Clinical and sonographic evaluation of Endobutton distal biceps brachii tendon repair: what constitutes normal post-operative appearances?

OBJECTIVE: Distal biceps brachii tendon (DBBT) rupture is an uncommon but functionally significant injury given the loss of supination, flexion strength and pain that often result. Prompt surgical repair is preferred in most patients. Clinicoradiological post-operative follow-up is typically performed to assess DBBT repair integrity and function, frequently using ultrasound, though to date, no studies have described post-operative DBBT repair sonographic appearances. The purpose of this study was to evaluate post-operative DBBT sonographic appearances in the context of Endobutton repair with the following aims:i.Establish typical ultrasound appearances 12 months post-surgeryii.Establish the relationship between ultrasound appearances and clinical/functional outcomes. MATERIALS AND METHODS: Sixty patients between February 2016 and October 2017 undergoing DBBT repair were prospectively recruited, all undergoing clinical and sonographic assessment 12 months post-surgery. Ultrasound data was collected on tendon integrity, tendon calibre and presence of intratendinous calcification, peritendinous fluid and peritendinous soft tissue/scarring. Clinical data was collected on active range of motion (ROM) (flexion, extension, supination, pronation) and strength (flexion and supination). RESULTS: A total of 57/60 patients had intact DBBT repairs identified sonographically and clinically at 12 months. DBBT repairs had significantly increased cross-sectional area (mean 260%, 95% CI: 217%, 303%) compared with non-operated DBBT. Ninety-three percent of DBBT repairs were hypoechoic. Thirty percent contained intratendinous calcification. Peritendinous fluid/soft tissue was rarely observed. There was no significant correlation between DBBT calibre and strength/ROM parameters. CONCLUSION: Normal post-operative sonographic appearances of Endobutton DBBT repair comprise a hypoechoic tendon significantly increased in calibre compared with non-operated tendon ± intratendinous calcification. DBBT repair calibre varies greatly, but is not associated with any significant difference in strength/ROM.

Identifying atypical femoral fractures--a retrospective review.

Subtrochanteric atypical femoral fractures (AFFs) have been reported in patients on osteoporosis therapy (bisphosphonates and denosumab). In 2010, and again in 2013, the ASBMR AFF Task Force developed strict diagnostic criteria for AFFs. This is the first study using these criteria to define the prevalence of AFFs in Canada. This study is a retrospective review of all adult patients (April 2002-March 2013) with an ICD 10 code for hip, femoral or subtrochanteric fracture, from two referral hospitals in Alberta, Canada. All identified as isolated subtrochanteric fractures were further evaluated by chart review, prescription review and examination of radiographs. Of 349 subjects, 79 had isolated subtrochanteric fractures. Of the 70 cases of subtrochanteric fractures that were radiographically assessed (9 films unavailable), 41 fulfilled ASBMR 2013 AFF criteria. The remaining subjects had subtrochanteric fractures but did not meet the ASBMR criteria to qualify as AFFs. There were 11 AFFs in 2012/2013, giving a rate of AFFs of 1.42 per 100,000 50 + year adults, compared to a rate of 103.47 per 100,000 50+ year adults for typical hip fractures. Isolated subtrochanteric fractures are rare. They cannot reliably be identified by ICD coding alone. In this study, only 59 % of all isolated subtrochanteric/femoral shaft fractures fulfilled the ASBMR task force criteria for true AFFs. The rate of typical hip fractures was substantially higher than the rate of AFFs, defined by ASBMR diagnostic criteria.

Ultrasound-guided aspiration and injection of an intraneural ganglion cyst of the common peroneal nerve.

BACKGROUND: Intraneural ganglion cysts are rare, benign, mucinous lesions that occur within neural sheaths and are thought to involve cystic fluid exiting from nearby synovial joints. They often present as tender masses causing paresthesias in the distribution of the involved nerve, muscle weakness or cramping, or localized or referred pain. CASE DESCRIPTION: We present a case of a patient who initially presented with foot drop due to an intraneural ganglion cyst of the common peroneal nerve. This cyst was successfully treated using ultrasound guidance to aspirate the cyst and inject corticosteroid to prevent further inflammation. LITERATURE REVIEW: Standard of care has previously involved surgical resection, but this has been associated with a high frequency of recurrence. Due to the risks of nerve and vessel damage, there have been efforts to find alternative ways of resolving these cysts. PURPOSES AND CLINICAL RELEVANCE: Aspiration and injection of corticosteroid is a useful and minimally invasive alternative to surgery for managing intraneural ganglion cysts.

Tennis leg--a new variant of an old syndrome.

This syndrome, while common, is not well recognised in the rheumatology literature. We describe two cases, one classical and one unusual with ultrasound illustrations. The literature, from the original description in 1883, is reviewed with a focus on both the clinical and anatomical variants.

Systematic assessment of inflammation by magnetic resonance imaging in the posterior elements of the spine in ankylosing spondylitis.

OBJECTIVE: Magnetic resonance imaging (MRI) is sensitive for scoring inflammatory lesions in the spine, but attention has primarily focused on vertebral bodies, and no study has systematically examined the posterior elements. We aimed to systematically determine the frequency and distribution of inflammatory changes in the posterior elements of the spine using MRI, and to assess the reliability of their detection and their impact on discrimination of spinal MRI. METHODS: We scanned 32 patients recruited to placebo-controlled trials of anti-tumor necrosis factor therapy. Inflammatory lesions were detected by systematic review of consecutive sagittal STIR slices of the entire spine. Two readers evaluated pretreatment and posttreatment scans, blinded to treatment and time point. Inflammation was scored dichotomously (present/absent) in each posterior structure. Reproducibility was assessed by calculating random model variance components and generalizability coefficients, and discrimination by using Guyatt's effect size. RESULTS: Most patients (87.5%) had > or =1 lesion in the posterior elements (mean +/- SD number of affected spinal levels per patient 6.7 +/- 5.3), and they were detected most frequently in the thoracic spine. Interobserver reproducibility for total lesion count was very good to excellent for lesions in the thoracic spine and transverse and spinous processes. The addition of a simple dichotomous method for scoring posterior element inflammation substantially enhanced the discrimination observed using established MRI methods for scoring vertebral body inflammation. CONCLUSION: Inflammatory lesions in the posterior elements were present in the majority of patients with AS, and standard MRI protocols of the spine should be modified to ensure adequate visualization of posterolateral structures.

Noise exposure in orthopaedic practice: potential health risk.

Noise exposure is one of the major causes of permanent hearing loss in society. Exposure of health service staff to intense levels of noise in the workplace is a potential risk for the development of temporary and permanent hearing loss. In this prospective study, 18 members of the orthopaedic staff underwent hearing assessment by pure tone audiometry and speech discrimination prior to noise exposure at the workplace and immediately following cessation of work. The number of hours of exposure and noise levels in the workplace was also analysed. Only minimal temporary sensorineural threshold shifts were detected post-noise exposure. There was no change in speech discrimination scores and no individuals complained of tinnitus. The number of hours of exposure ranged from 1.5 to 8.5 hours (mean 5.2 hours). Recorded sound levels for instruments ranged from 119.6 dB at source to 73.1 decibels at 3 metres. Although high sound levels are recorded in the orthopaedic operating theatre, the intermittent nature exposure to the intense noise may protect staff against hearing loss, speech discrimination difficulties and tinnitus.