A radiographic and histologic evaluation of the patellar tendon after harvesting its central third.

Nineteen consecutive patients undergoing anterior cruciate ligament reconstruction using the central third of the ipsilateral patellar tendon were included in the study. Serial magnetic resonance images revealed that the donor-site gap in the tendon decreased with time (mean follow-up, 26 months). The thickness was significantly increased compared with the intact contralateral patellar tendon, regardless of when the magnetic resonance imaging was performed. Ultrasonography showed the same findings at a mean follow-up of 26 months. Histologic evaluation of the repair tissue in the central part of the tendon, as well as the tissue in the peripheral part of the patellar tendon at the donor site, revealed a significant increase in cellularity and vascularity as compared with normal control tendons. Thus, 2 years after the harvesting procedure, the patellar tendon displayed significant radiographic and histologic abnormalities. On the basis of these findings, reharvest of the patellar tendon, at least up to 2 years after primary harvest, cannot be recommended.

Observer reliability in the arthroscopic classification of osteoarthritis of the knee.

We studied 19 videotaped knee arthroscopies in 19 patients with mild to moderate osteoarthritis (OA) of the knee in order to compare the intraobserver and interobserver reliability and the patterns of disagreement between four orthopaedic surgeons. The classifications of OA of Collins, Outerbridge and the French Society of Arthroscopy were used. Intraobserver and interobserver agreements using kappa measures were 0.42 to 0.66 and 0.43 to 0.49, respectively. Only 6% to 8% of paired intraobserver classifications differed by more than one category. Observer-specific disagreement was evident both within and between observers. A small, but significant, occasional variation was also seen. Although reliability may improve by an analysis of disagreement, it appears that the arthroscopic grading of early osteoarthritic lesions is inexact.

Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment.

In a prospective, randomised, multicentre study, 112 patients (99 men and 13 women, aged between 21 and 63 years) with acute, complete rupture of tendo Achillis were allocated either to surgical treatment followed by early functional rehabilitation, using a brace, or to non-surgical treatment, with plaster splintage for eight weeks. The period of follow-up was for two years. Evaluation was undertaken by independent observers and comprised interviews, clinical measurements, isokinetic muscle performance tests, heel-raise tests and an overall outcome score. The rate of rerupture was 20.8% after non-surgical and 1.7% after surgical treatment (p < 0.001). Surgical and non-surgical treatment produced equally good functional results if complications were avoided. However, the rate of rerupture after non-surgical treatment was unacceptably high.

Tendon injury and repair after core biopsies in chronic Achilles tendinosis evaluated by serial magnetic resonance imaging.

OBJECTIVE: To evaluate the morphological response and healing process after transverse ultrasound guided core biopsies in chronic Achilles tendinosis using serial magnetic resonance imaging (MRI) over a period of one year. METHODS: The study included 10 patients. Six had five transverse core biopsies and were longitudinally evaluated by MRI before the biopsies and then after one week, three months, seven months, and one year. These patients started a three month eccentric training programme one to two weeks after the biopsy. Four "non-biopsied" and untreated patients were used for comparison. The clinical outcome was categorised according to the level of pain and performance. RESULTS: The MRI one week after the biopsies showed an increase in tendon volume (T1-WI) and mean signal intensity (PD-WI) of 29% and 30% (p = 0.04). During follow up, tendon volume and mean signal intensity gradually decreased. One year after the biopsy, the tendon volume had decreased by 20% and the intratendinous signal by 28% compared with the index MRI (p = 0.04). The untreated patients showed an increase in both tendon volume (39%, p = 0.06) and intratendinous signal (37%, p = 0.14) at the one year follow up. After one year, pain and performance had improved in the treated patients but not the untreated patients. CONCLUSION: Five transverse ultrasound guided core biopsies induced a lesion in the diseased Achilles tendon. Alterations during healing such as tendon size and intratendinous signal intensity could be evaluated by MRI. The tendon alterations had decreased one year after the core biopsies.

Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts.

The authors review the current knowledge on donor site-related problems after using different types of autografts for anterior cruciate ligament (ACL) reconstruction and make recommendations on minimizing late donor-site problems. Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for patients. The selection of graft, surgical technique, and rehabilitation program can affect the severity of pain that patients experience. The loss or disturbance of anterior sensitivity caused by intraoperative injury to the infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site discomfort and an inability to kneel and knee-walk. The patellar tendon at the donor site has significant clinical, radiographic, and histologic abnormalities 2 years after harvest of its central third. Donor-site discomfort correlates poorly with radiographic and histologic findings after the use of patellar tendon autografts. The use of hamstring tendon autografts appears to cause less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also appears to be a regrowth of the hamstring tendons within 2 years of the harvesting procedure. There is little known about the effect on the donor site of harvesting fascia lata and quadriceps tendon autografts. Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction using patellar tendon autografts. Reharvesting the patellar tendon cannot be recommended due to significant clinical, radiographic, and histologic abnormalities 2 years after harvesting its central third. It is important to regain full range of motion and strength after the use of any type of autograft to avoid future anterior knee problems. If randomized controlled trials show that the long-term laxity measurements following ACL reconstruction using hamstring tendon autografts are equal to those of patellar tendon autografts, we recommend the use of hamstring tendon autografts because there are fewer donor-site problems.

Etiology, histopathology, and outcome of surgery in achillodynia.

Fifty-eight patients suffering from achillodynia for a median of 12 months (range, 4-240 months) were analyzed using history, clinical findings, ultrasound findings, histopathology, and surgical outcome. Surgical criteria were daily pain or inability to perform sports activity and failure of nonoperative treatment. There were 34 men and 24 women, 31% (18 of 58 patients) of whom had no direct association with sports or vigorous physical activity. Ultrasonography was performed in all cases and showed low echogenous areas (N = 48), increased tendon diameter (N = 40), and/or peritendinous fluid (N = 11). Histopathological evaluation of tendon biopsies, obtained from regions showing pathology at surgery (N = 35), revealed altered fiber structure and arrangement, focal variations in cellularity, extracellular glycosaminoglycans, neovascularization, and/or hyalinization. In no case was inflammatory cell infiltration observed. At a median clinical follow-up of 25 months after surgery, symptoms were decreased in 86% of patients, and 76% had reached a higher activity level compared with the level before surgery. Complications occurred in 13% of operations. In conclusion, achillodynia is not always associated with excessive physical activity. Macroscopic pathologic tendons showed marked histopathologic changes, correlating well with ultrasound findings. Surgical treatment was beneficial in most cases, despite a relatively high complication rate. The etiology and reason for the lack of healing response to rest and nonoperative treatment are unclear.

Pathology of the Achilles tendon in association with ciprofloxacin treatment.

Achilles tendon pain or rupture after fluoroquionolone treatment has been described as an uncommon adverse effect. We report two patients with ciprofloxacin-associated Achilles tendon disease, one with histopathological examination. Microscopic evaluation showed irregular collagen fiber arrangement, hypercellularity, and increased interfibrillar glycosaminoglycans. These pathological features are also seen in tendon overuse injuries in athletes.

Intratendinous alterations as imaged by ultrasound and contrast medium-enhanced magnetic resonance in chronic achillodynia.

OBJECTIVES: We performed a comparative study of ultrasonography and gadolinium imaging contrast-enhanced T1-weighted magnetic resonance to evaluate tendon pathology in chronic Achilles tendon disorder. Another main issue was to evaluate the structural basis as defined by histopathology from hypoechoic compared with normoechoic areas within the same tendon. MATERIALS AND METHODS: Twenty patients (16 male, 4 females, median age 40 years) with chronic achillodynia participated in the study. Clinical examination revealed swelling and tenderness localized to the midportion of the Achilles tendon. Contrast medium-enhanced magnetic resonance imaging (CME-MRI) was performed in all patients. Ultrasonography-guided core biopsies were taken from regions with a clear widening of the tendon and a pathologic low-echo signal as well as from normoechoic areas. The specimens were analyzed with a standardized protocol giving a total tendon score (0-24), and a stereologic method for quantification of glycosaminoglycan (GAG)-rich areas. RESULTS: The volume of the intratendinous abnormality was larger in 13 of 20 when imaged by CME-MR (P < 0.05), whereas the shape and enlargement of the tendon per se were similarly imaged by ultrasound (US) and CME-MR. Tendon pathology as imaged by US was graded as severe from hypoechoic regions and moderate from normoechoic regions. The corresponding quantification of GAGs was 0.36 compared with 0.17, respectively (P < 0.001). CONCLUSION: CME-MR imaging revealed greater sensitivity in demonstrating intratendinous pathology than the ultrasound; this was documented by the larger size of the corresponding lesion and the fact that the pathology was occurring in areas that were considered normal by ultrasonography. US hypoechoic areas showed a markedly abnormal tendon structure including an increased amount of GAG-rich areas. However, moderate pathology was also found in the neighboring normoechogenous areas within the same tendon, indicating a more generalized disorder than depicted by echogenic properties.

Magnetic resonance signal, rather than tendon volume, correlates to pain and functional impairment in chronic Achilles tendinopathy.

PURPOSE: To depict abnormal tendon matrix composition using magnetic resonance imaging (MRI) in chronic Achilles tendinopathy, and correlate intratendinous signal alterations to pain and functional impairment. MATERIAL AND METHODS: MRI of the Achilles tendon was performed on 25 patients with chronic Achilles tendinopathy (median age 50, range 37-71 years). All patients suffered from pain in the mid-portion of the Achilles tendon. Intratendinous signal was calculated from five different sagittal sequences, using a computerized 3D seed-growing technique. Pain and functional impairment were evaluated using a questionnaire completed by patients. RESULTS: Severity of pain and functional impairment correlated to increased mean intratendinous signal in the painful tendon in all MR sequences (P < 0.05, median r = 0.38, range 0.28-0.43 for pain; P < 0.05, median r = 0.48, range 0.29-0.49 for functional impairment). However, tendon volume did not correlate to pain or functional impairment (P > 0.05). Difference in mean intratendinous signal between symptomatic and contralateral asymptomatic tendons was highly significant in all sequences (P < 0.05) except on T2-weighted images (P = 0.6). CONCLUSION: Severity of pain and disability correlated to increased MR signal rather than to tendon volume in patients with unilateral mid-portion chronic Achilles tendinopathy.

Increased expression of aggrecan and biglycan mRNA in Achilles tendinopathy.

OBJECTIVES: To determine the expression of mRNA encoding the proteoglycans aggrecan, versican, biglycan and decorin in mid-tendon samples of chronic painful Achilles tendinopathy and ruptured Achilles tendons, compared with normal tendons. METHODS: Total RNA isolated from frozen tendon samples (14 normal, 13 painful, 14 ruptured) was assayed by relative quantitative reverse transcription polymerase chain reaction for aggrecan, versican, biglycan and decorin mRNA, normalized using 18S rRNA. Differences between sample groups were tested by univariate analysis of variance with age as co-variate. RESULTS: In normal tendon samples expression of each of the proteoglycan mRNA decreased with increasing age. Decorin mRNA was the most highly-expressed of the proteoglycan mRNA, while versican mRNA expression was higher (3.8-fold) than that of aggrecan. In painful tendinopathy both aggrecan and biglycan mRNA expression increased (more than 10-fold and 5-fold, respectively) compared with normal tendon samples, but levels of versican and decorin mRNA were not significantly changed. In ruptured tendons the levels of aggrecan, biglycan and versican mRNA were not changed compared with normal tendon samples, but decorin mRNA decreased markedly. CONCLUSIONS: Increased aggrecan and biglycan mRNA expression in painful tendinopathy resembles the pattern in fibrocartilaginous regions of tendon, and may reflect an altered mechanical environment at the site of the lesion. Increased aggrecan mRNA expression may underlie the increase in glycosaminoglycan observed in painful tendinopathy.

Tendon tissue sampling.

Mechanical load is regarded as the most important etiologic factor in cumulative trauma disorders affecting human tendons. At present there is limited knowledge concerning adaptation and the influence of training on human tendon tissue and the time process of developing a chronic tendon disorder. Tendon tissue samples and data concerning tendon pathology and repair have been derived from biopsies removed during surgery for rupture or pain conditions and from autopsy material. The ultrasound-guided percutaneous core biopsy technique provides the possibility to obtain tendon tissue from human Achilles and patellar tendon with limited discomfort for the individual. The specimens can be used for diagnostic purposes or for research and have the potential to highlight novel knowledge in, for example, the early stages of painful human tendon disorders. The fact that the procedure is invasive is a limitation. Autopsy material has limitations regarding poor information on case history, post mortem alterations and legal regulations on the use of tissue for medical purposes. The inflammatory process quickly affects ruptured tendons. The subcutaneous tendons that sustain a rupture are commonly characterized by degenerative alterations. Many tendon ruptures are treated with surgery, facilitating easy access to biopsy material. In summary, tendon tissue sampling in humans has obvious limitations. The recently described use of the core biopsy technique in human tendon research and diagnosis gives potential for new knowledge concerning human tendon adaptation, repair and disease.

S-100 protein in carcinoid tumours of appendix.

A series of 12 carcinoid tumours of the appendix were examined with regard to S-100 protein immunoreactivity. All tumours were both argentaffin and argyrophil, and displayed immunoreactivity after application of a monoclonal antibody against serotonin. The S-100 protein immunoreactivity appeared in 11 of the 12 tumours, preferably in cells presumably of Schwann cell origin with long slender processes localized at the periphery of the carcinoid tumour buds. Immunoreactive cells with cytoplasmic processes were also seen extending between individual tumour cell in the tumour aggregates. In a few tumours S-100 immunoreactivity occurred in the cytoplasm of tumour cells with or without cytoplasmic extensions. The presence of S-100 protein immunoreactive cells, apparently as an integral component, and its shape and distribution indicate that the peripheral nervous system (PNS) is histogenetically involved in the development of carcinoid tumours of the appendix.

Calf muscle function after Achilles tendon rupture. A prospective, randomised study comparing surgical and non-surgical treatment.

In a prospective, randomised, multicentre study, 112 patients with Achilles tendon rupture (ATR) were allocated to surgical treatment (n=59), followed by early functional rehabilitation using a brace, and non-surgical treatment (n=53), i.e. eight weeks of plaster treatment. In this study, the results of the isokinetic muscle strength evaluation are presented for contractions in both the concentric and the eccentric mode, plantar flexion and dorsiflexion, two angular velocities and three different positions of the subject. The heel-raise test for endurance, maximum calf circumference and tendon width were also evaluated. The re-rupture rate was 20.8% in the non-surgically-treated group and 1.7% in the surgically-treated group. No significant differences were found between the treatment groups in terms of the isokinetic strength measurements and the endurance test among the patients who did not sustain a re-rupture. If a re-rupture is avoided, both surgical and non-surgical treatment for ATR produce good functional outcome; however, the muscle function was not restored after two years in either group.

Ultrasonography-guided percutaneous core biopsy in Achilles tendon disorder.

Ultrasound-guided percutaneous core biopsy technique was studied in 15 consecutive patients with chronic Achilles tendon disorder defined as persisting local pain during daily activities, localized pain and swelling on palpation 2-5 cm proximal to the calcaneal insertion. Ultrasound verified widening of the tendon and low echogenous areas at the site of pain. Percutaneous biopsies were taken from both the low echogenous areas and the normoechogenic tendon tissue. Of 104 core biopsies 99 were representative. Open biopsies were taken from the macroscopically injured and normal tendon for comparison. Core and open biopsies of the low echogenous and macroscopically injured tendon showed similar histopathology. In 10 patients the core biopsy was performed under local anesthesia with limited subjective symptoms. Five of these patients were operated 18-41 days later. No adverse effect was found referring to the biopsy taken a few weeks prior to surgery. No complications occurred. We conclude that the percutaneous core biopsy, guided by ultrasound and performed under local anesthesia, can be used under clinical and experimental in vivo studies for improving knowledge on pathoanatomy and healing processes of the Achilles tendon.

Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients.

We evaluated biopsy specimens from the Achilles tendon in 40 patients with long-standing achillodynia and an ultrasonographic widened tendon with hypoechogenic areas. We used a standardized protocol to assess the general tendon pathology score of paraffin-embedded specimens stained with HE. Stereologic measurement of the volume density of glycosaminoglycan (GAG)-rich areas, stained with the Alcian blue (pH 2.5)/periodic acid Schiff method (AB/PAS) was performed. 14 specimens obtained at autopsy served as reference material. Abnormal fiber structure and arrangement, focal variations in cellularity, rounded nuclei, decreased collagen stainability and increased non-collagenous extracellular matrix were seen in all biopsy specimens. Slight histopathological changes were noted in half of the controls. Increased vascularity was present in two thirds of the patient specimens and in one third of the controls, and signs of perivascular hemorrhage, as evidenced by hemosiderin deposition in 6/40 of the patients, but in none of the controls. The volume density of GAG-rich areas was higher in the patients 0.47 (0-0.86) than in the controls 0 (0-0.07). Changes in the fiber structure and arrangement, as well as increased amounts of interfibrillar GAG, appear to be characteristic morphological features in Achilles tendons with long-standing achillodynia and ultrasonographic widening. These findings may indicate that achillodynia is due to local disturbances in connective tissue metabolism or circulation or to both.

Function after Achilles tendon rupture in the elderly: 25 patients older than 65 years followed for 3 years.

We retrospectively analyzed the function after Achilles tendon rupture in 25 patients older than 65 years, 3 (1-5) years after the initial treatment. The patients' median age at the time of injury was 71 (65-86) years. The initial management was surgical in 14 patients and non-surgical (8-week immobilization) in 10, 1 patient was not treated. The ratio of the number of heel-raises on the injured to the uninjured side was median 0.64 (0-1.14), showing a reduction in performance. However, in both surgically- and non-surgically-treated patients, the subjective impairment was mild, and the patients were able to perform most walking activities. Only 9 patients reached their previous activity level. Co-morbidity was frequent: 17 patients had other diseases that affected their performance. 14 complications occurred in 11 patients. 5 patients sustained a rerupture (4 following initial closed treatment with plaster), 1 a deep venous thrombosis and 4 had superficial infections requiring antibiotic treatment. 1 patient sustained a fibular nerve injury following compression by the plaster cast and another a sural nerve injury during the operation. 2 patients had symptoms due to adhesions between the tendon and the skin. We conclude that Achilles tendon rupture in patients older than 65 years reduces lower limb function and that complications are common following surgical and non-surgical treatment.

Poor function after shoulder replacement in fracture patients. A retrospective evaluation of 29 patients followed for 2-12 years.

We evaluated the functional outcome 3 (2-12) years after arthroplasty in 29 proximal humerus fractures. The patients' average age at the time of surgery was 71 (47-87) years. The follow-up included a full clinical examination by an independent observer, a questionnaire concerning activities of daily living and pain, and radiographs. The shoulders had a marked reduction of performance, with a Constant score mean of 38 (16-69). All patients were able to eat with utensils, 10 could comb their hair, 19 managed to wash the contralateral armpit, 3 could reach the back pocket and 12 were able to take care of the perineal area. On the VAS-scale (0-100 mm), pain at rest was mean 21 (0-53) mm and on motion 47 (0-91) mm. The patients were stratified regarding surgical treatment within 3 weeks (18 acute vs. 11 late) and prosthetic design (14 Neer II vs. 14 Global modular) without significant differences, as assessed by the Constant scores. We conclude that the treatment of severe proximal humerus fractures with a prosthesis does not give complete pain relief and results in impaired shoulder function.

Function after anterior cruciate ligament injuries. Influence of visual control and proprioception.

Information about limb positions and movements consists of input from visual, vestibular, cutaneous, muscular, tendinous and joint receptors, but the relative contribution from each type and location of receptors is not known. The aim of this study was: a) to measure the contribution from visual control on extremity function, as measured with a one-leg hop test in healthy persons, in patients with an asymptomatic ACL injury, after non-operative treatment and in patients with a stable knee after an ACL reconstruction, b) to investigate if there was any relation between proprioception from the extremity, as measured with the threshold for detecting passive motion of the knee, and the one-leg hop test with a gradual decrease in visual control. There was a decrease in hop-length when the subjects were deprived of visual control that was significant when the dominant eye or both eyes were blinded, both in the 2 patient groups and the reference population. The magnitude of the length reduction did not differ between the groups or between injured and healthy limbs. In all 4 threshold tests performed as a measure of peripheral proprioception, a stronger relation to hop-length was recorded for the blinded hop than with full visual control in the patients with nonoperated ACL injuries. The coefficients of correlation between hop-length and the proprioceptive recordings in the injured limb were of the same magnitude as on the healthy side.

MR imaging in chronic Achilles tendon disorder.

OBJECTIVES: The primary objective was to compare 4 imaging sequences (T1-weighted, T2-weighted, proton density, and T1-weighted with gadolinium contrast agent enhancement) with regard to intratendinous signal abnormality in patients with achillodynia. The secondary objective was to relate the images to the clinical symptoms and histopathological findings. MATERIAL AND METHODS: Twenty patients (16 men, 4 women, median age 40 years) with chronic achillodynia participated in the study. The symptoms prohibited activity and clinical examination revealed swelling and tenderness 1.5-6 cm proximal to the Achilles tendon insertion. Of the 20 patients: 5 had bilateral achillodynia, 4 had had previous contralateral Achilles tendon disorder, and 11 had never had symptoms in the contralateral tendon region. These 11 tendons served as controls for comparison. MR imaging was performed on a superconductive 1.5 T unit. Both Achilles tendons were examined (n = 40) at the same time, and multiple sagittal and transversal images were obtained. The corresponding sections on these images were visually graded according to both extension and level of MR signal intensity. Tissue was obtained for microscopic examination from the most symptomatic side in all patients (n = 20). RESULTS: T1-weighted images following gadolinium contrast medium enhancement proved to be the best method by which to visualize intratendinous signal abnormality. This sequence revealed signal abnormality in 24/25 symptomatic tendons and in 1/11 control tendons (p < 0.001). Histopathological examination showed an increased noncollagenous extracellular matrix and altered fiber structure in the lesions corresponding to the contrast-enhanced areas. CONCLUSION: Gadolinium enhancement improved the imaging of intratendinous signal abnormality on T1-weighted images. There was a high level of extracellular glycosaminoglycans, which are highly-fixed negatively-charged macromolecules with extreme water-retaining capacity and which may have contributed to the enhancement by the gadolinium contrast agent.

MR evaluation of chronic Achilles tendinosis. A longitudinal study of 15 patients preoperatively and two years postoperatively.

PURPOSE: To evaluate surgically treated patients with chronic Achilles tendinosis by MR. MATERIAL AND METHODS: Gd-contrast-enhanced (CME) T1-, precontrast T1-, PD- and T2-weighted images were obtained preoperatively and 2 years following surgical treatment on 15 middle-aged patients with severe symptoms of chronic Achilles tendinosis. MR evaluation included the depiction of intratendinous signal alterations and their volume, and also measurement of tendon diameter. A questionnaire and clinical examination evaluated the clinical outcome. RESULTS: The most sensitive sequence to depict an intratendinous lesion was the CME T1-WI. There was marked regress of the estimated volume of the intratendinous signal alteration from a median of 1.2 cm3 preoperatively to 0.0 cm3 postoperatively on CME T1-WI. CME T1-WI showed a regress in intratendinous signal abnormality from 13 out of 15 patients preoperatively to 4 of 15 patients 2 years postoperatively. The a.p. dimension was 9 mm at both MR occasions. The clinical outcome was excellent in 8, good in 5, fair in 1 and poor in 1 patient. CONCLUSION: Surgical treatment of chronic Achilles tendinosis and its healing resulted in a decrease or elimination of the intratendinous signal alteration correlating to an improved clinical outcome 2 years postoperatively.