| Part I:The role of ultrasound acoustic radiation force impulse imaging in achilles tendons elasticityObjective:To evaluate the role of ultrasound acoustic radiation force impulse (ARFI) in Achilles tendons elasticity of healthy volunteers with different ages and diabetics.Materials and Methods:Bilateral Achilles tendons of 56 healthy individuals (29 men and 27 women; median age,42 years; range,25-65 years) and 12 patients with type II diabetes(7 men and 5 women; median age,49 years; range,46-55 years)were included in the study. The healthy volunteers were divided into four age groups according to ages:age group 1 (25-35 years), age group 2 (36-45 years), age group 3 (46-55 years), and age group 4 (56-65 years). Volunteers with a history of diabetes, Achilles tendon problems, systemic inflammatory disorders, long-term heavy loading of the tendon, or a condition that might influence our results, such as rheumatoid arthritis, spondyloarthropathies, or hypercholesterolemia, were excluded.12 patients with type Ⅱ diabetes were those that had no obvious clinical symptoms and any significant performance of peripheral neuropathy. They had the same age backet with the aboving healthy group 3 which was set as the control group. ARFI measurement was performed with a Siemens Acuson S2000TM ultrasound system. A linear array transducer (9L4) was equipped for B-mode ultrasound and ARFI elastography examinations. The probe was held perpendicular to the tendon and parallel to the longitudinal axis of tendon fibers while performing the examination. We selected the middle section of the tendon for ARFI measurement. Each Achilles tendon was first examined by a musculoskeletal radiologist with the volunteer being in a prone position and the foot hanging over the edge of the examination bed in a relaxed position to avoid tendon stress. Then, the same tendon was examined with the volunteer being in a lateral position and the foot being in passive flexion to ensure tension in the Achilles tendon. Longitudinal images of each tendon were obtained by ultrasound and ARFI elastography. ARFI measurementShear wave velocities (SWVs) of each tendon in the states of relaxation and tension were measured using ARFI technology. For each tendon, six measurements were performed. The mean value was calculated and used for analysis. The SWV levels of Achilles tendons in diabetes group were only measured in the relaxed state and were compared with the control group. According to the principle of ARFI technology, SWV value can quantitatively reflect the tissue stiffness. SWV values of Achilles tendons between different gender, different age groups, between relaxed and stress states and between diabetes group and the control group in relaxed states were observed, The SPSS program (version 13.0, SPSS, Chicago, IL, USA) was used for statistical analysis. P<0.05 was considered statistically significant.Results:SWVs of the four age groups varied within the range of 0.72-8.36 m/s in the relaxed state and within 1.06-8.72 m/s in the tense state. Significant differences in SWVs of Achilles tendon were found between any two age groups in the same status (P<0.05) and between different status in subjects aged 25-35 years (P<0.05) and 36-45 years (P<0.05). To understand the relationship of SWVs of the Achilles tendon in both relaxed and tense states with age, we constructed the distribution map of SWVs for healthy Achilles tendons of subjects at different ages in states of relaxation and tension. Increasing trend was observed in both relaxed and tense states, showing that the SWVs of the Achilles tendon in both relaxed and tense states were increased with age. However, there were no significant differences between men and women within any group in the same status (P>0.05) or between different states in subjects aged 46-55 years (P>0.05) and 56-65 years(P>0.05). SWVs of Achilles tendons in the diabetes group varied within the range of 4.89-7.80 m/s in the relaxed state, while SWVs of Achilles tendons in the control group varied within the range of 3.01-6.31 m/s. After using the t test, it showed that SWV values of Achilles tendon between diabetes group and control group in the relaxed state was statistically significant. It was observed that the SWV values in the diabetes group were higher than that in the control group.Conclusion:ARFI imaging provides quantitative information about tendon stiffness and represents an excellent supplementary technique to B-mode ultrasound. Furthermore, the elasticity of healthy tendon decreases with increasing age in subjects without disease and long-term heavy load lifting. Achilles tendons of Asymptomatic patients with type Ⅱ diabetes have decreased elasticity.Part Ⅱ:The role of high frequency ultrasonography in patients with rupture in Achilles tendonObjective:To evaluate the role of high frequency ultrasonography in the diagnosis of rupture in Achilles tendon.Materials and Methods:42 patients (age range 21-76 years, mean age 43.8 years) with acute closed achilles tendon ruptures which have been proved by operation were retrospectively studied, including 19 females and 23 males. The 42 patients had a total of 48 ruptures of Achilles tendon, including 36 unilateral Achilles tendon rupture and 12 bilateral Achilles tendon rupture. At the same time, we selected 18 cases of healthy volunteers as the control group to observe the ultrasonographic appearance of the normal Achilles tenond. These achilles tendons were studied by high frequency (9-14MHz) ultrasound in static and dynamic state with the inspected being in a prone position and the foot hanging over the edge of the examination bed. The continuity of the Achilles tendon, the site of rupture, the two broken ends of the rupture of Achilles tendon were observed. In addition, The sonographic characteristics of Achilles tendon rupture were compared with the control group.Results:Normal Achilles tendon of the health control group in the longitudinal plane on ultrasonography appeared as a fascicular structure being composed of thin, continuous and parallel hyperechoic lines with uniform distribution. Anechoic lines were observed among the hyperechoic lines. The tuber calcanei, the point of attachment of Achilles tendon, appeared as smooth and continuous arc. In the transverse plane, the Achilles tendon was relatively homogeneous hyperechoge with circular, half-moon or oval shaped.There were 28 complete ruptures of the 48 Achilles tendons, and 20 partial ruptures of Achilles tendon. The site of rupture, the two broken ends of the separation were clearly displayed by high frequency ultrasound. Ultrasound findings were corresponded with the site of rupture, the degree of tendon rupture shown in operation. Diagnosis coincidence rate is 100%.Complete rupture of the 28 Achilles tendons on ultrasonography appeared as: Achilles tendon discontinuity, separation of the two broken ends and retraction of the proximal end. There were low level echo or anechogenic area between the two broken ends which appeared as irregular hyperechoge. The distance between the two ends of showed dynamic changes in extension or flexion of ankle joint. the distance of the two broken ends were widened, while the distance were shortened in plantar flexion of ankle joint.Incomplete rupture of the 20 Achilles tendons on ultrasonography appeared as: discontinuity in part of the Achilles tendon fibers, focal hypoechoic. There were continuous tendon fibers in interior or edge of the tendon. In passive dorsiflexion movement of ankle joint the Achilles tendon had certain sliding. The distal and proximal broken ends had the same direction during movements.Conclusions:High frequency ultrasonography could clearly show the continuity condition of Achilles tendon. The site of rupture and the two broken ends of the rupture of Achilles tendon were displayed accurately. High frequency ultrasonography was helpful in clinical preoperative and could be used as the preferred imaging technique in the diagnosis of rupture in Achilles tendon with the advanges of convenient, low price, no trauma, repeated operation. It provided a reliable foundation for clinicians in surgical intervention of rupture of Achilles tendon. |
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