Systematik der Verletzungen von Rotatorenmanschette und Bizepssehne

Performance

Injuries of the rotator cuff and the biceps tendon demonstrate different patterns, which can be recognized clinically and radiologically.

Achievements

These patterns are impingement syndrome with additional trauma, isolated trauma of the rotator cuff and shoulder dislocation causing rotator cuff tears. Furthermore, it is clinically crucial to evaluate the extent of a rotator cuff injury.

Practical recommendation

Magnetic resonance imaging (MRI) is the modality of choice to differentiate these patterns.

     

Degree of tendon degeneration and stage of rotator cuff disease

Purpose

While tendon degeneration has been known to be an important cause of rotator cuff disease, few studies have objectively proven the association of tendon degeneration and rotator cuff disease. The purpose of this study was to investigate changes of tendon degeneration with respect to the stage of rotator cuff disease.

Methods

A total of 48 patients were included in the study: 12 with tendinopathy, 12 with a partial-thickness tear (pRCT), 12 with a full-thickness tear (fRCT), and 12 as the control. A full-thickness supraspinatus tendon sample was harvested en bloc from the middle portion between the lateral edge and the musculotendinous junction of the tendon using a biopsy punch with a diameter of 3 mm. Harvested samples were evaluated using a semi-quantitative grading scale with 7 parameters after haematoxylin and eosin staining.

Results

There was no significant difference in age, gender, symptom duration, and Kellgren-Lawrence grade between the groups except for the global fatty degeneration index. All of the seven parameters were significantly different between the groups and could be categorized as follows: early responders (fibre structure and arrangement), gradual responder (rounding of the nuclei), after-tear responders (cellularity, vascularity, and stainability), and late responder (hyalinization). The total degeneration scores were not significantly different between the control (6.08 ± 1.16) and tendinopathy (6.67 ± 1.83) (n.s.). However, the score of pRCT group (10.42 ± 1.31) was greater than that of tendinopathy (P < 0.001), and so was the score of fRCT (12.33 ± 1.15) than that of pRCT (p = 0.009).

Conclusion

This study showed that the degeneration of supraspinatus tendon increases as the stage of rotator cuff disease progresses from tendinopathy to pRCT, and then to fRCT. The degree of degeneration of tendinopathy was not different from that of normal but aged tendons, and significant tendon degeneration began from the stage of pRCT. The clinical relevance of the study is that strategies and goals of the treatment for rotator cuff disease should be specific to its stage, in order to prevent disease progression for tendinopathy and pRCT, as well to restore the structural integrity for fRCT.

Level of evidence

Diagnostic, Level I.

     

Real-time sonoelastography as novel follow-up method in Achilles tendon surgery

Purpose

To evaluate the sonoelastographic features of Achilles tendon healing after percutaneous treatment using real-time sonoelastography, a new tool able to quantify deformation in biological tissues.

Methods

Patients with atraumatic Achilles tendon ruptures, treated with a percutaneous technique, were assessed. Sonoelastographic evaluations were performed at the myotendinous junction, tendon body/lesion site and osteotendinous junction, both for the operated and contralateral side, at 40 days, 6 months and 1 year after surgery. Using standard regions of interest, the “strain index” (SI) was calculated as an indicator of tendon elasticity. Clinical outcomes were assessed by the ATRS questionnaire at 6 months and 1 year post-operatively and correlated with sonoelastographic findings. Sixty healthy tendons from 30 volunteers were used to provide a healthy control range.

Results

Twenty-five patients were recruited for this study. The SI in treated tendons showed progressive stiffening over time, especially at myotendinous junction and at the site of the sutured lesion, resulting in significantly higher stiffness than both the contralateral tendon and healthy volunteers. Peak thickness of treated tendons occurred at 6 months, with a tendency to reduce at 1 year, while never achieving a normal physiological state. Greatest remodelling was seen at the lesion site. The contralateral tendon showed significant thickening at the myotendinous and osteotendinous junctions. The SI of the contralateral tendon was found to be stiffer than physiological values found in the control group. ATRS score improved significantly between 6 months and 1 year, being negatively correlated with the SI (p < 0.001).

Conclusion

RTSE showed that operatively treated Achilles tendons become progressively stiffer during follow-up, while the ATRS score improved. From a biomechanical point of view, at 1 year after surgery Achilles tendons did not show a “restitutio ad integrum”. Real-time sonoelastography provides more qualitative and quantitative details in the diagnostics and follow-up of Achilles tendon conditions as the post-operative evolution of the repairing tissue.

Level of evidence

Diagnostic and therapeutic study, Level III.

     

Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe,efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up

Purpose

Although platelet-rich plasma (PRP) injection has shown controversial results for the treatment of Achilles tendinopathy, it remains the most used biological treatment. Recent findings seem to demonstrate that the stromal vascular fraction (SVF) within adipose tissue may counteract the impaired tendon homeostasis. The aim of this study was to prospectively compare the efficacy of PRP and SVF injection for the treatment of non-insertional Achilles tendinopathy.

Methods

Fourty-four patients were recruited in the study; 23 of them were assigned to the PRP group whereas 21 to the SVF group, treated unilaterally or bilaterally for a total of 28 tendons per group. All patients (age 18–55 years) were clinically assessed pre-operatively and at 15, 30, 60, 120 and 180 days from treatment, using the VAS pain scale, the VISA-A, the AOFAS Ankle-Hindfoot Score and the SF-36 form. The patients were also evaluated by ultrasound and magnetic resonance before treatment and after 4 (US only) and 6 months.

Results

Both treatments allowed for a significant improvement with respect to baseline. Comparing the two groups, VAS, AOFAS and VISA-A scored significantly better at 15 and 30 days in the SVF in comparison to PRP group (p?<?0.05). At the following time points the scores were not significantly different between the two groups. No correlation has been found between clinical and radiological findings.

Conclusions

Both PRP and SVF were safe, effective treatments for recalcitrant Achilles tendinopathy. The patients treated with SVF obtained faster results, thus suggesting that such a treatment should be taken into consideration for those patients who require an earlier return to daily activities or sport.

Level of evidence

Randomized Controlled Clinical Trial, Level 1.

     

Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side

Purpose

Vascularity of the subacromial bursa and rotator cuff tendons is key factors in the pathogenesis of subacromial bursitis and impingement syndrome, rotator cuff tendinitis, and rotator cuff tears. The purpose of this study was to investigate and describe blood supply to the cranial and caudal parts of the subacromial bursa and the vascularity of the rotator cuff tendons on the bursal side.

Methods

Fourteen fresh cadaveric shoulders from six females and eight males with a mean age of 71.7 (±10.8) years were studied. Before dissection, an arterial injection of 10% aqueous dispersion of latex was administered. Post-injection, the shoulders were fixed in an alcohol–formalin–glycerol solution.

Results

The cranial and caudal bursa of all specimens was mainly supplied by the thoracoacromial, suprascapular, and anterior and posterior circumflex humeral arteries. The cranial part of the bursa was supplied anteriorly by the thoracoacromial artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third. The caudal part received arterial blood anteriorly from the anterior circumflex humeral artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third of the caudal bursa. In addition, the suprascapular artery branched at the upper surface of the coracohumeral ligament, and the subcoracoid artery branched at the under surface of the same ligament.

Conclusion

The subacromial bursa appears well vascularized. The results of the present investigation showed that blood supply to the subacromial bursa at the caudal part and rotator cuff tendons on the bursal side was linked to the same arteries. The subcoracoid artery supplied interval rotator structures close to the caudal bursa. It is the wish of the authors that this meticulous anatomical work will help surgeons in their day-to-day clinical work, e.g. to minimize the risk of complications such as perioperative bleeding.

     

Functional rehabilitation of patients with acute Achilles tendon rupture: a meta-analysis of current evidence

Purpose

The optimal treatment for acute Achilles tendon rupture (ATR) is continuously debated. Recent studies have proposed that the choice of either operative or non-operative treatment may not be as important as rehabilitation, suggesting that functional rehabilitation should be preferred over traditional immobilization. The purpose of this meta-analysis of randomized controlled trials (RCTs) was to compare functional rehabilitation to immobilization in the treatment of ATR.

Method

This meta-analysis was conducted using the databases: PubMed, EMBASE, Rehabilitation and Sports Medicine Source, AMED, CINAHL, Cochrane Library and PEDro using the search terms: “Achilles tendon,” “rupture,” “mobilization” and “immobilization”. Seven RCTs involving 427 participants were eligible for inclusion, with a total of 211 participants treated with functional rehabilitation and 216 treated with immobilization.

Results

Re-rupture rate, other complications, strength, range of motion, duration of sick leave, return to sport and patient satisfaction were examined. There were no statistically significant differences between groups. A trend favoring functional rehabilitation was seen regarding the examined outcomes.

Conclusion

Functional rehabilitation after acute Achilles tendon rupture does not increase the rate of re-rupture or other complications. A trend toward earlier return to work and sport, and increased patient satisfaction was found when functional rehabilitation was used. The present literature is of low-to-average quality, and the basic constructs of the examined treatment and study protocols vary considerably. Larger, randomized controlled trials using validated outcome measures are needed to confirm the findings.

Level of evidence

II.

     

Clinical outcome of exercise therapy and early post-operative rehabilitation for treatment of neglected Achilles tendon rupture: a randomized study

Purpose

Treatment of neglected Achilles tendon rupture is very challenging. This randomized study aimed to compare the clinical outcome of early post-operative rehabilitation (EPR) with post-operative cast immobilization (PCI).

Methods

Fifty-seven patients with neglected Achilles tendon rupture were randomized to receive EPR (n = 26) or PCI (n = 31) management following surgery. Clinical outcome was monitored by follow-up at weeks 8, 12, 18 and 26 and year 2. The significance of intergroup differences from the Leppilahti scoring system (LSS), ultrasonography, multislice spiral computerized tomography (MSCT) and electromyography was assessed.

Results

Ultrasonography and MSCT revealed no occurrence of tendon elongation or adhesion. Four patients could perform sustained single-leg heel-raise exercise for 60 s at post-operative day 40. The PCI group also showed increased post-operative LSS score, but recovery was slower. Post-operative complications, such as ankle joint ankylosis and osteoporosis, only occurred in the PCI group.

Conclusions

Compared with cast immobilization, early post-operative rehabilitation results in better clinical outcome and faster overall tendon regeneration of neglected Achilles tendon rupture.

Level of evidence

II.

     

Preoperative and post-operative sleep quality evaluation in rotator cuff tear patients

Purpose

The aim of this study was to examine the potential relationship between subjective sleep quality and degree of pain in patients with rotator cuff repair.

Methods

Thirty-one patients who underwent rotator cuff repair prospectively completed the Pittsburgh Sleep Quality Index, the Western Ontario Rotator Cuff Index, and the Constant and Murley shoulder scores before surgery and at 6 months after surgery. Preoperative demographic, clinical, and radiologic parameters were also evaluated.

Results

The study analysed 31 patients with a median age of 61 years. There was a significant difference preoperatively versus post-operatively in terms of all PSQI global scores and subdivisions (p < 0.001). A statistically significant improvement was determined by the Western Ontario Rotator Cuff Scale and the Constant and Murley shoulder scores (p ? 0.001).

Conclusion

Sleep disorders are commonly seen in patients with rotator cuff tear, and after repair, there is an increase in the quality of sleep with a parallel improvement in shoulder functions. However, no statistically significant correlation was determined between arthroscopic procedures and the size of the tear and sleep quality. It is suggested that rotator cuff tear repair improves the quality of sleep and the quality of life.

Level of evidence

IV.

     

Excellent healing rates and patient satisfaction after arthroscopic repair of medium to large rotator cuff tears with a single-row technique augmented with bone marrow vents

Purpose

This study evaluated the repair integrity and patient clinical outcomes following arthroscopic rotator cuff repair of medium to large rotator cuff tears using a single-row technique consisting of medially based, triple-loaded anchors augmented with bone marrow vents in the rotator cuff footprint lateral to the repair.

Methods

This is a retrospective study of 52 patients (53 shoulders) comprising 36 males and 16 females with a median age of 62 (range 44–82) with more than 24-month follow-up, tears between 2 and 4 cm in the anterior–posterior dimension and utilizing triple-loaded anchors. Mann–Whitney test compared Western Ontario Rotator Cuff (WORC) outcome scores between patients with healed and re-torn cuff repairs. Multivariate logistic regression analysed association of variables with healing status and WORC score. Cuff integrity was assessed on MRI, read by a musculoskeletal fellowship-trained radiologist.

Results

Magnetic resonance imaging (MRI) demonstrated an intact repair in 48 of 53 shoulders (91%). The overall median WORC score was 95.7 (range 27.6–100.0). A significant difference in WORC scores were seen between patients with healed repairs 96.7 (range 56.7–100.0) compared with a re-tear 64.6 (27.6–73.8), p < 0.00056.

Conclusions

Arthroscopic repair of medium to large rotator cuff tears using a triple-loaded single-row repair augmented with bone marrow vents resulted in a 91% healing rate by MRI and excellent patient reported clinical outcomes comparable to similar reported results in the literature.

Level of evidence

IV.

     

Influence of patient and diagnostic parameters on reported retear rates after arthroscopic rotator cuff repair

Purpose

The purpose of this meta-analysis was to investigate patient and diagnostic parameters influencing the reported rates of recurrent rotator cuff defects after ARCR.

Methods

PubMed, EMBASE, Cochrane Library and Scopus databases were searched for clinical studies on tendon defects after ARCR. Imaging modalities, definitions, detection time points, and other known patient risk factors (patient age, tear severity, grade of fatty infiltration, repair technique) as well as reported defect rates were extracted. A meta-analysis of proportion and meta-regression analysis were used to investigate independent variables influencing reported defect rates.

Results

Of 109 articles reviewed, the diagnostic studies used magnetic resonance imaging (MRI) only (n?=?56), ultrasound (US) only (n?=?28), MRI or computed tomography (CT) arthrography (CTA, n?=?14) or a combination of US, MRI and CTA (n?=?11) up to 57 months after ARCR. Definitions of tendon defects were highly variable, including those of partial tendon healing with insufficient thickness defined as either an acceptable outcome (n?=?72) or a recurrent defect (n?=?22). Reported defect rates demonstrated highly significant heterogeneity between studies and groups. Follow-up time and the evaluation of partial tendon healing were independent factors of the defect rate alongside age, tear severity and repair technique. The type of imaging did not significantly alter defect rates.

Conclusion

A number of specific factors significantly alter the rates of rotator cuff defects reported after ARCR. Standardized protocols in clinical practice are required for consistent diagnosis of recurrent defects after ARCR.

Level of evidence

IV.

     

Preoperative NSAIDs,non-acute onset and long-standing symptoms predict inferior outcome at long-term follow-up after rotator cuff repair

Purpose

To evaluate mid- to long-term results after arthroscopic rotator cuff repair and to explore possible predictors of inferior outcome.

Methods

Patients treated for full-thickness supraspinatus and/or infraspinatus tears from 2004 to 2008, using a uniform single-row arthroscopic technique, were included in the study. Pre- and post-operative QuickDASH were used as the primary outcome measure, and VAS of pain, function and satisfaction were also collected. An additional questionnaire explored demographic and preoperative factors like onset and duration of symptoms, preoperative treatment and smoking habits.

Results

One hundred and forty-seven patients (82 %) were available at 6–9 years after surgery. All outcomes improved significantly from the preoperative values. A total of 8 % of patients had undergone additional surgery to the same shoulder during the follow-up period. Long-standing symptoms (>12 months) (P < 0.01), non-acute onset of symptoms (P < 0.01) and preoperative use of NSAIDs (P = 0.01) were correlated with inferior outcome at follow-up. No other factors investigated (i.e. gender, age, smoking and steroid injections) were found to affect the primary outcome (QuickDASH).

Conclusion

The current study is one of few reports of mid- to long-term outcomes after arthroscopic single-row repair of full-thickness rotator cuff tears. Global improvement in symptoms and function was found between the preoperative and the 6–9 years evaluation, and the technique therefore seems like a viable approach for treating tears of the supra- and the infraspinatus tendon. Several predictors of inferior long-term outcome after rotator cuff repair were, however, identified: preoperative use of NSAIDs, long-standing symptoms before surgery and non-acute onset of shoulder symptoms. In light of the current findings, accurate diagnosis and prompt treatment seem important in optimizing outcomes after rotator cuff surgery.

Level of evidence

IV.

     

C-arm flat-panel CT arthrography of the shoulder: Radiation dose considerations and preliminary data on diagnostic performance

Objectives

To investigate radiation dose and diagnostic performance of C-arm flat-panel CT (FPCT) versus standard multi-detector CT (MDCT) shoulder arthrography using MRI-arthrography as reference standard.

Methods

Radiation dose of two different FPCT acquisitions (5 and 20 s) and standard MDCT of the shoulder were assessed using phantoms and thermoluminescence dosimetry. FPCT arthrographies were performed in 34 patients (mean age 44?±?15 years). Different joint structures were quantitatively and qualitatively assessed by two independent radiologists. Inter-reader agreement and diagnostic performance were calculated.

Results

Effective radiation dose was markedly lower in FPCT 5 s (0.6 mSv) compared to MDCT (1.7 mSv) and FPCT 20 s (3.4 mSv). Contrast-to-noise ratios (CNRs) were significantly (p?<?0.05) higher in FPCT 20-s versus 5-s protocols. Inter-reader agreements of qualitative ratings ranged between к?=?0.47–1.0. Sensitivities for cartilage and rotator cuff pathologies were low for FPCT 5-s (40 % and 20 %) and moderate for FPCT 20-s protocols (75 % and 73 %). FPCT showed high sensitivity (81–86 % and 89–99 %) for bone and acromioclavicular-joint pathologies.

Conclusion

Using a 5-s protocol FPCT shoulder arthrography provides lower radiation dose compared to MDCT but poor sensitivity for cartilage and rotator cuff pathologies. FPCT 20-s protocol is moderately sensitive for cartilage and rotator cuff tendon pathology with markedly higher radiation dose compared to MDCT.

Key Points

? FPCT shoulder arthrography is feasible with fluoroscopy and CT in one workflow. ? A 5-s FPCT protocol applies a lower radiation dose than MDCT. ? A 20-s FPCT protocol is moderately sensitive for cartilage and tendon pathology.

     

Longer duration of operative time enhances healing metabolites and improves patient outcome after Achilles tendon rupture surgery

Purpose

The relationship between the duration of operative time (DOT), healing response and patient outcome has not been previously investigated. An enhanced healing response related to DOT may potentiate repair processes, especially in hypovascular and sparsely metabolized musculoskeletal tissues such as tendons. This study aimed to investigate the association between DOT and the metabolic healing response, patient-reported outcome and the rate of post-operative complications after acute Achilles tendon injury.

Methods

Observational cohort, cross-sectional study with observers blinded to patient grouping. A total of two-hundred and fifty-six prospectively randomized patients (210 men, 46 women; mean age 41 years) with an acute total Achilles tendon rupture all operated on with uniform anaesthetic and surgical technique were retrospectively assessed. At 2 weeks post-operatively, six metabolites were quantified using microdialysis. At 3, 6 and 12 months, patient-reported pain, walking ability and physical activity were examined using self-reported questionnaires, Achilles tendon total rupture score, foot and ankle outcome score and physical activity scale. At 12 months, functional outcome was assessed using the heel-rise test. Complications, such as deep venous thrombosis, infections and re-operations, were recorded throughout the study.

Results

Patients who underwent longer DOT exhibited higher levels of glutamate (p = 0.026) and glycerol (p = 0.023) at 2 weeks. At the 1-year follow-up, longer DOT was associated with significantly less loss in physical activity (p = 0.003), less pain (p = 0.009), less walking limitations (p = 0.022) and better functional outcome (p = 0.014). DOT did not significantly correlate with the rate of adverse events, such as deep venous thrombosis, infections or re-ruptures. Higher glutamate levels were associated with less loss in physical activity (p = 0.017). All correlations were confirmed by multiple linear regressions taking confounding factors into consideration.

Conclusion

The results from this study suggest a previously unknown mechanism, increased metabolic response associated with longer DOT, which may improve patient outcome after Achilles tendon rupture surgery. Allowing for a higher amount of traumatized tissue, as reflected by up-regulation of glycerol in patients with longer DOT, may prove to be an important surgical tip for stimulation of repair of hypometabolic soft tissue injuries, such as Achilles tendon ruptures.

Level of evidence

II.

     

Ruptured human Achilles tendon has elevated metabolic activity up to 1 year after repair

Purpose

Following Achilles tendon rupture, running is often allowed after 6 months. However, tendon healing is slow and the metabolic status of the tendon at this point is unknown. The purpose of this study was to investigate tendon metabolism (glucose uptake) and vascularization at 3, 6 and 12 months after Achilles tendon rupture as measured using PET and power Doppler ultrasonography (PDUS).

Methods

The study group comprised 23 patients with surgically repaired Achilles tendon rupture who were investigated at 3 months (n?=?7), 6 months (n?=?7) and 12 months (n?=?9) after surgery. The triceps surae complex was loaded over 20 min of slow treadmill walking while a radioactive tracer (¹⁸F-FDG) was administered prior to PET. Vascularization was measured in terms of PDUS flow activity, and patient-reported outcomes were scored using the Achilles tendon rupture score (ATRS) and sports assessment (VISA-A) questionnaire.

Results

Relative glucose uptake (¹⁸F-FDG) was higher in repaired tendons than in intact tendons at all time-points (6, 3 and 1.6 times higher at 3, 6 and 12 months, respectively; P?≤?0.001), and was also higher in the tendon core than in the periphery at 3 and 6 months (P?≤?0.02), but lower at 12 months (P?=?0.06). Relative glucose uptake was negatively related to ATRS at 6 months after repair (r?=??0.89, P?≤?0.01). PDUS flow activity was higher in repaired tendons than in intact tendons at 3 and 6 months (P?<?0.05 for both), but had normalized by 12 months.

Conclusion

These data demonstrate that the healing process as determined by metabolic activity and vascularization continues for 6 months after injury when large loads are typically allowed on the tendon. Indeed, metabolic activity remained elevated for more than 1 year after injury despite normalized vascularization. The robust negative correlation between tendon metabolism and patient-reported outcome suggests that a high metabolic activity 6 months after the injury may be related to a poor clinical healing outcome.

     

Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: a systematic review

Purpose

The optimum treatment strategy for the surgical management of partial-thickness rotator cuff tears (PTRCT) is evolving. In this study, two research questions were sought to be answered: “Does the repair technique for PTRCTs involving >50% of the tendon thickness have an effect on structural and functional outcomes of arthroscopic repair?” and “Is there a difference in outcomes of arthroscopically treated articular- and bursal-sided PTRCTs?”.

Methods

A systematic review according to the PRISMA statement was conducted to identify all literature published reporting on outcomes of arthroscopic treatment of PTRCTs classified with the Ellman classification with minimum 2-year follow-up. Prospective randomized trials were eligible for quantitative synthesis. A total of 19 studies, published between 1999 and 2015, met the inclusion criteria of this systematic review. Two studies reporting outcomes of articular-sided PTRCTs with prospective randomized study design were included in quantitative synthesis calculations.

Results

Arthroscopic repair of PTRCTs >50% thickness results in significant pain relief and good to excellent functional outcomes. When in situ repair was compared with repair of the tendon after completion to full-thickness RCT, there were no significant differences in functional or structural outcomes or complication rates. The best treatment method for low-grade PTRCTs remains unclear.

Conclusions

The repair technique (in situ repair versus repair of the tendon after completion to full-thickness RCT) did not significantly affect the outcomes for arthroscopic repair of PTRCTs >50% thickness. The current literature contains evidence for inferior outcomes and higher failure rates after arthroscopic debridement of bursal-sided compared to articular-sided PTRCTs, and some evidence suggests that repair of lower-grade bursal-sided tears may be beneficial over debridement.

Level of evidence

IV.

     

Ultrasound-guided dry needling with percutaneous paratenon decompression for chronic Achilles tendinopathy

Purpose

Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in management. In particular, due to the well-recognised surgical morbidity, treatment has steered towards less invasive routes. Previous studies have targeted pathology either inside or outside the tendon in isolation with varying results. This study aimed to target both pathological sites by combining dry needling with percutaneous hydrostatic decompression as a novel treatment.

Methods

Twenty-one patients with 26 chronic, non-insertional Achilles tendinopathy were prospectively enrolled. Ultrasound-guided dry needling of neovascular areas and small-volume hydrostatic paratenon decompression was performed 6-weekly. Sonographic assessment of tendon thickness and neovascularity was undertaken. Following treatment, a standardised physiotherapy regime was adopted. Visual analogue scores (VAS) were used as the primary outcome measure. Telephonic interviews were carried out 12 and 24 months post-treatment.

Results

Twenty-four tendons (in 19 patients) were successfully treated. The mean treatment session was 2. There was no significant change in neovascularity or tendon thickness. Therapeutic intervention led to a significant improvement in VAS at rest (42.4 ± 24.4 vs. 18.4 ± 26.0, p = 0.0005) and during activity (72.8 ± 16.0 vs. 33.7 ± 23.2, p < 0.0001). At 12 and 24 months, >75 % of patients were highly satisfied with their outcome with nearly half reporting complete resolution of their symptoms. >85 % were also able to return to their sporting interests.

Conclusion

Combined therapy of dry needling with percutaneous hydrostatic paratenon decompression under ultrasound guidance is a well-tolerated procedure with good short- and long-term pain and functional outcomes.

Level of evidence

Prospective case series, Level IV.

     

Quantitative ultrasound mapping of regional variations in shear wave speeds of the aging Achilles tendon

Objectives

Evaluate the effects of aging on healthy Achilles tendon and aponeurosis shear wave speed (SWS), a quantitative metric which reflects tissue elasticity.

Methods

Shear wave elastography was used to measure spatial variations in Achilles tendon SWS in healthy young (n?=?15, 25?±?4 years), middle-aged (n?=?10, 49?±?4 years) and older (n?=?10, 68?±?5 years) adults. SWS was separately measured in the free Achilles tendon, soleus aponeurosis and gastrocnemius aponeurosis in resting (R), stretched (dorsiflexed 15° from R) and slack (plantarflexed 15° from R) postures.

Results

SWS significantly increased with stretch and varied with age in all tendon regions. Slack free tendon SWS was significantly higher in older adults than young adults (p?=?0.025). However, stretched soleus aponeurosis SWS was significantly lower in older adults than young adults (p?=?0.01). Stretched gastrocnemius aponeurosis SWS was significantly lower in both middle-aged (p?=?0.003) and older (p?=?0.001) adults, relative to younger adults.

Conclusion

These results suggest that aging alters spatial variations in Achilles tendon elasticity, which could alter deformations within the triceps surae muscle–tendon units, thus affecting injury potential. The observed location- and posture-dependent variations highlight the importance of controlling ankle posture and imaging location when using shear wave approaches clinically to evaluate tendon disorders.

Key Points

? Shear wave elastography shows promise as a clinical quantitative ultrasound-based technique.? Aging induces location-dependent changes in Achilles tendon shear wave speed.? Spatial and postural dependence necessitates careful integration of this approach clinically.

     

Open surgical treatment for chronic midportion Achilles tendinopathy: faster recovery with the soleus fibres transfer technique

Purpose

The study aimed to compare two methods of open surgical treatment for midportion Achilles tendinopathy in sportsmen. A novel technique consisting in transferring some soleus fibres into the degenerated tendon to improve its vascularization and longitudinal tenotomies are evaluated and compared.

Methods

From 2006 to 2011, fifty-two competitive and noncompetitive athletes affected by midportion Achilles tendinopathy were surgically treated and prospectively evaluated at 6 months and at a final 4-year mean follow-up. Twenty patients had longitudinal tenotomies, and thirty-two had soleus fibres transfer. Clinical outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Time to return to walk and to run and tendon thickening were also recorded.

Results

Patients in the soleus transfer group had a higher increase in AOFAS and VISA-A score at 6 months and at the mean 4-year final follow-up (by 5.4 points, 95 % CI 2.9–7.9, p < 0.001 and by 5.7 points, 95 % CI 2.5–8.9, p = 0.001, for AOFAS and VISA, respectively). They also needed less time to return to run: 98.9 ± 17.4 days compared to 122.2 ± 26.3 days for the longitudinal tenotomies group (p = 0.0019). The soleus transfer group had a greater prevalence of tendon thickening (59.4 % compared to 30.0 % in the longitudinal tenotomies group, p = 0.037).

Conclusions

Open surgery for midportion Achilles tendinopathy is safe and effective in medium term. Despite similar outcomes in postoperative functional scores, soleus transfer allows a faster recovery but has a higher incidence of tendon thickening. These results should suggest the use of the soleus graft technique in high-level athletes.

Level of evidence

Prospective comparative study, Level II.

     

Validity and reliability of the Norwegian translation of the Achilles tendon Total Rupture Score

Purpose

Patient reported outcome measures (PROMs) are increasingly being used in clinical research. The Achilles tendon Total Rupture Score (ATRS) is a PROM designed to assess outcomes in patients with ruptures of the Achilles tendon. The aim of this study was to develop a Norwegian adaption of the ATRS and evaluate its validity and reliability.

Methods

The ATRS was translated into Norwegian in accordance with recommended guidelines. The study included 94 patients treated for Achilles tendon ruptures from January 2010 until February 2013, and the web-based questionnaires were administered twice. Reliability was assessed by Cronbach’s alpha, the intraclass correlation coefficient (ICC) and minimal detectable change (MDC). Construct validity was evaluated by calculating the Spearman’s correlation coefficient with the five subclasses of the Foot and Ankle Outcome Score (FAOS), the SF-36 subclass physical function and the SF-36 physical and mental summary scores.

Results

Both internal consistency (Cronbach’s alpha = 0.96) and test–retest reliability (ICC = 0.90) were excellent, and the MDC was 2.12 at the group level and 16.98 at the individual level. Construct validity was supported by Spearman’s correlation coefficients above 0.7 with the SF-36 subclass physical function and the SF-36 physical summary score as well as the FAOS subclasses Sport/Rec and quality of life. There was no floor effect, and 6 patients (6.4%) achieved a maximum score of 100.

Conclusions

The Norwegian adaption of the ATRS demonstrates acceptable validity and reliability for use in the Norwegian population to assess clinical outcomes in patients with Achilles tendon ruptures.