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1
Southwest Radiology Associates, 1200 Postoak Blvd., Ste. 426, Houston, TX
77056.
2
Mallinkckrodt Institute of Radiology, Washington University School of
Medicine, 520 S. Kingshighway Blvd., St. Louis, MO 63110.
3
Diagnostic Clinic, P. O. Box 2901, Largo, FL 33779-2901.
4
Department of Orthopaedic Surgery, Washington University School of Medicine,
One Barnes-Jewish Hospital Plaza, Ste. 11300 W. Pavilion, St. Louis, MO
63110.
Received March 29, 1999;
accepted after revision July 28, 2000.
Presented at the annual meeting of the American Roentgen Ray Society, San
Francisco, April-May 1998.
Abstract
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MATERIALS AND METHODS. Of 144 tenograms obtained consecutively from May 5, 1995, to March 17, 1997, 111 were located for at least a 6-month follow-up; 65 were posterior tibial, 39 peroneal, two anterior tibial, three flexor digitorum longus, and two flexor hallucis longus tenograms. Tenography was performed fluoroscopically with contrast material and anesthetic followed by steroid placement into tendon sheaths.
RESULTS. Of 65 patients undergoing posterior tibial tenography, 31 (48%) had complete or near-complete symptom resolution; 17 (26%) had no relief. Seventeen patients (26%) had initial relief with the subsequent return of pain to the pretenography level. Of 39 patients undergoing peroneal tenography, 18 (46%) had complete or near-complete symptom resolution; 10 (26%) had no and 11 (28%) had initial relief with subsequent pretenography pain return. Of three patients undergoing flexor digitorum longus tenography, one had complete, one had no, and one had initial relief with complete pretenography pain return. One of two patients who underwent flexor hallucis longus tenography had no relief; the other had initial relief with complete pain return. Two patients who underwent anterior tibial tenography had complete pain relief. We found no correlation between degree of tenosynovitis shown radiographically and therapeutic improvement with anesthetic and steroid injection. Tenography complications included one posterior tibial tendon rupture (0.89%) and 14 patients with skin discoloration at the tendon sheath injection site.
CONCLUSION. Forty-seven percent of surgical candidates whose condition was refractory to conservative therapy had complete or near-complete prolonged symptom relief after tenography. In appropriate patients, tenography is excellent therapy for tenosynovitis. Certain precautions make complications rare.
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The patients were referred by both orthopedic and podiatric surgeons. Patients were sent for diagnosis and potential treatment of tenosynovitis that usually was refractory to a variety of conservative treatments. Generally, patients had experienced symptoms for several weeks to several months. The typical clinical findings in these patients were pain and tenderness in the area of the involved tendon with activity and on physical examination.
The tenographic technique has been described in detail, and our technique was similar [3, 13, 15]. However, we briefly describe the tenographic technique. After the administration of a local anesthetic—usually 1% lidocaine, a 25-gauge needle was inserted into the tendon. A 10-mL syringe filled with a mixture of iothalamate meglumine (Conray; Mallinckrodt Medical, St. Louis, MO) diluted 2:1 with 1% lidocaine was attached via a flexible plastic connecting tube. While gentle continuous pressure was applied to the syringe plunger, the needle was slowly withdrawn from the tendon by pulling on the connecting tubing until free filling of the tendon sheath with contrast material was observed under fluoroscopy. Contrast material was injected until the tendon sheath failed to fill distally, until contrast material flowed proximally into the fascial sheath around the muscle, or until the patient complained of mild discomfort. Much care was taken that contrast material did not collect around the needle tip or disperse down the tendon so that contrast material was not injected into the tendon rather than into the tendon sheath. Multiple fluoroscopic spot radiographs were obtained during and immediately after injection in a 180° arc around the ankle using a fluoroscopic C-arm. Subsequently, the sheath was injected with steroid. As the steroid was injected, the contrast material became diluted and fluoroscopically less dense, confirming intrasheath placement. Follow-up overhead radiographs in anteroposterior, lateral, and both oblique projections were also taken. Although we first used methylprednisolone (Depo-Medrol; Pharmacia & Upjohn, Kalamazoo, MI) or triamcinolone (Aristospan; Lederle Parenterals, Carolina, Puerto Rico), we switched to betamethasone (Celestone; Schering, Kenilworth, NJ) because of our belief, supported by the product descriptions of these drugs, that less chance exists for a flare response after injection (not reported with betamethasone) and for skin discoloration or atrophy.
Each of the 111 tenograms was categorized according to a classification scheme we devised before evaluating the tenograms. Categorization of the tenographic findings was performed by two collaborating reviewers according to the number of sacculations on the tendon sheath as follows: mild, one to five sacculations (Fig. 1); moderate, six to 10 sacculations (Fig. 2); and severe, more than 10 sacculations (Fig. 3). Additionally, an area of stenosis (adhesion) measuring greater than 3 cm was categorized as severe. We were careful not to describe as stenosis the normal narrowing created by pressure from overlying retinacula at the level of the tibial plafond on the posterior tibial tendon (Figs. 2 and 4) and the two narrowings that occur more distally over the peroneal tendons (Figs. 1 and 5). Two tenograms were categorized as incompletely evaluated because of inadequate filling of the tendon sheath or too much extravasation, making interpretation inaccurate.
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Gradually, during the course of this study, the use of sonography before tenography evolved so that now pretenographic sonography is performed routinely at our institution in patients with a possible tear involving a tendon. If any tendon tear is found, the referring clinician is notified. A decision is then made as to whether a diagnostic tenogram alone or an anesthetic injection alone without steroids would be of benefit. Usually, when a tendon tear is shown on sonography, tenography is cancelled. Sonography is added to avoid injection of steroids into a tendon sheath with a partially or completely torn tendon because of the potential detrimental effect of steroids on collagen healing [16, 17].
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Of the 39 patients who underwent peroneal tenography (Table 3), 18 (46%) had complete or near-complete resolution of symptoms, 10 (26%) had no relief, and 11 (28%) had initial relief with subsequent return of pretenography symptoms. The one patient who could not be classified did not have relief.
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The two patients who underwent anterior tibial tenography had complete relief of symptoms. Of the three patients who underwent flexor longus digitorum longus tenography, one had complete relief, one had initial relief with complete return of pretenography pain, and one had no relief. Of the two patients who underwent flexor hallucis longus tenography, one had no relief; the other had initial relief with complete return of pretenography pain. Eleven patients underwent multiple tenography: two patients had repeated procedures at separate sessions; one patient had both peroneal and posterior tibial tendon sheaths injected; and tendon sheath injections were performed in the remaining patients as follows: bilateral peroneal (n = 1); bilateral posterior tibial (n = 3); posterior tibial, flexor digitorum longus, and flexor hallucis longus (n = 2); posterior tibial and anterior tibial (n = 1); and posterior tibial, flexor digitorum longus, and anterior tibial (n = 1) tendon sheaths.
Cross-referencing mild through severe radiographic appearances of posterior tibial tenograms with symptomatic improvement showed that 17 (61%) of 28 patients with mild tenosynovitis, six (25%) of 24 patients with moderate tenosynovitis, and seven (58%) of 12 patients with severe tenosynovitis had complete or near-complete relief of symptoms (Table 2). One tendon sheath was incompletely filled, which precluded evaluation, although this patient did report complete symptomatic relief. Although the p value was 0.009, the overall findings did not show any correlation between the severity of the posterior tibial tenosynovitis and improvement with therapeutic injection of anesthesia and steroid, because moderate tenosynovitis had poor improvement. Overall, 31 (48%) of 65 patients who underwent posterior tibial tenography had complete or near-complete relief of symptoms.
Cross-referencing mild through severe radiographic appearances of peroneal tenography patients with symptomatic improvement showed that 11 (55%) of 20 patients with mild tenosynovitis, six (46%) of 13 patients with moderate tenosynovitis, and one (20%) of five patients with severe tenosynovitis had complete or near-complete symptomatic relief (Table 3). One tendon sheath was incompletely filled, precluding evaluation. The p value for comparing severity of peroneal tenosynovitis and steroid effect was 0.37. These findings did not show any correlation between the radiographic severity of tenosynovitis and the therapeutic tenographic response. Overall, 18 (47%) of 38 patients who underwent peroneal tenography had complete or near-complete relief of symptoms.
Follow-up for all types of tenography procedures ranged from 6 to 28 months (average, 19 months). Overall, 52 patients (47%) who underwent tenography had prolonged complete or near-complete resolution of pain. Of the 60 patients (54%) who underwent tenography but did not have prolonged relief, 17 had surgical treatment. Histologic examination was not performed, but the gross surgical descriptions reflected the typical findings of tenosynovitis as previously described [2, 18]. No other histologic correlation was possible in these cases.
Of the five flexor digitorum longus and flexor hallucis longus tenograms, all findings were categorized as mild, with one patient (20%) having complete or near-complete relief of symptoms, and four patients (80%) having no or initial relief with complete return of pretenography pain. Of the two anterior tibial tenograms, both were categorized as mild, and both patients (100%) had complete or near-complete relief of symptoms.
Complications included one posterior tibial tendon rupture that was not thought to be present or was unrecognizable at the time of tenography. This finding represented a known rupture rate of 0.89%. Because all patients did not have surgical and histologic correlation, the exact number of patients with intrasubstance tears cannot be determined. However, we believe that full-thickness tears would be shown on tenography, with clinical symptoms leading to surgery. Two additional patients had tendon ruptures (Figs. 6A,6B and 7A,7B); one was of a posterior tibial tendon and the other was of a peroneal tendon, both of which were believed to be present at the time of tenography.
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Fourteen patients had skin discoloration at the tenogram injection site that was often between 18 and 25 mm. Loss of pigmentation was the most common skin or soft-tissue abnormality recognized (10 patients), almost always occurring in patients with dark skin. One of the 10 patients reported a return to normal skin color over several months. Four patients experienced transient bruising at the injection site, also about 20 mm. One patient (<1%) had an ill-defined area smaller than 25 mm around the tenogram injection site with partial paresthesia that was described as minimal numbing of the area.
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Clinically, tenosynovitis is divided into three types: peritendinitis, chronic tenosynovitis, and stenosing tenosynovitis [14]. The first two types are more likely to resolve with conservative treatment [8, 19]. Stenosing tenosynovitis usually requires surgery [20] because the intratendinous degeneration is often too severe to resolve with nonsurgical treatment.
Radiographically, tenosynovitis may be graded according to the tenographic findings, ranging from mild synovitis with minimal irregularity of the sheath to severe synovitis with marked irregularity, outpouchings, nodularity, and even stenosis [3]. In our study, each of our 111 tenograms was categorized on the basis of the number of sacculations as mild, moderate, and severe as described in the Materials and Methods section. We could not relate this tenographic classification to the clinical classification of peritendinitis and chronic tenosynovitis. Additionally, a long segment of stenosis (>3 cm) was categorized as severe and likely to represent stenosing tenosynovitis. "Stenosis" or nonfilling of segments of the sheath could occur from sheath fibrosis, from enlargement of the tendon occluding the sheath, or conceivably from extrinsic pressure compressing the sheath. Commonly, pressure effects from overlying retinacula provide narrowings over the posterior tibial tendon sheath (Figs. 2 and 4) at the tibial plafond and over the peroneal tendon sheaths (Figs. 1 and 5) proximal and distal to the sustentaculum talus. Tendon sheath narrowing in the site of these retinacula was not classified as stenosis in this study.
The extreme variation in the size of both the tendon and the sheath precluded the examiners from using these parameters as an accurate and consistent means to evaluate the tenograms. Furthermore, tendon sheath capacity may not be a reliable means to categorize tenosynovitis. We did not find any tendon sheaths without any sacculations or outpouchings in these patients. A normal asymptomatic sheath could possibly have the same appearance as those classified as mild; however, we did not perform tenography in asymptomatic individuals in this study, so it was not possible to know if some of the patients with minimal irregularity were actually "normal."
The therapeutic effect of tenography is likely a combination of local anesthesia, the antiinflammatory effects of the steroids, and the actual mechanical dilatation of the tendon sheath due to fluid placed into the sheath. Patients with stenosing tenosynovitis may not receive a therapeutic effect from the tenography if the injected liquid does not extend through the stenotic area. Subsequently, these patients with more advanced tendon disease and intrasubstance tendon degeneration may need surgery for treatment of their tenosynovitis.
Reported surgical findings in tenosynovitis include thickening of the tendon sheath, with constriction and degenerative changes of the tendon ranging from disorganization to rupture of collagen fibers or new bone formation and calcareous deposits [2, 18]. Effusion and reddish brown granulation tissue may be found in the tendon sheath. Histologic examination shows a variety of findings, from mild inflammation and synovial proliferation to fibrosis and advanced degeneration of the sheath and tendon [8]. Of our 17 patients who underwent surgery, no pathologic specimens were obtained. However, the gross surgical findings reflected these histologic descriptions.
More severe complications of the procedure are infection and tendon rupture. Meticulous sterile preparation and precautions should preclude infection. We did not have any known infectious complications in our study population.
Only one patient had a tendon rupture that could be considered caused or enhanced by the tenography; that rupture occurred 1 day after tenography while the patient was playing tennis. Her posterior tibial tenogram showed mild tenosynovitis. Rupture was confirmed on MR imaging and subsequent surgical repair. The other two patients who had tendon ruptures (one peroneal and one posterior tibial) had evidence of major tendon abnormality that supported a ruptured tendon at the time of tenography. The first of these ruptures occurred in the peroneus brevis tendon approximately 6 weeks after the patient's tenography when the patient misstepped while going down stairs. Her tenogram before the misstep showed a large mass effect at the distal aspect of her peroneal tendons, correlating with the area of rupture found at surgery (Fig. 6A,6B). Again, rupture was confirmed on MR imaging and then at surgery. The second patient had a rupture at the time of tenography of the posterior tibial tendon. No acute traumatic event was described by the patient. Her tenogram showed a large distal mass effect of the distal posterior tibial tendon (Fig. 7A,7B). Approximately 3 weeks after her tenography, because of the failure of conservative treatment and tenography, the patient underwent surgery that showed a complete rupture of the tendon at the site of the mass seen on tenography. Our tenographic findings, the gross surgical findings, and the patient's history suggested that the tendon was ruptured before the tenography. Therefore, these last two ruptures were thought to be preexisting ruptures not caused by tenography.
Our main recommendation to decrease the chance of tendon rupture is to protect the patient's ankle by refraining from sports or other strenuous activities for 6 weeks after the steroid injection [16, 17]. Recognizing a mass during tenography, or performing sonography or MR imaging before tenography in the patient with a clinically suspected tendon tear, could provide evidence of a preexisting partial or complete tendon rupture that would preclude steroid injection and potentially eliminate or decrease the number of ruptures after the procedure. Indeed, since this study, our policy of performing sonographic examinations of all patients presenting for tenography with a question of tendon tear versus tenosynovitis has allowed us to find a few cases of intrasubstance tendon disease or tears. In such patients, discussion of the findings with the referring doctor has usually led to cancellation of the tenography. If tenography is still requested after evidence of intratendinous disease, steroids are not injected with the tenography.
To prevent the spontaneous rupture of the posterior tibial tendon and the subsequent development of a flatfoot deformity, the use of a short leg cast or walking boot should be considered after posterior tibial sheath injections. Local steroid injection into a tendon has been associated with collagen necrosis and biomechanical weakness of the tendon in rabbits [16, 17]. These studies showed a decrease in biomechanical strength for 2 weeks and histologic abnormality for 6 weeks after the intratendinous injection. Therefore, although we perform peritendinous (not intratendinous) injections, we recommend protecting the ankle from strenuous activity for 6 weeks after injection. The use of a removable walking brace or cast for 6 weeks may be especially prudent after posterior tibial tendon sheath injection to prevent an acquired flatfoot deformity. This complication is more difficult to treat than ruptures of the flexor hallucis longus, flexor digitorum longus, or peroneal tendons, which do not typically result in ankle or foot deformity.
Because clinicians inject tendon sheaths, the question has been raised as to why tenography should be performed. Although clinicians supposedly inject ankle sheaths, it is impossible to know exactly what anatomic space is being injected without using contrast material. At times, the injection needle may actually be outside the sheath, especially in the ankle because of the abundant fat and soft tissue around the ankle tendons. We have encountered patients who did not improve whose injection was performed by the referring surgeon. Shortly thereafter, when tenography with contrast material was performed, the patient improved immediately.
Our study was limited by the use of telephone interviews for evaluation and follow-up of only 111 (77%) of a possible 144 patients who underwent tenography. The additional 33 patients could not be located. Another limitation was the lack of correlation with additional imaging studies such as sonography, MR imaging, or CT, which could provide information that was not available from tenography regarding the presence or absence of intratendinous disorders. The 0.89% rate of ruptures of the posterior tibial tendon after the procedure may have been higher if a physical examination, including radiography with the patient standing, had been performed on all patients, because rupture of this tendon is usually exhibited by a progressive planovalgus foot deformity instead of an acute rupture. Determining the true rupture rate is also difficult without surgical correlation of all patients.
We do not know the natural history of most types of tendinitis. We know that the posterior tibial tendon can progress from tendon degeneration to rupture, but the time frame, predisposing factors, and true incidence are unknown.
Certainly some (probably many) patients will get better after immobilization, conservative therapy, and time to heal, but to quantify this possibility is impossible. Recent studies on the posterior tibial tendon have shown good results with conservative therapy (approximately 80% at 6 months) [21]. One limitation of our study is that we were not certain of the severity of tendon involvement in each patient. The amount of variation in both tendon and sheath size precluded the categorization of tenosynovitis other than by the length of stenosis and number of sacculations. Counting the sacculations may also have reviewer bias. We could have reviewed findings in a larger number of patients but elected not to attempt to retrieve findings for patients who underwent tenography before May 1995 because of the long time interval.
In conclusion, in the evaluation and treatment of tenosynovitis, tenography may provide effective treatment in patients whose condition is refractory to conservative treatment, thereby obviating surgery. Although other imaging modalities offer direct visualization of the anatomy and surrounding pathology, 47% of patients, regardless of the radiographic appearance of the tenosynovitis, had long-term complete or near-complete relief of symptoms after the therapeutic injection of steroids, contrast material, and local anesthesia during tenography. No definite correlation was seen between the severity of tenosynovitis as classified radiographically and improvement with therapeutic injection, implying that regardless of the severity of the appearance of tenosynovitis, tenography with steroids, in the absence of tendon tear, may be an effective treatment.
The incidence of known complete tendon rupture after injection was one (0.89%) in 111 patients in this series. Despite the one posterior tibial tendon rupture that was probably enhanced on tenography, tenography is believed to be a safe, minimally invasive procedure when performed with careful fluoroscopic control. Given the limitations of this retrospective study, it is difficult to know with certainty the long- or short-term effects of steroid injection on tenosynovitis of the ankle tendons.
Compliance with precautions should decrease the chance of complications with tenography. Sonography performed before tenography for patients with the clinical suspicion of a tendon tear will help determine if the tendon has intrasubstance changes. In that case, injection of steroids can be avoided in hopes of preventing a partial tear from becoming complete.
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