Achilles CPPD
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- Опубліковано 7 вер 2024
- CPPD, also known as pseudogout or chondrocalcinosis can create some impressive ultrasound appearances.
CPPD likes to reside in hyaline cartilage, loves being inside fibrocartilage and can be seen crawling along ligaments or appearing inside tendons.
Unlike hydroxyapatite it does not need to be near the enthesis and it is often multifocal and multi locational. It has a relatively high atomic number and hence is readily seen on plain radiographs, unlike xanthomas, which can appear similar monographically, but are invisible on a plain radiograph.
Enjoy these examples of CPPD within the Achilles tendon.
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Happy scanning,
Steve Bird
Absolutely brilliant video! Seen these a couple of times in the achilles in my students as incidental and asymptomatic findings. Not as extensive as in this case though.
It was an extensive collection of them!!
Steve
I was also surprised by the extent. It makes a very pretty ultrasound appearance. Nice on the plain radiograph as well.
Steve
Very good and informative video!
If we're talking shoulders, somtimes in what we call the acute calcific schoulder, you can se the whole supraspiantus in a cloud like apperence, how far from the enthesis might it be able to travel?
Reegards Christian
Yes! this can be impressive and also very painful. The rule with hydroxyapatite is that it must come through an enthesis. So it must be adjacent to the enthesis. Once it it is the tendon it can track along the tendon for quite some length and oftern forms a fairly linear pathway along the tendon fibres. But it is always in contact with the enthesis where it is originating from!
Steve
When you speak about hydroxyapatite depositions (synonym for a 'regular' calcification?) only forming at the enthesis, would that be the result of compressive forces of the bone against the tendon creating hypoxia?
And sometimes I do think I see calcifications in the middle of a patellar tendon or achilles tendon, though rarely. In most cases they were related to a stump trauma against the tendon, at least in my experience. Would you call these dystrophic calcifications? And is heterotopic ossification within an achilles tendon also a possibility? How would you distinguish between these in an ultrasound image?
Would love to hear your thoughts on this.
Yes, hydroxyapatite is calcific tendinosis. Same thing. It happens at the enthesis only as the hydroxyapatite is a bone salt and needs to migrate from the bone, through the enthesis into the degenerative tendon. Then it can migrate back as well! So it is always adjacent to the enthesis, and you can see it easily on a plain radiograph.
The mid patellar or Achilles calcifications are dystrophic calcifications from old tendinosis, tear, trauma etc. I can't distinguish from heterotypic ossification on ultrasound, but the radiographs may be able to differentiate. They are going to be ignored either way.
Steve
@@birdultrasound4653 so these enthesofytes at the insertion of the achilles that grow out from the bone can resolve itself? Never heard this before, interesting.
@@NiekVink Enthesophytes are a little different. An enthesophyte is gone growing into an adjacent soft tissue structure like a tendon, ligament or retinaculum. An enthesophyte occurs due to a problem at the enthesis. The enthesis organ unit is designed to keep the osteocytes on the bone side and the tenocytes on the soft tissue side. When the enthesis is damaged by traction stresss or by a seronegative arthritis insult the osteocytes can grow into the adjacent soft tissue. So the enthesophyte is actually a peninsula of bone growing into the tendon territory. As it is made of actual bone it is not reversible and once you have an enthesophyte it is yours to keep forever. This is different from calcific tendinosis (hydroxyapatite) which is a bone salt that can pass from the bone, through the enthesis into the tendon and then may pass back again so it is something that can resolve with time.
Steve