[Isolated synovial chondromatosis of the subacromial bursa: report of a new case and review of the literature]

Synovial chondromatosis is a rare metaplasia of the synovium of unknown etiology that may involve occasionally the subacromial bursa. We report a new case diagnosed by ultrasound in a 30-year-old man and we present pathogenetic, diagnostic and therapeutic features of this disease with a literature review.

Coracoclavicular joint degeneration, an unusual cause of painful shoulder: a case report

A case of painful shoulder in a 42-year old right-hand dominant Caucasian female due to degeneration of the coracoclavicular joint is described. The pain was aggravated by weight lifting. The diagnosis was confirmed radiographically with simple plain films and clinically by the injection of local anaesthetic (xylocaine 2%) that lead to the exclusion of any other concomitant pathology of the acromioclavicular joint and the anterior subacromial space. The patient was treated successfully with an intraarticular steroid injection, and 30 months later she remains free of symptoms.

A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients

The purpose of this study was to compare acromioclavicular (AC) joint magnetic resonance imaging (MRI) findings in asymptomatic patients with those in symptomatic patients. The MRI scans of 25 patients with symptomatic AC joints were compared with 50 asymptomatic control subjects by use of the same grading scale. In the symptomatic group, AC joint arthritis grading was normal in 0%, mild in 20%, moderate in 52%, and severe in 28%. In the asymptomatic group, grading was normal in 18%, mild in 66%, moderate in 12%, and severe in 4%; there was a statistically higher grade of AC arthritis in the symptomatic group (P < .05). Of the symptomatic individuals, 80% demonstrated reactive bone edema in either the distal clavicle (6), the acromion (3), or both sides of the AC joint (11), whereas no individual in the asymptomatic group had this finding (P < .05). Reactive bone edema on MRI is a more reliable predictor of symptomatic AC pathology than degenerative changes seen on MRI and, when correlated with clinical examination, is reproducible.

The short term effects of a single corticosteroid injection on the range of motion of the shoulder in patients with isolated acromioclavicular joint arthropathy

This study is aimed at evaluating the short-term effects of a single corticosteroid injection of the acromioclavicular joint on the range of motion of the shoulder joint using a three dimensional electromagnetic tracking system (FASTRAK) in patients with isolated unilateral acromioclavicular joint (ACJ) arthropathy. Eighteen patients (16 male, 2 female; mean age: 47.53 years), with isolated unilateral ACJ arthropathy were included in the study. Injection of the symptomatic ACJ with local anaesthetic and corticosteroid was performed under image intensifier guidance. Bilateral shoulder FASTRAK assessment before and two weeks after injection of the symptomatic ACJ was performed, measuring flexion/extension, anatomical abduction, scapular abduction and horizontal cross body adduction. Pain was measured using a visual analogue scale. There was a significant difference in the range of movement between the symptomatic and asymptomatic shoulder before the injection (p < 0.01). Range of extension and pain score of the symptomatic shoulder improved significantly (p < 0.05 and p < 0.001, respectively) after the injection. In patients with radiographical evidence of degenerative ACJ disease, there was also significant improvement in the range of horizontal flexion (p < 0.05). Injection of the ACJ with local anaesthetic and corticosteroid was found to produce short-term pain relief and partial improvement in the range of movement. FASTRAK is useful in the measurement and documentation of range of motion, and can be used to assess the treatment outcome in patients with isolated ACJ arthropathy.

Acromial spur: relationship to aging and morphologic changes in the rotator cuff

This study's objective is to elucidate the relationship between acromial spur formation and rotator cuff pathology or aging. The subjects comprised 1029 shoulders in control, cadaveric, and operative groups. A radiograph in the supraspinatus outlet view was taken in all subjects. The lengths of the incident spurs were measured and classified into 3 sizes (small, <5 mm; medium, <10 mm; and large, > or =10 mm). The rotator cuff was macroscopically classified as normal or as having bursal-side fraying, joint-side tear, intratendinous tear, bursal-side tear, complete tear limited to the supraspinatus tendon, or massive tear. In the control group, the overall incidence of spurs and spur size increased with advancing age (P < .001), but the majority of spurs were small (<5 mm). In the cadaveric group, the overall incidence did not correlate with advancing age (P > .05). However, spur size increased with age in subjects aged 50 years or older (P < .001). The incidence of spurs in rotator cuffs with bursal-side tears was highest and was significantly higher than that in normal cuffs and cuffs with bursal-side fraying and intratendinous tears. We observed 40% of medium spurs and 69% of large spurs in cases with bursal-side tears, complete tears limited to the supraspinatus tendon, and massive tears. In the operative group, the overall incidence correlated to advancing age (P < .001), reaching 80% or more in subjects aged 30 years or older. In addition, the size of spurs was larger than that in the other 2 groups in all age groups with few exceptions (P < .05). Small spurs were associated with advancing age. Morphologic change to the bursal side of the rotator cuff may enhance spur growth. The presence of a small spur has no diagnostic value for rotator cuff tears. Spurs measuring 5 mm or more, however, are of diagnostic value because of their high rate of association with bursal-side tear, complete tears limited to the supraspinatus tendon, or massive tears.

Septic arthritis of the acromioclavicular joint

Septic arthritis of the acromioclavicular (AC) joint is a rare but rapidly destructive etiology of acute shoulder pain. We report a case of septic AC joint in the absence of trauma or intravenous drug use. A diabetic man presented with severe right shoulder pain and was later diagnosed with septic arthritis of the AC joint by magnetic resonance imaging (MRI) and positive blood cultures. Chronic diabetic foot ulcers were the source of the patient's group B streptococcus bacteremia.

Acromioclavicular joint osteoarthritis

The purpose of this study was to determine the correlation between routine radiography and magnetic resonance (MR) imaging in the analysis of the acromioclavicular (AC) joint osteoarthritis (OA). MR imaging studies of the shoulder in 50 patients performed over a 1-year period at a single institution with corresponding conventional radiographic examinations performed within 1 month of the MR imaging study were restrospectively evaluated by the consensus of two musculoskeletal radiologists with special attention to the AC joint. As conclusion, information provided by conventional radiography in the analysis of AC joint OA does not correlate with that provided by MR imaging. AC joint OA is more frequently detected with MR imaging than with radiography. MR imaging provides better assessment of the full extent of AC joint OA and its effect on the underlying RC.

Correlation of ultrasonographic findings to Tossy's and Rockwood's classification of acromioclavicular joint injuries

The aim of this study was to examine the value of ultrasonography to assess high-graded acromioclavicular (AC) joint injuries. We propose a new sonographic technique to evaluate the state of the soft tissues, specifically the deltoid and trapezoid muscles and their common fascia. Radiologic findings graded by Tossy's and Rockwood's classification were compared with sonographic findings for 92 patients with high-grade injuries of the AC joint. Of the 92 patients, 39 underwent operative treatment. A total of 36 patients were radiographically classified as type II and 56 with type III injuries, according to Tossy. In 4 cases, ultrasonography displayed disrupted insertions of the deltoid and, in 30 patients, of the trapezius muscle. All patients classified as type V, eight of 18 patients classified as type IV, nine of 31 patients classified as type III and two of 28 patients classified as type II injuries, according to Rockwood's classification, displayed a disrupted deltoid and trapezius insertion and common fascia on ultrasound (US). Comparison between sonographic and intraoperative findings revealed a sensitivity for diagnosing delta muscle detachment and fascial disruption of 100%. No true-negative results occurred. For trapezius muscle detachment, 24 of 30 patients were diagnosed correctly and nine true-negative results occurred. False-positive results were not encountered. The sensitivity was 80%. The specificity was 100%. We conclude that US provides additional information concerning soft tissues and that it may be useful to delineate type III injuries, in which nonoperative vs. operative treatment is still being debated. Diagnosis based only on sagittal X-ray examination may under- or over-estimate the soft tissue injury involved. Additional transaxillary X-ray as well as an US evaluation may need to be included in the diagnostic process. We propose this new sonographic technique for future studies.

Acromioclavicular joint cyst: nine cases of a pseudotumor of the shoulder

OBJECTIVE

(1) To analyse the imaging appearances of nine patients with acromioclavicular joint cysts presenting as shoulder masses for tumor staging with operative, histopathological and joint aspiration findings.

DESIGN AND PATIENTS

Retrospective review of imaging and correlation with clinical, operative and surgical notes. Images were reviewed by two musculoskeletal radiologists by consensus. Nine patients who presented clinically with a shoulder mass were evaluated by radiographs (n=9), ultrasound (n=1), conventional arthrography (n=3), MRI (n=6; with direct MR arthrography n=2, indirect MR arthrography n=4).

RESULTS

All patients had a focal mass superior to the AC joint, with a size ranging from 1.5 cm to 6 cm and a mean of 3.27 cm. Correlation was available with surgery (n=7), histopathology (n=2) and cyst aspiration (n=2). Two patients were managed conservatively. Geyser sign was positive in all three arthrograms. All MRIs revealed extensive rotator cuff tears with a column of fluid extending from the glenohumeral joint through the rotator cuff tear into the acromioclavicular joint and acromioclavicular cyst. Chondrocalcinosis was seen in the acromioclavicular joint cyst (n=2) and in the glenohumeral joint (n=1). Aspirate in two patients contained calcium pyrophosphate dihydrate crystals.

CONCLUSION

Acromioclavicular joint cysts may present as a tumor mass. They are associated with extensive rotator cuff tears and there is usually communication of the cyst with the joint space. This feature excludes a diagnosis of tumor. AC joint cysts may be associated with calcium pyrophosphate dihydrate deposition disease.

The causes of pain in benign solitary enchondromas of the proximal humerus

Patients with benign solitary enchondromas of the proximal humerus frequently present to the diagnosing physician with shoulder pain. Once the lesion is considered benign, emphasis can be placed on identifying the etiology for the pain. We reviewed our experience with these patients to identify the cause of the presenting pain. A retrospective review of clinical records and radiographic studies (radiographs, magnetic resonance images, and bone scans) was done for all patients presenting to an orthopaedic oncology unit with solitary enchondroma of the proximal humerus. Attention was focused on diagnostic evidence of additional disease in the shoulder. Fifty-seven patients (mean age, 53.6 years) met the criteria of the study and were included for evaluation. Of patients presenting with pain, 82% (47 of 57 patients) had findings seen on magnetic resonance imaging scans that correlated with the initial clinical diagnostic impression, suggesting that other disease was present that could explain the pain. Solitary enchondromas of the proximal humerus often are found incidentally during the initial evaluation of patients with shoulder pain. This study showed that additional treatable disease usually is present in patients with enchondromas of the proximal humerus.

Direct arthroscopic distal clavicle resection: a technical review

Degenerative change involving the acromioclavicular (AC) is frequently seen as part of a normal aging process. Occasionally, this results in a painful clinical condition. Although AC joint symptoms commonly occur in conjunction with other shoulder pathology, they may occur in isolation. Treatment of isolated AC joint osteoarthritis is initially non-surgical. When such treatment fails to provide lasting relief, surgical treatment is warranted. Direct (superior) arthroscopic resection of the distal (lateral) end of the clavicle is a successful method of treating the condition, as well as other isolated conditions of the AC joint. The following article reviews appropriate patient evaluation, surgical indications and technique.

The acromioclavicular joint

Acute injuries of the AC joint have a limited differential diagnosis. A thorough examination and appropriate radiographs can identify nearly all problems while ruling out tumors as a causal factor. AC injury frequently occurs with other fractures, dislocations, or soft tissue injury around the shoulder. The single unifying diagnosis one searches for in medical conditions is frequently absent in musculoskeletal injury. For effective management of AC separations, the primary care physician need only distinguish type I, II, and III injuries from surgically treated type IV, V, and VI injuries. Types I, II, and III injuries should be treated with pain control and progressive rehabilitation as described previously. Patients who have types IV, V, and VI injuries should be referred to an orthopedic surgeon. Chronic injuries of the AC joint are also clearly diagnosed by appropriate physical examination and radiographs. Steroid injections can aid in the diagnosis and management of these conditions. Injury to one shoulder component predisposes to other shoulder injuries. A thorough examination will reveal these other associated abnormalities that may not be part of the presenting complaint. With practice in the examination of the shoulder and intra-articular injections, the primary care physician can effectively treat most common AC conditions. Only after conservative measures fail is it necessary to refer the patient for surgical management.

Synovial chondromatosis of the acromioclavicular joint

A 53-year-old woman presented with swelling of 3 years' duration on the right anterior chest wall. A radiograph showed coarse calcifications around the subclavicular region and erosion of the ipsilateral acromioclavicular joint. Computed tomography also showed calcifications in soft tissue. Magnetic resonance imaging revealed a tumor around the clavicle extending to the anterior aspect of chest wall, which had low signal intensity on T1-weighted imaging and high signal intensity on T2-weighted imaging. The histologic findings were of a hyaline cartilage-like mass consisting of mature chondrocytes and an extracellular matrix. The histologic diagnosis of synovial chondromatosis was made. The present case is unusual in respect of the location and size of the tumor.

A serial comparison of arthroscopic repairs for partial- and full-thickness rotator cuff tears

PURPOSE

To compare the outcome of arthroscopic rotator cuff repair and subacromial decompression in partial-thickness rotator cuff tears (PTRCT) with those in full-thickness rotator cuff tears (FTRCT).

TYPE OF STUDY

Prospective serial follow-up study.

METHODS

Of 46 consecutive patients who were treated with arthroscopic rotator cuff repair, 42 patients who were followed-up serially for 2 years were enrolled as study subjects. The average age of the patients at the time of the operation was 55 years, and the mean duration of follow-up was 34 months. The subjects included 22 cases of PTRCT and 20 cases of FTRCT.

RESULTS

At the final follow-up, the PTRCT group showed changes in scores from 7.2 to 0.9 for average pain and from 34 to 91 for the shoulder functional evaluation score of the American Shoulder and Elbow Society (ASES score). The FTRCT group showed changes in scores from 7.6 to 1.2 for pain and from 29 to 88 for the ASES score. There were no significant differences between the 2 groups ( P >.05). The average range of shoulder motion was significantly improved in both groups at the final follow-up versus their preoperative values. Evaluation at the final follow-up showed that 93% of the total subjects showed good or excellent results, and 95% showed satisfactory results with regard to pain reduction and functional outcomes. The 2 fair results were the result of acromioclavicular arthritis.

CONCLUSIONS

It may be anticipated that arthroscopic rotator cuff repair and subacromial decompression will give satisfactory postoperative outcomes in both PTRCT and FTRCT in terms of pain relief and functional recovery. However, careful preoperative examination of the acromioclavicular joint is critical to avoid procedural failure.

LEVEL OF EVIDENCE

Level IV.

Shoulder arthroscopy: principles and practice

Shoulder arthroscopy has an expanding role in the diagnostic and therapeutic management of shoulder disorders. This article describes the principles of shoulder arthroscopy, including basic technique,indications, and complications. The clinical applications to several shoulder pathologies, such as rotator cuff disorders, glenohumeral instability, and biceps anchor superior lesions, ar reviewed.

Isolated Acromioclavicular Joint Pathology in the Symptomatic Shoulder on Magnetic Resonance Imaging

The acromioclavicular (AC) joint is a synovial joint that is predisposed to painful syndromes because of mechanical stress or developmental variation. It is often overlooked in the evaluation of patients with shoulder pain, however. Isolated AC joint pathology was studied on magnetic resonance imaging scans of patients with symptoms suggesting rotator cuff pathology. The conditions identified included osteoarthritis, distal clavicle osteolysis, and os acromiale syndrome.

Magnetic resonance imaging of the coracoclavicular ligaments: its role in defining pathoanatomy at the acromioclavicular joint

Four patients with acromioclavicular joint injuries (one type II, two type III, one type V), two patients without acromioclavicular joint injury, and a fresh-frozen cadaver underwent magnetic resonance imaging (MRI) and plain radiographs. The normal conoid and trapezoid ligaments were easily identified in the cadaver and the two uninjured patients. Magnetic resonance imaging revealed disruption of both coraclavicular ligaments in the three patients with type II and type III injuries. However, the patient with the type V injury had disruption of the trapezoid ligament alone. Thus, the grade of injury, as determined by the change in the coracoclavicular interval onplain radiography and defined by the Rockwood classification system, failed to correlate with the pathoanatomy seen on MRI in two of the four injured patients. These findings suggest that improvements in the classification of these injuries may be necessary.

Vascular endothelial growth factor 121 and 165 in the subacromial bursa are involved in shoulder joint contracture in type II diabetics with rotator cuff disease

Vascular endothelial growth factor (VEGF) is a glycoprotein that plays an important role in neovascularization and increases vascular permeability. We reported that VEGF is involved in motion pain of patients with rotator cuff disease by causing synovial proliferation in the subacromial bursa (SAB). The present study investigates whether VEGF is also involved in the development of shoulder contracture in diabetics with rotator cuff disease. We examined 67 patients with rotator cuff disease, including 36 with complete cuff tears, 20 with incomplete tears, and 11 without apparent tears (subacromial bursitis). The patients were into groups according to the presence or absence of diabetes (14 type II diabetics and 53 non-diabetics). Specimens of the synovium of the SAB were obtained from all patients during surgery. Expression of the VEGF gene in the synovium of the subacromial bursa was evaluated by using the reverse transcriptase polymerase chain reaction. The VEGF protein was localized by immunohistochemistry, and the number of vessels was evaluated based on CD34 immunoreactivity. The results showed that VEGF mRNA was expressed in significantly more diabetics (100%, 14/14) than in non-diabetics (70%, 37/53) (P=0.0159, Fisher's test). Investigation of VEGF isoform expression revealed VEGF121 in all 14 diabetics and in 37 of the 53 non-diabetics, VEGF165 in 12 of the 14 diabetics and in 21 of the 53 non-diabetics, and VEGF189 in 1 of the 14 diabetics and in 2 of the 53 non-diabetics. No VEGF206 was expressed in either group. VEGF protein was localized in both vascular endothelial cells and synovial lining cells. The mean number of VEGF-positive vessels and the vessel area were also significantly greater in the diabetics (p<0.015, Mann-Whitney U test). Synovial proliferation and shoulder joint contracture were more common in the diabetics (P=0.0329 and P=0.073, respectively; Fisher's test). The mean preoperative range of shoulder motion significantly differed in terms of elevation between two groups: 103.8 degrees in diabetics and 124.9 degrees in no diabetics (p=0.0039 Mann-Whitney U test). In contrast, external rotation did not significantly differ: 44 degrees in diabetics and 49 degrees in non-diabetics (p=0.4957, Mann-Whitney U test). These results suggest that VEGF121 and VEGF165 expression in the SAB is responsible for the development of shoulder joint contracture, especially in elevation, among type II diabetic patients with rotator cuff disease.

Prevalence of osteophytes associated with the acromion and acromioclavicular joint

Osteophytes as a stigma for shoulder impingement syndrome and osteoarthritis of the acromioclavicular (AC) joint were studied on the acromions and AC joints in 346 skeletons (230 males; 116 females), ranging in age from 15-100 years. Osteophytes were found on 28.9% (200/692) of the acromions, mostly on the anteroinferior aspect (54%; 108/200). Of these 28.9%, 87% (174/200) were of the traction type and 13% (26/200) of the claw type. Regarding the clavicles, 11.6% (80/692) had osteophytes on the articular facets of their lateral ends; all were of the traction type. There were statistically more osteophytes on the right than on the left side of both acromion and clavicle (P < 0.05). The occurrence of osteophytes and increasing age were significantly correlated (r = 0.65, P < 0.001). No gender differences were noted in the frequency of osteophytes on acromions or clavicles. These data should prove beneficial to clinicians in planning a proper course of treatment for patients suffering from painful conditions of the shoulder.

MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection

OBJECTIVE

Our objective was to evaluate the predictive value of various MRI findings in the acromioclavicular joint for pain relief after intraarticular injection.

MATERIALS AND METHODS

The acromioclavicular joint of 50 patients (20 women, 30 men; mean age, 51 years; range, 25-75 years) was evaluated on MRIs of the shoulder. Osteophytes, subchondral cysts and irregularities, bone marrow edema, joint effusion, and joint capsule hypertrophy were assessed by two musculoskeletal radiologists in consensus. Local anesthetics were injected into the acromioclavicular joint with fluoroscopic guidance. Patients graded pain relief on a visual analogue scale (0-100%) after 15 min. The relationship between pain relief and MRI findings was assessed with the Mann-Whitney U test. Pain relief equal to or greater than 70% was rated as a positive response to the injection. This cutoff value was used to calculate sensitivity, specificity, accuracy, and predictive values of the various MRI findings in determining which acromioclavicular joints were responsive to joint injections.

RESULTS

Mean pain relief after injection was 38%. Pain relief was significantly related to capsular hypertrophy (p = 0.007) and was equal to or greater than 70% in 11 patients. The sensitivity in diagnosing a successful injection (range, 9-82%) was highest for caudal osteophytes (82%) and capsular hypertrophy (73%). The specificity (range, 51-97%) was highest for subchondral cysts (97%), subchondral bone marrow edema (95%), and joint effusion (92%).

CONCLUSION

Pain relief after intraarticular injection is significantly related to capsular hypertrophy diagnosed on MRI. MRI findings have a reasonable sensitivity and a high specificity in predicting relevant short-term pain relief after intraarticular injection.

Clinical testing for tears of the glenoid labrum

PURPOSE

With the increasing use of shoulder arthroscopy, diagnosis of glenoid labral lesions has become increasingly common. However, a physical examination maneuver that would allow a definitive clinical diagnosis of a glenoid labral tear, and more specifically a SLAP lesion, has been elusive. This study correlated the results of commonly used examination maneuvers with findings at shoulder arthroscopy. The working hypothesis was that 7 commonly used clinical tests, alone or in logical combinations, would provide diagnoses with reliability greater than the accepted standards for magnetic resonance imaging arthrography; i.e., greater than 95% sensitivity and specificity.

TYPE OF STUDY

Consecutive sample, sensitivity-specificity study.

METHODS

Sixty shoulders undergoing arthroscopy for a variety of pathologies were examined before surgery. All subjects submitted to the Speed test, an anterior apprehension maneuver, Yergason test, O'Brien test, Jobe relocation test, the crank test, and a test for tenderness of the bicipital groove. The examination results were compared with surgical findings and analyzed for sensitivity and specificity in the diagnosis of SLAP lesions and other glenoid labral tears.

RESULTS

The results of the O'Brien test (63% sensitive, 73% specific) and Jobe relocation test (44% sensitive, 87% specific) were statistically correlated with presence of a tear in the labrum and the apprehension test approached statistical significance. Performing all 3 tests and accepting a positive result for any of them increased the statistical value, although the sensitivity and specificity were still disappointingly low (72% and 73%, respectively). The other 4 tests were not found to be useful for labral tears, and none of the tests or combinations were statistically valid for specific detection of a SLAP lesion.

CONCLUSIONS

Clinical testing is useful in strengthening a diagnosis of a glenoid labral lesion, but the sensitivity and specificity are relatively low. Thus a decision to proceed with surgery should not be based on clinical examination alone.