A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy.

PURPOSE: This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT). METHODS: A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment. RESULTS: Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention. CONCLUSION: The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.

Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial.

PURPOSE: Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied. METHODS: Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome. RESULTS: All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction. CONCLUSIONS: Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain. LEVEL OF EVIDENCE: II.

Anatomy of the sural nerve and its relation to the achilles tendon by ultrasound examination.

Sural nerve injury is a relatively common complication after surgery on the Achilles tendon. Studies to determine the course of the sural nerve have been performed on cadaveric specimens. The purpose of this cross-sectional study was to use ultrasound to determine the relations of the sural nerve in a healthy population. The authors performed ultrasound examination of the posterior triangle of the ankle and Achilles tendon to determine the course of the sural nerve relative to the Achilles tendon in healthy participants. The mean distance between the nerve and the tendon was 21.48, 11.47, 5.8, and 0.81 mm lateral to the Achilles tendon as measured at the insertion and 4, 8, and 11 cm proximally, respectively. Male participants tended to have a nerve that was initially more lateral to the Achilles insertion compared with women. The distance between the sural nerve and the Achilles tendon was found to be lower in older participants, with the nerve passing significantly closer to the tendon at all levels (P<.01). Three anatomical variants were reported, with the nerve crossing the lateral border of the Achilles low or high or with multiple branches yet to converge. The course of the sural nerve can be visualized and plotted relative to the Achilles tendon using ultrasound examination in healthy participants. Older patients may be at an increased risk of iatrogenic nerve injury because the nerve courses closer to the Achilles tendon than that in young patients. Intraoperative ultrasound examination may be a useful modality to prevent sural nerve injury during Achilles tendon surgery.

Standardization of the functional syndesmosis widening by dynamic U.S examination.

BACKGROUND: Dynamic US examination is a convenient, accurate, inexpensive and reproducible diagnostic tool for assessing the integrity of the distal tibiofibular syndesmosis in ankle injuries. However normal values for physiological functional widening of the anterior tibiofibular clear space in healthy subjects has yet to be determined. The purpose of this study was to determine normal values for the syndesmosis clear space on ultrasound examination. METHODS: We evaluated 110 healthy subjects. A dynamic U.S examination was performed in neutral (N), forced internal rotation (IR) and external rotation (ER) of the ankle. In each position the anterior tibiofibular clear space was measured at the level of the anterior inferior tibio-fibular ligament (AITFL). Height and calf length were also recorded. Results were analyzed in relation to age, activity, dominant leg and gender. RESULTS: Mean age was 32 years (range 16-60). There were 59 males and 51 females. 60% were professional athletes. Mean height was 173 cm (range 149-192). Functional Mean position measurements for clear space opening were: N=3.7mm, IR=3.6mm and ER=4.0mm. In younger men and women the clear space was significantly wider in neutral (Men: Y=3.8, O=3.4 \ Women: Y=3.8, O=3.4) and with rotational force application (Men ER: Y=4.1, O=3.6 \ Women ER: Y=4.1, O=3.8) compared to older subjects (p<0.05). There was no correlation with activity, height or the leg length.Females had a higher syndesmosis widening ratio (ER/N) under stress than males (p<0.01) this tended to occur more commonly in active subjects. CONCLUSIONS: Normal values for the syndesmosis clear space on ultrasound examination were determined as 3.78mm in neutral, 3.64mm in internal rotation and 4.08mm in external rotation. The clear space was shown to decrease with age both as an absolute measure and when rotational stresses are applied. Females tend to have a larger clear space and a greater functional widening.These findings provide a useful reference for radiologists and sports physicians when performing ultrasound assessment of ankle syndesmotic injuries and we encourage use of this modality.

A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: a preliminary study.

BACKGROUND: Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis. HYPOTHESIS: Dynamic ultrasound (US) examination can accurately diagnose anteroinferior tibiofibular ligament (AITFL) rupture. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line. RESULTS: The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Delta between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Delta (Delta = ER - N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination. CONCLUSION: We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination.

Prospective evaluation of patients with acute cholecystitis treated with percutaneous cholecystostomy and interval laparoscopic cholecystectomy.

BACKGROUND: Emergency laparoscopic cholecystectomy has been advocated for the treatment of acute cholecystitis; however it can be a difficult task, especially in public hospitals, with relatively high conversion and complication rates. Percutaneous cholecystostomy is a simple and effective procedure allowing patients to recover from the acute event and undergo elective laparoscopic surgery at a later stage. METHODS: We prospectively assessed a protocol of initial conservative treatment in patients admitted with acute cholecystitis. Patients who did not respond to medical treatment were treated by percutaneous cholecystostomy. Following discharge the patients were seen in the outpatient clinic and elective laparoscopic cholecystectomy was considered and scheduled as necessary. The details of the operation were collected with emphasis on complications and conversion rate. RESULTS: During a 3-year period, 224 patients who were admitted with acute calculous cholecystitis entered the protocol. Fifty-four patients did not improve under medical treatment and percutaneous cholecystostomy was performed. In spite of adequate drainage, 5 patients still did not improve: 3 patients were successfully operated upon urgently and recovered, while 2 patients who had severe concomitant diseases and multi-organ failure, died. Forty-nine patients were discharged with the catheter and later re-evaluated for elective operation. In 7 patients common bile duct stones were found and were removed by ERCP prior to the elective operation. Twenty-five patients underwent delayed laparoscopic cholecystectomy with a low conversion rate (8%), and only minor complications (16%). CONCLUSIONS: Conservative treatment and delayed operation is still an acceptable choice in the treatment of acute cholecystitis. Percutaneous cholecystostomy is an effective tool, with high success rate and low morbidity, and allows for better pre-operative evaluation of the biliary system and safe interval laparoscopic surgery. Laparoscopic cholecystectomy after drainage of the gall bladder is a low morbidity procedure with relatively low conversion rate.

Acute epiploic appendagitis: CT findings in 33 cases.

Acute epiploic appendagitis (AEA) is a benign self-limiting process presenting with acute abdominal pain often misdiagnosed clinically as either diverticulitis or appendicitis, but which has a pathognomonic CT appearance. The CT findings in 33 adult patients diagnosed by CT over a 33-month period as having AEA were retrospectively reviewed. The study group included 24 men and 9 women, with a mean age of 44.6 years. The mean age of the male patients was lower than that of the female patients, 40.9 vs 54.7 years. All patients presented with acute abdominal pain, mainly in the left ( n=21) and right ( n=9) lower quadrants, with localized tenderness in all patients and peritoneal irritation in 15 of them. Low-grade fever was found in 8 patients and mild leukocytosis in 16. Characteristic CT findings of an oval fatty mass with central streaky densities and surrounded by mesenteric stranding adjacent to the serosal surface of the colon were seen in all cases. Additional findings included mural thickening of the juxtaposed colon in 16 patients and peritoneal fluid in 7. One patient underwent surgery on the basis of an erroneous diagnosis of acute appendicitis. As CT is often used nowadays to evaluate various acute abdominal complaints, it may be the first imaging modality by which AEA is diagnosed. AEA should be included in the differential diagnosis in young male patients with localized left lower abdominal pain and tenderness.