0226: polydocanol use and success

S22 Ultrasound in Medicine and Biology Volume 35, Number 8S, 2009

significantly in regards to surface transducers, the area of the transducerthat is disinfected, the methods used for disinfection and also thecleaning and maintenance of the transducer cable. It has also demon-strated the need to extend this study to allow collection of further data.

0223

Tendinopathies of the Wrist and HandCarlo Martinoli, University of Genova, Italy

Ultrasound (US) is an efficient, rapid and inexpensive alternative toMR imaging for evaluation of a wide spectrum of tendon disorders ofthe wrist and hand. In traumatic injuries, complete and partial tears ofthe flexor and extensor tendons can be reliably identified with US. TheUS pattern shows a gap between tendon ends occupied by a hypoechoicinterval due to debris or frayed residual fibers. The tendon ends mayappear as stump-like structures or, following elongation trauma, aretapered. In closed injuries of the extensor tendons, US can recognizethe cause of the tear, often due to bony spurs or attrition from surgicalhardware. In flexor tendon injuries, US is particularly helpful in locat-ing the two ends of the ruptured tendon as they may be retracted aconsiderable distance from the site of the tear. Dynamic scanning mayhelp to distinguish partial from complete tears when the injury hasoccurred with an elongation mechanism. Postoperatively, dynamicscanning is a critical means to assess how the tendon glides and to ruleout adhesions. Discontinuity in the tendon and detection of suturesfloating freely in an empty sheath indicate a retear. Dynamic scanningis also reliable to demonstrate tendon instability related to the injury ofannular pulleys (climber’s finger), sagittal bands (boxers’ knuckle) andretinacula (ECU instability). As a result of fibrosing degeneration,retinacula and annular pulleys may become thickened producing pain-ful gliding, blockage or triggering of the underlying tendons. This mostoften occurs in the trigger finger and de Quervain disease. Some wristtendons may be involved by specific overuse or degenerative changes.Among these conditions, US is an excellent tool for investigating theproximal (I-II compartment) and distal (II-III compartment) intersec-tion syndromes and the FCR tendinopathy.

0224

Ultrasound (US)- Guided Percutaneous Treatment of LateralEpicondylitisLuca M Sconfienza, IRCCS Policlinico San Donato, San DonatoMilanese, ItalyFrancesca Lacelli, ASL 2 - Ospedale Santa Corona, Pietra Ligure,ItalyGiovanna Grillo, Department of Internal Medicine, University ofGenova, ItalyAlberto Aliprandi, IRCCS Policlinico San Donato, San DonatoMilanese, ItalyGiovanni Serafini, ASL 2 - Ospedale Santa Corona, Pietra Ligure,ItalyEnzo Silvestri, Ospedale Evangelico Internazionale, Genova, Italy

Purpose: Lateral epicondylitis is a common cause of elbow pain ingeneral population. We show the efficacy of a percutaneous treatmentunder US guidance in treating this condition.Methods and Materials: 32 patients (18 males, 14 females, mean age45�8.6) suffering from lateral epicondylitis underwent an US-guidedpercutaneous treatment. They were randomly subdivided into twogroups. In the first group (16 patients), under local anesthesia and USguidance, a needle was advanced into the enthesis of the commonextensor tendon. There, we performed multiple punctures to obtain ascarification of the enthesis and of the preinsertional portion of the

was performed. A visual analogue scale was used to evaluate the degreeof pain pre-and post-treatment at 2, 12, 24 and 48 weeks.Results: In the first group, no significant improvement compared tobaseline was found at 2 weeks but was present at 12, 24, and 48 weeks(p�.001 for all). In the second group, significant improvement com-pared to baseline was found at 2 weeks (p�.001) but not at 12, 24, and48 weeks. Comparison between the groups showed significant differentoutcome in favour of the second group at two weeks (p�.001) and infavour of the first group at 12, 24, and 48 weeks (p�.001).Conclusion: US-guided percutaneous dry-needling alone is more ef-fective than steroid injection. The efficacy of this treatment seems to belong-lasting. It can be considered as an effective and minimally inva-sive treatment for lateral epicondylitis.

0225

Calcifying Tendinitis of the Rotator Cuff: Is Percutaneous US-Guided Treatment More Effective than Simple Steroid Injection?Luca M Sconfienza, IRCCS Policlinico San Donato, San DonatoMilanese, ItalyFrancesca Lacelli, ASL 2 - Ospedale Santa Corona, Pietra Ligure,ItalyEnzo Silvestri, Ospedale Evangelico Internazionale, Genova, ItalyNadia Perrone, ASL 2 - Ospedale Santa Corona, Pietra Ligure, ItalyFrancesco Sardanelli, IRCCS Policlinico San Donato, San DonatoMilanese, ItalyGiovanni Serafini, ASL 2 - Ospedale Santa Corona, Pietra Ligure,Italy

Purpose: Calcifying tendinitis of the rotator cuff occurs in up to 20%of the population. No standard of care has been established. Our workcompares the outcome of a US-guided percutaneous treatment ofpatients affected with calcifying tendinitis of the rotator cuff with theoutcome of patients affected with the same disease treated with asimple steroid injection.Methods and Materials: Among patients referred for US-guidedtreatment of calcifying tendinitis, we randomly treated 87 (39 males;age range 35-64, mean 46.1 � 8.6) with an US-guided percutaneoustreatment while 49 with a simple steroid injection (21 males; age range30.69, mean 44.2 � 9.6). Clinical conditions of patients and controlswere assessed using Constant’s score (CS) and visual analogue score(VAS). Patients were clinically followed up to 5 years.Results: At baseline, patients and controls were homogeneous for age(P � 0.74) and sex (P � 0.45) distribution, CS (P � 0.39) and VAS(P � 0.67). CS and VAS of treated patients resulted in significantimprovement than that of injected patient at 1 month, 3 months and 1year (P � 0.001), but were not significantly different at 5 years (P �0.654 and P � 0.486, respectively).Conclusion: The treated patients had a better outcome compared to theinjected group in the long-term analysis. Thus, the US-guided treatmentis highly effective in giving a prompt functional recovery and relieffrom pain. On the long term, a spontaneous healing occurs also ininjected patients, but only after 5 years.

0226

Polydocanol Use and SuccessLisa Briggs, Premiere Orthopaedics, Australia

This workshop is designed to introduce you to a relatively “new “painrelief procedure with the use of ultrasound guidance. Polidocanol(Aethoxysklerol®) is a sclerosing agent used to sclerose neo-vasculari-sation. This change is related to tendinosis of the tendon. With thischange in the tendon, neo-vascularisation occurs to aid in the repairphase. Unfortunately, with new blood flow small nerves also infiltrate

Abstracts S23

Under ultrasound guidance it is possible to demonstrate the neo-vascularisation of the structure with the use of colour Doppler. The“feeder” vessel/s is identified and ultrasound is used to the guide theneedle into the correct region. Once the vessel/s are demonstrated thePolidocanol is injected into the vessel, and subsequently the vessels aresclerosed /obliterated immediately. With the use of ultrasound and theguiding of the needle the accuracy is greatly increased, therefore, thereis a greater degree of confidence that the correct structures have beensclerosed. This gives a better outcome for the patient. The theorybehind this type of pain relief is, if there is decreased neo-vascularisa-tion , there is decreased pain , the patient may commence light exerciseand hopefully regain full movement - pain free. This technique ispredominately used in the “loading “tendons. These are the Achillestendon, patellar tendon, lateral elbow - common extensor origin, quad-riceps tendon at patellar insertion - and some studies have also includedthe flexor tendons of the hands.

0227

The Posterior Interosseous Nerve - Where Have You Been AllMy Life?Chris Sykes, Mercy Private Hospital, Australia

Ultrasound is a highly sensitive and specific modality for the diagnosisof lateral epicondylitis, and sonographic evaluation of the lateral elbowis a commonly requested examination.Sonographic musculoskeletal examinations have their best utility whentargeted to the area of clinical suspicion. While the lateral epicondyleand CEO are routinely the target of sonographic examination, lateralelbow pain can also result from neuropathy affecting the nerves of thearm - in particular, the posterior interosseous nerve (PIN). The PINmay be affected by direct trauma or idiopathic compression. TermedPosterior Interosseous Nerve Entrapment or Radial Tunnel Syndrome,compression of the PIN can result in focal pain that mimics the clinicalpicture of lateral epicondylitis. For this reason, sonographic examina-tion for lateral elbow pain where lateral epicondylitis is suspectedshould include examination of the PIN.The Posterior Interosseous Nerve (PIN), or deep branch of the radialnerve branches from the radial nerve just distal to the elbow joint. ThePIN then passes through the radial tunnel. The course of the PINthrough the radial tunnel takes it past a number of structures wherecompression of the nerve can occur. The most significant site is thesuperior arcade of the superficial layer of the supinator muscle (TheArcade of Frohse).Radial tunnel syndrome is characterized by pain located in the regionof the radial tunnel - approximately 2.5cm distal to the elbow crease.Pain may be brought on by direct pressure or supination of the forearmand may also be exacerbated by resisted extension of the index finger.Radial tunnel syndrome should also be suspected where treatment oflateral epicondylitis has failed.Assessment of the nerve should focus on identification of anatomy. ThePIN should be assessed for any contour deformation, mass effect orswelling. The nerve should follow a smooth path through the radialtunnel. While a dramatic change in nerve diameter is diagnostic fornerve compression, sharp contour changes should also be viewed withsuspicion. Additionally, masses such as ganglia may compress thenerve. The CEO should also be assessed. Assessment of the contralat-eral nerve and CEO is mandatory.Sonography has established a role in assessment of the lateral elbow forlateral epicondylitis. Radial tunnel syndrome may however mimic thiscondition clinically. Sonography is an ideal imaging modality to assessthe PIN and assessment of this structure should form a routine part ofelbow examination for lateral elbow pain. Sonographers should also

as pain identified distal to the lateral epicondyle raises the suspicion ofradial tunnel syndrome.

0230

Ultrasound Detection of Intermittent and Positional DependentEndoleaks; Evidence for a Novel Mehanism of AAA Sac GrowthAfter Endovascular RepairKathryn J Busch, Camperdown Vascular Laboratory, AustraliaGeoffrey H White, Department of Vacular Surgery, Royal PrinceAlfred Hospital, AustraliaJames May, The University of Sydney, AustraliaJohn P Harris, Department of Vacular Surgery, Royal Prince AlfredHospital, AustraliaJudith Doyle, Camperdown Vascular Laboratory, AustraliaMartin R Forbes, Camperdown Vascular Laboratory, AustraliaVirginia Makeham, Royal Prince Alfred Hospital, AustraliaAlison Burnett, Royal Prince Alfred Hospital, Australia

Introduction: Ultrasound is a reliable tool for real-time identificationof endoleaks after endovascular repair of abdominal aortic aneurysms(AAA). We have identified a unique subset of patients in whom theendoleak has been shown to be intermittent, with strong evidence ofvariations in flow with patient positioning.Methods: All patients presenting with prior endograft repair of AAAwere imaged with Philips HDI 5000 and IU22 ultrasound systems usinga standard protocol including spectral and colour Doppler analysis.When there were signs of AAA sac growth or instability, patientpositioning was varied during the examination including left and rightdecubitus views to search for evidence of intermittent endoleak. Cor-relation was made to angiography and CT imaging.Results: Intermittent endoleaks were confirmed in 13 patients, all ofwhom had sac enlargement. There was evidence of positional depen-dence in 11 of the 13 cases. This represents an incidence of less than1% in a series of more than 1200 endovascular repairs, but 48% (13 of27) of patients with unstable AAA sac or endotension. These endoleakswere not seen on CT scans in 80% of studies, and 11 of 13 were notseen on supine angiography.Conclusion: Endoleaks may be intermittent and position-dependent.Duplex ultrasound is an essential component in diagnosis, enhanced byultrasound’s ability to capture dynamic, real time images. Specialposturing should be used in patients with suspicious signs.

0231

Detection and Characterization of Endoleaks After EndovascularRepair of Abdominal Aortic Aneurysm: Comparison of ContrastEnhanced Ultrasound (CEUS) with Computed TomographicAngiography (CTA)Rosa Gilabert, Ultrasound Unit. Diagnosing Imaging Center.Hospital Clinic. Barcelona, SpainLaura Bunesch, Ultrasound Unit. Diagnosing Imaging Center.Hospital Clinic. Barcelona, SpainAngeles Garcia-Criado, Ultrasound Unit. Diagnosing ImagingCenter. Hospital Clinic. Barcelona, SpainIsabel Real, Vascular Radiology. Diagnosing Imaging Center.Hospital Clinic. Barcelona, SpainVicenc Riambau, Vascular Service. Diagnosing Imaging Center.Hospital Clinic. Barcelona, Spain

Endoleaks are the most common complication after endovascular repair(EVAR) of abdominal aortic aneurysm, and require close surveillance.Objective: To evaluate the CEUS efficacy in the detection and char-acterization of endoleaks, and to compare the results with data obtained