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Extended report
Validation of ultrasound imaging for Achilles entheseal fibrocartilage in bovines and description of changes in humans with spondyloarthritis
  1. Sibel Zehra Aydin1,
  2. Emine Bas2,
  3. Onur Basci3,
  4. Emilio Filippucci4,
  5. Richard J Wakefield1,
  6. Çiğdem Çelikel2,
  7. Mustafa Karahan3,
  8. Pamir Atagunduz5,
  9. Mike Benjamin6,
  10. Haner Direskeneli5,
  11. Dennis McGonagle1
  1. 1Section of Musculoskeletal Diseases, The Leeds Institute of Molecular Medicine, University of Leeds and Chapel Allerton Hospital, Leeds, UK
  2. 2Marmara University Faculty of Medicine, Pathology, Istanbul, Turkey
  3. 3Marmara University Faculty of Medicine, Orthopedics, Istanbul, Turkey
  4. 4Clinica Reumatologica, Università Politecnica delle Marche, Ancona, Italy
  5. 5Marmara University Faculty of Medicine, Rheumatology, Istanbul, Turkey
  6. 6Cardiff University, Cardiff, UK
  1. Correspondence to Dr Sibel Zehra Aydin, University of Leeds, Section of Musculoskeletal Disease, Chapel Allerton, LS7 4SA Leeds, UK; drsibelaydin{at}


Background Entheseal fibrocartilage (EF) derangement is hypothesised to be pivotal to the pathogenesis of spondyloarthritis. Ultrasound is useful for visualisation of the enthesis but its role in EF visualisation is uncertain. This work aimed to demonstrate face and content validity of ultrasound for EF visualisation both by bovine histological evaluation and EF imaging in spondyloarthritis.

Methods Achilles enthesis of 18 bovine hindfeet was visualised using a MyLab 70 ultrasound machine. The presence of tissue with EF characteristics was documented and histological confirmation was performed on five randomly selected sections using Masson trichrome staining. Ultrasound of the Achilles tendon (AT) was performed in 19 patients with spondyloarthritis and 21 healthy controls (HC).

Results The bovine EF could be visualised in all cases and seen as a thin, uncompressible, well-defined, anechoic layer between the hyperechoic bone and the hyperechoic fibrils of the enthesis both in longitudinal and transverse scans. This region corresponded to EF on histological examination. The same pattern of low signal corresponding to EF location was seen in 17/19 patients and all HC. Discontinuities of the anechoic layer around the erosions and enthesophytes were observed in the spondyloarthritis group. The thickness of the anechoic layer was not significantly different in spondyloarthritis and HC (0.5±0.1 vs 0.5±0.2 mm, p=0.9) whereas the thickness of the EF was greater in men (0.6±0.2 vs 0.5±0.1 mm; p=0.009) compared with women.

Conclusion Ultrasound can visualise EF of the AT insertion, which can be abnormal in cases of spondyloarthritis. This has implications for a better understanding of enthesopathy.

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  • Funding SZA was funded by the Articulum Fellowship.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the Ethical Committee of Marmara University Medical School.

  • Provenance and peer review Not commissioned; externally peer reviewed.