肌肉骨骼超声在评估慢性足底筋膜炎中的临床应用

目的:观察肌肉骨骼超声在评估慢性足底筋膜炎中的临床应用。方法:应用肌肉骨骼超声对21例单侧足底筋膜炎患者进行足底筋膜厚度的评估,由一位有经验的超声医生分别对患侧和健侧的足底筋膜厚度进行测量,测量2次,时间间隔为2～3d。结果:应用肌肉骨骼超声测量健侧和患侧足底筋膜厚度重复性测量信度分别为0.92和0.87,对比健侧与患侧足底筋膜厚度,患侧明显高于健侧(P<0.05)。结论:肌肉骨骼超声可有效可靠地评估足底筋膜厚度,对于诊断慢性足底筋膜炎及评估治疗效果有着重要的意义。     

Sonoelastography of Plantar Fascia: Reproducibility and Pattern Description in Healthy Subjects and Symptomatic Subjects

The purpose of the work reported here was to describe the sonoelastographic appearance of the plantar fascia of healthy volunteers and patients with fasciitis. Twenty-three healthy subjects and 21 patients with plantar fasciitis were examined using B-mode and real-time sonoelastography (RTSR) scanning. B-Mode examination included fascia thickness and echotexture. Echogenicity and echovariation of the color histogram were analyzed. Fasciae were classified into type 1, blue (more elastic); type 2, blue/green (intermediate); or type 3, green (less elastic). RTSE revealed 72.7% of fasciae as type 2, with no significant association with fasciitis (χ² = 3.6, df = 2, p = 0.17). Quantitative analysis of the color histogram revealed a significantly greater intensity of green (mean = 77.8, 95% confidence interval [CI] = 71.9–83.6) and blue (mean = 74.2, 95% CI = 69.7–78.8) in healthy subjects. Echovariation of the color red was 33.4% higher in the fasciitis group than in the healthy group (95% CI = 16.7–50.1). Sonoelastography with quantitative analysis of echovariation can be a useful tool for evaluation of plantar fascia pathology.     

Contrast‐Enhanced Sonography for Monitoring Neoadjuvant Chemotherapy in Soft Tissue Sarcomas

Neoadjuvant chemotherapy is a mainstay in treating soft tissue sarcomas. Soft tissue sarcomas can show an increase in size and central necrosis, with a decrease in the viable tumor, as an initial response to neoadjuvant chemotherapy. Thus, the maximum tumor diameter may not reliably assess the response to this therapy. Contrast‐enhanced sonography may address this limitation. We evaluated 4 patients with soft tissue sarcomas by contrast‐enhanced sonography, performed concomitantly with conventional imaging (computed tomography, magnetic resonance imaging, or positron emission tomography). Quantitative analysis was also performed on 1 sarcoma. A viable, enhancing tumor versus tumor necrosis was nearly identical on contrast‐enhanced sonography and conventional imaging. Preliminary results demonstrate potential for contrast‐enhanced sonographic monitoring of soft tissue sarcomas during neoadjuvant chemotherapy.     

Echo-enhancing sonography of a large-vessel hemangioma of the neck.

Because of the slow flow in the venous spaces of large-vessel hemangiomas, demonstration of color flow signals with conventional color Doppler or power Doppler sonography may be difficult. We report the case of a 22-year-old female patient with a soft tissue tumor containing multiple fluid-filled spaces in the right supraclavicular region. Gray-scale, color, and power Doppler sonography could not differentiate between cystic lymphangioma and large-vessel hemangioma. The intravenous echo-enhancing contrast agent Levovist was administered, and a significant echo-enhancing effect on color and power Doppler imaging was demonstrated in the fluid-filled spaces and lasted for about 3 minutes. Histopathologic study of the excised tumor confirmed the sonographic diagnosis of hemangioma. Levovist appears useful in depicting slow flow in a large-vessel hemangioma.     

反向脉冲谐波超声造影显像评价肝恶性肿瘤介入治疗疗效

目的探讨反向脉冲谐波超声造影显像评价肝恶性肿瘤介入治疗疗效的临床应用价值.方法对10例接受介入治疗后的肝恶性肿瘤病灶进行反向脉冲谐波超声造影显像,观察病灶的血流灌注,并与造影前后病灶的彩色多普勒显像进行对照,超声检查后随访14～16个月.结果应用反向脉冲谐波超声造影显像,本组的10例介入治疗后肝肿瘤灶血流显示率(60%)较造影前(10%)提高,且高于彩色多普勒超声造影显像方式(40%).随访发现复发的4例中,反向脉冲谐波超声造影显像均可见血流信号(100%),彩色多普勒超声造影显像在2例中(50%)观察到血流信号,而造影前仅在1例中(25%)观察到血流信号.结论反向脉冲谐波超声造影显像对于评估肝恶性肿瘤介入治疗疗效较传统超声显像方法更可靠,并有望成为经皮介入治疗的有效辅助工具.     

Diagnosis and treatment of plantar fasciitis

Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.     

Analysis of contrast in images generated with transient acoustic radiation force

Several mechanical imaging methods are under investigation that use focused ultrasound (US) as a source of mechanical excitation. Images are then generated of the tissue response to this localized excitation. One such method, acoustic radiation force impulse (ARFI) imaging, utilizes a single US transducer on a commercial US system to transmit brief, high-energy, focused acoustic pulses to generate radiation force in tissue and correlation-based US methods to detect the resulting tissue displacements. Local displacements reflect relative mechanical properties of tissue. The resolution of these images is comparable with that of conventional B-mode imaging. The response of tissue to focused radiation force excitation is complex and depends upon tissue geometry, forcing function geometry (i.e., region of excitation, or ROE) and tissue mechanical and acoustic properties. Finite element method (FEM) simulations using an experimentally validated model and phantom experiments have been performed using varying systems, system configurations and tissue-mimicking phantoms to determine their impact on image quality. Image quality is assessed by lesion contrast. Due to the dynamic nature of ARFI excitation, lesion contrast is temporally-dependent. Contrast of spherical inclusions is highest immediately after force cessation, decreases with time postforce and then reverses, due to shear wave interaction with internal boundaries, differences in shear modulus between lesions and background and inertial effects. In images generated immediately after force cessation, contrast does not vary with applied force, increases with lesion stiffness and increases as the ROE size decreases relative to the size of the structure being imaged. These studies indicate that improved contrast in radiation force-generated images will be achieved as ROE size decreases; however, frame rate and thermal considerations present trade-offs with small ROE size.     

Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs

Background

Due to complexity of the plantar intrinsic foot muscles, little is known about their muscle architecture in vivo. Chronic plantar fasciitis may be accompanied by muscle atrophy of plantar intrinsic foot muscles and tibialis posterior compromising the dynamic support of the foot prolonging the injury. Magnetic resonance images of the foot may be digitized to quantify muscle architecture. The first purpose of this study was to estimate in vivo the volume and distribution of healthy plantar intrinsic foot muscles. The second purpose was to determine whether chronic plantar fasciitis is accompanied by atrophy of plantar intrinsic foot muscles and tibialis posterior.

Methods

Magnetic resonance images were taken bilaterally in eight subjects with unilateral plantar fasciitis. Muscle perimeters were digitally outlined and muscle signal intensity thresholds were determined for each image for volume computation.

Findings

The mean volume of contractile tissue in healthy plantar intrinsic foot muscles was 113.3 cm³. Forefoot volumes of plantar fasciitis plantar intrinsic foot muscles were 5.2% smaller than healthy feet (P = 0.03, ES = 0.26), but rearfoot (P = 0.26, ES = 0.08) and total foot volumes (P = 0.07) were similar. No differences were observed in tibialis posterior size.

Interpretations

While the total volume of plantar intrinsic foot muscles was similar in healthy and plantar fasciitis feet, atrophy of the forefoot plantar intrinsic foot muscles may contribute to plantar fasciitis by destabilizing the medial longitudinal arch. These results suggest that magnetic resonance imaging measures may be useful in understanding the etiology and rehabilitation of chronic plantar fasciitis.     

In vitro Model Test and Preliminary Clinical Application of a New Method of Ultrasonographic Imaging: Vascular Enhancement Technology

Vascular enhancement technology (VET) is a new form of ultrasonographic technology that can optimize images by enhancing the B-mode display with information derived from power Doppler. We designed an in vitro model to evaluate the accuracy and application method of VET and to apply this technology preliminarily in vivo in the vascular periphery. An in vitro model was designed with a flow pump system to simulate blood flow in soft tissue and the intracranial vasculature. Modeling vessels were imaged by traditional B mode, color Doppler flow imaging and VET. The diameter of the various silicon tubes was measured to verify the accuracy of VET. For in vivo application, 15 normal subjects and 26 patients suspected of having carotid artery plaques and cerebrovascular disease were examined using these three image modes. The imaging effects were observed and compared. VET imaging could clarify the lumens of the modeling vessels and reduce artifacts. The caliber of three sizes of silicon tubing was also measured accurately by VET. Of 15 normal subjects, sound artifacts in large vessels were inhibited and the intermedia membrane was clearly displayed by VET. The boundaries of carotid plaques were manifested by VET with well-defined edges. Three cases of hypoechoic soft plaque on the anterior wall missed in B-mode imaging were detected by VET. Intracranial scanning with VET identified cerebral vascular disease, including cerebral stenosis, arteriovenous malformations and aneurysms. The size and shape of the focus displayed by VET coincided with that observed using digital subtraction arteriography. VET is helpful in improving detection of the boundary of vessels and visualization of the microvasculature. (E-mail: duanyy@fmmu.edu.cn)     

Modern Concepts of the Diagnosis and Treatment of Necrotizing Fasciitis

Background: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. Objectives: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. Discussion: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. Conclusion: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.     

Detection of bleeding in injured femoral arteries with contrast-enhanced sonography.

OBJECTIVE: The purpose of this study was to investigate the feasibility of detecting acute arterial bleeding by means of contrast-enhanced sonography. METHODS: Puncture injury was produced transcutaneously with an 18-gauge needle in 26 femoral arteries (13 in the control group and 13 in the contrast-enhanced group) of rabbits. A sonographic contrast agent (Optison; Mallinckrodt Inc, St Louis, MO) was administered intravenously at a dose of 0.06 to 0.07 mL/kg. Sonography of the femoral arteries was performed before and after injury, both before and after injection of Optison, with B-mode imaging, color Doppler imaging, and pulse inversion harmonic imaging (PIHI). RESULTS: The specific location of active bleeding could not be visualized in B-mode and PIHI scans in the control group (no Optison injection). After administration of Optison, the bleeding site was visualized because of the increased echogenicity of the extravasated blood at the puncture site in both B-mode imaging and PIHI. In color Doppler images, bleeding sites were localized successfully in 84.6% of the cases in the presence of Optison and in 30.8% of the cases without Optison. Histologic examination (light microscopy) of the hematoma confirmed the presence of contrast agent microbubbles in the extravascular space surrounding the artery. CONCLUSIONS: Contrast-enhanced sonography may provide an effective method for detecting arterial bleeding.     

Characterization of a linear streak artifact with pulse inversion tissue harmonics in musculoskeletal sonography.

OBJECTIVE: To understand a linear artifact that projects deep to reflective structures that move rapidly while using tissue harmonic imaging with pulse inversion (PI) sonography. We hypothesize that this artifact is due to a cancellation error between firings in PI imaging, and it is, therefore, similar in generation to the twinkling artifact in color Doppler sonography. This artifact could be studied with the use of surfaces of different roughness to represent different rates of motion, in which roughness corresponds to spatial fluctuations in surface height. Given very slight variations in beam focusing as occurs with sonographic imaging arrays, these spatial fluctuations translate into temporal fluctuations in the received signal as would occur with tissue motion. METHODS: We scanned 4 different sandpaper grits and a smooth surface through a water path using fundamental and PI mode, 1- and 2-pulse techniques, respectively. The sandpaper and the smooth surface were scanned through a water path at mechanical indices of 0.1 to 0.7. Four independent images were subtracted pairwise to remove nonfluctuating signals. These noise pixels were counted and analyzed. RESULTS: Analysis of variance showed that the noise generated behind the different surfaces was highly significantly different. Two-tailed t tests generally showed significant differences in the quantity of noise between fundamental and harmonic imaging behind the roughest 3 grades of sandpaper. A multiple regression model showed significantly greater slopes for harmonic imaging for all grades of sandpaper and the smooth surface. CONCLUSIONS: The noise and, by extension, the linear streak artifact in musculoskeletal imaging are dependent on the mechanical index and are functions of sandpaper roughness. This would be equivalent to a subtraction error between 2 firings due to soft tissue motion, and the artifact may be a way to identify rapid soft tissue motion in PI images.     

二次谐波成像评价肝癌血液灌注的初步研究

为评价二次谐波成像在反映肝脏血流灌注的价值，我们观察了９例肝癌患者的二次谐波成像特点。先行基波成像和ＣｏｌｏｒＤｏｐｐｌｅｒ（ＣＤ）成像。经外周静脉注射微气泡型声学造影剂后用１．８／３．６ＭＨｚ（ＨＰ５５００）或１．７／３．４ＭＨｚ（ＡＴＬ－ＨＤＩ５０００）行二次谐波成像。造影后二次谐波Ｄｏｐｐｌｅｒ成像（ＳＨＤＩ），所有病例彩色血流信号均明显增加，尤以正常区增加明显。二次谐波灰阶成像可见病灶周边和部分病灶内的血管，比ＣＤ显示更多血管。结论：二次谐波成像提高了血管显示能力，丰富了超声反映肝内病变特征的手段     

Objective measurements of image quality

Tissue harmonic imaging (THI) and compound imaging have been reported clinically to improve contrast resolution, tissue differentiation and overall image quality. However, there have been limited studies to date to quantify objectively the improvements in image quality achieved with these new imaging techniques. The aim of this study was to quantify differences in image quality that exist between conventional B-mode imaging, harmonic imaging, compound imaging and harmonic compound imaging. An ATL HDI 5000 scanner with three probes (C5-2, L7-4 and L12-5) was tested with two different types of test object, the Gammex-RMI model 404 GS LE and the Gammex-RMI 403 GS LE. The measurement limitations associated with subjective analysis methods were not present in this study because an automated image analysis program was used to determine the image quality parameters. Therefore, subtle differences between the four imaging modes could be detected. Significant improvements in lateral resolution and slice thickness as a function of depth were found with THI. Contrast resolution and anechoic target detection improved with compound imaging, and harmonic compound imaging improved lateral resolution, slice thickness as a function of depth and contrast resolution.     

结节性筋膜炎的超声表现及误诊分析

目的探讨结节性筋膜炎二维及彩色多普勒超声声像图特点,分析超声误诊原因。方法回顾性分析53例经手术和病理证实的结节性筋膜炎患者的术前超声声像图表现,并归纳总结结节性筋膜炎的临床及超声病理特征。结果 53例结节性筋膜炎超声表现为单发圆形或类圆形结节,浅分叶状;43例为低回声,部分夹杂中高回声结构,8例为中等回声,2例为高回声;边界清楚或欠清楚,无明显包膜;53例结节后方回声均无衰减,50例结节后方回声增强;活动度好,与皮肤无粘连;CDFI:20例结节内部及周边未见明显血流,adler分级0级,33例结节内部或周边可测及血流信号,adler分级Ⅰ级18例,Ⅱ级15例,脉冲多普勒显示为动脉血流。其中病变累及皮下脂肪层45例,累及肌肉筋膜6例,累及血管2例。超声提示皮下结节44例(83%,44/54),超声误诊9例(17%,9/54,脂肪瘤5例,淋巴结2例,血管瘤2例)。结论结节性筋膜炎超声声像图有一定的特征性,彩色多普勒超声对结节性筋膜炎的诊断及鉴别诊断具有重要的临床价值。     

Customized heel pads and soft orthotics to treat heel pain and plantar fasciitis

We describe the design of a new cost-effective, comfortable orthotic designed to treat heel pain associated with plantar fasciitis. The heel pad is fabricated from a 4 degrees Sorbothane medial wedge with a customized insertion of low-density Plastazote. The orthotic is medium-density Plastazote reinforced with cork in the medial longitudinal arch. One pair of orthotics takes less than 1 hour to make. Pilot data were collected retrospectively to evaluate the efficacy of the orthotic for reducing pain. Ten clients at a hand and foot orthotic clinic with a mean age of 71+/-9.1 years and with unilateral or bilateral heel pain associated with plantar fasciitis were provided with customized heel pads and soft, molded orthotics at their initial visit. Pain levels were recorded with verbal and Likert-type scales. After 5 weeks of heel pad and orthotic use, all patients showed a reduction in pain, with the overall reduction being highly significant (P相似文献   

Use of ultrasonographic guidance in interventional musculoskeletal procedures: a review from a single institution.

We have evaluated the utility of ultrasonographic guidance for intervention in the musculoskeletal system. All interventional musculoskeletal procedures using ultrasonographic guidance performed at our institution from July 1998 through November 1999 were reviewed. Examinations were performed using either a linear or curved phased array transducer, based on depth and local geometry. The choice of needle was likewise optimized for specific anatomic conditions. One hundred ninety-five procedures were performed on 167 patients from July 1998 through November 1999. Thirty-one procedures had magnetic resonance correlation within 6 months beforehand. Excluding large-joint aspirations and injections, we found that 180 of the procedures were more readily performed using ultrasonography than any other imaging modality. These included therapeutic injections into tendon sheaths (biceps, flexor digitorum longus, posterior tibial, and iliopsoas), Morton's neuromas, plantar fascia, wrist ganglia, and tarsal tunnel cysts; peritendinous hamstring injections; and synovial cyst and muscle biopsies. In all cases, the target of interest was identified easily with ultrasonography, and needle position was documented readily. Also in all cases, aspiration or medication delivery to the site of interest was observed during real time and was documented on postprocedure images of the area. No significant complications (e.g., bleeding, infection, and neurovascular compromise) were encountered during or immediately after any procedure. Ultrasonography is a readily available imaging modality useful for guiding interventional procedures in the musculoskeletal system. The ability to document exact needle placement in real time confirms accurate placement of therapeutic injections, fluid aspiration, and soft tissue biopsies.     

Imaging local scatterer concentrations by the Nakagami statistical model

The ultrasonic B-mode image is an important clinical tool used to examine the internal structures of the biological tissue. Due to the fact that the conventional B-scans cannot fully reflect the nature of the tissue, some useful quantitative parameters have been applied to quantify the properties of the tissue. Among various possibilities, the Nakagami parameter was demonstrated to have an outstanding ability to detect the variation of the scatterer concentration. This study is aimed to develop a scatterer concentration image based on the Nakagami parameter map to assist in the B-mode image for tissue characterization. In particular, computer simulations are carried out to generate phantoms of different scatterer concentrations and echogenicity coefficients and their B-mode and Nakagami parametric images are compared to evaluate the performance of the Nakagami image in differentiating the properties of the scatterers. The simulated results show that the B-mode image would be affected by the system settings and user operations, whereas the Nakagami parametric image provides a comparatively consistent image result when different diagnosticians use different dynamic ranges and system gains. This is largely because the Nakagami image formation is only based on the backscattered statistics of the ultrasonic signals in local tissues. Such an imaging principle allows the Nakagami image to quantify the local scatterer concentrations in the tissue and to extract the backscattering information from the regions of the weaker echoes that may be lost in the B-mode image. These findings suggest that the Nakagami image can be combined with the use of the B-mode image simultaneously to visualize the tissue structures and the scatterer properties for a better medical diagnosis.     

Sonography in primary hyperparathyroidism: review with emphasis on scanning technique.

OBJECTIVE: To review the sonographic features and focused sonographic scanning techniques that may assist in the preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism. METHODS: The sonographic findings were reviewed in 54 of 58 consecutive patients with pathologically proven parathyroid adenomas. A systematic scanning approach including real-time gray scale, color and power Doppler, and graded compression gray scale imaging was used in all patients. RESULTS: Fifty-four (93%) of 58 proven adenomas were correctly identified by sonography. Gray scale imaging alone was sufficient for identifying 26 (100%) of 26 large (> or =1-cm) and 3 (11%) of 25 small (<1-cm) parathyroid adenomas. However, for 25 (89%) of 28 small adenomas, a combination of color and power Doppler and graded compression real-time gray scale imaging was required for sonographic localization and identification. CONCLUSIONS: Knowledge of typical locations and characteristic imaging features, as well as a systematic scanning approach, can result in accurate preoperative sonographic localization of parathyroid adenomas.