Patient-reported outcome and muscle-tendon pain after periacetabular osteotomy are related: 1-year follow-up in 82 patients with hip dysplasia.

Background and purpose - Larger prospective studies investigating periacetabular osteotomy (PAO) with patient-reported outcome measures developed for young patients are lacking. We investigated changes in patient-reported outcome (PRO), changes in muscle-tendon pain, and any associations between them from before to 1 year after PAO. Patients and methods - Outcome after PAO was investigated in 82 patients. PRO was investigated with the Copenhagen Hip and Groin Outcome Score (HAGOS). Muscle-tendon pain in the hip and groin region was identified with standardized clinical tests, and any associations between them were analyzed with multivariable linear regressions. Results - HAGOS subscales improved statistically significantly from before to 1 year after PAO with effect sizes ranging from medium to very large (0.66-1.37). Muscle-tendon pain in the hip and groin region showed a large decrease in prevalence from 74% (95% CI 64-83) before PAO to 35% (95% CI 25-47) 1 year after PAO. Statistically significant associations were observed between changes in HAGOS and change in the sum of muscle-tendon pain, ranging from -4.7 (95% CI -8.4 to -1.0) to -8.2 (95% CI -13 to -3.3) HAGOS points per extra painful entity across all subscales from before to 1 year after PAO. Interpretation - Patients with hip dysplasia experience medium to very large improvements in PRO 1 year after PAO, associated with decreased muscle-tendon pain. The understanding of hip dysplasia as solely a joint disease should be reconsidered since muscle-tendon pain seems to play an important role in relation to the outcome after PAO.

Does the physical activity profile change in patients with hip dysplasia from before to 1 year after periacetabular osteotomy?

Background and purpose - Knowledge of physical activity profiles among patients with hip dysplasia is lacking. We investigated whether patients with hip dysplasia change physical activity profile from before to 1 year after periacetabular osteotomy. Furthermore, we investigated associations between change in accelerometer-based physical activity and change in self-reported participation in preferred physical activities (PA). Patients and methods - Physical activity was objectively measured at very low to high intensity levels with accelerometer-based sensors. Subjectively, PA was recorded with Copenhagen Hip and Groin Outcome Score (HAGOS) in 77 patients. Associations between the 2 were analyzed with simple linear regression analyses. Results - Changes in accelerometer-based physical activity ranged from -2.2 to 4.0% points at all intensity levels from baseline to 1-year follow-up. These changes represent very small effect sizes (-0.16 to 0.14). In contrast, self-reported PA showed a statistically and clinically relevant increase of 22 (CI 14-29) HAGOS PA points 1 year post-surgery. Associations between change in accelerometer-based physical activity and change in self-reported PA were, however, not statistically significant and correspond to a percentage change in physical activity of only -0.87% to 0.65% for a change of 10 HAGOS PA points. Interpretation - Patients with hip dysplasia do not seem to change physical activity profile 1 year post-surgery if measured with objective accelerometer-based sensors. This is interesting as self-reported PA indicates that patients' ability to participate in physical activity increases, suggesting that this increased self-reported participatory capacity is not manifested as increased objectively measured physical activity.

Muscle-tendon-related abnormalities detected by ultrasonography are common in symptomatic hip dysplasia.

INTRODUCTION: Hip dysplasia is characterized by reduced acetabular coverage of the femoral head leading to an increased mechanical load on the hip joint and the acting hip muscles. Potentially, the muscles and tendons functioning close to the hip joint may present with overuse-related ultrasonography findings. The primary aim was to report the prevalence of muscle-tendon-related abnormalities detected by ultrasonography in 100 patients with symptomatic hip dysplasia. The secondary aim was to investigate correlations between muscle-tendon-related abnormalities detected by ultrasonography and clinically identified pain related to muscles and tendons. MATERIALS AND METHODS: One hundred patients (17 men) with a mean age of 29 ± 9 years were included. Muscle-tendon-related abnormalities were detected with a standardized ultrasound examination. Correlations between muscle-tendon-related abnormalities detected by ultrasonography and clinically identified pain related to muscles and tendons were tested with Spearman's rank correlation coefficient. RESULTS: The most prevalent ultrasonography findings were identified in the iliopsoas tendon [50% (95% CI 40; 60)], the adductor longus tendon [31% (95% 22; 40)] and the gluteus medius/minimus tendons [27% (18; 36)]. Significant correlations between ultrasonography findings and pain related to muscles and tendons were only found for the iliopsoas tendon (ρ = 0.24 and p = 0.02) and the gluteus medius/minimus tendons (ρ = 0.35 and p < 0.001). CONCLUSIONS: Muscle-tendon-related abnormalities detected by ultrasonography in the hip and groin region are common in patients with symptomatic hip dysplasia, and the ultrasonography findings of the iliopsoas and gluteus medius/minimus tendons are weakly to moderately correlated to pain related to muscles and tendons in these structures. Both the iliopsoas and the gluteus medius/minimus have a pronounced stabilizing role in the dysplastic hip joint, and the common muscle-tendon-related abnormalities in these patients may be caused by injuries related to excessive use or degenerative changes in the muscle-tendon tissue.

Long-Term Prognosis of Plantar Fasciitis: A 5- to 15-Year Follow-up Study of 174 Patients With Ultrasound Examination.

BACKGROUND: Plantar fasciitis (PF) affects 7% to 10% of the population. The long-term prognosis is unknown. PURPOSE: Our study had 4 aims: (1) to assess the long-term prognosis of PF, (2) to evaluate whether baseline characteristics (sex, body mass index, age, smoking status, physical work, exercise-induced symptoms, bilateral heel pain, fascia thickness, and presence of a heel spur) could predict long-term outcomes, (3) to assess the long-term ultrasound (US) development in the fascia, and (4) to assess whether US-guided corticosteroid injections induce atrophy of the heel fat pad. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: From 2001 to 2011 (baseline), 269 patients were diagnosed with PF based on symptoms and US. At follow-up (2016), all patients were invited to an interview regarding their medical history and for clinical and US re-examinations. Kaplan-Meier survival estimates were used to estimate the long-term prognosis, and a multiple Cox regression analysis was used for the prediction model. RESULTS: In all, 174 patients (91 women, 83 men) participated in the study. All were interviewed, and 137 underwent a US examination. The mean follow-up was 9.7 years from the onset of symptoms and 8.9 years from baseline. At follow-up, 54% of patients were asymptomatic (mean duration of symptoms, 725 days), and 46% still had symptoms. The risk of having PF was 80.5% after 1 year, 50.0% after 5 years, 45.6% after 10 years, and 44.0% after 15 years from the onset of symptoms. The risk was significantly greater for women (P < .01) and patients with bilateral pain (P < .01). Fascia thickness decreased significantly in both the asymptomatic and symptomatic groups (P < .01) from 6.9 mm and 6.7 mm, respectively, to 4.3 mm in both groups. Fascia thickness (P = .49) and presence of a heel spur (P = .88) at baseline had no impact on prognosis. At follow-up, fascia thickness and echogenicity had normalized in only 24% of the asymptomatic group. The mean fat pad thickness was 9.0 mm in patients who had received a US-guided corticosteroid injection and 9.4 mm in those who had not been given an injection (P = .66). CONCLUSION: The risk of having PF in this study was 45.6% at a mean 10 years after the onset of symptoms. The asymptomatic patients had PF for a mean 725 days. The prognosis was significantly worse for women and patients with bilateral pain. Fascia thickness decreased over time regardless of symptoms and had no impact on prognosis, and neither did the presence of a heel spur. Only 24% of asymptomatic patients had a normal fascia on US at long-term follow-up. A US-guided corticosteroid injection did not cause atrophy of the heel fat pad. Our observational study did not allow us to determine the efficacy of different treatment strategies.

Muscle-tendon-related pain in 100 patients with hip dysplasia: prevalence and associations with self-reported hip disability and muscle strength.

The primary aim was to identify muscle-tendon-related pain in 100 patients with hip dysplasia. The secondary aim was to test whether muscle-tendon-related pain is associated with self-reported hip disability and muscle strength in patient with hip dysplasia. One hundred patients (17 men) with a mean age of 29 years (SD 9) were included. Clinical entity approach was carried out to identify muscle-tendon-related pain. Associations between muscle-tendon-related pain and self-reported hip disability and muscle strength were tested with multiple regression analysis, including adjustments for age and gender. Self-reported hip disability was recorded with the Copenhagen Hip and Groin Outcome Score (HAGOS), and muscle strength was assessed with a handheld dynamometer. Iliopsoas- and abductor-related pain were most prevalent with prevalences of 56% (CI 46; 66) and 42% (CI 32; 52), respectively. Adductor-, hamstrings- and rectus abdominis-related pain were less common. There was a significant inverse linear association between muscle-tendon-related pain and self-reported hip disability ranging from -3.35 to - 7.51 HAGOS points in the adjusted analysis (P < 0.05). Besides the association between muscle-tendon-related pain and hip extension a significant inverse linear association between muscle-tendon-related pain and muscle strength was found ranging from -0.11 to - 0.12 Nm/kg in the adjusted analysis (P < 0.05). Muscle-tendon-related pain exists in about half of patients with hip dysplasia with a high prevalence of muscle-tendon-related pain in the iliopsoas and the hip abductors and affects patients' self-reported hip disability and muscle strength negatively.

No association between pseudotumors, high serum metal-ion levels and metal hypersensitivity in large-head metal-on-metal total hip arthroplasty at 5-7-year follow-up.

OBJECTIVE: The relationship between metal wear debris, pseudotumor formation and metal hypersensitivity is complex and not completely understood. The purpose of this study was to assess the prevalence of pseudotumor formation in a consecutive series of metal-on-metal (MoM) total hip arthroplasty (THA) and to investigate its relationship to serum metal-ion levels and hypersensitivity to metal. METHODS: Forty-one patients (31 males), mean age 52 (28-68) years, with a total of 49 large-head MoM THA participated in a 5-7-year follow-up study. Patients underwent ultrasonography, serum metal-ion concentrations were measured, metal allergy and atopic dermatitis were evaluated, and the questionnaires of the Oxford Hip Score (OHS), Harris Hip Score (HHS) and the Short-Form Health Survey (SF-36) were completed. RESULTS: Pseudotumors were found in eight patients, but they were asymptomatic and their serum metal-ion levels were similar to those observed in patients with no pseudotumors (p > 0.36). The capsule-stem distance of mean 8.6 mm (SD 3.82, 95% CI: 5.40-11.79) was wider (p = 0.02) in patients with pseudotumours than in patients without pseudotumors of mean 5.6 mm (SD 2.89, 95% CI: 4.68-6.58). Positive patch test reactions were seen in three patients. Higher serum metal-ion levels of chromium and cobalt were significantly correlated with steeper cup inclination and smaller femoral head sizes, and were associated with female gender (p < 0.04). CONCLUSION: We found no association between pseudotumor formation, serum metal-ion levels, metal patch test reactivity, and atopic dermatitis. However, clinicians should be aware of asymptomatic pseudotumors, and we advise further exploration into the mechanisms involved in the pathogenesis of pseudotumors.

The diagnostic and prognostic value of ultrasonography in soccer players with acute hamstring injuries.

BACKGROUND: An injury to the hamstring muscle complex is the most common injury in soccer. Ultrasound of acute hamstring injuries is often used as a clinical tool for diagnosing hamstring injuries and guiding players in when they can return to play. PURPOSE: To (1) investigate the characteristic sonographic findings of acute hamstring injuries in soccer players, (2) compare the mean injury severity (time to return to play) in injured players with and without sonographically verified abnormalities, and (3) correlate the length of the injured area and absence from soccer play (time to return to play) to investigate if ultrasonography can be used as a prognostic indicator of time to return to play. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Players from 50 teams participating in 1 of the top 5 Danish soccer divisions were followed in the period from January to December 2008. Of 67 players with acute hamstring injuries, 51 underwent ultrasonographic examination of the injured thigh and were included in this study. RESULTS: Ultrasonographic examinations were performed 1 to 10 days after injury (mean, 5.2 ± 3.0 days), and sonographic findings were present in 31 of 51 cases (61%). Two thirds of the injuries were to the biceps femoris muscle and one third to the semitendinosus muscle. No total ruptures were documented. The 51 acute hamstring injuries resulted in absence from soccer of a mean 25.4 ± 15.7 days per injury, with no significant difference between players with and without sonographically verified abnormalities (P = .41). No correlation existed between the length of the injured area and injury severity (r = 0.19, P = .29). CONCLUSION: The biceps femoris is the most commonly injured hamstring muscle detected by ultrasound, and more than half of the injuries are intramuscular. Because neither the presence of sonographic findings nor the size of the findings was correlated with time to return to play in injured soccer players, the prognosis of hamstring injuries should not be guided by these findings alone.

Animal-associated bacteria, Erysipelotrix rhusiopathiae, as the cause of infection in a total hip arthroplasty.

Invasive infection with animal-associated bacteria, Erysipelotrix rhusiopathiae, is unusual and has, to our knowledge, never been described as the cause of infected total hip arthroplasty. We describe how an infected total hip arthroplasty caused by these bacteria is eradicated using standard surgical and antibiotic treatment. Before 2-stage revision surgery, the patient had persistent groin pain, elevated C-reactive protein, radiographic periprosthetic osteolysis, excessive intra-articular fluid, and periprosthetic activity accumulation on the white cell scan. The patient was treated with benzylpenicillin after confirmed sensitivity of E rhusiopathiae diagnosed by culture of five tissue samples and polymerase chain reaction of the prosthetic sonicate sample. Sixteen weeks after the last stage of revision surgery, there were no signs of reoccurring infection.

What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?

BACKGROUND AND PURPOSE: An acetabular labral tear is a diagnostic challenge. Various clinical tests have been described, but little is known about their diagnostic sensitivity and specificity. We investigated the diagnostic validity of clinical tests and ultrasound as compared with MR arthrography. PATIENTS AND METHODS: We examined 18 patients (18 hips, 2 men, median age 43 (32-56) years) with impingement test, FABER test, resisted straight leg raise test, ultrasound, and MR arthrography. They had had previous periacetabular osteotomies due to symptomatic, acetabular dysplasia. All hips showed no or only slight signs of osteoarthritis (Tönnis grade 0-1). RESULTS: MR arthrography identified labral tears in 17 of the 18 hips. Ultrasound had a sensitivity of 94%, a positive predictive value of 94%, and was false negative in only 1 case compared to MR arthrography. The impingement test had the best diagnostic ability of the clinical tests, with a sensitivity of 59% and a specificity of 100%. The positive predictive value was 100% while the negative predictive value was 13%. INTERPRETATION: The impingement test is helpful in identifying acetabular labral tears. If this test is negative and if a labral tear is still suspected, ultrasound can reliably diagnose most tears of the acetabular labrum. MR arthrography is indicated in cases where ultrasound is negative, but the patient suffers continued, specific symptoms.

Can contrast-enhanced ultrasonography replace multidetector-computed tomography in the detection of liver metastases from colorectal cancer?

PURPOSE: To compare the sensitivity and specificity of contrast-enhanced ultrasonography (CEUS) and 4-slice multidetector-computed tomography (MDCT) in the detection of liver metastases in patients with colorectal cancer (CRC). MATERIALS AND METHODS: Candidates for this prospective study were 461 consecutive patients referred to the Department of Colorectal Surgery, Aarhus University Hospital with primary or local recurrence of CRC. The patients underwent liver ultrasonography (US), CEUS, MDCT and intraoperative ultrasonography (IOUS). Fine-needle biopsy was performed on all suspicious lesions. The examinations were interpreted blindly and the combination of US, CEUS, biphasic MDCT, IOUS, follow up and biopsy was the gold standard. RESULTS: Three hundred and sixty-five patients were included. All patients had undergone preoperative US, CEUS and MDCT and 65.5% had received IOUS. The gold standard found liver metastases in 54 patients (14.8%). Multidetector CT found significantly more metastases than CEUS in 15 (28%) of the patients (p=0.02). In a patient-by-patient analysis MDCT had a non-significantly higher sensitivity in the detection of liver metastases compared to CEUS (0.89 versus 0.80, p=0.06). The specificity of CEUS (0.98) was slightly better than that of MDCT (0.94) (p=0.02). CONCLUSION: Multidetector CT found significant more metastases than CEUS, and MDCT had in patient-by-patient analysis a non-significant better sensitivity (p=0.06) in detecting liver metastases in patients with CRC.

Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study.

BACKGROUND: A recent study published in The American Journal of Sports Medicine showed that asymptomatic soccer players with an increased risk of developing Achilles and patellar tendon injuries within the next 12 months can be identified with use of ultrasonography. HYPOTHESIS: Prophylactic eccentric training and stretching can reduce both the frequency of asymptomatic ultrasonographic changes in Achilles and patellar tendons in soccer players and the risk of these asymptomatic intratendinous changes becoming symptomatic. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Two hundred and nine Danish professional soccer players from the best national league (Super League) were followed over 12 months with use of ultrasonography and injury registration. Half the teams were randomized to an intervention group with prophylactic eccentric training and stretching of the Achilles and patellar tendons during the soccer season. RESULTS: The eccentric training and stretching did not reduce the injury risk, and, contrary to all expectations, the injury risk during the season was increased in players with abnormal patellar tendons at the beginning of the study in January. Eccentric training and stretching in players with normal patellar tendons significantly reduced the proportion of players with ultrasonographic changes in the patellar tendons at the end of the season (risk difference [RD] = 12%; 95% confidence interval [CI], 2%-22%; P = .02), but the training had no effect on the Achilles tendons (RD = 1%; 95% CI, -7% to 9%; P = .75). The presence of preseason ultrasonographic abnormalities in the tendons significantly increased the risk of developing tendon symptoms during the season (relative risk = 1.9; 95% CI, 1.2-3.1; P = .009). CONCLUSIONS: This study demonstrates that with the use of ultrasonography, tendon changes in soccer players can be diagnosed before they become symptomatic. The prophylactic eccentric training and stretching program reduces the risk of developing ultrasonographic abnormalities in the patellar tendons but has no positive effects on the risk of injury. On the contrary, in asymptomatic players with ultrasonographically abnormal patellar tendons, prophylactic eccentric training and stretching increased the injury risk.

The value of contrast enhanced ultrasonography in detection of liver metastases from colorectal cancer: a prospective double-blinded study.

OBJECTIVE: To compare sensitivity and specificity of contrast enhanced ultrasonography (CEUS) with conventional ultrasonography (US) in detection of liver metastases in patients with colorectal adenocarcinoma (CRC) in a patient-by-patient analysis. MATERIALS AND METHODS: A prospective study of 461 consecutive patients referred to the Department of Colorectal Surgery, Aarhus University Hospital with primary or local recurrence of CRC. In order to detect possible liver metastases all patients underwent liver US, followed by CEUS by another investigator. Multislice CT scanning (MDCT), and intraoperative ultrasonography (IOUS) were then performed. Fine-needle biopsy was performed on all suspicious lesions. Each examination was interpreted blindly and the combination of biphasic MDCT, IOUS, follow up and biopsy was the gold standard. RESULTS: Standard of reference found liver metastases in 54 patients (14.8%). Contrast enhanced ultrasonography improved the sensitivity significantly in detection of liver metastases from 0.69 by US to 0.80 (p=0.031). In 24 patients, CEUS found a higher number of metastases than US (p<0.001). The specificity (0.98) and the positive predictive value (0.86) was the same. CONCLUSION: Contrast enhanced ultrasonography improves sensitivity in detection of liver metastases in patients with CRC and in nearly half of the cases CEUS found a higher number of metastases than US.

Significance of ultrasonographically detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer players: a longitudinal study.

BACKGROUND: Chronic tendinosis of the Achilles or patellar tendons, or both, is one of the most frequent and severe conditions that affects athletes in sports such as soccer. It can often end an athlete's sports activity. HYPOTHESIS: Ultrasonography of asymptomatic tendons can be used to predict which athletes will develop tendon symptoms. STUDY DESIGN: Longitudinal study. METHODS: Using ultrasonography of the ankle and knee, we examined 54 elite soccer players in the top Danish soccer league before and after a single season (in January and December). RESULTS: At the start of the season, ultrasonography had revealed abnormalities in 29% of those examined. Eighteen percent (18 of 98 tendons) were observed to have abnormal sonographic findings in the patellar tendon at the initial examination in January. These athletes were found to have a 17% risk of developing symptomatic jumper's knee during the 12-month season. Eleven percent (11 of 96 tendons) were observed to have abnormal sonographic findings in the Achilles tendon at the initial examination; it was calculated that they had a 45% risk of developing symptoms of Achilles tendinosis. Only one of the players with normal tendons in January actually developed symptoms by the end of the season. CONCLUSIONS: For the first time it is now possible to identify risk factors for the development of serious tendon disorders in asymptomatic athletes. Future studies may be directed at developing preventive treatment to reduce the risk of chronic, therapy-resistant symptoms of tendinosis and ruptures.