Candy Closure Technique for Chronic Open Infective Lateral Malleolus Bursitis.

The aim of this study was to report the effectiveness of the Candy closure technique as a treatment for chronic open infective lateral malleolus bursitis. From June 2014 to March 2018, we performed the Candy closure technique as a treatment for chronic open infective lateral malleolus bursitis in nine patients without secondary operation. We first performed infectious tissue debridement to control infection, and if primary closure was not possible, we performed the Candy closure technique for small wounds. The duration of the wound prior to surgery varied from 4 weeks to 2 years. Seven cases were due to infection on the bursa and two cases were ulcer-type bursitis. All the wounds were small (average, 3.80 cm2; range, 2.25-4 cm2) and circular. Seven wounds showed complete healing at 4 weeks after surgery, one wound showed complete healing at 8 weeks after surgery, and one wound with infected state was lost to missing follow-up. Of the seven wounds that showed complete healing, one wound recurred 6 months after surgery. The Candy closure technique is a simple method for ensuring healing and coverage of chronic open lateral malleolus bursitis, especially for small wounds with dead space.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa.

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

Intra-rater and inter-rater reliability of the standardized ultrasound protocol for assessing subacromial structures.

BACKGROUND: US-examinations related to shoulder impingement (SI) often vary due to methodological differences, examiner positions, transducers, and recording parameters. Reliable US protocols for examination of different structures related to shoulder impingement are therefore needed. OBJECTIVES: To investigate the intra- and inter-rater reliability of the existing ultrasound (US) examinations of the subacromial space, the subacromial-subdeltoid bursa, and the supraspinatus tendon. METHOD: In a three-phased design, two physiotherapists using a standardized US protocol examined the thickness of the supraspinatus tendon (SUPRA) and subacromial subdeltoid (SASD) bursa in two imaging positions, and the acromial humeral distance (AHD) in one position. Additionally, agreement on dynamic impingement (DI) examination was performed. The intra- and inter-rater reliability was carried out on the same day. PARTICIPANTS: Forty-six sports active participants with a mean age of 37 years (range 18-57) participated. Twenty-two had SI and pain within previous week and 24 did not have SI or pain within previous week. RESULTS: Intra- and inter-rater reliability ICC (2,3) models were all above 0.80 (range 0.82-0.99) with no systematic bias (Bland Altman plots). For the DI examination, the overall agreement was 98% and 93%, with Kappa of 0.96 and 0.82, for intra- and inter-rater reliability, respectively. CONCLUSION: The reliability of the current standardized protocol for US examination of SI was excellent and considered feasible for clinical practice.

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.

The role of tendon and subacromial bursa in rotator cuff tear pain: a clinical and histopathological study.

PURPOSE: To evaluate a possible association of shoulder pain with the clinical features and the histopathological changes occurring in the ruptured tendon and subacromial bursa of patients with rotator cuff tear. METHODS: One hundred and eighty patients were clinically evaluated with the constant score and the visual analogue pain scale. Radiographs and MRI were performed. The chronology of the rupture, the muscle fatty degeneration according to Goutallier's scale and the tear size were evaluated. For each patient, a biopsy of the supraspinatus tendon and subacromial bursa was performed during arthroscopic rotator cuff tear repair and the specimens were histopathologically analysed. RESULTS: Clinically, the shoulder was more painful in females, in the presence of a chronic cuff lesion and a low Goutallier's grade (P < 0.05). No association was found between pain and age of the patient and between pain and tear size. Histologically, hypertrophy and inflammation of the tendon and hypertrophy, inflammation, oedema and necrosis of the subacromial bursa were directly associated with pain (P < 0.05). Pain decreased significantly in the presence of fatty metaplasia and necrosis of the tendon (P < 0.05). CONCLUSIONS: This study defines the main clinical and histopathological features of painful rotator cuff tear. In particular, a greater association of pain was observed with the histopathological changes in the bursa compared with those in the rotator cuff. Considering that the bursa plays also an essential role during the healing process, this "new" role of the subacromial bursa as pain generator has important repercussions in both pharmacological and surgical treatments of rotator cuff tears. LEVEL OF EVIDENCE: IV.

Olecranon extrabursal endoscopic bursectomy.

Olecranon bursitis is a common clinical problem. It is often managed conservatively because of the high rates of wound complications with the conventional open surgical technique. Conventional olecranon bursoscopy utilizes an arthroscope and an arthroscopic shaver, removing the bursa from inside-out. We describe an extrabursal endoscopic technique where the bursa is not entered but excised in its entirety under endoscopic vision. A satisfactory view is obtained with less morbidity than the open method, while still avoiding a wound over the sensitive point of the olecranon.

Evaluation of the current treatment concepts in Germany, Austria and Switzerland for acute traumatic lesions to the prepatellar and olecranon bursa.

BACKGROUND: Although traumatic lacerations of the olecranon (OB) and praepatellar bursae (PB) are common entities often associated with complications, no study could be found on this injury. The aim of this study was to survey the current treatment concepts for acute traumatic laceration of the OB and PB in Germany, Austria and Switzerland. MATERIALS AND METHODS: An international online survey was conducted among orthopaedic and trauma surgeons in Germany (TraumaNetwork DGU), Austria (Austrian Society of Trauma (ÖGU) and Orthopaedic (ÖGO) Surgeons) and Switzerland (Swiss Orthopaedic Surgeons and Swiss Society of Infectious Disease (CH)) (n=1967). The survey comprised of five demographical questions, the current treatment concepts were evaluated using a case study. RESULTS: The overall-response-rate was 16% (12-46%). 88% of the responding physicians were male, aged 47.5 ± 10.2 years with a mean working experience of 20.1 ± 10.6 years. 54% of the surveyed physicians were either senior or chief physicians. Treatment concepts varied significantly between DGU and ÖGO/CH (p=0.02/p=0.006), no significant differences could be found between DGU and ÖGU. Generally, German and Austrian trauma surgeons favoured bursectomy (86.7%/90.9%) and immobilisation (68.3%/77.3%). Austrian orthopaedic surgeons performed fewer bursectomies (69.3%) but had the highest proportion for administering antibiotics (73.9%). Less than 50% of Swiss physicians indicated bursectomy as a treatment option. CONCLUSION: Overall, this survey revealed a significant heterogeneity in treatment approaches in Central Europe. Further evidence is needed to identify the best treatment concepts for traumatic lacerations of the OB and PB.

A watertight construct in arthroscopic rotator cuff repair.

BACKGROUND: It is unknown which type of rotator cuff repair technique best isolates the healing zone interface from the synovial fluid environment. The purpose of this study was to determine the leakage area and pattern onto the rotator cuff footprint after 3 different rotator cuff repairs. MATERIALS AND METHODS: Six fresh frozen cadaveric glenohumeral joints in each of 3 groups were injected with gelatin to a pressure of 103 mm Hg (∼2 psi) after 1 of 3 different rotator cuff repairs of a supraspinatus tear: (1) single-row repair (SR), (2) knotless transosseous equivalent repair (KTE), and (3) traditional transosseous equivalent repair (TTE), which uses medial tied knots. Specimens were cycled in external rotation and abduction and were cooled to allow the gelatin to solidify. The supraspinatus was dissected off the footprint and photographs were taken. Scion Image (Frederick, MD, USA) was used to quantify the area. RESULTS: The average area of leakage was 1.09 cm(2) for the SR and 1.15 cm(2) for the KTE. The TTE did not demonstrate any leakage. The pattern of leakage for the KTE was medial and central on the footprint, whereas the SR demonstrated leakage up to the tied knots. The difference in the area of leakage in the SR and KTE compared with the TTE was statistically significant. There was no difference in area of leakage between the SR and KTE. CONCLUSION: A transosseous equivalent repair technique best prevents leakage onto the rotator cuff footprint compared with single-row and knotless repairs.

Clinical features of partial anterior bursal-sided supraspinatus tendon (PABST) lesions.

BACKGROUND: We characterized partial anterior and bursal supraspinatus tendon (PABST) lesions and compared their clinical features, postoperative functional scores, and healing rate with full-thickness rotator cuff tears (FTRCTs) and small FTRCTs. MATERIALS AND METHODS: There were 31 PABST lesions (6.2%), 392 FTRCTs, and 32 small FTRCTs among 495 shoulders with rotator cuff disorders. The mean patient age was 52.7 years in the PABST group, 60.1 years in the FTRCT group, and 56.9 years in the small FTRCT group. Functional and clinical variables were compared between the groups, and cuff healing was evaluated with computed tomography arthrography or ultrasonography. RESULTS: The mean patient age was statistically lower, the mean symptom duration was shorter, and trauma was more frequent in the PABST group compared with the FTRCT and small FTRCT groups. Coronal acromial spurs were found more frequently in the PABST group than in the FTRCT group. In all groups, range of motion, visual analog scale for pain, and functional scores improved continuously throughout the follow-up. There were 2 unhealed cuffs (10.5%) in the PABST group, 72 (35.6%) in the FTRCT group (P = .146), and 5 (25%) in the small FTRCT group (P = .238). CONCLUSIONS: We characterized PABST lesions that may be overlooked because of their peculiar location in the far anterolateral insertional section of the supraspinatus tendon at the bursal side. PABST lesions usually occur in younger patients, and trauma is frequently associated with acute symptom onset. Surgical treatment was effective for pain reduction and functional improvement.

Joint appendages: the structures which have historically been overlooked in arthritis research and therapy development.

Rheumatologists have largely conceptualised joint disease in inflammatory and degenerative arthritis in terms of bone, cartilage and the synovial lining, but have tended to overlook other integral components of the joints which are attached close to joint margins. We discuss these structures under the umbrella term of 'appendages'. These structures include ligaments, tendons, entheses or joint insertions, regional fibrocartilages, bursae and other peri-articular joint structures including fat pads and nails. In this review, we highlight how these structures play key pathophysiological roles in inflammatory arthritis and we emphasise how an understanding of these structures is collectively important for both clinical practice and future rheumatological research.

Arthroscopic footprint reconstruction of bursal-side delaminated rotator cuff tears using the suture-bridge technique.

For a bursal-side retracted laminated rotator cuff tear, simple repair of the retracted bursal-side rotator cuff might be insufficient because the repaired tendon could remain as an intratendinous tear of the rotator cuff. We present a repair method for intratendinous rotator cuff tears using the suture-bridge technique. We believe that this method helps to preserve the remnant rotator cuff tendon without tissue damage and restores the normal rotator cuff footprint in bursal-side delaminated rotator cuff tears.

Effects of a tetramethoxyhydroxyflavone p7f on the expression of inflammatory mediators in LPS-treated human synovial fibroblast and macrophage cells.

The inhibitory effects of 5,6,3',5'-tetramethoxy 7,4'-hydroxyflavone (labeled as p7F) were elucidated on the productions of proinflammatory cytokines as well as inflammatory mediators in human synovial fibroblasts and macrophage cells. p7F inhibited IL-1beta or TNF-alpha induced expressions of inflammatory mediators (ICAM-1, COX-2, and iNOS). p7F also inhibited LPS-induced productions of nitric oxide and prostaglandin E2 in RAW 264.7 cells. In order to investigate whether p7F would inhibit IL-1 signaling, p7F was added to the D10S Th2 cell line (which is responsive to only IL-1beta and thus proliferates), revealing that p7F inhibited IL-1beta-induced proliferation of D10S Th2 cells in a doseresponse manner. A flow cytometric analysis revealed that p7F reduced the intracellular level of free radical oxygen species in RAW 264.7 cells treated with hydrogen peroxide. p7F inhibited IkappaB degradation and NF-kappaB activation in macrophage cells treated with LPS, supporting that p7F could inhibit signaling mediated via toll-like receptor. Taken together, p7F has inhibitory effects on LPS-induced productions of inflammatory mediators on human synovial fibroblasts and macrophage cells and thus has the potential to be an antiinflammatory agent for inhibiting inflammatory responses.

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Adhesive capsulitis of the shoulder: the rate of manipulation following distension arthrogram.

To determine the rate of manipulation under anaesthesia (MUA) following distension arthrogram for adhesive capsulitis of the shoulder. Thirty-nine patients (42 shoulders) between 1998 and 2004 were treated with distension arthrogram for adhesive capsulitis diagnosed by the clinical picture of progressive pain and stiffness. Capsular disruption into the subscapular bursa was demonstrated in 40 of the 42 shoulders (95%). Thirty-seven of 42 (88%) shoulders were painfree following distension arthrogram. 15 of 42 (36%) shoulders underwent MUA following distension arthrogram for stiffness although 10 of these (67%) were painfree. Prior to distension arthrogram, the range of external rotation (ER) was no different between those that had MUA and those that did not (P = 0.36). The improvement in ER was 33% (P = 0.28) in those that had MUA and 50% (P = 0.001) in those that did not. The only complication was a vasovagal episode during the procedure. Distension arthrogram can be used as a therapeutic procedure for achieving symptomatic pain relief in the majority of adhesive capsulitis and decrease the rate of MUA of the shoulder.

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.

Adhesion of the subacromial bursa may cause subacromial impingement in patients with rotator cuff tears: pressure measurements in 18 patients.

In order to determine whether adhesion of the subacromial bursa leads to impingement, we measured the subacromial contact pressures before and after release of adhesion of this bursa. 18 shoulders with cuff tears and adhesion of the subacromial bursa were evaluated in 8 male and 10 female patients, of mean age 62 (53-71) years and who had no particular limitation of shoulder motion. We recorded subacromial pressures using a very sensitive film inserted under the acromion during surgery. In passive scapular plane elevation (scaption) at 100 degrees, the mean subacromial contact pressure and area declined from 1.43 (SD 0.23) MPa before release to 1.14 (SD 0.35) MPa after release (p < 0.001), and from 163 (SD 81) mm2 before release to 80 (SD 46) mm2 after release (p < 0.001), respectively. We suggest that adhesion of the subacromial bursa increases impingement between the acromion and the insertion of rotator cuff tendons.

Sonographic study of painful shoulder.

OBJECTIVE: To identify sonographically the site and entity of alterations in a high number of patients with shoulder pain. METHODS: Two different experienced operators (both rheumatologists), who were blinded to the clinical data, performed sonographic examinations on 528 shoulders of 425 consecutive patients with painful shoulder and in both shoulders of 198 control subjects. They carried out ultrasound examinations separately using a 7.5 MHz linear transducer. Investigation included the long head of the biceps tendon, the supraspinatus tendon, infraspinatus tendon, subscapularis tendon, acromioclavicular joint, glenohumeral joint, subacromial-subdeltoid bursa, subscapularis bursa, and finally identification of calcifications. Before the ultrasonographic exam, a third experienced rheumatologist performed a physical examination in all patients using specific tests of movement for evaluation of the long head of biceps tendon, the supraspinatus tendon, infraspinatus tendon, subscapularis tendon, and acromioclavicular joint. RESULTS: Sonographic alterations were found in a total of 94.1% of patients. The structure most frequently involved was the supraspinatus tendon (64.6%). The long head of the biceps tendon (48.1%) and the acromioclavicular joint (51.5%) were also frequently involved. Different types of alterations in the various structures were detected. Significant differences were found with respect to controls. A high sensitivity and specificity of sonography was demonstrated compared to physical examination. CONCLUSIONS: Sonography evaluates accurately the single anatomic structures of the shoulder and identifies both the site and type of changes in patients with painful shoulder. The high sensitivity/specificity, non-invasiveness and low costs of this technique justify its routine utilisation in clinical rheumatological practice.

Clinics in diagnostic imaging (77). Pes anserine bursitis.

Many cystic lesions occur around the knee and may produce overlapping clinical features, rendering the clinical diagnosis difficult. A 50-year-old woman presented with a soft tissue swelling on the medial aspect of her right knee. The diagnosis of pes anserine bursitis was made, based on typical MR imaging features. Cystic masses occurring in and around the knee, such as bursae and recesses, meniscal and ganglion cysts, and benign and malignant soft tissue masses that may mimic cysts, are classified and described. The role of MR imaging in making an accurate diagnosis and distinguishing among the various masses is discussed.