Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale.

PURPOSE: In tendon research, using ultrasound (US), studies often refer to tendon thickness, structural abnormalities and neovascularisation. The reliability concerning these measurements and evaluations is seldom reported. The aim of this study was to assess the intra- and inter-observer reliability for quantitative measures (thickness) and qualitative evaluations (structure and neovascularisation) of symptomatic and asymptomatic Achilles and patellar tendons with US and colour Doppler using a modified Öhberg score. METHODS: Twenty-eight consecutive patients with symptomatic and asymptomatic Achilles (n = 27) and patellar tendons (n = 26) were included. Tendon anteroposterior thickness was measured. Tendon structure and neovascularisation were evaluated using a modified Öhberg score. US-images were evaluated twice by four independent observers. RESULTS: Mean thickness for Achilles and patellar tendons was 8.4 mm (±2.0) and 5.5 mm (±1.7), respectively. The reliability for measures of distance was high all over (ICC = 0.963-0.999). A moderate-strong correlation was found between observers concerning evaluation of neovascularisation (r = 0.767-0.992) and poor-moderate correlation concerning evaluation of structural changes (r = 0.379-0.837). Intra-observer reliability was moderate strong for evaluations of both tendon structure (k = 0.537-0.873) and neovascularisation (k = 0.639-0.864). CONCLUSIONS: With a strict method for how to measure tendon thickness and set criteria for evaluating structural changes and amount and distribution of neovascularisation, US and colour Doppler is a reliable method for evaluating Achilles and patellar tendons. The modified, 4-graded, Öhberg score was found to be a reproducible instrument for assessment of tendon structure and neovascularisation.

Sclerosing injections and ultrasound-guided arthroscopic shaving for patellar tendinopathy: good clinical results and decreased tendon thickness after surgery-a medium-term follow-up study.

PURPOSE: Treatment of patellar tendinopathy/jumper's knee with ultrasound-guided sclerosing injections or ultrasound-guided arthroscopic shaving has shown good clinical short-term results. Former studies indicate that the tendon thickness and structure stays unaffected after successful treatment. The aim of this study was to evaluate the sonographic findings and clinical outcome 3-5 years after treatment of patellar tendinopathy with ultrasound-guided sclerosing injections or arthroscopic shaving. METHODS: Fifty-seven patellar tendons (43 patients) with chronic patellar tendinopathy were evaluated, with ultrasound, colour Doppler (CD) and visual analogue scale (VAS) for pain and satisfaction with treatment, 3-5 years after treatment. Functional status was evaluated with a single question-"Back in full loading activity?" yes or no. RESULTS: At endpoint (mean 46 months), there was a significant decrease in anteroposterior thickness of the proximal patellar tendon in patients treated with ultrasound-guided arthroscopic shaving but not after sclerosing injections. Tendon structure had improved, and CD local blood flow had diminished significantly in both groups. There were good clinical results with a significant decrease in VAS for pain after sclerosing injections (VAS 64 ± 18 â†’ 17 ± 23) with 74 % satisfied patients and also after arthroscopic shaving (VAS 77 ± 16 â†’ 13 ± 23) with 80 % satisfied patients. There were no significant differences in VAS between groups. A significant correlation between low local blood flow and high patient satisfaction was found. CONCLUSIONS: Tendon thickness decreased over time after ultrasound-guided arthroscopic shaving, and tendon structure and local blood flow decreased after both treatments. There were good, and similar, clinical results with both methods. LEVEL OF EVIDENCE: III.

Postoperative septic arthritis after anterior cruciate ligament reconstruction: does it affect the outcome? A retrospective controlled study.

PURPOSE: To determine whether the outcome after septic arthritis after anterior cruciate ligament reconstruction (ACLR) is inferior compared with uncomplicated ACLR when treated promptly by use of a standard protocol. METHODS: At Capio Artro Clinic, 4,384 primary ACLRs were performed during 2001-2009. All patients with postoperative septic arthritis were retrospectively reviewed, and 43 met the inclusion criteria. Twenty-seven patients agreed to re-examination (infection group) and were compared with 27 matched patients with uncomplicated ACLR (control group). The mean follow-up period was 60 months and 66 months in the infection group and control group, respectively. Re-examination included objective (radiographs, physical examination, functional testing, range of motion, strength, stability, International Knee Documentation Committee questionnaire) and subjective (Knee Injury and Osteoarthritis Outcome Score, Tegner score, Lysholm score, European Quality of Life-5 Dimensions, subjective satisfaction questions, Single Assessment Numeric Evaluation of knee function, visual analog scale pain rating) evaluation. RESULTS: There were no significant differences in objective knee function between the groups at follow-up. For subjective knee function, no significant differences between the groups were detected with the Single Assessment Numeric Evaluation score, pain during activity, or Lysholm score. The infection group scored lower on 4 of 5 Knee Injury and Osteoarthritis Outcome Score subscales: pain (P = .014), function in daily living (P = .008), sports/recreation (P = .015), and quality of life (P = .007). The infection group scored lower versus control patients on the Tegner score (P = .001) and European Quality of Life-5 Dimensions scores (P = .004). Both groups improved over time, but the control group scored better only on the Tegner score (P = .004). CONCLUSIONS: Septic arthritis after ACLR did not result in inferior objective knee function compared with uncomplicated ACLR. Subjectively, infection patients were as satisfied as non-infection patients, but rehabilitation took longer and fewer patients returned to sports. The findings of this study suggest that anterior cruciate ligament grafts may be retained with prompt, thorough arthroscopic lavage and debridement; correct antibiotics according to cultures; and repeated arthroscopy if necessary. LEVEL OF EVIDENCE: Level III, retrospective case-control therapeutic study.

Sclerosing polidocanol injections or arthroscopic shaving to treat patellar tendinopathy/jumper's knee? A randomised controlled study.

BACKGROUND: Proximal patellar tendinopathy/jumper's knee (PT/JK) is well known to be difficult to treat. Recent studies using an ultrasound and colour Doppler-based treatment approach on the dorsal side of the tendon, sclerosing polidocanol injections and ultrasound-guided arthroscopic shaving, have shown promising clinical results. OBJECTIVES: To compare the clinical effects after treatment with sclerosing polidocanol injections and arthroscopic shaving. MATERIAL AND METHODS: 52 patellar tendons (43 men and two women) with ultrasound and colour Doppler-verified diagnosis of PT/JK were randomly assigned to treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections (group A) or ultrasound and colour Doppler-guided arthroscopic shaving (group B). All patients were involved in patellar tendon loading sports or recreational activities, and had had a long duration of pain symptoms from the proximal patellar tendon. Pain during patellar tendon loading activity, and at rest, before and after treatment (visual analogue scale; VAS), and patient satisfaction with the result of the treatment, was registered. RESULTS: After treatment, the patients treated with arthroscopic shaving had a significantly lower VAS score at rest and during activity, and were significantly more satisfied compared with the patients in the sclerosing injection group. CONCLUSIONS: Both treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections and arthroscopic shaving showed good clinical results, but patients treated with arthroscopic shaving had less pain and were more satisfied with the treatment result. Because surgical treatment is a one-stage treatment return to sports was faster in this group.

Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol.

Two to three ultrasound (US) and colour Doppler (CD)-guided injections of the sclerosing substance Polidocanol (5 mg/ml) have been demonstrated to give good clinical results in patients with chronic midportion Achilles tendinopathy. This study aimed to investigate if a higher concentration of Polidocanol (10 mg/ml) would lead to a less number of treatments, and lower volumes, needed for good clinical results. Fifty-two consecutive Achilles tendons (48 patients, mean age 49.6 years) with chronic painful midportion Achilles tendinopathy, were randomised to treatment with Polidocanol 5 mg/ml (group A) or 10 mg/ml (group B). The patients and treating physician were blinded to the concentration of Polidocanol injected. All patients had structural tendon changes and neovascularisation in the Achilles midportion. Treatment was US + CD-guided injections targeting the region with neovascularisation (outside ventral tendon). A maximum of three treatments (6-8 weeks in between) were given before evaluation. Patients not satisfied after three treatments were given additional treatment with Polidocanol 10 mg/ml, up to five treatments. For evaluation, the patients recorded the severity of Achilles tendon pain during activity on a visual analogue scale (VAS), before and after treatment. Patient satisfaction with treatment was also assessed. At follow-up (mean 14 months) after three treatments, 18/26 patients in group A and 19/26 patients in group B were satisfied with the treatment and had a significantly reduced level of tendon pain (P < 0.05). After completion of the study, additional treatments with Polidocanol 10 mg/ml in the not satisfied patients resulted in 26/26 satisfied patients in both groups A and B. In summary, we found no significant differences in the number of satisfied patients, number of injections or volumes given, between patients treated with 5 or 10 mg/ml Polidocanol.

Ultrasound- and Doppler-guided arthroscopic shaving to treat Jumper's knee: a technical note.

Here we present a new technique for arthroscopic treatment of patellar tendinopthy-Jumper's knee, were arthroscopic shaving and Ultrasound + Doppler examination are performed simultaneously. Using this technique, the tendon and the areas with structural tendon changes and high blood flow are continuously demonstrated in the operating field. By this, the shaving procedure can be more exactly addressed to the area of interest on the dorsal surface of the tendon, and the trauma to the Hoffa fat pad and the tendon is minimized.

Treatment of Jumper's knee: promising short-term results in a pilot study using a new arthroscopic approach based on imaging findings.

Sclerosing injections targeting the area with neovessels and nerves on the dorsal side of the patellar tendon has been demonstrated as giving promising clinical results in patients with chronic painful Jumper's knee-patellar tendinosis (PT). However, a mean number of three treatments with 6-8 weeks in between were needed for a good clinical result. This study aimed to evaluate a more radical removal of the area with neovessels and nerves by using arthroscopic shaving. Fifteen patients (12 men and three women) with the diagnose Jumper's knee-PT in altogether 15 patellar tendons were included. All patients had a long duration of pain-symptoms (mean 27 months) from the patellar tendon, and ultrasonography (US) + colour Doppler (CD) examination showed structural tendon changes with hypo-echoic areas and a neovascularisation inside and on the dorsal side of the tendon, corresponding to the painful area. All patients were treated with arthroscopic shaving of the dorsal side of the proximal tendon. At follow-up (mean 6 months) after treatment, there was a good clinical result in 13/15 tendons (6/8 elite athletes). The satisfied patients were back to previous (before injury) sport activity level, and the amount of pain recorded on a visual analogue scale (VAS)-scale had decreased significantly (VAS from 79 to 12, P < 0.05). A telephone follow-up 13 months (mean) postoperatively showed that the same 13/15 were still satisfied and active in their sports, and that the 2/15 poor cases were still not satisfied with the treatment. Our short-term results indicate that arthroscopic shaving targeting the area with neovessels and nerves on the dorsal side of the patellar tendon has a potential to reduce the tendon pain and allow for the majority of patients to go back to full tendon loading activity within 2 months after surgery. Further studies evaluating this new technique for treating Jumper's knee-PT are in progress.