed to assess if the demonstrated efficacy of this treatment persisted 3 years after discontinuation of therapy. METHODS: A follow-up study of 52 patients (68 tendons) treated with 6 months of glyceryl trinitrate therapy or placebo was performed 3 years after cessation of therapy. Assessment included pain scores, return to previous activity, the Victorian Institute of Sport Achilles tendon scale (VISA-A), asymptomatic patient outcomes, clinical assessment of tendon tenderness, and functional hop test. RESULTS: Patients treated with topical glyceryl trinitrate had significantly less Achilles tendon tenderness (p = 0.03), and improved VISA-A scores (p = 0.04) than those in the placebo group; 88% (28 of 32 tendons) of patients were completely asymptomatic at 3 years (VISA-A score of 100) compared to 67% (24 of 36 tendons) of patients treated with rehabilitation alone (p = 0.03 with Chi square analysis). Other outcome measures showed nonsignificant trends towards improvement in the glyceryl trinitrate group (pain scores p = 0.07, functional hop test p = 0.07, and return to sport p = 0.16). The mean estimated effect size for all outcome measures was 0.21. CONCLUSIONS: Topical glyceryl trinitrate treatment has demonstrated efficacy in treating chronic noninsertional Achilles tendinopathy, and the treatment benefits continue at 3 years. Significant differences in asymptomatic patient outcomes for the glyceryl trinitrate group continue at 3 years, and this is confirmed by the effect size estimate. This suggests that the mechanism of action of topical glyceryl trinitrate on chronic tendinopathies is more than an analgesic effect.