Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study.

OBJECTIVE: Chronic tendinosis of the Achilles tendon is a common overuse injury that is difficult to manage. We report on a new injection treatment for this condition. SUBJECTS AND METHODS: Thirty-six consecutive patients (25 men, 11 women; mean age, 52.6 years) with symptoms for more than 3 months (mean, 28.6 months) underwent sonography-guided intratendinous injection of 25% hyperosmolar dextrose every 6 weeks until symptoms resolved or no improvement was shown. At baseline and before each injection, clinical assessment was performed using a visual analogue scale (VAS) for pain at rest (VAS1), pain during normal daily activity (VAS2), and pain during or after sporting or other physical activity (VAS3). Sonographic parameters including tendon thickness, echogenicity, and neovascularity were also recorded. Posttreatment clinical follow-up was performed via telephone interview. RESULTS: Thirty-three tendons in 32 patients were successfully treated. The mean number of treatment sessions was 4.0 (range, 2-11). There was a mean percentage reduction for VAS1 of 88.2% (p < 0.0001), for VAS2 of 84.0% (p < 0.0001), and for VAS3 of 78.1% (p < 0.0001). The mean tendon thickness decreased from 11.7 to 11.1 mm (p < 0.007). The number of tendons with anechoic clefts or foci was reduced by 78%. Echogenicity improved in six tendons (18%) but was unchanged in 27 tendons (82%). Neovascularity was unchanged in 11 tendons (33%) but decreased in 18 tendons (55%); no neovascularity was present before or after treatment in the four remaining tendons. Follow-up telephone interviews of the 30 available patients a mean of 12 months after treatment revealed that 20 patients were still asymptomatic, nine patients had only mild symptoms, and one patient had moderate symptoms. CONCLUSION: Intratendinous injections of hyperosmolar dextrose yielded a good clinical response--that is, a significant reduction in pain at rest and during tendon-loading activities--in patients with chronic tendinosis of the Achilles tendon.

Tolerance of local anesthetic for transrectal ultrasound-guided prostate biopsy: our experience and a literature review.

PURPOSE: To determine whether local anesthetic injection or gel reduced pain during transrectal ultrasound-guided prostate biopsies and whether there was significant difference between quadrant and apex-only anesthesia. METHODS: Between September 2001 and May 2002, 240 male patients with elevated prostate-specific antigen and (or) abnormal digital rectal examination were randomized into 1 of 4 groups: 1) transrectal lidocaine gel, 2) quadrant lidocaine injections, 3) apex-only lidocaine injections, or 4) no local anesthetic. Patients scored their pain on a numerical rating scale where 0 indicated no pain and 10 indicated worst pain. We analyzed mean and standard deviations of scores, using a 1-way analysis of variance (ANOVA) and post hoc multiple comparisons with Tukey's honestly significant difference (HSD) studentized range test to determine whether there were significant differences across the groups. RESULTS: There was no significant difference between local anesthetic gel (mean 3.1, SD 1.9) and no anesthetic (mean 3.5, SD 1.9) or between quadrant (mean 1.7, SD 1.7) and apex-only (mean 2.0, SD 1.8) local anesthetic injections. There was significant difference between quadrant injections (mean 1.7, SD 1.7) and no local anesthetic (mean 3.5, SD 1.9) and between apex-only injections (mean 2.0, SD 1.8) and no local anesthetic (mean 3.5, SD 1.9). CONCLUSION: There was significant pain reduction with local anesthetic injections but not with gel, and since there was no significant difference in efficacy between quadrant and apex-only injections, we recommend apex-only local anesthetic injections for transrectal ultrasound--guided prostate biopsies because it simplifies the injection procedure.

Limited-sequence magnetic resonance imaging in the evaluation of the ultrasonographically indeterminate pelvic mass.

OBJECTIVE: To evaluate the usefulness of limited-sequence magnetic resonance imaging (MRI) in the elucidation of ultrasonographically indeterminate pelvic masses. This study focused only on pelvic masses in which the origin of the mass (uterine v. extrauterine) could not be determined by ultrasonography (US). The origin of a pelvic mass has clinical implications. A mass arising from the uterus is most likely to be a leiomyoma, which is a benign lesion, whereas an extrauterine mass will have a higher likelihood of malignancy and usually requires surgery. METHODS: Eighty-one female patients whose pelvic mass was of indeterminate origin on US also underwent limited-sequence MRI of the pelvis. Most of the MRI examinations were performed on the same day as the US. Limited-sequence MRI sequences included a quick gradient-echo T1-weighted localizer and a fast spin-echo T2-weighted sequence. Final diagnoses were established by surgical pathology or by clinical and imaging follow-up. RESULTS: Limited-sequence MRI was helpful in 79 of the 81 cases (98%). Fifty-two of the 81 masses (64%) were leiomyomas. One was a leiomyosarcoma. The extrauterine masses (26/81 [32%]) were identified as 14 ovarian malignancies, 4 endometriomas, 3 dermoids, an ovarian fibroma, an infarcted fibrothecoma, an infarcted hemorrhagic cyst, a sigmoid diverticular abscess and a gastrointestinal stromal tumour of the ileum. In the other 2 cases (2/81 [2%]), the origin of the pelvic mass remained indeterminate. Both of these indeterminate masses showed low signal on T2-weighted images and were interpreted as probable leiomyomas. They were not surgically removed but were followed clinically and had a stable course. CONCLUSION: Limited-sequence MRI is a quick and efficient way to further evaluate ultrasonographically indeterminate pelvic masses. Limited-sequence MRI of the pelvis can suffice, in these cases, without requiring a full MRI examination.

High-resolution sonography of the triangular fibrocartilage: initial experience and correlation with MRI and arthroscopic findings.

OBJECTIVE: The aim of our study was to compare the findings of high-resolution sonography of the triangular fibrocartilage with those of MRI and arthroscopy. SUBJECTS AND METHODS. Thirteen patients with clinically suspected triangular fibrocartilage tears prospectively underwent sonography, followed by MRI, of their wrists. Triangular fibrocartilage tears were classified as predominantly ulnar or predominantly radial. Only the surgeon was aware of the results of both studies, and eight patients subsequently underwent arthroscopy. The findings of the different techniques were compared. RESULTS: For the presence or absence of a tear, seven (87.5%) of eight sonographic examinations correlated with arthroscopy, and 11 (84.6%) of 13 sonographic examinations correlated with MRI. Sonography missed one small radial tear that was detected at arthroscopy and MRI, but sonography showed an ulnar tear in triangular fibrocartilage that appeared normal on MRI. CONCLUSION: High-resolution sonography shows good correlation with MRI and arthroscopy for the evaluation of triangular fibrocartilage tears. Sonography has the potential to be a rapid and cost-effective means of diagnosing tears of the triangular fibrocartilage, particularly those involving the ulnar aspect of the cartilage.