Moderate value of non-contrast magnetic resonance imaging after non-dislocating shoulder trauma

Diagnostic performance of long head of biceps tendon tears on MRI: systematic review and meta-analysis

OBJECTIVES

The purpose of this meta-analysis was to determine the diagnostic performance of conventional MRI and MR arthrography for tendinosis, and partial and complete tears of the long head of the biceps tendon (LHBT) using arthroscopy as the reference standard.

MATERIALS AND METHODS

A systematic review was performed using predefined data fields in PubMed, and all articles published from January 2000 up to April 2022 were retrospectively pooled and reviewed. Six MRI studies on complete tear (n = 555) and ten studies on partial tear/tendinosis (n = 2487) were included in the analysis. Two of the included studies in each group investigated the use of MR arthrography. The data sets were analyzed using a univariate approach with the DerSimonian and Laird random effects model and the proportional hazards model.

RESULTS

MRI shows high specificities in diagnosing complete tears of the LHBT ranging from 93.0 to 99.0%. Diagnostic sensitivity was more heterogeneous ranging from 55.9 to 90.0%. The overall negative likelihood ratio was 0.29 (95% CI: 0.17-0.50) and the overall positive likelihood ratio was 37.3 (95% CI: 11.9-117.4). The mean sensitivity in diagnosing partial tear/tendinosis of the LHBT was 67.8% (95% CI: 54.3-78.9%) and the specificity was 75.9% (95% CI: 63.6-85.0%), resulting in a balanced accuracy of 71.9%. The overall negative likelihood ratio was 0.44 (95% CI: 0.32-0.59) and the overall positive likelihood ratio was 2.64 (95% CI: 1.91-3.65).

CONCLUSION

MRI is highly specific for the diagnosis of complete tears of the LHBT, whereas diagnostic sensitivity was more heterogeneous. The diagnosis of partial tears and/or tendinosis of the LHBT remains challenging on MRI, which may warrant complementary clinical examination or other imaging modalities to increase diagnostic confidence in equivocal cases.

CLINICAL RELEVANCE STATEMENT

Conventional MRI and MR arthrography have high diagnostic performance for complete tendon tear when compared to arthroscopy. The diagnosis of tendinosis/partial tears remains challenging and may require comparison with clinical tests and other imaging modalities.

KEY POINTS

•There is no clear consensus regarding the primary imaging modality for the evaluation of LHBT disorders. •Conventional MRI and MR arthrography are highly specific in diagnosing complete tears of the LHBT. •Diagnosis of partial tears/tendinosis of the LHBT on conventional MRI and MR arthrography remains a diagnostic challenge.

Clinical Approach to Inconclusive Subscapularis Tear Diagnosis: a Meta-analysis

To identify factors associated with subscapularis (SSC) tears and provide a theoretical basis for clinical diagnosis, we included studies related to subscapularis tears published before February 1, 2023. We screened for six predictors across previous studies for the meta-analysis. The predictors included age, sex, coracoid overlap (CO), coracohumeral distance (CHD), impairment of the long head of the biceps tendon (LHB), and dominant arm. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the studies. The risk ratios (RRs) and the weighted mean differences (WMDs) were used to evaluate the effect size of categorical variables and continuous variables, respectively. The Egger test was used to assess the publication bias of the studies. Ten studies were included from seven countries. A total of 2 126 patients were enrolled, of whom 1 041 had subscapularis tears and 1 085 did not. The study showed that age (WMD, 4.23 [95% CI, 2.32-6.15]; P<.00001), coracoid overlap (WMD, 1.98 [95% CI, 1.55-2.41]; P<.00001), coracohumeral distance(WMD, -1.03 [95% CI, -1.17- -0.88]; P<.00001), and an injury of the long head of the biceps tendon (RR, 4.98 [95% CI, 3.75-6.61]; P<.00001) were risk factors for subscapularis tears. These risk factors can help clinicians identify subscapularis tears early and select appropriate interventions. The level of evidence is 3.

The long head of biceps at the shoulder: a scoping review

BACKGROUND

This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.

METHODS

PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.

RESULTS

214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.

CONCLUSIONS

The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.

PRE-REGISTRATION

OSF: https://osf.io/erh9m.

Can indirect magnetic resonance arthrography be a good alternative to magnetic resonance imaging in diagnosing glenoid labrum lesions?: a prospective study

Background

This study was designed to evaluate and compare the diagnostic value of magnetic resonance imaging (MRI) and indirect magnetic resonance arthrography (I-MRA) imaging with those of arthroscopy and each other.

Methods

This descriptive-analytical study was conducted in 2020. All patients who tested positive for labrum lesions during that year were included in the study. The patients underwent conservative treatment for 6 weeks. In the event of no response to conservative treatment, MRI and I-MRA imaging were conducted, and the patients underwent arthroscopy to determine their ultimate diagnosis and treatment plan. Imaging results were assessed at a 1-week interval by an experienced musculoskeletal radiologist. Image interpretation results and arthroscopy were recorded in the data collection form.

Results

Overall, 35 patients comprised the study. Based on the kappa coefficient, the results indicate that the results of both imaging methods are in agreement with the arthroscopic findings, but the I-MRA consensus rate is higher than that of MRI (0.612±0.157 and 0.749±0.101 vs. 0.449±0.160 and 0.603±0.113). The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of MRI in detecting labrum tears were77.77%, 75.00%, 91.30%, 50.00%, and 77.14%, respectively, and those of I-MRA were 88.88%, 75.00%, 92.30%, 66.66%, and 85.71%.

Conclusions

Here, I-MRA showed higher diagnostic value than MRI for labral tears. Therefore, it is recommended that I-MRA be used instead of MRI if there is an indication for potential labrum lesions.

[Development of a risk stratification model for subscapularis tendon tear based on patient-specific data from 528 shoulder arthroscopy]

OBJECTIVE

To identify and screen sensitive predictors associated with subscapularis (SSC) tendon tear and develop a web-based dynamic nomogram to assist clinicians in early identification and intervention of SSC tendon tear.

METHODS

Between July 2016 and December 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with completely MRI and clinical data were retrospectively analyzed. Patients admitted between July 2016 and July 2019 were included in the training cohort, and patients admitted between August 2019 and December 2021 were included in the validation cohort. According to the diagnosis of arthroscopy, the patients were divided into SSC tear group and non-SSC tear group. Univariate analysis, least absolute shrinkage and selection operator (LASSO) method, and 10-fold cross-validation method were used to screen for reliable predictors highly associated with SSC tendon tear in a training set cohort, and R language was used to build a nomogram model for internal and external validation. The prediction performance of the nomogram was evaluated by concordance index (C-index) and calibration curve with 1 000 Bootstrap. Receiver operating curves were drawn to evaluate the diagnostic performance (sensitivity, specificity, predictive value, likelihood ratio) of the predictive model and MRI (based on direct signs), respectively. Decision curve analysis (DCA) was used to evaluate the clinical implications of predictive models and MRI.

RESULTS

The nomogram model showed good discrimination in predicting the risk of SSC tendon tear in patients [C-index=0.878; 95% CI(0.839, 0.918)], and the calibration curve showed that the predicted results were basically consistent with the actual results. The research identified 6 predictors highly associated with SSC tendon tears, including coracohumeral distance (oblique sagittal) reduction, effusion sign (Y-plane), subcoracoid effusion sign, biceps long head tendon displacement (dislocation/subluxation), multiple posterosuperior rotator cuff tears (≥2, supra/infraspinatus), and MRI suspected SSC tear (based on direct sign). Compared with MRI diagnosis based on direct signs of SSC tendon tear, the predictive model had superior sensitivity (80.2% vs. 57.0%), positive predictive value (53.9% vs. 53.3%), negative predictive value (92.7% vs. 86.3%), positive likelihood ratio (3.75 vs. 3.66), and negative likelihood ratio (0.25 vs. 0.51). DCA suggested that the predictive model could produce higher clinical benefit when the risk threshold probability was between 3% and 93%.

CONCLUSION

The nomogram model can reliably predict the risk of SSC tendon tear and can be used as an important tool for auxiliary diagnosis.

Development and Validation of a Web-Based Dynamic Nomogram to Improve the Diagnostic Performance of Subscapularis Tendon Tear

Background

There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on magnetic resonance imaging (MRI). The omission of SSC tendon tears can lead to muscle atrophy, fatty infiltration and increased tear accompanied by aggravated shoulder pain and loss of function. An effective noninvasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a dynamic nomogram to improve diagnostic performance.

Methods

From July 2016 to October 2021, 528 consecutive cases of patients who underwent shoulder arthroscopic surgery with preoperative shoulder MRI were retrospectively analyzed. The least absolute shrinkage and selection operator (LASSO) method was used to identify the sensitive factors associated with SSC tendon tears, which were then incorporated into the nomogram. The prediction performance of the nomogram was evaluated by concordance index (C index) and calibrated with 1,000 bootstrap samples combined with external validation of another cohort.

Results

The LASSO method showed that six items including coracohumeral distance (oblique sagittal plane), effusion (Y-face), effusion (subcoracoid), malposition of the long head tendon of the biceps, multiple posterosuperior rotator cuff tears, and considering SSC tendon tears on MRI (based on direct signs) were determined as sensitive predictors. The nomogram achieved a good C index of 0.878 (95% CI, 0.839–0.918) with a good agreement on the risk estimation of calibration plots. The areas under the receiver operator characteristic (ROC) curves of the two methods showed that dynamic nomograms had better prediction performance than MRI diagnosis based on direct signs (training set 0.878 vs. 0.707, validation set 0.890 vs. 0.704).

Conclusion

The study identified sensitive predictors associated with SSC tendon tears and first developed a web-based dynamic nomogram as a good supplementary evaluation tool for imaging diagnosis that could provide an individualized risk estimate with superior prediction performance, even in patients with small or partial tears.

Identifying key factors associated with subscapularis tendon tears and developing a risk prediction model to assist diagnosis

Background

There are still some challenges in diagnosing subscapularis (SSC) tendon tears as accurately as posterosuperior rotator cuff tears on MRI. The omission of SSC tendon tear can lead to muscle atrophy, fatty infiltration, and increased tearing accompanied by aggravated shoulder pain and loss of function. An effective non-invasive evaluation tool will be beneficial to early identification and intervention. The study aims to identify sensitive predictors associated with SSC tendon tears and develop a risk prediction model to assist in diagnosis.

Methods

Data on 660 patients who received shoulder arthroscopic surgery with preoperative shoulder MRI were collected retrospectively. Of these, patients with SSC tendon tears were defined as the SSC tear group, and patients with intact SSC tendon were enrolled in the non-SSC tear group. Logistic regression analysis was used to identify the key predictors of SSC tendon tears which were then incorporated into the nomogram.

Results

Among 22 candidate factors, five independent factors including coracohumeral distance (CHD, oblique sagittal plane) (OR, 0.75; 95%CI, [0.67–0.84]), fluid accumulation (Y-face) (OR, 2.29; 95%CI, [1.20–4.38]), long head of biceps tendon (LHB) dislocation/subluxation (OR, 3.62; 95%CI, [1.96–6.68]), number of posterosuperior (PS) rotator cuff tears (OR, 5.36; 95%CI, [3.12–9.22]), and MRI diagnosis (based on direct signs) (OR, 1.88; 95%CI, [1.06–3.32]) were identified as key predictors associated with SSC tendon tears. Incorporating these predictors, the nomogram achieved a good C index with a good agreement on the risk estimation of calibration plots. Higher total points of the nomogram were associated with a greater risk of SSC tendon tears.

Conclusion

When evaluating the severity of SSC tendon injury, the combination of reliable predictors can improve the sensitivity and diagnostic performance of MRI. This model provides an individualized probability of risk prediction, which is convenient for clinicians to identify patients at high risk for SSC tendon tears to avoid missed diagnosis.

Can subcoracoid cyst formation be a sign of anterosuperior rotator cuff tears and biceps pulley lesions? A prospective radiologic and arthroscopic correlation study

BACKGROUND

The aim of this study was to investigate the pathologies associated with subcoracoid cysts (ScCs) in patients with rotator cuff (RC) tears and the postoperative appearance of ScCs after arthroscopic repair.

METHODS

A total of 114 patients who underwent arthroscopic RC repair were prospectively evaluated. The inclusion criteria were as follows: patients with or without ScCs, patients with Patte class 1 or 2 tears, and patients who were 40-65 years of age. Forty-four patients with ScCs (group 1) were evaluated during the 12-month study period. Fifty-two patients who had no ScCs (group 2) were evaluated as a control group. Preoperative and postoperative cyst volumes were measured on magnetic resonance imaging (MRI), and arthroscopic findings were noted.

RESULTS

Thirty-one patients (70%) in group 1 had a subscapularis tear vs. 10 patients (19%) in group 2 (P < .001). Biceps lesions were encountered in 32 patients (72%) in group 1, whereas 12 patients (23%) had a biceps lesion in group 2 (P < .001). Cyst volume was significantly higher in the following situations: (1) patients who had a subscapularis tear compared with patients without a subscapularis tear, (2) patients who had biceps pulley lesions compared with patients without pulley lesions, and (3) patients who had both pathologies (P = .047, P = .01, and P = .002, respectively). Cyst volumes significantly decreased following RC repair in group 1 (P < .001).

CONCLUSION

Among patients with small- to medium-sized, full-thickness supraspinatus tears, the prevalence of biceps pulley lesions and/or subscapularis tears is higher in patients with ScCs.

Magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair

PURPOSE

To evaluate the diagnostic accuracy between magnetic resonance arthrography (MRA) and arthroscopic examination for the assessment of pathologies of the long head of the biceps (LHB) prior to rotator cuff (RC) repair. The hypothesis was that MRA is suitable to identify biceps instabilities, due to improved visibility of the biceps pulley.

METHODS

Sixty-six patients aged 58.5 ± 17.6 (range, 46-71) scheduled to have RC repair between 2016 and 2017 were prospectively enrolled. MRA images of the LHB were interpreted by one radiologist and two surgeons, then compared to arthroscopic findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated by comparing MRA axial readings to arthroscopic assessment in the neutral position (static instability), MRA sagittal readings to arthroscopic assessment in external rotation (dynamic s instability), MRA coronal and axial readings to arthroscopic assessment in the neutral position (tendinopathy).

RESULTS

Among the three observers, the radiologist obtained the highest sensitivity and specificity for MRA, which were respectively: (1) for static instability, 62% (C.I. 35-85) and 77% (C.I. 63-88); (2) for dynamic instability, 50% (C.I. 29-71) and 62% (C.I. 46-77), and (3) for tendinopathy, 49% (C.I. 36-62) and 100% (C.I. 3-100).

CONCLUSIONS

MRA is not suitable for the diagnosis of LHB lesions prior to arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Diagnosis of Superior Labrum Anterior-to-Posterior Tears by Using MR Imaging and MR Arthrography: A Systematic Review and Meta-Analysis

Purpose To evaluate the diagnostic accuracies of nonenhanced magnetic resonance (MR) imaging and MR arthrography for diagnosis of superior labrum anterior-to-posterior (SLAP) tears by using a systematic review and meta-analysis. Materials and Methods A comprehensive literature search was performed on the two main concepts of MR imaging (MR imaging, and direct and indirect MR arthrography) and SLAP tears. Inclusion criteria consisted of original studies that assessed the diagnostic accuracy of MR imaging, direct MR arthrography, and/or indirect MR arthrography for the detection of SLAP tears, by using surgical findings as the reference standard. The Quality Assessment of Diagnostic Accuracy Studies 2, or QUADAS-2 Quality Assessment of Diagnostic Accuracy Studies 2 Quality Assessment of Diagnostic Accuracy Studies 2 , tool was used to assess methodologic quality. Meta-analyses were performed that compared MR imaging studies to direct MR arthrography studies and indirect MR arthrography studies, 3-T studies to 1.5-T studies, and low-bias MR imaging studies to low-bias direct MR arthrography studies. Study variation was analyzed by using the Cochran Q test of heterogeneity and the I² statistic. Results Thirty-two studies met inclusion and exclusion criteria, including 3524 imaging examinations: 1963 direct MR arthrography examinations (23 studies), 1402 MR examinations (14 studies), and 159 indirect MR arthrography examinations (three studies). Twelve studies had low risk for bias, two had questionable risk, and 18 had high risk. Mean sensitivities of direct MR arthrography, MR imaging, and indirect MR arthrography for SLAP tear diagnosis were 80.4%, 63.0%, and 74.2%, respectively. Mean specificities of direct MR arthrography, MR imaging, and indirect MR arthrography were 90.7%, 87.2%, and 66.5%, respectively. Summary receiver operator characteristic (ROC) curve demonstrated superior accuracy of direct MR arthrography compared with those of MR imaging and indirect MR arthrography. Similar findings were observed in the low-bias subanalysis. Summary ROC curve demonstrated overall superiority of 3-T imaging, with or without intra-articular contrast material compared with 1.5-T imaging, with or without intra-articular contrast material. Significant variance was observed for MR imaging and direct MR arthrography (P < .001) studies for both mean sensitivity and specificity. Conclusion Direct MR arthrography appears to be more accurate than nonenhanced MR imaging for diagnosis of SLAP tears, whereas 3-T MR imaging with or without intra-articular contrast material appears to improve diagnostic accuracy compared with 1.5-T MR imaging with or without intra-articular contrast material. ^© RSNA, 2017 Online supplemental material is available for this article.

A systematic review and meta-analysis of diagnostic test of MRA versus MRI for detection superior labrum anterior to posterior lesions type II-VII

OBJECTIVE

To determine the diagnostic performance of magnetic resonance arthrography (MRA) and magnetic resonance imaging (MRI) in superior labrum anterior to posterior lesions (type II-VII) of the shoulder.

MATERIAL AND METHODS

PubMed and Scopus search engines, an electronic search of articles was performed from inception to February 19, 2016. Diagnostic performance of index tests was compared by the summary area under receiver operator characteristic curve (AUROC).

RESULTS AND CONCLUSIONS

In all, 117 of 493 studies were eligible and 32 studies (2,013 shoulders) and 11 studies (1,498 shoulders) were evaluated with MRA and MRI. The summary sensitivity, specificity, likelihood ratio (positive and negative) and AUROC were 0.87 (95 % confidence interval, CI: 0.82, 0.91), 0.92 (95 %CI: 0.85, 0.95), 10.28 (95 %CI: 5.84, 18.08), 0.14 (95 %CI: 0.10, 0.20) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRA, and 0.76 (95 %CI: 0.61, 0.86), 0.87 (95 %CI: 0.71, 0.95), 5.89 (95 %CI: 2.5, 13.86), 0.28 (95 %CI: 0.17, 0.47) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRI. The diagnostic performance of MRA was superior to MRI by both direct and indirect comparisons for the detection of SLAP lesions.