Humeral head cysts and rotator cuff tears: an MR arthrographic study

Ultrasonography Outperforms Magnetic Resonance Imaging in Diagnosing Partial-Thickness Subscapularis Tear

PURPOSE

To evaluate the diagnostic reliability of ultrasonography (US) and magnetic resonance imaging (MRI) for subscapularis (SSC) tears with shoulder arthroscopy as the gold standard and to investigate the diagnostic value of 2 MRI signs (lesser tuberosity cysts and subcoracoid cysts) for SSC tears.

METHODS

We consecutively enrolled 437 patients who were scheduled to undergo arthroscopic rotator cuff repair from January 2019 to December 2020. Patients with previous shoulder surgery or shoulder fracture, recurrent shoulder instability, and systemic inflammatory disease were excluded. Preoperative US and MRI of the shoulder were performed and interpreted with a standardized approach. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of US and MRI were calculated using arthroscopic findings as the gold standard.

RESULTS

Of the 437 patients, 157 had SSC tears confirmed at the time of arthroscopy, 126 of whom had partial-thickness tears. US correctly diagnosed 122 of 157 patients with SSC tears, with an overall sensitivity of 77.7% (confidence interval [CI] 70.6%-83.5%), which was significantly greater than that of MRI (49.7%, CI 42.0%-57.4%, P < .001). For partial-thickness SSC tears, US correctly diagnosed 93 of 126 positive patients and 276 of 311 negative patients. This resulted in a sensitivity of 73.8% (CI 65.5%-80.7%), specificity of 88.7% (CI 84.8%-91.8%), and accuracy of 84.4% (CI 80.7%-87.5%). As with MRI, the sensitivity, specificity, and accuracy were 38.1% (CI 29.7%-47.2%), 86.5% (CI 82.3%-89.9%), and 72.5% (CI 68.2%-76.5%), respectively. Lesser tuberosity cysts and subcoracoid cysts were 2 MRI signs with high specificity (98.2% and 94.6%); however, their sensitivities were relatively low (19.8% and 33.8%).

CONCLUSIONS

US is a reliable and accurate diagnostic method for SSC tears, especially in easily missed partial-thickness tears. Lesser tuberosity cyst and subcoracoid cyst are highly specific but insensitive MRI signs for SSC tear.

LEVEL OF EVIDENCE

Level I, diagnostic, testing of previously developed diagnostic criteria.

Impact of 30 years' high-level rock climbing on the shoulder: an magnetic resonance imaging study of 31 climbers

BACKGROUND

Rock climbers are particularly susceptible to shoulder injuries due to repetitive upper-limb movements on vertical or overhanging terrain. However, the long-term effects of prolonged climbing on the shoulder joints are still unknown.

PURPOSE

The purpose of this study was to analyze the prevalence of pain and degenerative changes in the shoulder joints after high-level rock climbing over at least 25 years. We hypothesized that specific climber-associated patterns of degeneration would be found.

METHODS

Thirty-one adult male high-level rock climbers were compared to an age- and sex-matched control group of 31 nonclimbers. All participants underwent a detailed interview, standardized clinical examination, and bilateral (climbers) or unilateral (nonclimbers, dominant side) magnetic resonance imaging (MRI) scans. Clinical and MRI findings of the groups were compared.

RESULTS

The lifetime prevalence of shoulder pain in the rock climbers was 77%. The rock climbers had significantly more abnormalities in the labrum (82% vs. 52%; P = .002), long biceps tendon (53% vs. 23%; P = .006), and cartilage (28% vs. 3%; P = .005). These increased changes positively correlated with climbing intensity. There were no differences between the 2 groups with respect to rotator cuff tendon pathology (68% vs. 58%; P = .331) and acromioclavicular joint degeneration (88% vs. 90%; P = .713). Despite the increased degenerative changes in the rock climbers, their Constant score (CS) was still better than that of the nonclimbers (CS 94, interquartile range [IQR] 92-97, vs. CS 93, IQR 91-95; P = .019).

CONCLUSIONS

Prolonged high-level rock climbing leads to a high prevalence of shoulder pain and increased degenerative changes to the labrum, long biceps tendon, and cartilage. However, it is not related to any restriction in shoulder function.

Evaluation of arthroscopic rotator cuff repair results in patients with anterior greater tubercle cysts

PURPOSE

The purpose of this study was to investigate the clinical results of arthroscopic rotator cuff repair in patients with anterior greater tubercle cyst in magnetic resonance imaging (MRI).

METHODS

The cyst-present group comprised 38 patients with anterior greater tubercle cyst in MRI, and age- and sex-matched 30 patients without cyst in humeral head were included in the control group. The cystic group was divided into two groups, smaller than 5 mm (21 patients) and larger than 5 mm (17 patients), according to the cyst size. A total of three groups were created. In the evaluation of clinical outcomes, modified University of California at Los Angeles (UCLA) and the Western Ontario Rotator Cuff Index (WORC) were used. The visual analog scale (VAS) was used to assess pain. One-way analysis of variance was used to compare VAS, UCLA, and WORC scores among the groups.

RESULTS

There was a statistically significant difference in the clinical results of VAS, UCLA, and WORC among the cystic and noncystic groups in the anterior greater tubercle ( p < 0.05). There was also a statistically significant difference in the clinical results of UCLA, WORC, and VAS scores according to the cyst sizes in the anterior greater tubercle cyst group ( p < 0.05).

CONCLUSION

Anterior greater tubercle cysts have negative effects on rotator cuff repair results. If the anterior greater tubercle cyst size is greater than 5 mm, the negative effects of rotator cuff repair results are more pronounced. An understanding of anterior greater tubercle cysts has a critical importance for rotator cuff surgery planning.

Association between the location of tuberosity cysts and rotator cuff tears: A comparative study using radiograph and MRI

BACKGROUND

The association between tuberosity cysts and rotator cuff tears (RCTs) and the nature of the major contributing factors to tuberosity cyst formation continue to be controversial. The purpose of our study was to evaluate the strength of associations of RCT and various factors involved in the chronicity of RCT with tuberosity cysts, using magnetic resonance imaging (MRI) and radiographs.

METHODS

We reviewed consecutive patients with various disease entities between August 2004 and July 2013. After excluding unsuitable patients, this study involved 1007 shoulders of 906 consecutive patients. Each tuberosity cyst was categorized as an anterior greater tuberosity (GT), posterior GT, lesser tuberosity, and bare-area cyst. The odds ratios (ORs) and 95% confidence intervals (CIs) between the tuberosity cysts and various factors were evaluated by logistic regression analyses; p-value was set below 0.05.

RESULTS

Anterior GT cysts and posterior GT cysts on MRI or anterior GT cysts on radiographs were significantly associated with supraspinatus tendon (SST) tears ( p ≤ 0.019) and infraspinatus tendon (IST) tears ( p ≤ 0.004). Among the shoulder pathologies, RCTs only significantly associated with cyst formation (OR 4.23, 95% CI 3.17-5.65; p < 0.001). The retraction grade of Patte was significantly associated with anterior GT cyst (OR 3.65, 95% CI 2.42-5.48; p < 0.001).

CONCLUSION

Detecting an anterior GT cyst in a radiograph, even a low prevalence, in a patient with symptomatic shoulder indicates a need to consider RCT, especially of the SST, IST, and a high possibility of a retracted tear.

Mimickers of Hill-Sachs Lesions [Formula: see text]

The purpose of this article is to describe the imaging appearance, etiology, clinical features, and treatment of rare presentations of common bone and joint diseases known to mimic Hill-Sachs lesions. Knowledge of uncommonly encountered manifestations of ankylosing spondylitis, rheumatoid arthritis, septic joint, hyperparathyroidism, hydroxyapatite deposition disease, malignant bone tumors, and benign bone cysts which mimic traumatic Hill-Sachs lesions is important for radiologists to guide the clinical care of patients who present with shoulder symptoms.

The value of radiographic markers in the diagnostic work-up of rotator cuff tears, an arthroscopic correlated study

OBJECTIVE

To evaluate the value of radiographs during the diagnostic work-up of rotator cuff tears, using arthroscopy as reference standard.

MATERIALS AND METHODS

This retrospective study included 236 shoulders of 236 patients. All radiographs were evaluated for inferior cortical acromial sclerosis, lateral acromial spur, superior migration of the humeral head, greater tubercle cysts, and subacromial space calcifications. Predictive value of these radiographic signs in predicting rotator cuff tears was determined with arthroscopy as reference standard.

RESULTS

According to arthroscopy, 131 shoulders were diagnosed with rotator cuff tears. Seventy-two out of 131 shoulders (55%) had inferior cortical acromial sclerosis, 37 (28%) lateral acromial spur, 21 (16%) superior migration of the humeral head, 7 (5%) greater tubercle cysts and 15 subacromial space calcifications (11%). Inferior cortical acromial sclerosis (P = 0.001), lateral spur (P = 0.001), superior migration (P = 0.002), and cysts (P = 0.03) were significantly and independently associated with rotator cuff tears, whereas subacromial calcifications (p = 0.21) was not. Inferior cortical acromial sclerosis, superior migration, lateral acromial spur, and cysts combined have a positive predictive value of 78%.

CONCLUSIONS

The combination of inferior cortical acromial sclerosis, lateral acromial spur, superior migration of the humeral head, and greater tubercle cysts has a high positive predictive value for the presence of full-thickness rotator cuff tears. In patients with a high suspicion for having a rotator cuff tear based on radiographic findings, MRI can be performed directly without the delay and costs caused by an additional ultrasound exam.

Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain

BACKGROUND

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms.

MATERIALS AND METHODS

We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined.

RESULTS

Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51).

CONCLUSION

Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.

Revision of Failed Rotator Cuff Reconstruction With a Large Humeral Head Cyst

A revision rotator cuff repair is a technically challenging surgical procedure. This can be further complicated by the presence of poor quality of the cuff tissue, as well as a large greater tuberosity cyst, typically located at the rotator cuff footprint. This Technical Note discusses the surgical approach to deal with a revision rotator cuff tear with a large humeral head cyst. This described arthroscopic technique is performed in a single-stage procedure using a human dermal allograft (GraftJacket) for augmentation. This technique was specifically designed to (1) address the limited area for anchor placement, (2) use a bone graft, demineralized bone matrix, for repairing the bone cyst, and (3) optimize the biology for healing by augmenting the reconstruction with GraftJacket.

Conventional Radiology in Rheumatoid Arthritis

In clinical practice, the conventional radiography is still the radiologic method for the diagnosis of rheumatoid arthritis (RA). Moreover, it provides a quick overview of the symptomatic joints to narrow the differential diagnosis and to evaluate progression. RA is a polyarticular disease with bilateral and symmetric involvement of the peripheral joints, especially small joints, and less frequently, the cervical spine. The radiologic features are soft tissue swelling, periarticular osteoporosis, erosions, loss of joint space, and in advanced disease, osteolysis and typical subluxations or deformities, such as ulnar deviation.

Lesser tuberosity cysts and their relationship with subscapularis tears and subcoracoid impingement

BACKGROUND

We aimed to evaluate cysts in the lesser tuberosity of humeral head seen on magnetic resonance imaging (MRI) and their relationship with subcoracoid impingement and subscapularis tears evident on arthroscopic surgery videos. Our hypothesis was that the cysts would be more frequent with subscapularis tears and in the case of subcoracoid impingement.

METHODS

Patients who underwent shoulder arthroscopy between January 2010 and January 2016 were retrieved to evaluate subscapularis tears on surgery videos and lesser tuberosity cysts (LTC), coracohumeral distances (CHD) on both sagittal oblique and transverse sections of MRI retrospectively. There were 137 patients meeting the study criteria with subscapularis tear evident on surgery video and having preoperatively studied magnetic resonance images. All the tears were classified according to the Lafosse's system. The control group was constituted with 121 patients who underwent shoulder arthroscopy and were diagnosed with no subscapularis tear. Then, any statistically significant relationship between these parameters was investigated by the use of statistics software.

RESULTS

The mean age (57), gender distribution (female for 67.1%), and involved shoulder (right for 62.8%) rate of the groups were statistically similar. The existence rate of LTC was 55.5% and 19% for the study and control groups, respectively (P = .000). The study group was then evaluated in two groups regarding the existence of a cyst in the lesser tuberosity. There was no statistical difference between these two groups in terms of coracohumeral distances and tear type (P > .05). The study group was also divided into two depending on the transverse section CHD whether it was under 7 mm or not. There was still no statistical difference between these subgroups in terms of a cyst existence (P > .05). The supraspinatus tear rate and age distribution was also not differing in patients with and without LTC.

CONCLUSIONS

The LTCs were significantly associated with subscapularis tears, and could be used as an indicator in the interpretation of MRI scans. However, there was no relationship between the subcoracoid impingement and LTCs.

Dislocation of the Shoulder Joint - Radiographic Analysis of Osseous Abnormalities

Radiography remains pivotal to the workup of instability lesions of the shoulder, both in the acute as well as the chronic settings. The goal of radiography is to detect osseous abnormalities and locate them in order to determine the direction of instability. In antero-inferior instability, Hill-Sachs lesions are often visible at radiography and should not be confused with various differential diagnoses, which are usually more laterally located. Bankart lesions are more difficult to detect on conventional radiography, but there are less false positives than for Hill-Sachs lesions. The Garth view represents an excellent radiographic view to detect antero-inferior instability impaction fractures at both the humeral and glenoid sides. Accurate quantification of bony abnormalities and detection of lesions to the soft-tissue stabilizers of the shoulder however require advanced cross-sectional imaging techniques.

Locations of lesser tuberosity cysts and their association with subscapularis, supraspinatus, and long head of the biceps tendon disorders

BACKGROUND

Humeral head cysts are not uncommon in individuals with rotator cuff disorders. The cysts are usually considered an indicator of rotator cuff pathologies; however, they may have different meanings in different regions.

PURPOSE

To determine the frequency of cysts within and adjacent to the lesser tuberosity and the relationship between these cysts and subscapularis, supraspinatus, and long head of the biceps tendon (LHBT) disorders.

MATERIAL AND METHODS

We retrospectively reviewed 760 consecutive shoulder magnetic resonance imaging (MRI) examinations. Among these MRIs, we selected a group of patients with cysts located around the lesser tuberosity. The study population was also divided into two subgroups, patients with cysts within the lesser tuberosity and those with cysts adjacent to the lesser tuberosity. In addition to the number and size of cysts, the MRI appearance of the tendons was evaluated.

RESULTS

Eighty-one (10.7%) patients had cysts within and/or adjacent to the lesser tuberosity, 34 (42%) patients had cysts within the lesser tuberosity, and 47 (58%) patients had cysts adjacent to it. LHBT and subscapularis tendon disorders were significantly related to more than one cyst. In a univariate analysis, cysts within the lesser tuberosity were significantly associated with LHBT and subscapularis tendon disorders; however, multivariate analyses showed that only LHBT disorders were significantly associated with cysts within the lesser tuberosity.

CONCLUSION

Cysts within the lesser tuberosity were less common than cysts adjacent to it. LHBT and subscapularis tendon disorders were more frequently found in patients with more than one cyst within and/or adjacent to the lesser tuberosity. In addition, cysts within the lesser tuberosity were associated with LHBT disorders.

How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging

BACKGROUND

Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs.

METHODS

Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol.

RESULTS

No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups.

CONCLUSION

MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.

Intratendinous supraspinatus cyst as a cause of shoulder impingement

We report the case of a 29-year-old gentleman with shoulder impingement. An articular-sided intratendinous supraspinatus cyst was identified as the cause of his symptoms. Arthroscopic cyst debridement resulted in a good outcome at 1-year follow-up. Cysts around the shoulder are a well described pathological entity. They consist of different categories, including intraosseus cysts of the humeral head and glenoid, paralabral cysts and cysts associated with the acromioclavicular joint. Although paralabral cysts that lie intramuscularly or between the muscle bellies have frequently been reported, this is the first report of an intratendinous supraspinatus cyst with an intact rotator cuff. We describe the case, its management and the postsurgical outcome.

Pit above the lesser tuberosity in axial view radiography

PURPOSE

This study examined the relationship between the presence of a pit above the lesser tuberosity on axial view radiographs and rotator cuff tears and compared the demographic data between groups according to the presence of a pit above the lesser tuberosity. The hypothesis of this study was that the radiographic finding of a pit above the lesser tuberosity is related to rotator cuff tears.

METHODS

For 112 patients with a symptomatic rotator cuff tear, plain radiographs of the symptomatic shoulder (tear side radiographs) and plain radiographs of the asymptomatic contralateral shoulder (no-tear side radiographs) were assessed. Seventeen radiological findings, including a pit above the lesser tuberosity, osteophytes, subchondral cysts, and sclerosis, were recorded by one blinded observer. Demographic data such as age, duration of symptoms, sex, arm dominance, smoking history, trauma history, American Shoulder and Elbow Surgeons score, Constant score, and involved tendon were collected.

RESULTS

A pit above the lesser tuberosity was noted on tear side radiographs of 40 patients (35.7 %) and on the no-tear side radiographs of 27 patients (24.1 %), representing a significant difference (P = 0.040). A pit associated with a rotator cuff tear was observed more often in the dominant arm (P = 0.040) and more often in patients with less previous trauma (P = 0.024).

CONCLUSIONS

A pit above the lesser tuberosity on axial view radiography was associated with a rotator cuff tear and occurred more often in the dominant arm of patients who had no trauma history.

LEVEL OF EVIDENCE

Prognostic study, Level III.

Premature cystic lesions in shoulders of elite junior javelin and volleyball athletes: a comparative evaluation using 3.0 Tesla MRI

BACKGROUND

The purpose of this study was to evaluate clinical and magnetic resonance imaging (MRI) findings in the shoulders of high performance competitive junior javelin athletes and volleyball players. The hypothesis was that structural lesions already exist in young and asymptomatic overhead athletes.

METHODS

Thirty-one healthy high performance junior elite athletes were included. Group 1 consisted of 15 male javelin throwers (mean age, 17.7 ± 0.8 years) and group 2 of 16 male volleyball players (16.9 ± 1.0 years). Questionnaire-based interviews, comprehensive clinical examination, and shoulder scoring systems (visual analog scale [VAS] and Constant-Murley Score) were completed. Bilateral shoulder imaging was performed using a 3.0 Tesla MRI.

RESULTS

The Constant-Murley Score of group 1 was 95.5 ± 3.6 and 94.7 ± 4.6 points for group 2. Group 1 demonstrated a mean VAS of 0.9 ± 1.6 and group 2 a mean of 0.6 ± 0.8 points. Postero-superior intraosseous cysts of the humeral head were detected in 73.3% of all javelin throwers in the dominant shoulder, but only in 13.3% in the nondominant shoulder (P = .008). In the volleyball group, such cyst formation was rarely seen in 12.5% in the dominant versus 6.3% in the nondominant shoulder (P = .66).

CONCLUSION

A high percentage of junior elite athletes already demonstrate osseus signs of overloading especially in the group of javelin athletes, although none had a history of prior shoulder pathology. Therefore, junior overhead athletes might be at risk for the early development of structural lesions at the insertion of the posterior rotator cuff similar to lesions already known for adult athletes, even though they do not present clinical signs of overuse at that age.

Footprint reconstruction in a rotator cuff tear associated cyst of the greater tuberosity: augmented anchorage

Tears of the rotator cuff (RC) complicated by bone cysts at the footprint might represent a challenge for the shoulder surgeon. This might be additionally aggravated in elderly patients with inferior bone quality due to osteopenia or osteoporosis. In this report we present a technique for open repair of RC tears by augmenting the cystic lesion at the greater tuberosity using bone void filler in combination with a double row anchor reconstruction technique. Despite disadvantageous position and size of the cyst, using this technique the footprint can be restored by obtaining an anatomical position of the supraspinatus tendon. The application range of this technique is not limited to defined bony defects and presents a promising novel surgical approach. Level of evidence V.

Cysts within and adjacent to the lesser tuberosity: correlation with shoulder arthroscopy

OBJECTIVE

The purpose of our study was to determine if cysts in and adjacent to the lesser tuberosity are associated with rotator cuff pathology found at arthroscopy.

MATERIALS AND METHODS

A retrospective review was undertaken of the magnetic resonance (MR) imaging of 286 consecutive arthroscopic procedures performed by a single orthopedic shoulder surgeon from February 2001 to June 2009. Images of the shoulders were reviewed by an experienced fellowship-trained musculoskeletal radiologist, reader 1, and a musculoskeletal fellow, reader 2, for the presence and location of lesser tuberosity cysts. Cysts were grouped by their location into those within the lesser tuberosity and those adjacent to the lesser tuberosity. Interreader agreement was calculated using kappa values.

RESULTS

A total of 26 patients (17 men, 9 women; age range 14–84 years; mean of 61 years) had cysts in or adjacent to the lesser tuberosity. For reader 1, patients with cysts located in the lesser tuberosity were found to be significantly older(p=00.03) and more likely to have subscapularis tendon tears(p=00.02) than patients with cysts located adjacent to the tuberosity. No significant difference in any category between patients with a cyst located in the lesser tuberosity and those adjacent to the tuberosity was identified for reader 2. Interreader agreement of imaging findings ranged from fair to near perfect agreement.

CONCLUSION

Cysts located in the lesser tuberosity at the insertion of the subscapularis tendon are suggestive of subscapularis tendon pathology and may occur in older individuals.

Clinical update: MR imaging of the shoulder

Magnetic resonance imaging has become an important diagnostic adjunct in the evaluation of shoulder conditions, and the technology continues to evolve. Direct magnetic resonance arthrography can improve detection of labral and rotator cuff pathology, especially partial thickness tears of the rotator cuff. Special positioning, such as abducted-externally rotated views, improves visualization of the rotator cuff and posterior superior labrum in throwing athletes. Diagnosis-specific sequencing such as fat suppression, spin-echo and proton-density techniques, and higher power magnets (3.0 T) allow for an unprecedented level of soft tissue detail. Clinical expertize is required to differentiate between normal anatomic variants, incidental findings, and true pathology. Although magnetic resonance imaging findings may be diagnostic in some cases, clinical correlation with history and physical examination findings is critical.

Arthroscopic grafting of greater tuberosity cyst and rotator cuff repair

Cysts of the greater tuberosity can be a normal finding independent of age and concurrent rotator cuff tear. The presence of a large greater tuberosity cyst can present a challenge at the time of rotator cuff repair. We present a 1-step arthroscopic technique to address these defects at the time of rotator cuff repair using a synthetic graft (OsteoBiologics, San Antonio, TX) originally designed to address osteoarticular defects. With the viewing portal established laterally, a portal allowing perpendicular access to the cyst is established. The cyst is thoroughly debrided, and a drill sleeve is then introduced perpendicular to the surrounding bone, serving as a guide for the matching drill to create a circular socket. A correspondingly sized TruFit BGS cylindrical implant (OsteoBiologics) is then implanted by use of the included instrumentation. The scaffold is placed flush with the surrounding bone. Because our arthroscopic rotator cuff protocol uses a tension-band technique with placement of suture anchors distal and lateral to the rotator cuff footprint, we are subsequently able to proceed with routine rotator cuff repair.