More severe supraspinatus tendon degeneration on the contralateral shoulders in patients treated for symptomatic rotator cuff tears compared to healthy controls: a quantitative MRI-based study

BACKGROUND

Patients treated for symptomatic rotator cuff tear (RCT) on one shoulder seem to have a higher prevalence of RCT on the contralateral shoulder.

PURPOSE

To compare the supraspinatus (SSP) tendon and RC muscle properties on the contralateral shoulder in patients after repair surgery to those healthy individuals using quantitative magnetic resonance imaging (MRI).

MATERIAL AND METHODS

A total of 23 patients treated for RCT (group A) and 23 healthy controls (group B) were recruited. Constant score, visual analog scale score (VAS), and MRI examinations were conducted. The SSP tendon structural status was graded based on the Zlatkin classification and quantified on ultrashort echo time (UTE)-T2* mapping images. Fatty degeneration of RC muscles was classified according to the Goutallier classification and quantified on T2 mapping.

RESULTS

The Constant and VAS scores were comparable between groups A and B (all P >0.05). No significant differences were observed in tendon structural status between the two groups (P >0.05). However, significant differences were established in UTE-T2* values of the SSP tendon on the distal subregion between groups A and B (16.4 ± 2.4 ms vs. 14.8 ± 1.2 ms; P = 0.01). Regarding muscle degeneration, no significant differences were displayed in T2 values and Goutallier classification of RC muscles (all P >0.05).

CONCLUSION

Patients with a treated RCT demonstrated inferior SSP tendon in the distal subregion on the contralateral shoulders one year postoperatively compared to that of healthy controls based on quantitative MRI data.

Percutaneous bone marrow concentrate and platelet products versus exercise therapy for the treatment of rotator cuff tears: a randomized controlled, crossover trial with 2-year follow-up

BACKGROUND

Surgical repair is recommended for the treatment of high-grade partial and full thickness rotator cuff tears, although evidence shows surgery is not necessarily superior to non-surgical therapy. The purpose of this study was to compare percutaneous orthobiologic treatment to a home exercise therapy program for supraspinatus tears.

METHODS

In this randomized-controlled, crossover design, participants with a torn supraspinatus tendon received either 'BMC treatment', consisting of a combination of autologous bone marrow concentrate (BMC) and platelet products, or underwent a home exercise therapy program. After three months, patients randomized to exercise therapy could crossover to receive BMC treatment if not satisfied with shoulder progression. Patient-reported outcomes of Numeric Pain Scale (NPS), Disabilities of the Arm, Shoulder, and Hand, (DASH), and a modified Single Assessment Numeric Evaluation (SANE) were collected at 1, 3, 6, 12, and 24 months. Pre- and post-treatment MRI were assessed using the Snyder Classification system.

RESULTS

Fifty-one patients were enrolled and randomized to the BMC treatment group (n = 34) or the exercise therapy group (n = 17). Significantly greater improvement in median ΔDASH, ΔNPS, and SANE scores were reported by the BMC treatment group compared to the exercise therapy group (-11.7 vs -3.8, P = 0.01; -2.0 vs 0.5, P = 0.004; and 50.0 vs 0.0, P < 0.001; respectively) after three months. Patient-reported outcomes continued to progress through the study's two-year follow-up period without a serious adverse event. Of patients with both pre- and post-treatment MRIs, a majority (73%) showed evidence of healing post-BMC treatment.

CONCLUSIONS

Patients reported significantly greater changes in function, pain, and overall improvement following BMC treatment compared to exercise therapy for high grade partial and full thickness supraspinatus tears.

TRIAL REGISTRATION

This protocol was registered with www.

CLINICALTRIALS

gov (NCT01788683; 11/02/2013).

The value of combined ultrasound contrast arthrography and subacromial-subdeltoid bursography for detecting and differentiating the rotator cuff tear subtypes in patients with the uncertain rotator cuff tear

OBJECTIVES

In this study, ultrasound (US) contrast arthrography and subacromial-subdeltoid bursography with the contrast agent of SonoVue were performed to evaluate their value for detecting and differentiating the rotator cuff tear (RCT) subtypes in patients with the uncertain RCT.

METHODS

A total of 102 patients with the clinically suspected RCTs in the orthopedic clinic were prospectively recruited and underwent conventional high-frequency US for the category of undoubted full-thickness RCT, uncertain RCT, and intact rotator cuff. Among these patients, the patients with uncertain RCT underwent the subsequent US contrast arthrography and subacromial-subdeltoid bursography. The arthroscopic findings were used as the gold standard in this study.

RESULTS

After the conventional US screening, 62 patients with uncertain RCT underwent the subsequent US contrast arthrography and subacromial-subdeltoid bursography. All the US contrast arthrography and subacromial-subdeltoid bursography were successfully performed and no severe side effects were observed in all the patients. For full-thickness tears, the sensitivity and specificity of the combined US contrast arthrography and subacromial-subdeltoid bursography were 94.7% (CI: 0.72-1.0) and 81.4% (CI: 0.66-0.91), respectively, and for articular-side tears 100% (CI: 0.51-1) and 100% (CI: 0.92-1), respectively, and for the bursal-side tears 84.6% (CI: 0.54-0.97) and 97.9% (CI: 0.88-1.0), respectively. The main inconsistency between the contrast-enhanced US and arthroscopy was that 7 patients with arthroscopic proved concurrent articular- and bursal-side tears were indicated as full-thickness RCTs on contrast-enhanced US.

CONCLUSIONS

Combined US contrast arthrography and subacromial-subdeltoid bursography are useful for detecting the RCT subtypes in patients with the uncertain RCTs.

CLINICAL RELEVANCE STATEMENT

When conventional high-frequency US has some difficulty in differentiating the full-thickness from partial-thickness RCTs, combined US contrast arthrography and subacromial-subdeltoid bursography could be used to improve the detection accuracy of RCT subtypes.

KEY POINTS

• This is the first study by injection of the US contrast agent SonoVue into the shoulder joint cavity and subacromial-subdeltoid bursa for the detection and differentiation of the RCT subtypes among the people with the uncertain RCT by conventional US screening. • The SonoVue was injected into the glenohumeral joint cavity under US guidance to differentiate the full-thickness RCTs from partial-thickness RCTs. • Combined US contrast arthrography and subacromial-subdeltoid bursography are useful for detecting the RCT subtypes in patients with the uncertain RCTs.

Effect of Porcine-Derived Absorbable Patch-Type Atelocollagen for Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Trial

BACKGROUND

Even though arthroscopic rotator cuff repair is recognized as a standard treatment option, the risk of postoperative retear is a major concern.

PURPOSE

To evaluate the effect of porcine-derived absorbable patch-type atelocollagen during arthroscopic rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 64 patients with rotator cuff tears diagnosed on magnetic resonance imaging (MRI) were enrolled prospectively from November 2020 to December 2021. Both groups had repairs using the suture bridge technique. For the atelocollagen group, before securing the lateral anchors, we inserted porcine-derived absorbable patch-type atelocollagen between the footprint and the tendon. On postoperative day 2, the patients underwent MRI to confirm containment of the patch-type atelocollagen. At 6 months and 1 year postoperatively, the signal intensity of the repaired tendon was assessed using MRI. Patients were evaluated using the Constant score as the primary outcome, along with the visual analog scale for pain; range of motion; American Shoulder and Elbow Surgeons score; University of California, Los Angeles, score; and Korean Shoulder Score preoperatively and at 2, 3, 6, and 12 months postoperatively.

RESULTS

No significant changes in the Constant score as primary outcome, pain or other functional scores, and range of motion were observed between the groups at 1 year postoperatively. The patch-type atelocollagen was confirmed to be contained by the time-zero MRI scan taken 2 days postoperatively. Among the 55 patients included in final analysis, 12 retear cases were recorded (21.8% retear rate). A significantly lower retear rate was found in the atelocollagen group, as 3 cases were observed in this group (10.3%) and 9 cases were observed in the conventional repair group (34.6%) (P = .048).

CONCLUSION

The Constant score was not different between the groups. The retear rate after rotator cuff repair was significantly lower in the group that received porcine-derived absorbable patch-type atelocollagen compared with in the conventional group.

REGISTRATION

KCT0005184 (Clinical Research Information Service [CRIS]; https://cris.nih.go.kr).

A systematic review on sonoelastography for rotator-cuff post-repair assessment

Surgical repair of rotator cuff tears is performed routinely; however, the risks of re-tears and the associated consequences are significant. Sonoelastography, an imaging modality that evaluates the mechanical properties of tissues, can examine the dynamic transitions in rotator cuff stiffness following retear and investigate the relationship between these changes and the occurrences of retears. This systematic review aimed to summarize the role of perioperative sonoelastography in repaired rotator cuffs. A comprehensive search of the PubMed, Embase, and Cochrane databases was conducted, covering studies published until June 19, 2023. The Newcastle-Ottawa scale was used for quality assessment. The key information extracted from each study included the injury/surgery type, follow-up duration, sonoelastography mode, and main sonoelastographic findings. Eleven eligible studies comprising 355 patients were included. All studies focused on supraspinatus muscles and tendons with previous arthroscopic repairs. During the postoperative 1st - 6th months, muscle stiffness increased in the supraspinatus and decreased in the ipsilateral deltoid. Failure to recover supraspinatus muscle elasticity might be indicative of potential tendon re-tear; however, it is imperative to first establish correlations with other imaging modalities. Conflicting findings have been observed regarding stiffening or softening of the supraspinatus tendon after surgical repair. The preoperative stiffness of the supraspinatus tendon did not correlate with postoperative tendon integrity or function.

A novel 3D MRI-based approach for assessing supraspinatus muscle length

Rotator cuff (RC) tears are a common source of pain and decreased shoulder strength. Muscle length is known to affect muscle strength, and therefore evaluating changes in supraspinatus muscle length associated with RC pathology, surgical repair, and post-operative recovery may provide insights into functional deficits. Our objective was to develop a reliable MRI-based approach for assessing supraspinatus muscle length. Using a new semi-automated approach for identifying 3D location of the muscle-tendon junction (MTJ), supraspinatus muscle length was calculated as the sum of MTJ distance (distance between 3D MTJ position and glenoid plane) and supraspinatus fossa length (distance between root of the scapular spine and glenoid plane). Inter- and intra-operator reliability of this technique were assessed with intraclass correlation coefficient (ICC) and found to be excellent (ICCs > 0.96). Muscle lengths of 6 patients were determined before RC repair surgery and at 3- and 12-months post-surgery. Changes in normalized muscle length (muscle length as a percentage of pre-surgical muscle length) at 3 months post-surgery varied considerably across patients (16.1 % increase to 7.0 % decrease) but decreased in all patients from 3- to 12-months post-surgery (0.3 % to 17.2 %). This study developed a novel and reliable approach for quantifying supraspinatus muscle length and provided preliminary demonstration of its utility by assessing muscle length changes associated with RC pathology and surgical repair. Future studies can use this technique to evaluate changes over time in supraspinatus muscle length in response to clinical intervention, and associations between muscle length and shoulder function.

Neuromuscular electrical stimulation of humeral adductors in subjects with rotator cuff tear

INTRODUCTION

In symptomatic patients with rotator cuff tear, MRI and radiographic studies have ascribed the pain symptom to insufficient humeral head depression during arm elevations. The arm adductors such as the teres major and pectoralis major may contribute to depression of the humerus head during arm elevations. Researchers have demonstrated that neuromuscular electrical stimulation (NMES) of the serratus anterior and lower trapezius can control scapular motions and improve acromiohumeral distance. It is unknown, however, if adductor neuromuscular training could help patients with rotator cuff tear.

MATERIALS AND METHODS

A cross-sectional study of NMES of the teres major and pectoralis major was conducted on 30 symptomatic subjects with rotator cuff tear. We measured the acromiohumeral distance by ultrasonography and scapular kinematics during arm elevation with a three-dimensional motion tracking system.

RESULTS

The acromiohumeral distance significantly increased during NMES of the teres major (0.73 mm, p < 0.001). However, the distance significantly decreased with NMES of the pectoralis major (0.78 mm, p < 0.001). Additionally, scapular upward rotation was greater during NMES of the teres major than during NMES of the pectoralis major (3.4°, p < 0.001). Scapular external rotation decreased significantly more during NMES of the pectoralis major than during NMES of the teres major (1.6°, p = 0.003).

CONCLUSIONS

NMES of the teres major can increase acromiohumeral distance and scapular upward rotation during arm elevation. However, the decreased upward and external rotation of the scapula during arm elevation with NMES of the pectoralis major may be associated with subacromial impingement.

Deep learning-based screening tool for rotator cuff tears on shoulder radiography

BACKGROUND

Early diagnosis of rotator cuff tears is essential for appropriate and timely treatment. Although radiography is the most used technique in clinical practice, it is difficult to accurately rule out rotator cuff tears as an initial imaging diagnostic modality. Deep learning-based artificial intelligence has recently been applied in medicine, especially diagnostic imaging. This study aimed to develop a deep learning algorithm as a screening tool for rotator cuff tears based on radiography.

METHODS

We used 2803 shoulder radiographs of the true anteroposterior view to develop the deep learning algorithm. Radiographs were labeled 0 and 1 as intact or low-grade partial-thickness rotator cuff tears and high-grade partial or full-thickness rotator cuff tears, respectively. The diagnosis of rotator cuff tears was determined based on arthroscopic findings. The diagnostic performance of the deep learning algorithm was assessed by calculating the area under the curve (AUC), sensitivity, negative predictive value (NPV), and negative likelihood ratio (LR-) of test datasets with a cutoff value of expected high sensitivity determination based on validation datasets. Furthermore, the diagnostic performance for each rotator cuff tear size was evaluated.

RESULTS

The AUC, sensitivity, NPV, and LR- with expected high sensitivity determination were 0.82, 84/92 (91.3%), 102/110 (92.7%), and 0.16, respectively. The sensitivity, NPV, and LR- for full-thickness rotator cuff tears were 69/73 (94.5%), 102/106 (96.2%), and 0.10, respectively, while the diagnostic performance for partial-thickness rotator cuff tears was low at 15/19 (78.9%), NPV of 102/106 (96.2%) and LR- of 0.39.

CONCLUSIONS

Our algorithm had a high diagnostic performance for full-thickness rotator cuff tears. The deep learning algorithm based on shoulder radiography helps screen rotator cuff tears by setting an appropriate cutoff value.

LEVEL OF EVIDENCE

Level III: Diagnostic Study.

Can coracoacromial ligament degeneration be evaluated with preoperative MRI?

BACKGROUND

Subacromial impingement syndrome is one of the most common causes of painful shoulder in the middle-aged and elderly population. Coracoacromial ligament (CAL) degeneration is a well-known indicator for subacromial impingement.

PURPOSE

To examine the relationship between CAL thickness on preoperative magnetic resonance imaging (MRI), arthroscopic CAL degeneration and types of rotator cuff tears.

MATERIAL AND METHODS

Video records of patients who underwent arthroscopic shoulder surgery between 2015 and 2021 were retrospectively scanned through the hospital information record system. In total, 560 patients were included in this study. Video records of the surgery were used to evaluate the grade of coracoacromial ligament degeneration and the type of cuff tear. Preoperative MRI was used to measure CAL thickness, acromiohumeral distance, critical shoulder angle, acromial index, and acromion angulation.

RESULTS

Significant differences were observed between grades of CAL degeneration in terms of CAL thickness (P < 0.001). As CAL degeneration increases, the mean of CAL thickness decreases. According to the results of post-hoc analysis, the mean CAL thickness of normal patients was significantly higher than those of patients with full-thickness tears (P = 0.024) and massive tears (P <0.001). Patients with articular-side, bursal-side, and full-thickness tears had significantly higher CAL thickness averages than patients with massive tears.

CONCLUSION

This study showed that the CAL thickness decreases on MRI as arthroscopic CAL degeneration increases. High-grade CAL degeneration and therefore subacromial impingement syndrome can be predicted by looking at the CAL thickness in MRI, which is a non-invasive method.

Rotator Cuff Injuries in the Pediatric Population: A Retrospective Review of Patient Characteristics and Treatment at a Single Center

BACKGROUND

As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce. A greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to better guide clinical decision-making.

HYPOTHESIS

To identify pediatric patients with magnetic resonance imaging-confirmed RCI treated at a single center to summarize injury characteristics, treatment, and outcomes. It was hypothesized that injuries would occur predominantly in overhead throwing athletes and would demonstrate good outcomes among both operatively and nonoperatively treated patients.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A retrospective review of pediatric patients (<18 years old) diagnosed with and treated for an RCI between January 1, 2011 and January 31, 2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was used to compare operatively and nonoperatively treated cohorts.

RESULTS

A total of 52 pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Mean age was 15 years and 67% of patients were male. Injuries were related most commonly to participation in throwing sports. Operative management occurred in 23% of patients, while 77% were managed nonoperatively. Treatment cohorts differed based on tear type, with all complete tears being managed operatively (P < 0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. Return to play was longer for operatively managed patients (7.1 vs 4.5 months; P < 0.01).

CONCLUSION

The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated with sports and involve the supraspinatus tendon. RCIs were associated with good outcomes and low rates of reinjury in patients managed both nonoperative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients.

CLINICAL RELEVANCE

This retrospective study fills the hole in the literature by detailing the patterns associated with RCI characteristics and treatment outcomes. In contrast to studies of adult RCIs, our results suggest that outcomes are good regardless of treatment type.

Higher Upper Subscapularis Goutallier Grade and Coracohumeral Distance Narrowing Are Predictive of Subscapularis Tears in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

To evaluate the relation between subscapularis (SSC) Goutallier grade or coracohumeral distance (CHD) and SSC tears, as well as the relation between these radiographic variables and long head of the biceps tendon lesions.

METHODS

A retrospective analysis was conducted on prospectively maintained data on patients who underwent arthroscopic rotator cuff repair of SSC tears between 2011 and 2021 with at least 6 months of follow-up. Patients with identified subscapularis tears during arthroscopy were included. A control group was established by randomly selecting patients without SSC tears from the same study period. Goutallier grading and CHD were obtained from preoperative magnetic resonance imaging (MRI) scans. Receiver operating characteristic analysis was conducted to define optimal cutoff values for these diagnostic measures.

RESULTS

The study included 735 patients with SSC tears and 249 patients in the control group. Comparing subscapularis tear and intact groups' Goutallier grades revealed significant differences in infraspinatus, upper and lower SSC, and overall SSC (P < .001). No significant difference was detected in supraspinatus Goutallier grade (P = .364). An SSC tear was observed in 58.3% (n = 265) of patients with Goutallier grade 0 of the upper SSC, 77.1% (n = 195) of patients with grade 1 changes, 98.7% (n = 155) with grade 2 changes, and 100% of grade 3 or 4 changes. Goutallier grade of the upper SSC showed a significant correlation with tear size (rs = 0.533; P < .01). CHD measurements were lower in individuals with SSC tears compared to those without tears (6.6 ± 1.7 vs 9.6 ± 1.8; P < .001). Upper SSC Goutallier grade >1 had an acceptable area under the curve (AUC) of 0.742. CHD of 7.96 mm or less had an excellent predictive AUC of 0.879.

CONCLUSIONS

Higher Goutallier grade and CHD narrowing are potential associations predictive of SSC tears. Routine MRI assessment of muscle of the upper SSC and the CHD can contribute to the diagnostic accuracy of SSC tears and offer valuable information regarding the severity of such tears.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Magnetic resonance imaging based coracoid process morphology and its associations with isolated subscapularis tendon tears in Chinese patients

OBJECTIVES

This study aims to assess the association between isolated subscapularis tears and coracoid morphology using magnetic resonance imaging (MRI) and to calculate the optimal cut-off values of the significant predictor to predict subscapularis tears.

PATIENTS AND METHODS

Between January 2018 and December 2022, a total of 60 patients (29 males, 31 females; mean age: 58.4±8.4 years; range, 18 to 80 years) diagnosed with subscapularis tendon tears who were treated as Group A and 60 patients (29 males, 31 females; mean age: 46.8±11.5 years; range, 18 to 80 years) without subscapularis tendon tears who were treated as Group B were included. Axial coracoid-humeral distance (aCHD), sagittal coracoid-humeral distance (sCHD), coracoid overlap (CO) and coracoid angle (CA) of all patients were measured. Logistic regression was used to investigate the association between subscapularis tears as variables including aCHD, sCHD, CO and CA. Receiver operating characteristic curve analysis was used to determine the diagnostic values of coracoid morphology for subscapularis tears.

RESULTS

The mean values of CO, aCHD and sCHD in Group A were 22.16 mm, 5.13 mm, and 5.56 mm, respectively. The mean values in Group B were 16.99 mm, 7.18 mm, and 7.29 mm, respectively. The degree of CA in Group A was 95.81 and 111.69 in Group B. The differences in the above measurement values were significant between two Groups. The CO was found to be associated with higher odds of subscapularis tears. The optimal cut-off value of CO was 19.79 mm.

CONCLUSION

Based on our study results, CO is positively associated with isolated subscapularis tears. In addition, coracoid bursa effusion, cysts in the lesser tuberosity or a tear and malposition of long head of the biceps tendon on MRI may predict the presence of a clinically significant subscapularis tear.

Pneumothorax during shoulder surgery

Background

Pneumothorax following shoulder arthroscopy, although rare, is documented in over 30 PubMed case reports as occurring during or within 10 hours post-procedure.

Case Presentation

A fit septuagenarian underwent a two-hour arthroscopic rotator cuff repair with IV anaesthesia and laryngeal mask airway, without a nerve block. With one hour remaining of the operation, the patient had desaturation and hypotension. Lung sliding was absent on ultrasound and x-ray confirmed left-sided tension pneumothorax. Successful thoracic drain insertion and lung re-expansion facilitated his recovery, allowing discharge after 24 hours and symptom-free status at 6 months.

Interpretation

This case highlights pneumothorax as an uncommon yet possible post-arthroscopic event. The speculated aetiology is the surgical procedure, where pump-induced pressure fluctuations may displace air into surrounding tissue. Instances of pneumomediastinum and subcutaneous emphysema without pneumothorax suggest arthroscopic origin of air. Prompt perioperative ultrasound can aid in detecting such critical complications.

Role of Critical Shoulder Angle in Degenerative Type Rotator Cuff Tears: A Turkish Cohort Study

BACKGROUND This retrospective study investigated the association between the critical shoulder angle (CSA) and the development of full-thickness rotator cuff tears (FTRCTs) in the Turkish population. The CSA is an imaging parameter that quantifies the relationship between the inclination of the glenoid and the lateral extension of the acromion in the coronal plane. The CSA is an anatomical measurement, and higher CSA values have been associated with an increased incidence of FTRCTs. However, there is a lack of data on CSA regarding the Turkish population. MATERIAL AND METHODS In this study, CSA measurements were recorded in 2 groups: 50 patients with FTRCT who had arthroscopic repair (group 1) and 50 age- and sex-matched individuals with no FTRCT detected by magnetic resonance imaging (group 2). Sex, age, affected side, dominant side, and smoking status were recorded for each patient. The CSA measurements of the affected sides were performed on true anterior-posterior view radiographs. RESULTS The results showed a statistically significant difference between the mean CSA values of group 1 (37.48°) and group 2 (33.53°), P<0.001. CSA values of 36 and above had a sensitivity of 73.58%, specificity of 74.47%, positive predictive value of 75%, and negative predictive value of 74.47% for detecting FTRCT. CONCLUSIONS CSA measurement on radiographs is a useful diagnostic tool in the Turkish population, and an above-average CSA value is associated with a significantly increased incidence of degenerative-type FTRCT.

Natural History of Quantitative Fatty Infiltration and 3D Muscle Volume After Nonoperative Treatment of Symptomatic Rotator Cuff Tears: A Prospective MRI Study of 79 Patients

BACKGROUND

The severity of fatty infiltration (FI) predicts the treatment outcome of rotator cuff tears. The purpose of this investigation was to quantitatively analyze supraspinatus (SSP) muscle FI and volume at the initial presentation and after a 3-month minimum of conservative management. We hypothesized that progression of FI could be predicted with initial tear size, FI, and muscle volume.

METHODS

Seventy-nine shoulders with rotator cuff tears were prospectively enrolled, and 2 magnetic resonance imaging (MRI) scans with 6-point Dixon sequences were acquired. The fat fraction within the SSP muscle was measured on 3 sagittal slices, and the arithmetic mean was calculated (FI SSP ). Advanced FI SSP was defined as ≥8%, pathological FI SSP was defined as ≥13.5%, and relevant progression was defined as a ≥4.5% increase in FI SSP . Furthermore, muscle volume, tear location, size, and Goutallier grade were evaluated.

RESULTS

Fifty-seven shoulders (72.2%) had normal FI SSP , 13 (16.5%) had advanced FI SSP , and 9 (11.4%) had pathological FI SSP at the initial MRI scan. Eleven shoulders (13.9%) showed a ≥4.5% increase in FI SSP at 19.5 ± 14.7 months, and 17 shoulders (21.5%) showed a ≥5-mm 3 loss of volume at 17.8 ± 15.3 months. Five tears (7.1%) with initially normal or advanced FI SSP turned pathological. These tears, compared with tears that were not pathological, had significantly higher initial mediolateral tear size (24.8 compared with 14.3 mm; p = 0.05), less volume (23.5 compared with 34.2 mm 3 ; p = 0.024), more FI SSP (9.6% compared with 5.6%; p = 0.026), and increased progression of FI SSP (8.6% compared with 0.5%; p < 0.001). An initial mediolateral tear size of ≥20 mm yielded a relevant FI SSP progression rate of 81.8% (odds ratio [OR], 19.0; p < 0.001). Progression rates of 72.7% were found for both initial FI SSP of ≥9.9% (OR, 17.5; p < 0.001) and an initial anteroposterior tear size of ≥17 mm (OR, 8.0; p = 0.003). Combining these parameters in a logistic regression analysis led to an area under the receiver operating characteristic curve (AUC) of 0.913. The correlation between FI SSP progression and the time between MRI scans was weak positive (ρ = 0.31).

CONCLUSIONS

Three risk factors for relevant FI progression, quantifiable on the initial MRI, were identified: ≥20-mm mediolateral tear size, ≥9.9% FI SSP , and ≥17-mm anteroposterior tear size. These thresholds were associated with a higher risk of tear progression: 19 times higher for ≥20-mm mediolateral tear size, 17.5 times higher for ≥9.9% FI SSP , and 8 times higher for ≥17-mm anteroposterior tear size. The presence of all 3 yielded a 91% chance of ≥4.5% progression of FI SSP within a mean of 19.5 months.

LEVEL OF EVIDENCE

Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Intrasynovial autograft for reconstruction of chronic large rotator cuff tears in a rabbit model: biomechanical, computed tomography, and histological results

BACKGROUND

Rotator cuff (RC) tears are a common cause of shoulder dysfunction and pain, posing significant challenges for orthopedic surgeons. Grafts have been proposed as a solution to augment or bridge torn tendons, but optimal clinical outcomes are not always achieved due to poor graft integration, suboptimal mechanical properties, and immunological reactions. The aim of this study was to investigate the biomechanical, CT and histological results of RC reconstruction using an intrasynovial tendon autograft, in a chronic large tear subscapularis rabbit model.

METHODS

Twenty-six adult male Zealand white rabbits were used in this study. Large defects in the subscapularis tendons were produced bilaterally in 20 rabbits. After 6 weeks, secondary procedures were performed to the right shoulder of the rabbits, which were reconstructed with an intrasynovial interposition autograft (graft group). The left shoulder did not undergo any further treatment (defect group). The specimens were randomly divided into two equal time groups and underwent biomechanical testing, CT analysis, and histological evaluation at 6, and 12 weeks after reconstruction. In addition, 6 rabbits that were not operated, were used as a control group.

RESULTS

At 12 weeks post-repair, the graft group exhibited a significant increase in ultimate failure load compared to the defect group (p < 0.05). Furthermore, the 12-week graft group demonstrated comparable stiffness to that of the control group. CT analysis indicated no significant progression of intramuscular fat accumulation in both graft groups, in contrast to the 12-week defect group when compared to the control group. Finally, histological evaluation revealed a gradual integration of the graft with the host tissue at 12 weeks.

CONCLUSION

Our study suggests that intrasynovial flexor tendon autografts hold promise as an effective interposition graft for the reconstruction of chronic large RC tears, as they improve the biomechanical and biological properties of the repaired tendon. Nonetheless, further investigations in preclinical large animal models are warranted to validate and extrapolate these findings to human studies.

Can three-dimensional models enhance understanding and knowledge of rotator cuff tears?

OBJECTIVES

Magnetic resonance imaging (MRI) is currently the standard diagnostic tool for rotator cuff tears. However, its two-dimensional (2D) output, displayed on a monitor, can complicate the interpretation of anatomy. Three-dimensional (3D) imaging may offer a solution to this issue. This study aimed to demonstrate the diagnostic and interpretive value of a 3D model in assessing lesion anatomy. The hypothesis was that 3D models, compared to 2D MRI, can enhance the comprehension and knowledge of rotator cuff injuries, improve the application of classifications for total tears, and provide a more precise definition of the size and type of tear.

METHODS

A prospective single-centre study was conducted. 3D models for rotator cuff tears were created and analysed in conjunction with preoperative MRI for each patient up to 2 months before surgery. The 3D models were based on the preoperative MRI. Collected data included 2D plane measurements by MRI in coronal and sagittal planes, descriptions of 3D lesion geometry (new shapes), 3D measurements in coronal and sagittal planes, arthroscopic classifications of rotator cuff injuries, and arthroscopic measurements in coronal and sagittal planes.

RESULTS

After examining 25 cases, 3D imaging demonstrated similar arthroscopic values post-bursectomy in the sagittal plane (16.70 ​mm for 3D and 18.28 ​mm for post-bursectomy, p-value ​= ​0.189), although these measurements did not align with those of MRI (which underestimated measurements, p-value ​= ​0.010). Both MRI measurement and 3D imaging showed similar measurement accuracy in the coronal plane when compared to arthroscopic measurements taken before and after bursectomy. The creation of 3D objects enabled the analysis of new geometries, including the length, width, and depth of each lesion. These geometries included the rectangle, rectangular trapezoid, scalene trapezoid, irregular pentagon, and irregular hexagon.

CONCLUSIONS

3D models can enhance the understanding and knowledge of rotator cuff injuries. They can be a promising tool for diagnosing and interpreting the anatomy of the injury, particularly in the sagittal plane. The new 3D understanding of the pathological process has led to the description of new geometric features not visible in conventional 2D MRI.

LEVEL OF EVIDENCE

II - Development of diagnostic criteria on consecutive patients (all compared to "gold" standard).

Re-tear after arthroscopic rotator cuff tear surgery: risk analysis using machine learning

BACKGROUND

Postoperative rotator cuff retear after arthroscopic rotator cuff repair (ARCR) is still a major problem. Various risk factors such as age, gender, and tear size have been reported. Recently, magnetic resonance imaging-based stump classification was reported as an index of rotator cuff fragility. Although stump type 3 is reported to have a high retear rate, there are few reports on the risk of postoperative retear based on this classification. Machine learning (ML), an artificial intelligence technique, allows for more flexible predictive models than conventional statistical methods and has been applied to predict clinical outcomes. In this study, we used ML to predict postoperative retear risk after ARCR.

METHODS

The retrospective case-control study included 353 patients who underwent surgical treatment for complete rotator cuff tear using the suture-bridge technique. Patients who initially presented with retears and traumatic tears were excluded. In study participants, after the initial tear repair, rotator cuff retears were diagnosed by magnetic resonance imaging; Sugaya classification types IV and V were defined as re-tears. Age, gender, stump classification, tear size, Goutallier classification, presence of diabetes, and hyperlipidemia were used for ML parameters to predict the risk of retear. Using Python's Scikit-learn as an ML library, five different AI models (logistic regression, random forest, AdaBoost, CatBoost, LightGBM) were trained on the existing data, and the prediction models were applied to the test dataset. The performance of these ML models was measured by the area under the receiver operating characteristic curve. Additionally, key features affecting retear were evaluated.

RESULTS

The area under the receiver operating characteristic curve for logistic regression was 0.78, random forest 0.82, AdaBoost 0.78, CatBoost 0.83, and LightGBM 0.87, respectively for each model. LightGBM showed the highest score. The important factors for model prediction were age, stump classification, and tear size.

CONCLUSIONS

The ML classifier model predicted retears after ARCR with high accuracy, and the AI model showed that the most important characteristics affecting retears were age and imaging findings, including stump classification. This model may be able to predict postoperative rotator cuff retears based on clinical features.

Reverse shoulder arthroplasty for primary glenohumeral osteoarthritis: significantly different characteristics and outcomes in shoulders with intact vs. torn rotator cuff

PURPOSE

To compare outcomes of reverse shoulder arthroplasty (RSA) for primary osteoarthritis (OA) with and without rotator cuff (RC) tears to those with secondary OA due to RC tears.

METHODS

We reviewed records of all patients who received RSA for primary OA or secondary OA. All patients had preoperative radiographs, computed tomographic arthrography (CTA), and/or magnetic resonance imaging (MRI) scans of their shoulders to assess their etiology, glenoid morphology, and fatty infiltration. Pre- and postoperative (at minimum follow-up of 2 years) Constant scores and range of motion were compared between patients who had RSA for primary OA with and without RC tears to those with secondary OA due to RC tears.

RESULTS

Of the initial cohort of 605 shoulders (583 patients), 153 were lost to follow-up (25.3%), 25 required revision with implant removal (4.1%), and 13 died of causes unrelated to the surgery (2.1%), and left a final cohort of 414 patients. Of the final cohort, 97 had primary OA with intact RC, 62 had primary OA with RC tears, and 255 had secondary OA. Postoperative Constant scores were significantly higher for primary OA with intact RC (73.8 ± 14.3), compared with both primary OA with RC tears (66.1 ± 14.6, P < .001) and secondary OA (64.1 ± 14.8, P < .001). There were no differences in pre- or postoperative scores between primary OA with RC tears and secondary OA.

CONCLUSION

At 2 or more years following RSA, Constant scores were significantly higher for primary OA with intact RC, compared to either primary OA with RC tears or secondary OA, whereas there were no differences in pre- or postoperative scores of shoulders that had primary OA with RC tears vs. secondary OA. The authors recommend distinguishing primary OA with intact RC from primary OA with RC tears, as the two have considerably different characteristics and prognosis following RSA.

Fat Fractions of the Rotator Cuff Muscles Acquired With 2-Point Dixon MRI: Predicting Outcome After Arthroscopic Rotator Cuff Repair

OBJECTIVES

The aim of this study was to quantify and compare fat fraction (FF) and muscle volume between patients with failed and intact rotator cuff (RC) repair as well as a control group with nonsurgical conservative treatment to define FF cutoff values for predicting the outcome of RC repair.

MATERIALS AND METHODS

Patients with full-thickness RC tears who received magnetic resonance imaging (MRI) before and after RC repair including a 2-point Dixon sequence were retrospectively screened. Patients with retear of 1 or more tendons diagnosed on MRI (Sugaya IV-V) were enrolled and matched to patients with intact RC repair (Sugaya I-II) and to a third group with conservatively treated RC tears. Two radiologists evaluated morphological features (Cofield, Patte, and Goutallier), as well as the integrity of the RC after repair (Sugaya). Fat fractions were calculated from the 2-point Dixon sequence, and the RC muscles were segmented semiautomatically to calculate FFs and volume for each muscle. Receiver operator characteristics curves were used to determine FF cutoff values that best predict RC retears.

RESULTS

In total, 136 patients were enrolled, consisting of 3 groups: 41 patients had a failed RC repair (58 ± 7 years, 16 women), 50 patients matched into the intact RC repair group, and 45 patients were matched into the conservative treatment group. Receiver operator characteristics curves showed reliable preoperative FF cutoff values for predicting retears at 6.0% for the supraspinatus muscle (0.83 area under the curve [AUC]), 7.4% for the infraspinatus muscle (AUC 0.82), and 8.3% for the subscapularis muscle (0.94 AUC).

CONCLUSIONS

Preoperative quantitative FF calculated from 2-point Dixon MRI can be used to predict the risk of retear after arthroscopic RC repair with cutoff values between 6% and 8.3%.

Clinical Impairments and Rotator Cuff Tendon Pathology in Primary and Intrinsic Secondary Adhesive Capsulitis

OBJECTIVE

This study was conducted to compare the differences in clinical impairments between patients with primary and intrinsic secondary adhesive capsulitis and confirm rotator cuff tendon pathology in intrinsic secondary adhesive capsulitis.

DESIGN

This study included 130 patients with unilateral adhesive capsulitis in freezing or frozen stages. Clinical impairment was evaluated using visual analog scale score, shoulder passive range of motion, Cyriax stage, and Constant-Murley score. Plain radiography, ultrasonography, single-contrast arthrography, and intravenous gadolinium-enhanced magnetic resonance imaging were performed in all patients.

RESULTS

Among 130 patients, 77 patients were diagnosed as primary adhesive capsulitis and 53 patients as intrinsic secondary adhesive capsulitis. Among intrinsic secondary adhesive capsulitis patients, 44 rotator cuff tendon tears, 6 calcific tendinitis, and 3 rotator cuff tendon tears with calcific tendinitis were observed. No significant intergroup difference was observed in all clinical parameters, including shoulder passive range of motion, visual analog scale, Cyriax stage, and Constant-Murley score. The prevalence of subacromial subdeltoid bursitis was significantly higher in intrinsic secondary adhesive capsulitis compared with primary adhesive capsulitis.

CONCLUSIONS

There was no significant difference in all clinical parameters investigated between patients with primary and intrinsic secondary adhesive capsulitis caused by rotator cuff tendon pathology.

Decreased rotator cuff muscle cross-sectional areas in subjects with adhesive capsulitis: a study comparing male and female subjects

OBJECTIVE

To compare rotator cuff (RC) muscle cross-sectional areas (CSA) in subjects with adhesive capsulitis (AC) to age- and sex-matched controls.

MATERIALS AND METHODS

We retrospectively analyzed 97 shoulder MRIs or MR arthrography studies, of which 42 were clinically diagnosed with AC (27 female, 15 male) and 55 were age- and sex-matched controls (38 female, 17 male). All AC subjects underwent imaging ≥ 6 months after symptom onset. All imaging was examined to exclude RC full-thickness tears and prior surgery. A standardized T1 sagittal MR image was segmented in each subject to obtain the CSA of subscapularis (SSC), supraspinatus (SSP), and infraspinatus (ISP) muscles. Differences in CSAs between AC and control subjects were analyzed by sex (females and males separately) and all subjects combined.

RESULTS

AC females had significantly decreased SSC (P = 0.002) and total (P = 0.006) CSAs compared to controls. Male AC subjects showed decreased SSC (P = 0.044), SSP (P = 0.001), and total (P = 0.005) CSAs. Across all subjects, male and female, the AC cohort had significantly decreased SSC (P = 0.019) and total (P = 0.029) CSAs compared to controls.

CONCLUSION

Decreased RC muscle CSAs were present in AC subjects with ≥ 6 months of symptom duration, with decreased SSC and total CSAs in male and female subjects, and decreased SSP CSA in males.

A Machine Learning Model Demonstrates Excellent Performance in Predicting Subscapularis Tears Based on Pre-Operative Imaging Parameters Alone

PURPOSE

To develop a machine learning model capable of identifying subscapularis tears before surgery based on imaging and physical examination findings.

METHODS

Between 2010 and 2020, 202 consecutive shoulders underwent arthroscopic rotator cuff repair by a single surgeon. Patient demographics, physical examination findings (including range of motion, weakness with internal rotation, lift/push-off test, belly press test, and bear hug test), and imaging (including direct and indirect signs of tearing, biceps status, fatty atrophy, cystic changes, and other similar findings) were included for model creation.

RESULTS

Sixty percent of the shoulders had partial or full thickness tears of the subscapularis verified during surgery (83% of these were upper third). Using only preoperative imaging-related parameters, the XGBoost model demonstrated excellent performance at predicting subscapularis tears (c-statistic, 0.84; accuracy, 0.85; F1 score, 0.87). The top 5 features included direct signs related to the presence of tearing as evidenced on magnetic resonance imaging (MRI) (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology.

CONCLUSIONS

In this study, machine learning was successful in predicting subscapularis tears by MRI alone in 85% of patients, and this accuracy did not decrease by isolating the model to the top features. The top five features included direct signs related to the presence of tearing as evidenced on MRI (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. Last, in advanced modeling, the addition of physical examination or patient characteristics did not make a significant difference in the predictive ability of this model.

LEVEL OF EVIDENCE

Level III, diagnostic case-control study.

The effect of cuff arthropathy stage on sleep disturbance and kinesiophobia in reverse shoulder arthroplasty patients

BACKGROUND

The current study aimed to determine the changes in pre-and post-operative Pittsburg sleep quality index (PSQI) and Tampa scale of kinesiophobia (TSK) values ​​according to the Hamada classification in patients who underwent reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy (RCTA).

METHODS

One hundred and eight patients who underwent RSA for RCTA were reviewed retrospectively. The patients were divided into two groups with low grade (stages 1-2-3) (n = 49) and high grade (stages 4a-4b-5) (n = 59) according to the Hamada classification, which is the radiographic evaluation of RCTA. PSQI and TSK values ​​were calculated preoperatively, and post-operatively at the 6th week, 6th month, and 1st year. The change in PSQI and TSK values ​​between the evaluations and the effect of staging according to the Hamada classification on this change was examined.

RESULTS

When compared in preoperative evaluations, PSQI and TSK scores were found to be lower in low-grade group 1 (7.39 ± 1.56, 51.88 ± 4.62, respectively) than in high-grade group 2 (10.47 ± 2.39, 57.05 ± 3.25, respectively) according to Hamada classification (both p < 0.001). In the postoperative evaluations, PSQI and TSK results decreased gradually compared to the preoperative evaluations, and there was a severe decrease in both parameters between the 6th-week and 6th-month evaluations (both p < 0.001). Preoperatively, 102 (95%) patients had sleep disturbance (PSQI ≥ 6), and 108 (100%) patients had high kinesiophobia (TSK > 37). In the 1st year follow-ups, sleep disturbance was observed in 5 (5%) patients and kinesiophobia in 1 (1%) patient. When the Hamada stages were compared, it was seen that there was a significant difference before the operation (both p < 0.001), but the statistically significant difference disappeared in the PSQI value in the 1st year (p = 0.092) and in the TSK value in the 6th month (p = 0.164) post-operatively. It was observed that Hamada staging caused significant differences in PSQI and TSK values ​​in the preoperative period but did not affect the clinical results after treatment.

CONCLUSIONS

RSA performed based on RCTA improves sleep quality and reduces kinesiophobia. RCTA stage negatively affects PSQI and TSK before the operation but does not show any effect after the treatment.