The Use of Shear-Wave Ultrasound Elastography in the Diagnosis and Monitoring of Musculoskeletal Injuries

Ultrasound elastography is a valuable method employed to evaluate tissue stiffness, with shear-wave elastography (SWE) recently gaining significance in various settings. This literature review aims to explore the potential of SWE as a diagnostic and monitoring tool for musculoskeletal injuries. In total, 15 studies were found and included in the review. The outcomes of these studies demonstrate the effectiveness of SWE in detecting stiffness changes in individuals diagnosed with Achilles tendinopathy, Achilles tendon rupture, rotator cuff rupture, tendinosis of the long head of the biceps tendon, injury of the supraspinatus muscle, medial tibial stress syndrome, and patellar tendinopathy. Moreover, SWE proves its efficacy in distinguishing variations in tissue stiffness before the commencement and after the completion of rehabilitation in cases of Achilles tendon rupture and patellar tendinopathy. In summary, the findings from this review suggest that SWE holds promise as a viable tool for diagnosing and monitoring specific musculoskeletal injuries. However, while the field of ultrasound elastography for assessing musculoskeletal injuries has made considerable progress, further research is imperative to corroborate these findings in the future.

High-frequency Quantitative Ultrasound Imaging of Human Rotator Cuff Muscles: Assessment of Repeatability and Reproducibility

This study evaluated the repeatability and reproducibility of using high-frequency quantitative ultrasound (QUS) measurement of backscatter coefficient (BSC), grayscale analysis, and gray-level co-occurrence matrix (GLCM) textural analysis, to characterize human rotator cuff muscles. The effects of varying scanner settings across two different operators and two US systems were investigated in a healthy volunteer with normal rotator cuff muscles and a patient with chronic massive rotator cuff injury and substantial muscle degeneration. The results suggest that BSC is a promising method for assessing rotator cuff muscles in both control and pathological subjects, even when operators were free to adjust system settings (depth, level of focus, and time-gain compensation). Measurements were repeatable and reproducible across the different operators and ultrasound imaging platforms. In contrast, grayscale and GLCM analyses were found to be less reliable in this setting, with significant measurement variability. Overall, the repeatability and reproducibility measurements of BSC indicate its potential as a diagnostic tool for rotator cuff muscle evaluation.

A prospective study of 100 patients with rotator cuff tendinopathy showed no correlation between subacromial bursitis and the efficacy of ultrasound-guided corticosteroid injection

OBJECTIVES

The objective of this study was to determine whether the presence of subacromial bursitis in patients with rotator cuff tendinopathy (RCT) was associated with a better outcome after ultrasound (US)-guided subacromial corticosteroid injection.

METHODS

A single-center prospective study was performed including patients referred for subacromial injection to manage RCT. At baseline, all patients received an US-guided intra-bursal injection of betamethasone (1 ml). The primary endpoint was reduced pain 3 months (M3) after the procedure: a good responder was defined by a decrease in Visual Analogue Scale pain of more than 30%. Secondary endpoints included functional recovery assessed by the Oxford Shoulder Score (OSS) and clinical success at 6 weeks (W6). We also explored the association between good clinical response and other factors, such as US or X-ray features.

RESULTS

One hundred patients were included and 49 presented with subacromial bursitis. At M3, 60% of patients (54/100) were considered good responders. The rate of good responders did not differ between the bursitis and non-bursitis groups (p = 0.6). During follow-up, OSS improved over time whether bursitis was present or not. We did not find any US or X-ray features significantly associated with a favorable clinical outcome.

CONCLUSION

The presence of subacromial bursitis did not influence clinical outcomes at 3 months post-subacromial injection in patients suffering from RCT.

CLINICAL RELEVANCE STATEMENT

The presence of subacromial bursitis did not influence clinical outcomes at 3 months post-subacromial corticosteroid injection in patients with rotator cuff tendinopathy. For patient management, looking for ultrasonographic signs of bursitis does not appear relevant for the indication of the injection.

KEY POINTS

• Ultrasound-guided subacromial corticosteroid injections led to a significant improvement in 60% of patients suffering from rotator cuff tendinopathy. • The presence of subacromial bursitis was not associated with better improvement at 3 months post-injection. • Except for the Minnesota score referring to job satisfaction, we did not find any baseline clinical, X-ray, or ultrasound characteristics associated with a successful outcome.

Calcific Tendinopathy Atypically Located Outside the Rotator Cuff: A Systematic Review

BACKGROUND AND PURPOSE

Calcific tendinopathy is a common cause of painful shoulder easily identified with ultrasound or conventional radiography. Although the rotator cuff is by far the most common location of the disease and diagnostic or treatment strategies are well known in clinical practice, a lack of awareness characterizes the assessment of the other sites affected by this condition; consequently, the risk of underestimating the prevalence of atypical non-rotator cuff calcific tendinopathy is high. This may lead to expensive or invasive diagnostic exams and/or inappropriate treatment, whereas the condition is usually self-limited. The present study aims at analysing the frequency of calcific tendinitis in uncommon sites, in order to fill a gap in knowledge and awareness regarding non-rotator cuff calcific tendinopathy, thus avoiding improper clinical choices and helping to identify this condition.

METHODS

This systematic review was conducted following the PRISMA guidelines. We performed a search on Pubmed and Scopus databases concerning atypically sited extra-rotator cuff calcific tendinopathy published since 1950.

RESULTS

The research found a total of 267 articles and 793 non-rotator cuff cases of calcific tendinopathy registered. The spine (213 – 26.86%), foot and ankle (191 – 23.95%), and hip (175 – 22.06%) appeared to be the most common sites of calcific tendinopathy after the rotator cuff, whereas the longus colli C1-C2 (204 – 25.72%), Achilles (173 – 21.81%), and rectus femori (61 – 7.69%) were the most commonly affected tendons.

CONCLUSION

A better awareness of this condition in several different sites of the body than the rotator cuff could avoid unnecessary choices both in assessment and treatment.

Does Morphology of the Shoulder Joint Play a Role in the Etiology of Rotator Cuff Tear?

BACKGROUND

The etiology of rotator cuff tears (RCTs) have been investigated for years and many underlying causes have been identified. Shoulder joint morphology is one of the extrinsic causes of RCTs.

AIM

Morphometric measurements on MRI sections determined which parameters are an important indicator of RCT in patients with shoulder pain. The aim of this study was to determine the risk factors in the etiology of RCTs by evaluating the shoulder joint morphology with the help of previously defined radiological parameters.

METHOD

Between January 2019-December 2020, 408 patients (40-70 years old) who underwent shoulder MRI and met the criteria were included in the study. There were 202 patients in the RCT group and 206 patients in the control group. Acromion type, acromial index (AI), critical shoulder angle (CSA), acromiohumeral distance (AHD), lateral acromial angle (LAA), acromial angulation (AA), acromion-greater tuberosity impingement index (ATI), and glenoid version angle (GVA) were measured from the MRI images of the patients.

RESULTS

AI (0.64 vs. 0.60, p = 0.003) CSA (35.3° vs. 32.4°, p = 0.004), ATI (0.91 vs. 0.83, P < 0.001), and AA (13.6° vs. 11.9°, p = 0.011) values were higher in the RCT group than in the control group and the difference was significant. AHD (8.1 mm vs. 9.9 mm, P < 0.001), LAA (77.2° vs. 80.9°, p = 0.004) and GVA (-3.9° vs. -2.5°, P < 0.001) values were lower in the RCT group than in the control group, and again the difference was significant. According to the receiver operating characteristic curve analysis, the cutoff values were 0.623 for AI and 0.860 for ATI.

CONCLUSION

Acromion type, AI, CSA, AHD, LAA, AA, ATI, and GVA are suitable radiological parameters to evaluate shoulder joint morphology. High AI, CSA, AA, ATI, GVA and low AHD and LAA are risk factors for RCT.

The effect of shear wave elastography in the diagnosis of delaminated partial-thickness rotator cuff tears

AIM

To assess the effectiveness of shear wave elastography (SWE) in diagnosing delaminated partial-thickness rotator cuff tears (DPT-RCT).

MATERIAL AND METHODS

A retrospective study was carried out on 137 patients with DPT-RCT. The study included complete clinical data, including the images of conventional ultrasound (US), SWE, Magnetic Resonance Imaging (MRI) and shoulder arthroscopic surgery. The features of US, SWE, and MRI were evaluated. The study analysed the Shear-Wave Velocity (SWV) among three types of DPT-RCT, and between the regions of tears, normal contralateral, and affected unilateral supraspinatus tendon. Furthermore, receiver operating characteristic (ROC) curves were evaluated.

RESULTS

 The SWE detection rate was significantly higher (91.2%) compared to US (73.7%) and MRI (87.6%) for the overall diagnosis of DPT-RCT. Similarly, SWE yielded higher rates of detection for types 1 (89.5%) and 2 (92.3%) of DPT-RCT as compared to US (71.7%, 69.2%) and MRI (81.6%, 94.9%), respectively. However, there was no significant difference in the accuracy of diagnosing type 3 among the three methods. The SWV of the 137 supraspinatus tendon tears was 3.64±0.60 m/s, which was higher than that of the normal supraspinatus tendon (2.43±0.47 m/s, p<0.01) as well as the region of tears (1.61±0.54 m/s, p<0.01). Nevertheless, there was no significant difference in SWV among the three types of DPT-RCT. The cutoff thresholds of SWV for identifying normal tendon from DPT-RCT and for identifying DPT-RCT from the region of tears were 2.96m/s and 2.39m/s, respectively.

CONCLUSIONS

SWE with SWV can provide both quantitative and qualitative diagnostic information for DPT-RCT, which can be used as a crucial supplement imaging method.

Effect of isokinetic eccentric training on the human shoulder strength, flexibility, and muscle architecture in physically active men: A preliminary study

Strengthening the rotator cuff muscles is important for injury prevention and rehabilitation. Since muscle fascicle length improves motor performance and is suggested to reduce the risk of injury for the hamstring, it may be an important variable to promote multidirectional changes in the function and macroscopic structure for the shoulder. Recent literature reviews overwhelmingly suggest that eccentric exercises improve fascicle length and functional measures for the lower limb. However, there is a research gap for the shoulder. Since ultrasound imaging is the most commonly used imaging technique to quantify muscle structure, but has yielded heterogeneous results in different studies, there is another issue and a research gap for the imaging method. Based on the research gaps, the purpose of this study was to evaluate the effects of standardized eccentric strength training on the function and structure of the external rotator cuff muscles using an isokinetic dynamometer and MRI. Therefore, a preliminary pre-post intervention study was conducted and 16 physically active men were recruited in October 2021. For the right shoulder, an eccentric isokinetic training was performed twice a week for almost six weeks. The primary outcome measures (external rotators) were active and passive range of motion, eccentric and concentric torque at 30, 60, and 180°/s isokinetic speed, and fascicle length and fascicle volume for the supraspinatus and infraspinatus muscles. The findings show a training effect for the absolute mean values of eccentric strength (+24%, p = .008). The torque-angle relationship increased, especially in the final phase of range of motion, although a 4% (p = .002) decrease in passive range of motion was found in the stretch test. Positive changes in muscle structure were shown for the supraspinatus muscle fascicle length (+16%, p = .003) and fascicle volume (+19%, p = .002). Based on the study results, we can conclude that eccentric isokinetic training has a significant positive effect on the shoulder. To our knowledge, this is the first eccentric training study using both isokinetic dynamometer and muscle diffusion tensor imaging to access functional and structural changes in the human shoulder rotator cuff muscles. The methods were shown to be applicable for interventional studies. Based on these results, populations such as high-performance handball players with highly trained shoulders should be included in future studies.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

Ultrasound-guided injection through the rotator cuff interval: a clinical perspective of one institution's results and description of technique

CONTEXT

Fluoroscopic injection through the rotator cuff interval (RCI) is a common technique for diagnostic arthrography and therapeutic intervention. Ultrasound approaches through the RCI have been less commonly studied, but there is a growing body of literature.

OBJECTIVES

The purpose of this study was to present a standardized technique of ultrasound-guided injection into the glenohumeral joint utilizing the RCI in magnetic resonance imaging (MRI) arthrography (MRA) and to report one medical group's experience with the technique.

METHODS

A retrospective chart review of all ultrasound-guided injections into the glenohumeral joint utilizing the RCI was performed from July 1, 2014 through June 1, 2021. Data were compiled for age, gender, body mass index (BMI), and prior surgery on the shoulder. The primary endpoint was successful administration of intra-articular dilute gadolinium contrast adequate for radiologic interpretation. A total of 487 injections into the glenohumeral joint via the RCI were performed. One hundred and fifty-five patients had previous shoulder surgery, with the remainder naive to intervention.

RESULTS

The success rate of injections into the glenohumeral joint was 99.4 %, with only three injections considered unsuccessful. The three unsuccessful injections did not succeed because of a lack of intra-articular contrast media present. This success rate is impressive and promising, particularly when considering that 155 of the patients had previous surgery, which could potentially cause complications, and because these injections were performed over a long period of 7 years.

CONCLUSIONS

Accessing the RCI under ultrasound guidance is a very successful technique for injection within the glenohumeral joint.

Influence of subscapularis tendon reattachment after reverse shoulder arthroplasty: clinical findings and ultrasonographic evaluation of the subscapularis at 89 months mean follow-up

BACKGROUND

Reverse shoulder arthroplasty (RSA) is commonly used to treat rotator cuff arthropathy. In the deltopectoral approach for RSA, the subscapularis tendon is (partly) detached. The clinical effects of subscapularis reattachment are still under debate. An observational study was performed to evaluate the clinical effects of subscapularis tendon reattachment on the mid- to long-term following RSA.

METHODS

In this study, 40 patients for a total of 46 shoulders with a reverse shoulder prosthesis participated. Constant Murley Score (CMS), Oxford Shoulder Score (OSS), Range of Motion (ROM) and abduction and internal rotation strength were measured. The integrity of the subscapularis tendon at follow-up was assessed using ultrasound. Outcomes were compared between three groups: repair and intact at follow-up, repair and not intact, and no repair.

RESULTS

Mean follow-up was 89 months with a minimum of three years. CMS, OSS, ROM and strength did not differ between groups. One-third of the initially reattached subscapularis tendons were still present at follow-up. No dislocations were reported.

CONCLUSION

This study showed no clinical effects of subscapularis reattachment after reverse shoulder arthroplasty on the mid- to long-term.

Intramuscular migration of calcium deposits into the deltoid muscle: two cases of a rare complication of rotator cuff calcific tendinopathy

Rotator cuff calcific tendinopathy is a common non-traumatic shoulder pain condition that occurs predominantly in the supraspinatus tendon. Ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) is a valid treatment in the resorptive phase. A complication of calcific tendinopathy is migration of calcium deposits outside the tendon. The most common site of migration is the subacromialsubdeltoid bursa (SASD). Another, but not frequent, type of migration is the intramuscular migration which mostly affects the supraspinatus, the infraspinatus and the biceps brachii muscles. This paper reports two cases of migration of calcification from the supraspinatus tendon to the deltoid muscle. The aforementioned site of migration has so far never been described in literature. Both patients presented calcification in the resorptive phase and therefore were treated by US-PICT.

The role of bone morphology of the greater tuberosity and lateral acromion on subacromial space during scaption: a three-dimensional dynamic simulation analysis

BACKGROUND

The bone morphology of the greater tuberosity and lateral acromion plays a central role in subacromial impingement syndrome. The critical shoulder angle (CSA) and greater tuberosity angle (GTA) are two-dimensional measurement parameters that have been validated to evaluate it radiologically. These markers are, however, static and don't consider the dynamic effect of glenohumeral motion.

OBJECTIVES

This study aimed to better understand the biomechanics in subacromial impingement with a dynamic simulation based on a validated 3D biomechanical model coupling joint kinematics and 3D reconstructed computed tomography.

STUDY DESIGN & METHODS

Sixty-one patients were included in this study: a case group of 44 patients with degenerative rotator cuff tears involving only the supraspinatus, and a control group of 17 without a rotator cuff tear. Patients with previous surgeries, traumatic cuff tears, and cuff tear arthropathy were excluded. CSA, GTA, and impingement-free range of motion (IF-ROM) of the glenohumeral joint in scaption were calculated. Correlation tests were used to determine the relationship between ROM and CSA, GTA, and combined CSA and GTA values.

RESULTS

CSA and GTA were significantly higher in the rotator cuff tear group (p = 0.001 and < 0.001), while IF-ROM was significantly higher in the control group (p = 0.001). There was no overall correlation between CSA and GTA (R = 0.02, p = 0.8). Individual correlation between both angles with IF-ROM was negatively weak for CSA (R = -0.4, p < 0.001) and negatively moderate for GTA and IF-ROM (R = -0.5, p < 0.001). However, combining both angles resulted in a negatively high correlation with IF-ROM (R = -0.7, p < 0.001).

CONCLUSION

Subacromial space narrowing during scaption is highly correlated to the cumulative values of GTA and CSA. These findings suggest that the combined bony morphology of the lateral acromion and greater tuberosity plays an important role in subacromial impingement.

LEVEL OF EVIDENCE

III.

The Efficiency of Gray-Level Ultrasound Histogram Analysis in Patients with Supraspinatus Tendinopathy

BACKGROUND

Musculoskeletal ultrasonography is a viable substitute for magnetic resonance imaging (MRI) that offers advantages in terms of time efficiency and cost-effectiveness. The gray-level histogram is a tool used to depict the distribution of pixel gray levels that provide quantitative data.

AIM

The objective of our research was to establish a threshold value for ultrasonography-measured supraspinatus tendon gray-level values by comparing patients with tendinopathy to those without.

MATERIALS AND METHODS

This study comprised a cohort of 271 individuals, consisting of 124 patients diagnosed with supraspinatus tendinopathy and 147 cases without the aforementioned condition who underwent shoulder MRI and ultrasound examinations. Two radiologists independently conducted the gray-level histogram analyses. The histogram parameters were determined, including the mean, minimum, median, maximum, fifth, 10th, 25th, 50th, 75th, 90th, and 95th percentiles, as well as skewness, kurtosis, and variance. The interobserver agreement was evaluated using the interclass correlation coefficient.

RESULTS

The supraspinatus tendinopathy group's all gray-level values were lower than those of the control group, and the difference was statistically significant (P < .05). The supraspinatus tendinopathy group exhibited greater values of skewness and kurtosis in comparison to the control group (P < .05). The area under the curve of the 95th percentile of the gray-level value was the highest (area under the curve = 0.960; cut-off value = 82.5; sensitivity = 96.7%; specificity = 88.2%).

CONCLUSION

The analysis of the histogram of gray-level values has the potential to be a promising method for the monitoring of patients with supraspinatus tendinopathy. This approach could be considered a feasible alternative to MRI.

Treatment of Calcific Tendonitis of the Rotator Cuff: An Updated Review

Rotator cuff calcific tendonitis (RCCT) is a disorder that can greatly impair patients' quality of life. A literature review was conducted to find the most effective and newest treatments for RCCT. PubMed and Cochrane Review databases were searched, without strict inclusion/exclusion criteria, for peer-reviewed articles between 1941 and 2021 that discussed RCCT etiology and treatments. If nonoperative measures (non-steroidal anti-inflammatory drugs, physical therapy, and corticosteroids) are unsuccessful, other options include extracorporeal shockwave therapy, ultrasound-guided injection techniques, and minimally invasive surgery. Because RCCT can resolve spontaneously, patients should progress to invasive options only if conservative first-line treatments have failed. [Orthopedics. 2023;46(6):e326-e332.].

Contrast-Enhanced Ultrasound-Assessed Supraspinatus Muscle Perfusion Indicates Better Tissue Vitality and Outcome After Supraspinatus Tendon Repair and Subacromial Decompression

OBJECTIVE

Supraspinatus tendon (SSP) tears are a frequent indication for shoulder surgery. Therapy options include physiotherapy, tendon repair and less invasive surgical options like subacromial decompression (SAD). The selection of the most appropriate treatment depends on the specific characteristics and needs of each patient subgroup. Typically, physically active patients are candidates for tendon repair, while a conservative approach is preferred for individuals with severe muscle degeneration or low physical demands. The goal of this study was to assess the impact of contrast-enhanced ultrasound (CEUS)-assessed SSP muscle perfusion on post-operative shoulder function and tendon healing in patients undergoing SSP repair or SAD, thereby enhancing personalized therapy for SSP tendon tears.

METHODS

Two cohorts of patients with SSP tendon tears were treated either by SAD or tendon repair. Pre-operative and 6-month post-operative SSP muscle perfusion was quantified using CEUS and investigated as a surrogate for tissue vitality. The magnetic resonance imaging-derived parameters fatty infiltration and tendon retraction and established shoulder function scores were assessed pre- and post-operatively.

RESULTS

Thirty-five SSP repair patients were compared with 20 SAD patients. Pre-operative perfusion was comparable in the SAD and SSP repair cohorts when a re-tear occurred (wash-in perfusion index = 103.8 ± 124.0 vs. 114.6 ± 155.0, p = 0.83), while being significantly higher among patients with an intact repair (103.8 ± 124 vs. 325.4 ± 388.6, p = 0.006). Below-median pre-operative muscle perfusion was associated with lower post-operative shoulder function (Constant score: 59 ± 28 vs. 78 ± 19, p = 0.012).

CONCLUSION

CEUS can visualize SSP muscle perfusion as a surrogate for tissue vitality and tendon healing, which is associated with better post-operative shoulder function.

Pattern of Radiographic and Sonographic Findings of Adult Patients Presented with Shoulder Pain at Tikur Anbessa Hospital, Addis Ababa, Ethiopia

Background

Shoulder pain is one of the most common presentations in the orthopedic clinic. Multiple factors have been found to cause shoulder pain. Radiographs and ultrasound are widely available, relatively cheap modalities in assessing shoulder pain. The aim of this study is to assess the radiographic and sonographic imaging patterns of shoulder pain.

Methods

A descriptive prospective cross-sectional hospital-based study was conducted at the Department of Radiology of Tikur Anbessa Specialized Hospital among patients with shoulder pain that came for imaging from August 2021-January 2022.

Result

Of the 73 patients with shoulder pain included in the study, 67% were females while 33% males. The mean age was 51.7 years. Radiographs found pathology in 53% of the cases. Acromioclavicular joint osteoarthritis, greater tuberosity degenerative changes, rotator cuff calcification were common radiographic findings. Ultrasound detected pathologies in 87% of the cases. The common pathologies were rotator cuff pathologies, biceps tendon pathologies, acromioclavicular joint degeneration, greater tuberosity degenerative changes, subacromial subdeltoid bursitis, and adhesive capsulitis. There was a significant association between greater tuberocity degenerative changes and supraspinatous pathologies with age, greater tuberocity degenerative changes with supraspinatous pathologies, acromiohumeral distance of <7mm with supraspinatous pathology.

Conclusion

Radiographs and ultrasound are valuable imaging modalities for shoulder pain. Low acromiohumeral interval, greater tuberosity degenerative changes, and acromioclavicular joint osteoarthritis are associated with rotator cuff tears. Rotator cuff pathologies are the most common pathologies observed in ultrasound. We recommend ultrasound to be second step after radiograph due to its low cost and wide availability.

Clinical effectiveness of supraspinatus tendon reconstruction using autogenous fascia latas for irreparable posterosuperior massive rotator cuff tears: study protocol for a randomized, controlled clinical trial

BACKGROUND

Supraspinatus tendon reconstruction (STR) was recently introduced as a new treatment option for irreparable posterosuperior massive rotator cuff tears (IPMRCT). STR was thought to be more advantageous than superior capsule reconstruction (SCR) for restoring supraspinatus (SSP) dynamics. However, there has been no prospective randomized controlled study on the early clinical efficacy of STR.

METHODS

A single-site, prospective, observers and patients double-blinding randomized controlled trial was designed. Fifty-eight patients aged 50-85 years with IPMRCT will be randomized 1:1 to receive either STR or SCR. The clinical outcomes were evaluated using the American Society for Shoulder and Elbow Surgery (ASES) score, range of motion (ROM), visual analogue scale (VAS) for pain, acromiohumeral distance (AHD), Goutlliar grade for fatty infiltration in the SSP, Sugaya grade for the autogenous fascia latas, isokinetic muscle strength testing and surface electromyography (EMG) testing for shoulder abduction muscle strength and complications.

DISCUSSION

The results of this study will contribute to the treatment algorithm of IPMRCT and assist surgeons in making treatment decisions. This is the first randomized controlled trial to compare the effects of STR and SCR for the treatment of IPMRCT.

TRIAL REGISTRATION

We registered the trial in chictr.org.cn on July 17, 2023 (register number: ChiCTR2300073716). Items from the WHO trial registry were found within the protocol.

[Value of contrast-enhanced percutaneous ultrasound in the diagnosis of rotator cuff tear subtype]

OBJECTIVE

To explore characteristics of contrast-enhanced ultrasound (CEUS) images features and diagnostic value of rotator cuff tear subtypes.

METHODS

From January 2019 to March 2022, percutaneous ultrasound-guided subacromial bursography (PUSB) with persutaneous ultrasound-guide tendon lesionography (PUTL) was performed on 114 patients with suspected rotator cuff injury were evaluated, including 54 males and 60 females ranged in age from 35 to 75 years old with an average of (58.8±8.7 ) years old;76 patients on the right side and 38 patients on the left side;the course of disease ranged from 0.13 to 111 months with an average of (10.2±9.8) months. GE LOGIQ E9 color doppler ultrasound diagnostic high frequency(6 to 12 MHz) was used to CEUS Using arthroscopy as gold standard, receiver operating characteristic (ROC) curve was used to evaluate diagnostic efficacy of US, MRI and CEUS for rotator cuff injury, also sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated.

RESULTS

The sensitivity of US in diagnosing full-thickness tears was 72.1%, specificity was 93.0%, and accuracy was 85.1%. The sensitivity, specificity and accuracy of MRI diagnosis of full-thickness tear were 90.9%, 92.6% and 92.1% respectively. The sensitivity, specificity and accuracy of CEUS in diagnosis of full-thickness tear were 100%. The sensitivity, specificity and accuracy of US in the diagnosis of partial tear were 85.7%, 77.2% and 79.8% respectively. The sensitivity, specificity and accuracy of MRI diagnosis of partial tear were 83.7%, 81.7% and 82.5% respectively. The sensitivity, specificity and accuracy of CEUS in diagnosis of partial tear were 95.7%, 92.6% and 93.9% respectively. There were significant differences in diagnosis results of US, MRI and CEUS for rotator cuff bursa tear (P<0.001). Kapp test showed good consistency between CEUS and arthroscopy in diagnosing rotator cuff tear subtypes (full-thickness and partial tears).

CONCLUSION

Using PUSB/PUTL to observe distribution of contrast media in bursa, tendon and joint cavity to evaluate the type of rotator cuff tear, its diagnostic performance is significantly better than US and MRI. Therefore, percutaneous contrast-enhanced ultrasound can be a reliable method for diagnosing subtypes of rotator cuff tears.

Providing safe and effective rehabilitation by assessing supraspinatus muscle elasticity using ultrasound real-time tissue elastography after rotator cuff repair: A case series

INTRODUCTION

Although surgical techniques have advanced to avoid a postoperative re-tear after rotator cuff surgery, it remains unclear how to directly evaluate the risk of a re-tear.

OBJECTIVE

To describe how muscle elasticity with real-time tissue elastography could be used to avoid re-tear in individual cases after rotator cuff repair.

CASE DESCRIPTION

This case series included four patients, two per tear size (small and large/massive), with contrasting changes in muscle elasticity of the supraspinatus muscle. All patients underwent primary arthroscopic or open rotator cuff repair. The elasticity of the supraspinatus muscle was evaluated at relaxed and elongated positions of 0° and 60° shoulder abduction angles, respectively. The change in muscle elasticity at 1 month after surgery was characteristically different, and we predicted that a greater elasticity in the elongated position indicated a higher risk of re-tear. The cases with high risk underwent careful rehabilitation to avoid re-tear, and no re-tears were recorded in this report.

CONCLUSION

Our findings suggested that evaluation of muscle elasticity using real-time tissue elastography, which provides an indication of the risk of re-tear, in the clinical setting might be useful for therapists, who could adjust the intensity of rehabilitation, and for patients.

Subacromial space measured by ultrasound imaging in asymptomatic subjects and patients with subacromial shoulder pain: an inter-rater reliability study

BACKGROUND

Acromiohumeral distance (AHD) and supraspinatus tendon thickness (STT) measured by ultrasound (US) can be combined in the occupation ratio (OR). Inter-rater reliability on these subacromial measures depends on the US experience of raters and on the subject status, differing between asymptomatic or patients with subacromial shoulder pain (SSP).

OBJECTIVE

To evaluate inter-rater reliability between two raters with different US experience (experienced examiner and novice examiner).

METHODS

In total, 20 asymptomatic subjects (controls) and 21 patients with SSP were examined on one shoulder. Inter-rater reliability was evaluated with intraclass correlation coefficient (ICC).

RESULTS

ICC for controls was good for AHD at rest and at 60° (0.76-0.77), moderate for STT and AHD at 60° with weights (0.53-0.72), while OR was poorly reliable (below 0.44). ICC for SSP was moderate for AHD at rest and at 60°, STT, OR at rest and at 60° (0.52-0.74) and poor for AHD at 60° with weights and OR at 60° with weights (0.33-0.36). Bland-Altman plots showed systematic bias.

CONCLUSION

Inter-rater reliability varied largely from poor to good between two examiners with different US experience. Clinicians might use the US as additional tool for detecting the subacromial structures, but a structured training including also symptomatic subjects is suggested. Researchers may further investigate the OR in matched case-control studies, and an overall agreement phase is recommended before starting the inter-rater reliability phase.

Fat quantification of the rotator cuff muscles using CT histogram analysis in comparison with Dixon MRI sequence

OBJECTIVES

To quantify the proportion of fat within the rotator cuff muscles using CT histogram analysis (HA) and to compare fat fraction (FF) values obtained from CT and T2*-corrected 6-echo three-dimensional gradient-echo Dixon sequences.

METHODS

Twenty-six patients who underwent both shoulder CT and MRI were enrolled. The FF of rotator cuff muscles was measured on FF maps of the Dixon technique. Using CT, the FF values were obtained in two ways: 1) CT mean Hounsfield Unit (HU) measurement-based fat quantification using subcutaneous fat and the teres major muscle as internal standards; and 2) CT HA-based fat quantification in which pixels from -190 to -30 HU were arbitrarily classified as fat, and those from -30 to 150 HU as muscle. Afterward, the relationship between FF values from MRI (FF-MR), CT mean HU-based analysis (FF-HU), and CT HA (FF-HA) was assessed.

RESULTS

There were strong positive correlations (p < 0.001) between FF-MR and FF-HA, which were higher when compared with FF-HU (r = 0.90 vs. 0.77 for total). For a total of 104 rotator cuff muscles, the intraclass correlation between FF-MR and FF-HA was excellent (ICC, 0.90), which was higher than that between FF-MR and FF-HU (ICC, 0.76). The ICCs showed excellent interobserver agreement between FF-MR, FF-HU, and FF-HA (ICCs, 0.93-0.96).

CONCLUSIONS

Fat quantification within the rotator cuff muscles using CT HA is both feasible and reliable.

ADVANCES IN KNOWLEDGE

CT HA provides reliable quantification of intramuscular fat and has strengths regarding its retrospective applicability to conventional CT studies without additional radiation dose to subjecting patients.

Treatment of calcific tendinopathy of the rotator cuff with ultrasound-guided puncture and aspiration

OBJECTIVE

Calcific tendinopathy of the rotator cuff is a common condition caused by the deposition of calcium crystals in the tendons of the rotator cuff. This study aimed to analyze the effectiveness of ultrasound-guided puncture and aspiration in calcific tendinopathy of the should in 86 patients treated at our center and to determine the factors associated with poor prognosis after this treatment.

MATERIAL AND METHODS

This retrospective descriptive study included 86 patients with calcific tendinopathy of the rotator cuff treated with ultrasound-guided puncture and aspiration between 2015 and 2019 for whom clinical and radiological variables were collected 1, 3, 6, and 12 months after the procedure.

RESULTS

One year after treatment, 81.4% patients showed clinical improvement and 96.5% showed radiological improvement. Complications were observed in 34.9%; all complications were mild.

CONCLUSIONS

Ultrasound-guided puncture and aspiration is an effective treatment for calcific tendinopathy of the shoulder, resulting in a high rate of clinical and radiological improvement and a low rate of minor complications. This technique has additional advantages, such as interaction with the patient and the lack of ionizing radiation.

Massive rotator cuff tears with short tendon length can be successfully repaired using synthetic patch augmentation

BACKGROUND

Choosing the optimal treatment for massive rotator cuff tears (MRCTs) still poses a surgical problem. In MRCTs with good muscle quality, but short tendon length, nonaugmented repairs lead to high failure rates of up to 90%. The aim of the study was to evaluate midterm clinical and radiologic outcomes of massive rotator cuff tears with good muscle quality, but short tendon length, which were repaired with synthetic patch augmentation.

METHODS

A retrospective study of patients who underwent arthroscopic or open rotator cuff repairs with patch augmentation between 2016 and 2019 was performed. We included patients older than 18 years, who presented with an MRCT confirmed by an magnetic resonance imaging (MRI) arthrogram showing good muscle quality (Goutallier ≤ II) and short tendon length (length <15 mm). Constant-Murley score (CS), Subjective Shoulder Value (SSV), and range of motion (ROM) were compared pre- and postoperatively. We excluded patients older than 75 years or with presence of rotator cuff arthropathy Hamada stage ≥2a. Patients were followed up for 2 years minimum. Clinical failures were defined by reoperation, forward flexion <120° or a relative CS < 70. Structural integrity of the repair was assessed using an MRI scan. Comparison between different variables and outcomes was performed using Wilcoxon-Mann-Whitney and χ2 tests.

RESULTS

Fifteen patients (mean age 57 years, 13 [86.7%] male, 9 [60%] right shoulders) were reevaluated with a mean follow-up of 43.8 months (27-55 months). There was a significant improvement in the absolute CS (from 33 to 81 points, P = .03), the relative CS (from 41% to 88%, P = .04), the SSV (from 31% to 93%, P = .007), and forward flexion (from 111° to 163°, P = .004) but not in external rotation (from 37° to 38°, P = .5). There were 3 clinical failures (1 atraumatic, 2 traumatic) with reoperations (2 reverse total shoulder arthroplasties and 1 refixation). Structurally, there were 3 Sugaya grade 4 and 5 Sugaya grade 5 reruptures resulting in a retear rate of 53%. The presence of a complete or partial rerupture was not associated with inferior outcomes compared with intact cuff repairs. There were no correlations between the grade of retraction, muscle quality, or rotator cuff tear configuration and rerupture or functional outcomes.

CONCLUSION

Patch augmented cuff repair leads to a significant improvement of functional and structural outcomes. Partial reruptures were not associated with inferior functional outcomes. Prospective randomized trials are needed to confirm the results found in our study.

Increased operative time has a negative impact on clinical outcome in arthroscopic rotator cuff repair

BACKGROUND

Few data are available about the impact of operative time on outcome of rotator cuff repair.

AIM

The aim of this study was to evaluate the impact of operative time on clinical outcome and tendon healing after arthroscopic rotator cuff repair.

METHODS

Patients operated on for distal supraspinatus tear in our institution between 2012 and 2018 were included retrospectively. Operative time, from skin incision until skin closure, was extracted from medical files. For statistical analysis, operative time was treated as a quantitative variable. Endpoints were clinical outcome (Constant score, range of motion), tendon healing (on CT or MRI) and complications at 1 year. The significance threshold was set at p = 0.05.

RESULTS

A total of 219 Patients, with a mean age of 54.6 years (range 40-70 years), were included. Mean operative time 44.9 min (range 14-140 min). Significant correlations (p < 0.05) were found for Constant score and external rotation at 1 year: increasing operative time by 1 min led to a decrease in Constant score of 0.115 points, or 6.9 points for a 60-min increase (p = 0.0167) and a decrease in external rotation of 0.134°, or 8.04° for a 60-min increase (p = 0.0214). No significant correlations were found for anterior elevation at 1 year (p = 0.2577), tendon healing at 1 year (p = 0.295) or onset of complications during follow-up (p = 0.193).

DISCUSSION

The minimal clinically important difference in Constant score in patients undergoing rotator cuff surgery is between 6 and 10 points. An increase of more than 60 min in operative time significantly impacted clinical outcome of arthroscopic distal supraspinatus repair, but not tendon healing.

LEVEL OF EVIDENCE

Level III: Retrospective Cohort Design. Therapeutic Study.