Comparison of patient characteristics and treatment approaches for femoral and inguinal hernias utilizing dynamic ultrasound at a single institution.

PURPOSE: To assess the differences in management approach to femoral versus inguinal hernias and to identify patient characteristics associated with each hernia type. METHODS: Imaging studies for patients who had undergone dynamic ultrasound evaluation for the symptom of groin pain between January 1, 2010, and March 31, 2019, at a single institution Musculoskeletal Department were analyzed. Positive femoral hernia imaging studies were compared to studies for inguinal hernias and matching medical records for imaging studies were analyzed. Association of patient characteristics (age, sex, smoking, diabetes) with hernia type was assessed. Primary outcomes were surgical versus non-surgical approach, type of surgery, number of follow-up visits, and pain resolution. RESULTS: A total of 1319 patients presented with groin pain and were assessed with dynamic ultrasound (534 female; 785 male; mean [± SD] age 48.2 ± 16.5). While 409 (31.0%) patients had a femoral hernia detected, 666 (50.6%) had an inguinal hernia detected (p < .05). Significantly more inguinal hernias were surgically repaired than femoral hernias (65.0% vs 53.9% p = .008), and more inguinal hernias than femoral hernias were treated with open surgery (71.0% vs 57.7%; p = .014). Patients with femoral hernias had significantly more follow-up clinic visits than patients with inguinal hernias (mean [± SD] 2.65 ± 4.80 vs 1.76 ± 1.27; p = .010). No difference in the percentage of patients who had pain resolution was observed (82.2% inguinal vs 75.0% femoral; p = .13). CONCLUSIONS: Femoral hernias were managed more conservatively than inguinal hernias at our institution.

[Value of US imaging of metacarpophalangeal joints in patients with early rheumatoid arthritis]. / Polyarthrite rhumatoïde débutante: apport de l'échographie des articulations métacarpophalangiennes.

Technological advances in the field of ultrasound imaging may have, especially in metacarpophalangeal joints, an impact on decision making in patients with early rheumatoid arthritis. First, the normal anatomy of the metacarpophalangeal joints is briefly reviewed. Then, the authors describe the main ultrasound imaging findings of early RA. The role of ultrasound imaging in the assessment of therapeutic response as well as the benefit of microbubble ultrasound contrast agents are considered.

US of soft-tissue foreign bodies and associated complications with surgical correlation.

Ultrasonography (US) allows detection of a variety of soft-tissue foreign bodies, including wood splinters, glass, metal, and plastic, along with evaluation of their associated soft-tissue complications. Cases were obtained from the authors' clinical experience over the past 1.5 years. Surgical correlation allowed confirmation of the presence of a foreign body and associated soft-tissue complications in all cases. All of the foreign bodies were echogenic when imaged with US. A surrounding hypoechoic rim and posterior acoustic shadowing or reverberation aided detection in several cases. Associated soft-tissue complications included a complete laceration of the posterior tibial tendon and septic flexor digitorum tenosynovitis. US allows accurate and efficient detection of radiolucent soft-tissue foreign bodies and aids assessment of their associated complications. For radiopaque foreign bodies, US can provide more precise localization and improved assessment of the surrounding soft tissues. US has emerged as the study of choice for detection and localization of radiolucent soft-tissue foreign bodies and can aid assessment of their associated complications.

Sonographic detection, evaluation and aspiration of infected acromioclavicular joints.

OBJECTIVE: To describe the sonographic findings of septic arthritis of the acromioclavicular joint. DESIGN AND PATIENTS: A retrospective study of five male patients was carried out. Four of the patients were referred because of signs and symptoms suggestive of glenohumeral joint septic arthritis, one for signs and symptoms suggestive of septic arthritis of the acromioclavicular joint. All the acromioclavicular joints were evaluated with ultrasound, aspirated and the aspirate cultured. RESULTS: All patients had normal ultrasound findings of their glenohumeral joints and distended acromioclavicular joints as determined by ultrasound. Ultrasound examination elicited focal tenderness over the acromioclavicular joint. Aspirates of each acromioclavicular joint grew pyogenic organisms. CONCLUSION: Infection in the acromioclavicular joint is uncommon, but is seen in increased frequency in immune-compromised patients and intravenous drug users. A normal glenohumeral joint on ultrasound in a patient suspected of having a septic shoulder should prompt careful review of the acromioclavicular joint. Aspiration of the acromioclavicular joint is easily performed under ultrasound guidance.

Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation.

PURPOSE: To determine the accuracy of the use of sonography for differentiation of full- from partial-thickness tears or tendinosis of the Achilles tendon by using surgical findings as the standard of reference and to identify sonographic characteristics of full-thickness tears that can be used to differentiate the two types of tears. MATERIALS AND METHODS: In part A of this study, sonographic findings (based on reports) in 26 consecutive cases of tears of the Achilles tendon were compared with surgical findings. In part B, the sonograms were blindly and retrospectively evaluated with respect to six sonographic characteristics possibly related to pathologic findings in the tendon, and the characteristics were correlated with surgical findings. RESULTS: In part A, statistical data regarding the use of sonographic findings to distinguish full- from partial-thickness tears were as follows: sensitivity, 100%; specificity, 83%; accuracy, 92%; positive predictive value, 88%; and negative predictive value, 100%. In part B, tendon thickness (P <.001), posterior acoustic shadowing (P =.007), and tendon retraction (P <.001) were correlated with full-thickness tears. Visualization of fat herniation (P =.051) and of the plantaris tendon (P =.098) demonstrated marginal correlation with full-thickness tears. Echogenicity at the site of the pathologic finding in the tendon showed no significant correlation. CONCLUSION: Sonography can be used to differentiate full- from partial-thickness tears or tendinosis of the Achilles tendon with 92% accuracy. Undetectable tendon at the site of injury, tendon retraction, and posterior acoustic shadowing demonstrate statistically significant correlation with full-thickness tears.

Sonographic detection of Baker's cysts: comparison with MR imaging.

OBJECTIVE: The objective of this study was to assess the ability of sonography to reveal Baker's cysts using MR imaging as a gold standard. MATERIALS AND METHODS: The study group consisted of 36 consecutive knees in 36 patients evaluated with both MR imaging and sonography. Inclusion criteria included axial proton density-weighted or T2-weighted MR images, a sonography report that documented the evaluation of the popliteal region of the knee, and sonographic and MR images that were available for review. The MR images were retrospectively reviewed for the presence of Baker's cyst (fluid signal between the semimembranosus and medial gastrocnemius tendons). Sonography reports were compared with the MR imaging results. The sonographic images were also retrospectively reviewed to determine whether any characteristic findings on sonography were significantly associated with the presence of Baker's cyst on MR imaging. RESULTS: Retrospective review of MR images revealed 21 Baker's cysts, one myxoid liposarcoma, one meniscal cyst, and 13 examinations with normal findings. The sonography reports revealed that the 21 Baker's cysts were correctly diagnosed, whereas the meniscal cyst and myxoid liposarcoma were misdiagnosed as Baker's cysts. Retrospective review of sonographic images showed a 100% sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in the diagnosis of Baker's cyst when hypoechoic or anechoic fluid was present between the semimembranosus and medial gastrocnemius tendons. No other sonographic characteristics were significant. CONCLUSION: Identification of fluid between the semimembranosus and medial gastrocnemius tendons in communication with a posterior knee cyst indicates Baker's cyst with 100% accuracy.

Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging.

OBJECTIVE: To demonstrate the MR depiction of the intertrochanteric or femoral neck extension of fractures of the greater trochanter, when standard radiographs show only a fracture of the greater trochanter. DESIGN AND PATIENTS: A retrospective review was performed of the MR and radiographic findings in 13 consecutive patients (10 men, 3 women; ages 24-86 years) with radiographic evidence of fracture of the greater trochanter who were examined with MR imaging. RESULTS: The MR study displayed the fracture of the greater trochanter in all cases. In all but three patients, MR examinations displayed an extension of the fracture into the intertrochanteric region, and in one, also an extension into the femoral neck, although the cortex at this level was not interrupted. CONCLUSION: When there is radiographic evidence of an isolated fracture of the greater trochanter, MR often shows an intertrochanteric or femoral neck extension of the fracture in both young and older adults. This finding may be a factor in determining the need for surgical intervention.

Sonography of Morton's neuromas.

OBJECTIVE: The objective is to evaluate the sonographic characteristics of Morton's neuromas and the usefulness of sonography in detecting them. MATERIALS AND METHODS: Thirty intermetatarsal spaces were evaluated with sonography to diagnose Morton's neuromas. The prospective sonographic reports were correlated with surgical and pathologic findings. Each sonogram was then blindly and retrospectively reviewed to characterize mass echotexture, location, size, and continuity with the plantar digital nerve when present. RESULTS: Surgery revealed 27 Morton's neuromas, one synovial cyst with infarcted tissue, one ganglion cyst, and one giant cell tumor of the tendon sheath. The prospective sonographic reports correctly identified neuromas in 85% of the cases. Retrospectively, 79.2% (19/24) of the neuromas were characterized as hypoechoic compared with muscle, whereas 12.5% (3/24) were of mixed echotexture and 8.3% (2/24) were anechoic. One half (50%) of the neuromas were located dorsal to the plantar aspect of the metatarsal heads, and 50% were both dorsal and plantar to this level. No statistical difference in height and width was found between neuromas and nonneuromas; however, nonneuromas were statistically greater in length than neuromas. All 15 masses in which presumed plantar digital nerve continuity with the mass was identified were neuromas. CONCLUSION: Sonography can reveal a Morton's neuroma in 85% of cases. Identification of the presumed plantar digital nerve in continuity with the mass improves diagnostic confidence. The finding of an interdigital mass greater than 20 mm in length should raise suspicion of an abnormality other than a neuroma.

Foot and ankle sonography.

Sonography of the foot and ankle offers many advantages. Currently, sonographic evaluation rivals or exceeds MR imaging for evaluation of tendons, joint and bursal pathology, and specific soft tissue pathology. The advantages of sonographic evaluation provide a strong impetus for applying this modality to imaging of foot and ankle pathology. Those who accept the challenge will have an expanded repertoire to offer in the pursuit of efficient and effective patient care.

Diagnosis of carpal tunnel syndrome. Ultrasound versus electromyography.

This article presents a new technique for diagnosing carpal tunnel syndrome using ultrasound. The ultrasound characteristics of the normal and abnormal median nerve are discussed in relation to carpal tunnel syndrome. The development of ultrasound as a new diagnostic modality for carpal tunnel syndrome is presented in a three-part study correlating the ultrasound measurements of the median nerve and electromyogram of the median nerve. A new algorithm for evaluating patients with carpal tunnel syndrome is presented.

Premature partial closure and other deformities of the growth plate: MR imaging and three-dimensional modeling.

PURPOSE: To examine growth plates of the distal femur and tibia with magnetic resonance (MR) imaging to detect bone bridges and other deformities in children. MATERIALS AND METHODS: Thirteen children (nine boys and four girls, aged 5-13 years; mean age, 9.8 years) were referred because of suspected or known bone bridging of the growth plate. Among the 13 patients, 10 had Salter-Harris fractures of the knee or ankle, two had Blount disease, and one had neonatal sepsis. Fat-saturated spoiled gradient-recalled images enabled reconstruction of a three-dimensional model of the growth plate. Patients underwent one to four MR examinations. RESULTS: Nine patients had bone bridging of less than 1% to 39% of the area of the growth plate. On MR images obtained in the growth plate of five patients, a stripe of low signal intensity indicated fracture. On MR images obtained in three patients, intrusions of growth plate cartilage into the metaphysis were seen to increase in depth over time. MR images obtained in four patients showed no bridges. In the two patients who underwent surgery, excellent correspondence was found between MR findings and surgical observations. CONCLUSION: Marked undulation or splitting of the growth plate may occur with fixation of some cartilage in the metaphysis or epiphysis while growth continues. The configuration of the growth plate and bone bridges can be accurately mapped with MR imaging. Treatment planning is facilitated.

Ultrasound diagnosis and surgical pathology of the torn interosseous membrane in forearm fractures/dislocations.

Ultrasound was used to effectively diagnose and precisely locate a torn interosseous membrane in 2 forearm fracture/dislocations. The ultrasound appearance of the torn interosseous membrane in cadavers and in the fractures/dislocations shows disruption of the anterior and posterior layers in midsubstance or adjacent to the radius or ulna. The surgical pathology in 3 forearm fractures/dislocations (2 Galeazzi injuries and 1 Essex-Lopresti injury) shows a longitudinal oblique tear of the interosseous membrane, parallel to its major palmar fibers, oriented from proximal radial to the distal ulnar. After ultrasound diagnosis, we demonstrated the feasibility of direct primary repair of the torn interosseous membrane associated with the Essex-Lopresti injury in a clinical case.

Longitudinal split of the peroneus longus and peroneus brevis tendons with disruption of the superior peroneal retinaculum.

Longitudinal split and subluxation of the peroneus brevis tendon have been reported in surgery literature, but few publications report on longitudinal tears of the peroneus longus tendon. The most likely proposed mechanism is a mechanical one. This report discusses the ultrasonographic appearance of peroneus longus and peroneus brevis tendon splits and the mechanism of injury.

The association between irregular greater tuberosities and rotator cuff tears: a sonographic study.

OBJECTIVE: Although an association between irregular greater tuberosities and rotator cuff tears has been suggested, no formal studies have been done. This study was designed to investigate the relationship between greater tuberosity irregularities, rotator cuff tears, and age. SUBJECTS AND METHODS: Sonographic examinations of both shoulders of 77 asymptomatic individuals (154 shoulders) between 30 and 80 years old were performed. The rotator cuffs and greater tuberosities were evaluated. Full- and partial-thickness rotator cuff tears were given equal significance. A two-tailed Fisher's exact test, a Student's t test, and logistic regression analysis were used to analyze the data. RESULTS: Sonography showed the greater tuberosity to be irregular in 36 (90%) of 40 shoulders with a rotator cuff tear. The greater tuberosity was irregular in only 12 (11%) of 114 shoulders without a rotator cuff tear. When the greater tuberosity was irregular, sonography showed 36 (75%) of 48 shoulders to have rotator cuff tears. When the greater tuberosity was normal, 102 (96%) of 106 of the rotator cuffs were normal on sonography. Statistical significance was detected (p < .001) for the association of greater tuberosity irregularity and rotator cuff tear. After accounting for age, a statistically significant association was found (p < .001) between rotator cuff status and greater tuberosity status. CONCLUSION: On sonography, greater tuberosity irregularities are reliable indicators in the assessment of shoulders for rotator cuff tears. In addition, we have shown that greater tuberosity irregularities are not simply related to aging.

Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: histologic correlation using a canine model.

OBJECTIVE: Ultrasound is thought to be clinically useful in evaluating bone formation through its presumed identification of fracture callus. However, documentation of the actual histology of the tissue identified by ultrasound has been lacking. The purpose of this study was to determine the histologic composition of the hyperechoic tissue "seen" by ultrasound. STUDY DESIGN: Unilateral fractures were created in eight canine tibias and then fixed by using locked intramedullary nailing without reaming. The limbs were studied at two, three, four, six, and eight weeks postoperatively with plain radiographs, ultrasound, and ultrasound-directed needle biopsy. RESULTS: The presence of a hyperechoic ultrasound signal was found to have a 100 percent correlation with the presence of hard fracture callus biopsy tissue. In addition, fracture union by ultrasound criteria significantly predated radiographic fracture union (5.6 vs. 7.3 weeks, p = 0.05). CONCLUSIONS: These results support and provide a scientific basis for the clinical use of ultrasound to assess tibial fracture healing following static interlocked nailing without reaming.

Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: clinical results.

OBJECTIVE: Based on the results of a pilot study indicating the potential value of ultrasound (US) as a diagnostic tool for the early assessment of fracture healing and the related need for secondary operative procedures in patients treated by statically locked intramedullary (IM) nailing without reaming, a protocol was established for a larger scale prospective trial. The purpose of this study was to evaluate the outcome of this follow-up trial. DESIGN/METHODS: All skeletally mature patients admitted to the Henry Ford Hospital (Detroit, Michigan) from January 1993 to August 1994 who had sustained an acute fracture of the tibial shaft and who were treated by statically locked IM nailing, without reaming, were candidates for study. Forty-seven patients with fifty fractures that could be evaluated by US were included. The adopted determinants for fracture healing were complete disappearance of the IM nail on US examination performed at six weeks postoperatively, or progressive disappearance of the nail noted between the initial six-week study and a second nine-week US examination, both in conjunction with periosteal callus formation. Radiographs were obtained to monitor maintenance of reduction and to further evaluate fracture healing. RESULTS: Of thirty-eight fractures with a positive US (thirty-two at six weeks, six at nine weeks), thirty-seven healed uneventfully, a positive predictive value of 97 percent. Radiographic fracture healing was not evident until, on average, nineteen weeks after injury. The single false-positive fracture progressed to nonunion. Of the twelve fractures with negative US studies, ten underwent secondary procedures (nine dynamization, one bone graft), with four progressing to nonunion. Two patients refused secondary surgery; screw failure occurred in both. Otherwise, there were no hardware failures in this series. CONCLUSIONS: The results of this study indicate that US may provide important prognostic information concerning fracture healing after unreamed tibial nailing, upon which subsequent treatment can be based.

Injection accuracy and clinical relief of de Quervain's tendinitis.

In a controlled, prospective, double-blind study, the incidence of accurate injection of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon compartments was defined and correlated with clinical relief of de Quervain's tendinitis. X-ray dye was included with steroid and lidocaine injections for 19 patients; dye location was immediately checked by 1 radiologist blinded to the clinical results. Dye was confirmed to be within the first dorsal compartment in 16 of 19 cases. There was relief of symptoms in 11 of 19 patients. Four of 5 patients with dye in both the APL and EPB tendon compartments, experienced relief of symptoms, while all 3 with dye in neither compartment experienced no relief. This suggests that accurate injection of steroids is required for relief of de Quervain's tendinitis. The EPB compartment was often missed (13/19 cases), possibly because it was separate or of small size and deep location. This may be a factor in failed injections, just as surgery can fail if a separate EPB compartment is not released.

US of the ankle: technique, anatomy, and diagnosis of pathologic conditions.

For specific indications, ultrasound (US) is an efficient and inexpensive alternative to magnetic resonance (MR) imaging for evaluation of the ankle. In addition to the tendons and tendon sheaths, other ankle structures demonstrated with US include the anterior joint space, retrocalcaneal bursa, ligaments, and plantar fascia. Ankle US allows detection of tenosynovitis and tendinitis, as well as partial and complete tendon tears. Joint effusions, intraarticular bodies, ganglion cysts, ligamentous tears, and plantar fasciitis can also be diagnosed. As pressure for cost containment continues, demand for US of the ankle may increase given its lower cost compared with that of MR imaging. In most cases, a focused ankle US examination can be performed more rapidly and efficiently than MR imaging. Familiarity with the technique of ankle US, normal US anatomy, and the US appearances of pathologic conditions will establish the role of US as an effective method of imaging the ankle.