Sonography of the Achilles Tendon After Complete Rupture Repair: What the Radiologist Should Know

The Usefulness of Concomitant Ultrasound Guidance With Surgery for Acute Achilles Tendon Rupture Using an Internal Brace

Background This study investigated the usefulness of intraoperative ultrasonography in the treatment of acute Achilles tendon rupture (ATR) using an internal brace (Achilles Midsubstance SpeedBridge, Arthrex Inc., Naples, FL), a technique that provides strong internal fixation. Methodology Forty-three patients were included and divided into two groups: Group A (n = 22), which received ultrasonography, and Group B (n = 21), which did not. In Group A, ultrasonography was used during suturing with a specialized jig to confirm the suture needle's position at the center of the proximal stump. Postoperative care in both groups involved initiating active dorsiflexion exercises on the day following surgery and permitting weight-bearing without orthosis once 0° dorsiflexion was achieved. The operative time, Japanese Society for Surgery of the Foot (JSSF) ankle/hindfoot scale, T2-weighted magnetic resonance imaging (MRI) findings at three months postoperatively, and complications were evaluated. Results Group A had a significantly shorter operative time (41.9 ± 7.5 minutes vs. 52.1 ± 6.5 minutes, P < 0.001) and a lower percentage of high-intensity areas on T2-weighted MRI (1.76% ± 2.68% vs. 8.74% ± 7.02%, P < 0.001) compared to Group B. No significant difference was observed in JSSF scale scores (P = 0.948). Additionally, no cases of re-rupture or wound infection were reported in either group. Conclusions Intraoperative ultrasonography in conjunction with this method may enable precise and reliable suturing, facilitating strong internal fixation and potentially enhancing clinical outcomes.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Postoperative Return to Play and the Role of Imaging

Return to play (RTP) following surgery is a complex subject at the interface of social and internal pressures experienced by the athlete, psychological readiness, and intrinsic healing of the surgically repaired structures. Although functional testing, time from surgery, clinical examination, and scoring metrics can help clarify an athlete's readiness to return to sport, imaging can allow for a more direct assessment of the structures in question. Because imaging is often included in the diagnostic work-up of pain following surgery, the radiologist must be familiar with the expected postsurgical imaging appearance, as well as the associated complications. We briefly review such findings following anterior cruciate ligament reconstruction, Achilles tendon repair, syndesmotic fixation, and ulnar collateral ligament reconstruction in the context of the athlete, highlighting issues related to RTP.

Presurgical Perspectives and Post-treatment Evaluation of Achilles Tendon Injuries

The Achilles is a commonly injured tendon, prone to degeneration and tear. Achilles tendon treatment ranges from conservative management to injections, tenotomy, open versus percutaneous tendon repair, graft reconstruction, and flexor hallucis longus transfer. Interpreting postoperative imaging of the Achilles tendon is a difficult task for many providers. This article clarifies these issues by presenting the imaging findings following standard treatments and depicts expected appearance versus recurrent tear and other complications.

Microfragmented Adipose Tissue (M-FATS) for Improved Healing of Surgically Repaired Achilles Tendon Tears: A Preliminary Study

INTRODUCTION

Tendon healing is a complicated process that results in inferior structural and functional properties when compared with healthy tendon; the purpose of this study was to assess the effects of the adjunct of microfragmented adipose tissue (M-FATS) after the suture of a series of Achilles tendons.

METHODS

After complete Achilles tendon tear, 8 patients underwent open suture repair in conjunction with perilesional application of a preparation of M-FATS rich in mesenchymal stem cells. Results were compared with a similar group of patients treated with conventional open suture. Outcomes were evaluated based on range of motion, functional recovery, and complications according to the American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Disability Index (FADI). Achilles tendons were examined by ultrasound (US) at 3 months.

RESULTS

The AOFAS and FADI scores showed no differences between the 2 groups. US evaluation showed quicker tendon remodeling in the M-FATS group. Adverse events were not documented for both procedures.

CONCLUSIONS

The combined application of derived M-FATS for tendon rupture is safe and presents new possibilities for enhanced healing.

LEVELS OF EVIDENCE

Level IIIb: Case control study.

Fast Functional Rehabilitation Protocol versus Plaster Cast Immobilization Protocol after Achilles Tendon Tenorrhaphy: Is It Different? Clinical, Ultrasonographic, and Elastographic Comparison

BACKGROUND

the incidence of Achilles tendon (AT) rupture is rising; however, there is no clear consensus regarding the optimal treatment. The aim of this retrospective study was to compare instrumental and patient-reported outcome scores after fast functional rehabilitation (group A) versus plaster cast immobilization (group B) programs in patients who underwent AT tenorrhaphy.

METHODS

33 patients, with similar clinical and demographic features, underwent open AT tenorrhaphy between January and July 2018. Of these, 15 patients were treated with fast functional rehabilitation program (group A), and 18 patients were treated with plaster cast immobilization protocol (group B). Sural triceps hypotrophy and functional scores (American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Achilles tendon Total Rupture Score (ATRS)) were recorded at a 12-month follow-up. Ultrasonography (US) and elastosonography (ES) were used to compare the characteristics of the tendons after surgery.

RESULTS

At 12 months, no significant differences in any of the patient-reported outcomes or the instrumental measurement tests were seen between the two groups.

CONCLUSIONS

fast functional rehabilitation after AT surgical repair is safe, effective, and may be the first choice of treatment, especially in young, collaborative, and active patients.

Prospective randomized clinical trial of open operative, minimally invasive and conservative treatments of acute Achilles tendon tear

INTRODUCTION

The acute Achilles tendon rupture (AATR) is a common injury of great importance in an increasingly active society. When early functional treatment is established, recent literature shows comparable rates of re-rupture in conservative and surgical treatments of AATR. However, there is no study comparing the outcome using a dynamometer. The aim of this study is to evaluate the results of patients with AATR treated conservatively and surgically using a dynamometer. In addition, the data are compared to evaluation of the Achilles tendon with ultrasound.

MATERIALS AND METHODS

Between 2012 and 2015, 90 patients (mean age 41 years, male-to-female ratio 81:9) with AATR were enrolled in a prospective, randomized, and monocentric study. Thirty patients were assigned to each of the three different treatment groups. Group OPEN received a conventional open suture of the Achilles tendon, group MIN received a minimally invasive suture and patients in group CONS were treated conservatively. Follow-up treatment was the same for all patients regardless of the group they were assigned to. Plantar flexion force was assessed using a dynamometer (Biodex® System 3 Pro, Biodex Medical Systems). Further evaluation included a physical test and ultrasound of the Achilles tendon.

RESULTS

Sixty-nine patients were available for a 24-month follow-up. In each of the OPEN and MIN groups, there was one re-rupture. In the CONS group, there were two re-ruptures. A positive correlation between the Biodex® dynamometer measurement and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS-AH) could be found in all groups. Nevertheless, there were no significant differences between the treatment groups after 2 years. On sonography, all patients showed isolated structure loosening and a significantly thickened cross-sectional area compared with the non-injured opposite side, without differences between the groups. There was no correlation between the Biodex® measurement and sonographic outcome.

CONCLUSION

At 24-month follow-up, no significant difference can be found in patients with AATR treated operatively or conservatively. It is, therefore, important to inform patients with AATR regarding the respective advantages and disadvantages of the individual treatment strategies.

LEVEL OF EVIDENCE

Randomized controlled trial; level 1.

Evaluation of Current Symptoms in Postoperative Achilles Tendons: A Multimodal Ultrasound Study

(1) Background: It is unknown which imaging parameters are associated with clinical persistent symptoms in postoperative Achilles tendons. This study used B-Mode, Power Doppler (PD-US), Ultrasound Tissue Characterization (UTC) and Shear Wave Elastography (SWE) to investigate which imaging parameters are associated with persistent symptoms in postoperative Achilles tendon tissue. (2) Methods: Retrospective, cross-sectional, multimodal imaging study. Based on the VISA-A score, postoperative tendons were assigned to two groups: 1. asymptomatic (VISA-A ≥ 90, n = 18); 2. symptomatic (VISA-A < 90, n = 10). The following imaging parameters were analyzed: UTC (echo type I, II, III, IV), B-Mode (diameter, cross sectional area, calcification, fiber irregularity), PD-US (Öhberg score) and SWE (SWE 3 mm, SWE area) using a t-test and a Mann–Whitney U test. (3) Results: SWE and PD-US showed significantly reduced elasticity and increased neovascularization in symptomatic tendons (SWE 3 mm p = 0.031, SWE area p = 0.046, Öhberg score p < 0.001). The only significant correlation between imaging parameters and the VISA-A score was assessed for SWE 3 mm (r = 0.378; p = 0.047) and the Öhberg score (r = −0.737; p < 0.001). Conclusions: Symptomatic postoperative Achilles tendons showed increased neovascularization and lower SWE values than asymptomatic ones. Future studies should examine the diagnostic accuracy of PD-US and SWE in detecting current symptoms in postoperative Achilles tendons.

Ultrasound of iliotibial band syndrome

Iliotibial band syndrome or friction syndrome is an overuse disorder of the lateral knee. It is commonly reported in athletes, such as runners and cyclists, and refers to pain related to physical activity. The diagnosis is based on clinical history and physical assessment. Imaging, including ultrasound, is mainly performed in recurrent or refractory cases. The purpose of this paper is to review the etiology, diagnosis, and therapy of iliotibial band syndrome with a focus on ultrasound imaging and ultrasound-guided treatment. Ultrasound findings include soft-tissue edematous swelling or discrete fluid collection, suggestive of bursitis, between the iliotibial band and the lateral femoral epicondyle. The thickening of the iliotibial band has been inconsistently reported. Treatment varies according to the disease phase and, in the acute phase, consists of rest, physical therapy, and anti-inflammatory medications. Ultrasound-guided local steroid injections are effective in relieving symptoms.

Post-operative MRI and US appearance of the Achilles tendons

The Achilles tendon is one of the most commonly ruptured tendons in the human body. Minimally invasive and open surgical repairs are commonly undertaken to manage acute Achilles ruptures. This article describes the postoperative imaging findings and their evolution after surgery. Ultrasound and magnetic resonance imaging provide crucial information regarding the morphology, structure, vascularization and mobility of the Achilles tendon on the surrounding planes. Morphologically, a repaired tendon is physiologically larger and wider than an intact one, with a loss of its fibrillary structure; the presence of surgical material in the context of the tendon is normal after the rupture has been repaired. After surgery, the tendon is more vascularized in power-Doppler imaging. Elastography and diffusion tensor Imaging are innovative tools which allow for the visualization of microstructural abnormalities not apprehensible using conventional imaging techniques. A treated Achilles tendon is unlikely to regain a normal imaging appearance, and the health care professional must distinguish between postoperative findings and actual pathological features. In this context, clinical examination still reigns supreme.

[Ultrasound of the Foot (Adapted According to SGUM Guidelines)]

Ultrasound of the Foot (Adapted According to SGUM Guidelines) Abstract. This review paper explains the simplified ultrasound anatomy of the foot including the ankle, midfoot and the toes. The adapted basic standard planes are described in detail according to SGUM guidelines and illustrated with a selection of high-resolution ultrasound images. A profound knowledge of the sonographic anatomy is essential for the detection of pathologies.

Ultrasound Features of Trigger Finger: Review of the Literature

Trigger finger is a common pathologic condition of the digital pulleys and flexor tendons in the hand. The key clinical finding is a transient blockage of the digit when it is flexed with subsequent painful snapping when it is extended. Imaging is a helpful guide for establishing the severity of the disease, identifying the underlying cause, and deciding the appropriate management. This narrative review aims to recall the anatomic and pathologic bases and describe the ultrasound features of trigger finger, also including common ultrasound findings and complications after therapy. Ultrasound enables an accurate static and dynamic evaluation of trigger finger as well as a comparison with the adjacent normal digits and thus should be considered the radiologic modality of first choice for its diagnosis.

Intrasheath Instability of the Peroneal Tendons: Dynamic Ultrasound Imaging

Peroneal intrasheath instability is a painful snapping condition of the lateral ankle. It consists of a transient retromalleolar subluxation of the peroneal tendons without disruption of the superior peroneal retinaculum or evidence of a previous definite trauma. In type A intrasheath instability, the peroneus longus and brevis tendons are intact, and there is an intertendinous intrasheath switch. In type B intrasheath instability, the peroneus brevis tendon has a longitudinal split tear through which the peroneus longus subluxates. Both types can be missed on a physical examination because there is no displacement of the peroneal tendons over the lateral malleolus. Dynamic ultrasound is the imaging modality of choice for evaluating retromalleolar subluxation of the peroneal tendons. This review article aims to provide an overview of the anatomic basis for peroneal intrasheath instability and provide physicians with guidelines for its ultrasound assessment.

Sonography of Non-neoplastic Disorders of the Hand and Wrist Tendons

Tendon disorders commonly cause hand and wrist disability and curtail the performance of work-related duties or routine tasks. Imaging is often needed for diagnosis, but it requires knowledge of the complex anatomic structures of the tendons of the hand and wrist as well as familiarity with related disorders. This review article aims to provide medical professionals with guidelines for the sonographic assessment of the tendons of hand and wrist and related disorders. Sonographic features of tendon disorders affecting the hand and wrist are described here, specifically: infectious tenosynovitis; tendon rupture or tearing; stenosing forms of tenosynovitis such as De Quervain disease and trigger finger; intersection syndrome; insertional tendinopathy; several forms of tendinous instability such as extensor carpi ulnaris instability, climber finger, and boxer knuckle; and tendinopathy in inflammatory rheumatic diseases. Postsurgical evaluation of the hand and wrist tendons is also discussed, including the healthy and pathologic appearances of operated tendons as well as impingement from orthopedic hardware. In conclusion, sonography is effective in assessing the tendons of the hand and wrist and related disorders and represents a valuable tool for diagnosis.

Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging

Plantar fascia (PF) disorders commonly cause heel pain and disability in the general population. Imaging is often required to confirm diagnosis. This review article aims to provide simple and systematic guidelines for imaging assessment of PF disease, focussing on key findings detectable on plain radiography, ultrasound and magnetic resonance imaging (MRI). Sonographic characteristics of plantar fasciitis include PF thickening, loss of fibrillar structure, perifascial collections, calcifications and hyperaemia on Doppler imaging. Thickening and signal changes in the PF as well as oedema of adjacent soft tissues and bone marrow can be assessed on MRI. Radiographic findings of plantar fasciitis include PF thickening, cortical irregularities and abnormalities in the fat pad located deep below the PF. Plantar fibromatosis appears as well-demarcated, nodular thickenings that are iso-hypoechoic on ultrasound and show low-signal intensity on MRI. PF tears present with partial or complete fibre interruption on both ultrasound and MRI. Imaging description of further PF disorders, including xanthoma, diabetic fascial disease, foreign-body reactions and plantar infections, is detailed in the main text. Ultrasound and MRI should be considered as first- and second-line modalities for assessment of PF disorders, respectively. Indirect findings of PF disease can be ruled out on plain radiography.

Teaching Points

• PF disorders commonly cause heel pain and disability in the general population.

• Imaging is often required to confirm diagnosis or reveal concomitant injuries.

• Ultrasound and MRI respectively represent the first- and second-line modalities for diagnosis.

• Indirect findings of PF disease can be ruled out on plain radiography.