Accuracy of long head of the biceps subluxation as a predictor for subscapularis tears

Repair of Isolated Subscapularis Tears With Concurrent Biceps Tenodesis Using a Single Anchor Results in Satisfactory Clinical Outcomes: Minimum 2-Year Follow-Up

PURPOSE

To investigate the clinical outcomes of patients treated with isolated subscapularis tear repair and biceps tenodesis using a single anchor.

METHODS

Patients diagnosed with subscapularis tear and who underwent arthroscopic surgery by a single surgeon between February 2017 and January 2022 were evaluated retrospectively. Inclusion criteria were patients who underwent repair of isolated subscapularis tear along with tenodesis for long head of the biceps tendon pathologies such as SLAP lesion, instability, partial tear, or tenosynovitis, with a minimum follow-up of 24 months. Assessment included active and passive range of motion, single-assessment numeric evaluation (SANE), visual analog scale (VAS), Constant-Murley score (CMS), and specific subscapularis and biceps tests. Improvements were analyzed using minimum clinically important difference (MCID) values.

RESULTS

A total of 20 patients were included. The mean age was 48.5 ± 7 years, and the follow-up period was 43.1 ± 12.7 months. Significant improvements were observed at the final follow-up in active forward flexion, active abduction, active internal rotation, as well as VAS, SANE, and CMS (P < .001). The MCID analysis showed that 100% of patients met the MCID for CMS, 90% for SANE, and 100% for VAS.

CONCLUSIONS

In the presence of an isolated subscapularis tear associated with long head of the biceps tendon pathologies, favorable clinical outcomes could be achieved by performing both tear repair and biceps tenodesis with a double-loaded single anchor. Most patients (>90%) achieved the MCID for the CMS, SANE, and VAS, indicating significant clinical improvement and satisfactory patient outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Evaluation of Conventional MR Imaging of the Shoulder in the Diagnosis of Lesions of the Biceps Pulley

RATIONALE AND OBJECTIVES

To determine the diagnostic accuracy and reproducibility of conventional MR imaging (MRI) of the shoulder in evaluating biceps pulley lesions using arthroscopy as the standard of reference.

METHODS

In a retrospective study, MR examinations of 68 patients with arthroscopically proven torn or intact biceps pulley were assessed for the presence of pulley lesions by three radiologists. The following criteria were evaluated: displacement of the long head of the biceps tendon (LHBT) relative to the subscapularis tendon (displacement sign), subluxation/dislocation of the LHBT, the integrity of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), lesions of the supraspinatus (SSP) and subscapularis (SSC) tendons adjacent to the rotator interval, presence of biceps tendinopathy and subacromial bursitis.

RESULTS

There were 42 patients with pulley lesions in the study group. Conventional MR imaging showed an overall sensitivity of 95.2%, 88.1% and 92.9%, a specificity of 61.5%, 73.1%, and 80.8% and an accuracy of 82.4%, 82.4% and 88.2% in the diagnosis of pulley lesions. Interobserver agreement was substantial (multirater k = 0.75). Biceps tendinopathy (97.6%, 95.2%, 97.6%), defects of the SGHL (86.3%, 81.0%, 88.1%) and the displacement sign (88.1%, 81.0%, 85.7%) were the most sensitive diagnostic criteria. Subluxation/dislocation of the LHBT was insensitive (78.6%, 42.9%, 33.3%), but specific (69.2%, 100,0%, 96.2%).

CONCLUSION

In the diagnosis of pulley lesions, conventional MR imaging is reproducible and shows high sensitivity and accuracy but moderate specificity.

Is It Time to Rethink the Relationship Between Subscapularis Tears and the Long Head of Biceps Tendon?

Introduction Pre-operative diagnosis of subscapularis tears remains a difficult challenge. Ultrasound has been shown to be ineffective at directly detecting subscapularis tears. It has been widely accepted that medial subluxation of the long head of biceps tendon (LHBT) is associated with full-thickness subscapularis tears. The aims of this study are to assess whether LHBT subluxation on ultrasound scanning has any predictive value for subscapularis tears and to determine the relationship between LHBT subluxation and subscapularis tears at arthroscopy. Methods Pre-operative ultrasound and arthroscopic findings for patients undergoing arthroscopic rotator cuff repair at our institution between March 2011 and January 2016 were analysed. The accuracy of LHBT subluxation on ultrasound and at arthroscopy as a predictor of subscapularis tears at arthroscopy was calculated. The correlation between LHBT subluxation and subscapularis tears was determined. A standardised technique was used for ultrasound scans, and the grade of the sonographer was recorded. Results Three hundred fifty-nine rotator cuff repairs were performed. Twenty-four patients had a subluxed LHBT. Ultrasound was poorly sensitive (50%), and a subluxed LHBT on ultrasound only correlated very weakly with subscapularis tears at arthroscopy (R = 0.268, p<0.001). At arthroscopy, 92 patients had full-thickness subscapularis tears. Of these, only 16 patients (17%) had a subluxed/dislocated LHBT. Of the 24 patients with a subluxed LHBT, eight had no subscapularis tears. Thus, LHBT subluxation/dislocation only correlated weakly with full-thickness subscapularis tears (R=0.252, p<0.001). Conclusion Due to their close anatomical relationship, traditional teaching suggests subscapularis tears are associated with medial LHBT subluxation. Our data indicate that, contrary to popular belief, the two are only weakly correlated. In our series, the majority of patients with subscapularis tears (83%) had their LHBT in-groove. The authors therefore recommend high vigilance during arthroscopy for the diagnosis and repair of subscapularis tears, regardless of pre-operative ultrasound findings and the intra-operative position of the LHBT.

Preoperative Shoulder MRI Findings to Predict Subscapularis Tendon Tear Requiring Surgical Repair

Purpose

This study aimed to investigate which indirect parameters on preoperative MRI were the principal predictors of subscapularis tendon tears (STTs) requiring surgical repair.

Materials and Methods

Preoperative MRI scans of 86 patients were retrospectively reviewed for visual assessment of the STT, pathology of the long head of the biceps tendon (LHBT), posterior decentering (PD) of the humeral head, humeral rotation, fatty degeneration, and subscapularis muscle atrophy. To evaluate atrophy, visual grading using the anatomical line connecting the coracoid tip to the glenoid base, designated as the base-to-tip line (BTL), and thickness measurements were performed in the en-face view.

Results

Arthroscopically, 31 patients (36%) exhibited Lafosse type III or IV STT and underwent surgical repair. LHBT pathology (p = 0.002), PD of the humeral head (p = 0.012), fatty degeneration (p < 0.001), and BTL grade (p = 0.003) significantly correlated with STT. In the multivariate analysis, PD of the humeral head (p = 0.011, odds ratio [OR] = 5.14) and fatty degeneration (p = 0.046, OR = 2.81) were independent predictors of STT.

Conclusion

PD of the humeral head and fatty degeneration of the subscapularis can help to diagnose clinically significant STT. Interpretation of these findings may contribute to the planning of an optimal surgical strategy.

Arthroscopic Subscapularis Repair With Preserved Biceps Anatomy

Arthroscopic subscapularis repair continues to improve with the advancement of surgical technique and critical focus on careful intraoperative evaluation. As identification of these tears increases, there is an expected increase in repair rates as well. Anatomically, the upper border of the subscapularis and the long head of the biceps (LHB) tendon are in close relation. Many surgeons have advocated concomitant LHB tenotomy versus tenodesis in conjunction with operative subscapularis tears. We hypothesized that in the setting of a preserved anatomic biceps pulley and no LHB pathology, isolated subscapularis repair would result in excellent clinical outcomes when compared with subscapularis repair and biceps tenotomy or tenodesis.

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 subcoracoid effusion be a more specific finding for subscapularis tear among rotator cuff pathologies on magnetic resonance imaging?

HYPOTHESIS AND BACKGROUND

Magnetic resonance imaging (MRI) is a well-known, noninvasive diagnostic method for rotator cuff tendon pathologies that are not very sensitive for subscapularis tendon tears. Subcoracoid effusion (SE) is an easily recognizable radiologic sign on MRI. In this study, we aimed to examine the relationship of SE with rotator cuff tear and to investigate whether SE could be a supportive finding in the diagnosis of subscapularis tear in preoperative MRI. Our hypothesis was that SE was a more specific finding of subscapularis tear than other rotator cuff tears.

METHODS

The data of patients who underwent shoulder arthroscopy in our clinic between 2017 and 2021 were analyzed retrospectively. Four groups were included in the study: patients with a rotator cuff tear accompanied by a subscapularis tear (group 1, n = 273), patients with isolated subscapularis tear (group 2, n = 57), patients with rotator cuff tear with intact subscapularis tendon (group 3, n = 190), and patients without any rotator cuff pathology (group 4, n = 263). Arthroscopic video records and MRIs of all patients were evaluated retrospectively. Subscapularis tendon tears were classified according to the Lafosse classification.

RESULTS

There was a statistically significant difference between the groups in terms of the presence of SE on MRI (P = .001). The presence of SE in group 1 and group 2 was statistically significantly higher than that in both group 3 and group 4 (P = .001), and there was no significant difference between group 3 and group 4 (P > .05). A significant relationship was found between Lafosse classification and SE (P = .001). When the diagnostic powers of the detection of SSC tear and the presence of SE on MRI for SSC tear were compared, Kappa values were 0.615 (P = .001) and 0.701 (P = .001), and overall diagnostic accuracy rates were 80.3% and 85.5%, respectively.

CONCLUSION

We conclude that SE is a more specific finding for subscapularis tears than other rotator cuff pathologies. We suggest that SE on MRI should also be considered in patients with a rotator cuff tear in whom a subscapularis tear was not detected in preoperative MRI and that the subscapularis tendon should be carefully evaluated during surgery in cases where the effusion is positive.

The prevalence, classification, radiological and arthroscopic findings of intratendinous subscapularis tears

PURPOSE

To investigate the clinical characteristics of intratendinous subscapularis (inSSC) tears.

METHODS

Retrospectively, 69 patients with arthroscopically confirmed inSSC tears were identified from 2018 to 2019. Preoperatively and at final follow-up, thorough physical examination was performed and clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score; University of California, Los Angeles [UCLA] score; visual analogue scale [VAS] for pain; and Simple Shoulder Test [SST]) were recorded. Features of pre-operative magnetic resonance image (MRI) such as high signalling within the tendon substance, communication to the bicipital groove and long head of biceps tendon (LHBT) lesions were investigated. Characteristics of arthroscopic view were investigated. Bear-hug and internal rotation resistance test at 90° abduction and external rotation (IRRT90°) test were used to assess the SSC strength.

RESULTS

The mean follow-up was 2.4 (2-3) years. The prevalence of arthroscopically confirmed inSSC tears was 69/675 (10.2%) among arthroscopic rotator cuff repairs. Pre-operative physical examination found positive IRRT90° and bear-hug test in 41/60 (68.3%) and 42/69 (60.8%) patients, respectively. The Cohen kappa coefficient was interpreted to be substantial for the evaluation of all MRI parameters. According to the conditions of LHBT, inSSC tears were classified into 3 types: type I: without LHBT subluxation and tear; type II: with LHBT subluxation or tears and type III: with LHBT dislocation. At final follow-up, mean ASES, UCLA, VAS, and SST scores improved significantly from mean of 50.6 ± 14.7, 19.4 ± 3.07, 6.2 ± 2.0, and 6.1 ± 2.5 to mean of 90.7 ± 9.5, 32.2 ± 1.8, 1.4 ± 1.2 and 9.8 ± 2.2, respectively (P < 0.001). Bilateral symmetric strength was found by bear-hug and IRRT90° test in all patients postoperatively.

CONCLUSION

Understanding features of pre-operative MRI, physical examination and arthroscopic view is helpful to identify inSSC tears. Arthroscopic repair yielded satisfactory clinical outcomes in patients with inSSC tears.

LEVEL OF EVIDENCE

Level IV.

The Digitation Sign Facilitates Diagnosis of Shoulder Subscapularis Lesions on Preoperative Magnetic Resonance Imaging

Purpose

The purposes of this study were to investigate a radiographic sign found on coronal magnetic resonance imaging (MRI) sequences in subscapularis (SSC) pathology, reporting interobserver reliability data and sensitivity and specificity; and to correlate the preoperative assessment of SSC pathology with intraoperative assessment of the SSc during shoulder arthroscopy.

Methods

A consecutive series of patients undergoing arthroscopic rotator cuff repair from January 2020 to December 2020 were examined. The positive diagnosis of a subscapularis tendon tear was prospectively determined and confirmed by arthroscopy. The “digitation sign” was assessed by 3 independent shoulder-trained fellows when evaluating the SSC in the coronal plane on T2-weighted images.

Results

Of the 132 patients included, 74 (56%) had SSC tendon tears confirmed during arthroscopy. Interobserver agreement for digitation sign was substantial (k= 0.640). Sensitivity for digitation sign only was 74.3%; for criteria of Adams et al. (Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy; Arthroscopy 2010;26:1427-1433) only, 83.8%; and for the combination of the 2 methods, 89.2%. Specificity was 84.5% for digitation sign only, 77.6% for Adams et al. criteria only, and 67.2% for the combination of the 2 methods. Sensitivity is statistically better when the digitation sign is added to the Adams et al. criteria for detection of SSC lesions. As expected, specificity is statistically lower. SSC tears are significantly associated with biceps lesions.

Conclusion

Preoperative systematic MRI evaluation by shoulder surgeons can diagnose subscapularis lesions by using the digitation sign in the coronal plane along with Adams et al. criteria, leading to good sensitivity. This easy-to-apply sign can be helpful in the initial MRI evaluation in the coronal plane, with improved sensitivity when combined with a systematic approach.

Level of Evidence

II, study of diagnostic test.

Subscapularis Tears: Evolution in Treatment Options

Subscapularis tears occur more commonly than previously reported. Owing to the importance of the subscapularis in shoulder function, strong consideration should be given to repairing a full-thickness subscapularis tear when present. Historically, subscapularis repairs were done through a deltopectoral approach with good results. More recently, arthroscopic techniques have been developed with similar outcomes. When tears of the subscapularis are irreparable, reconstructive options, including tendon transfers, capsular reconstruction, and reverse shoulder arthroplasty, exist and continue to evolve.

Usefulness of ultrasound in diagnosing long head of the biceps tendon malposition in patients with rotator cuff tears

PURPOSE

This study aimed to determine the role of preoperative shoulder ultrasonography (SUS) in detecting positional abnormalities of the long head of the biceps tendon (LHBT) and predicting subscapularis (SSC) tears in patients with rotator cuff injuries.

METHODS

A total of 331 patients (365 shoulders) who had undergone arthroscopic shoulder surgery for the treatment of rotator cuff tears were included in the study. Their preoperative SUS and magnetic resonance imaging (MRI) findings were examined retrospectively to assess the presence of LHBT abnormalities at the bicipital groove. Using arthroscopic findings as the standard of reference, the sensitivity, specificity, and diagnostic accuracy of SUS and MRI were calculated for detection of LHBT malposition. Furthermore, the correlation between SSC rupture and preoperative LHBT condition was evaluated by MRI and SUS.

RESULTS

LHBT malposition was preoperatively diagnosed with a sensitivity of 92%, specificity of 90%, and accuracy of 91% with SUS, and a sensitivity of 74%, specificity of 84%, and accuracy of 80% with MRI. Preoperative SUS was significantly superior to MRI in terms of sensitivity, specificity, and accuracy (p < 0.001 each). Further, the preoperative SUS LHBT findings could predict well the presence or absence of intraoperative SSC rupture (odds ratio: 1.73, p < 0.001).

CONCLUSION

SUS is a useful diagnostic modality for preoperative detection of LHBT malposition and prediction of SSC tears in patients with rotator cuff tears.

Predicting the clinically significant subscapularis tendon tear: malposition and tear of the long head of the biceps tendon on shoulder magnetic resonance imaging

BACKGROUND

The diagnostic accuracy of magnetic resonance imaging (MRI) is low for detecting a subscapularis tendon tear.

PURPOSE

To identify MRI findings that may predict the presence of a clinically significant subscapularis tendon tear requiring surgical repair.

MATERIAL AND METHODS

We reviewed shoulder MR images of patients who had undergone arthroscopic rotator cuff repair at our institution between June 2018 and May 2019. Patients were divided into two groups: the study group (n = 51), with an intermediate- to high-grade partial thickness tear of the subscapularis tendon suspected on preoperative MRI and intermediate or higher grade of the tendon tear proven on arthroscopy; and the control group (n = 18), with an intermediate- to high-grade partial thickness tear of the subscapularis tendon suspected on preoperative MRI but no tear or low-grade partial thickness tear of the tendon shown on arthroscopy. Preoperative MR images were retrospectively evaluated by two readers for the size of the subscapularis tendon tear, bone reactions at the lesser tuberosity, and long head of the biceps tendon (LHBT) pathology.

RESULTS

The subscapularis tendon tear measured by reader 2 was larger in the study group than in the control group. The prevalence of a tear (P = 0.006 for reader 1; P = 0.011 for reader 2) and malposition (P < 0.001 for both readers) of the LHBT were significantly greater in the study group.

CONCLUSION

A tear and malposition of the LHBT on MR images may predict the presence of a clinically significant subscapularis tendon tear.

Arthroscopic Revision Rotator Cuff Repair: The Role of Previously Neglected Subscapularis Tears

BACKGROUND

Concomitant full-thickness tear of the subscapularis tendon is often neglected during primary posterosuperior rotator cuff repair, and its significance has not been investigated by any previous clinical study.

PURPOSE

To investigate (1) the clinical and radiological outcomes of revision arthroscopic rotator cuff repair and (2) the number of neglected concomitant subscapularis full-thickness tears in the revision of posterosuperior rotator cuff retears and their structural integrity after repair.

STUDY DESIGN

Case series, Level of evidence, 4.

METHODS

This study retrospectively examined 58 patients who underwent arthroscopic rotator cuff revision for a retear of a previously repaired posterosuperior rotator cuff. Preoperative and postoperative functional scores and active range of motion (ROM) were assessed. The initial and most recent follow-up magnetic resonance imaging scans before revision and arthroscopic findings at the time of primary repair were reviewed to determine whether the concomitant subscapularis tear was newly developed or preexisting. Final confirmation of the tendon's full-thickness tear was made during the revision procedure.

RESULTS

At final follow-up, mean functional shoulder scores and ROM improved significantly compared with the preoperative values (P < .001). Among the 58 revision cases, 25 (43.1%) had a neglected full-thickness tear of the subscapularis tendon. The fatty infiltration grade of the neglected subscapularis tear progressed from a mean of 1.1 before primary repair to a mean of 1.6 before revision, and the change indicated statistically significant deterioration (P < .001). Despite clinical improvement after revision surgery, the retear rate was considerable in the re-repaired cuff tendons (37.9%) as well as for the repaired concomitant subscapularis tears (24%).

CONCLUSION

Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. The retear rate after the repair of neglected subscapularis tears was higher than expected. Thus, detecting and treating subscapularis tear via meticulous preoperative evaluation and thorough inspection during primary arthroscopy are essential.

The effect of bicipital groove morphology on the stability of the biceps long head tendon

BACKGROUND

Long head of biceps tendon (LHBT) instability is an important source of pain and disability for the shoulder. Supraspinatus and subscapularis tendons contribute to the formation of the biceps pulley system, which maintains biceps stability during shoulder movements. The aim of this study is to evaluate the effect of morphology of bicipital groove on the stability of LHBT. Also, to evaluate the relationship between bicipital groove morphology and subscapularis rupture and supraspinatus rupture.

MATERIAL AND METHODS

Surgical images and magnetic resonance images of 200 patients who underwent shoulder arthroscopy surgery in our clinic between January 2016 and December 2017 were retrospectively analyzed. The depth of groove, medial wall angle and opening angle values of 200 patients were measured on MRI. The stability of the biceps long head tendon, rotator cuff tear and SLAP lesions was recorded by monitoring the shoulder arthroscopy records in each groups.

RESULTS

There were 200 patients, 131 male and 69 female, with an average age of 40.9 ± 14.2 (range: 17.0-79.0) years. In 69 (34.5%) patients, long head of the biceps tendon (LHBT) instability was detected. The patients were divided into two groups according to LHBT instability.The subscapularis rupture was significantly more frequent in the group with LHBT instability (52.2%) than the group without LHBT instability (4.6%) (p < 0.001). The supraspinatus tear was observed in 72.5% in the group with instability and 56.5% in the non-instability group, which shows a statistical difference between the two groups (p = 0.027). The presence of SLAP was observed in similar rates in both groups (p = 0.053). Mean depth of groove, medial wall angle, and opening angle measurements were similar in both groups (p = 0.568, p = 0.393 and p = 0.598, respectively).

CONCLUSION

To conclude, the morphology of the bicipital groove is not related to the stability of LHBT, and the soft tissue factors above the bicipital groove rather than bone morphology are important in stability. In addition, subscapularis rupture is a pre-disposing factor for LHBT instability; therefore, we recommend a more careful examination of LHBT in patients with subscapularis rupture.

LEVEL OF EVIDENCE

III.

Prediction of the anterior shoulder pain source by detecting indirect signs for partial articular subscapularis tendon tears through conventional magnetic resonance imaging

PURPOSE

To evaluate the diagnostic efficacy of indirect signs for proximal articular-positioned, partial (< 50%), subscapularis tendon tears (facet 1 tears) via conventional magnetic resonance imaging (MRI).

METHODS

A retrospective study was conducted on 67 patients of Yoo's type 1 or 2A tears. Forty-five arthroscopic subacromial decompression and acromioclavicular resection cases served as controls. Indirect signs indicating a facet 1 tear included small defects, superior subscapularis recess (SSR), long head of the biceps (LHBT) configurations, bone edema or cyst formation on lesser tuberosity (LTBEC), and fatty infiltration of subscapularis muscle. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were checked.

RESULTS

SSR was the most sensitive sign (90%). The sensitivities and NPV of LHBT configurations and LTBEC were low (sensitivity: 42.9% and 17.9%, NPV: 56.4% and 44.4%, respectively). The specificities of all indirect signs were relatively high (> 90%). The Chi-squared test and multinomial logistic regression confirmed the significance of small defects, SSRs, and fatty infiltrations for facet 1 tears (p ≤ 0.014). The combined sensitivity and specificity were up to 97.7% and 92.3%, respectively, in the presence of either a small defect or an SSR.

CONCLUSIONS

Conventional MRI alone can detect facet 1 tears through indirect signs (small defects, SSR, and fatty infiltrations of the subscapularis muscle), predicting unspecified anterior shoulder pain due to concealed biceps instability, and facilitating preoperative diagnosis for a facet 1 tear.

LEVEL OF EVIDENCE

III.

Analysis of the results and adverse factors of arthroscopic repair of degenerative subscapular lesions

OBJECTIVE

To carry out a review of degenerative subscapularis ruptures (SSC) after their arthroscopic repair and to evaluate whether the results are comparable in terms of pain and function to those of younger patients with traumatic ruptures.

METHODS

The data of 80 SSC tears of the 660 rotator cuff tears operated on by the same team of surgeons from June 2008 to June 2018 were retrospectively reviewed. The clinical data of the surgical indications were collected: age, gender, laterality, intervention delay, associated pathologies, location of pain, value of the Visual Analogue Scale (VAS) and the Constant-Murley test (CMT); surgical data were also collected: type and size of lesion, associated biceps injury and associated surgical procedure, coracoid stenosis and associated surgical procedure, number and type of anchors used. A statistical study was performed with multiple linear regression test, parametric tests (Student's t or ANOVA) and non-parametric tests.

RESULTS

Of 80 patients, 36 were women (45%) and 44, men (55%); mean age 61years (range 47 to 81); mean delay of surgery 3.5months (range 1 to 6); right shoulder affected in 46 cases (57.5%), left in 34 (42.5%); 22 (27.5%) were isolated lesions, 58 (72.5%) were associated with supraspinatus rupture (SE). The mean improvement was 5.0 points in terms of the VAS and 39.9 points on average in the CMT. New breakage rate, 1.25%. Adverse factors: size of the tear, delay in intervention, women. Patients with type I-B rupture have a better overall result in the CMT than types I-A and III. The longer the delay, the worse results are observed, both for the VAS and the CMT. Women present worse and statistically significant results both in the VAS (P=.00) and in the CMT (P=.01).

CONCLUSIONS

Excellent and good results have been obtained in this group of patients, but there are adverse factors such as the size of the tear, the duration of the symptoms and the association of other pathologies, especially in women.

Subscapularis Tendon Tears - Usefulness of Written MRI Reports for Guiding Patient Referral to Shoulder Specialists

INTRODUCTION

 Rotator cuff tears are one of the most common reasons for shoulder pain, and patients often present initially to general practitioners. However, subscapularis tears are especially difficult to diagnose and hence adequate therapy is often delayed. General practitioners or non-specialist orthopedic surgeons need reliable MRI findings to allow timely referral of patients to shoulder specialists. The purpose of this study was to determine the validity of the written MRI report of patients with arthroscopically proven subscapularis tendon tears.

METHOD

 In this retrospective study, 97 patients (mean age 62.4 ± 10 years, 63 men) who underwent arthroscopic subscapularis repair between April 2013 and January 2015 by two experienced shoulder surgeons and who underwent a preoperative 1.5 T MRI study were included. All of these patients had high-field strength (i. e., ≥ 1.5 T) standard MRI scans performed within 4-164 (mean 57.4 ± 38.4) days before their arthroscopic procedures.

RESULTS AND CONCLUSION

 Subscapularis tendon tears, verified by arthroscopy, were correctly identified in only 37 of 97 cases in the written report of the preoperative MRI. This resulted in an overall low sensitivity of 38.1 %. Correctly predicted lesions were as follows: Fox and Romeo I 29.4 % (5/17 patients), Fox and Romeo II 20 % (7/35 patients), Fox and Romeo III 46.7 % (14/30 patients) and Fox and Romeo IV 73.3 % (11/15 patients). In contrast, concurrent supraspinatus tendon tears were identified correctly in 88.2 % of patients (60/68 cases, sensitivity 88.2 %, specificity 96.5 %). Preoperative written radiology reports provided by a heterogeneous group of 39 presumably non-MSK-specialized radiologic centers do not reliably detect subscapularis tendon tears and are not sufficient for guiding patients to specialist centers. Compared to other rotator cuff injuries, this study shows difficulties in the correct diagnosis of subscapular tendon injuries. However, this is necessary to provide patients with timely therapy. It can be assumed that MRI review by musculoskeletal-specialized radiologists would more often than not lead to the correct diagnosis.

KEY POINTS

  · Subscapularis tendon ruptures are difficult to diagnose on standard shoulder MRI.. · Written MRI reports from non-musculoskeletal-specialized radiologists are not reliable, especially for smaller lesions.. · Reliable findings are required for referral allocation to shoulder specialists (specialized musculoskeletal radiologists)..

CITATION FORMAT

· Lenz R, Kircher J, Schwalba K et al. Subscapularis Tendon Tears - Usefulness of Written MRI Reports for Guiding Patient Referral to Shoulder Specialists. Fortschr Röntgenstr 2021; 193: 797 - 803.

MR Imaging of the Rotator Cuff

The cause of rotator cuff tears is multifactorial with both intrinsic and extrinsic contributing factors. Understanding the normal MR anatomy of the rotator cuff and using an appropriate search pattern can help readers identify common pathologic conditions. Accurate designation using classification systems for tear thickness, size, and degree of retraction and muscle fatty infiltration and atrophy are important in guiding surgical management. Knowledge of common disease locations for the rotator cuff tendons can help focus reader searches and increase sensitivity.

Detecting Rotator Cuff Tears: A Network Meta-analysis of 144 Diagnostic Studies

BACKGROUND

Many imaging techniques have been developed for the detection of rotator cuff tears (RCTs). Despite numerous quantitative diagnostic studies, their relative accuracy remains inconclusive.

PURPOSE

To determine which of 3 commonly used imaging modalities is optimal for the diagnosis of RCTs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Studies evaluating the performance of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and ultrasound (US) used in the detection of RCTs were retrieved from the PubMed/MEDLINE and Embase databases. Diagnostic data were extracted from articles that met the inclusion/exclusion criteria. A network meta-analysis was performed using an arm-based model to pool the absolute sensitivity and specificity, relative sensitivity and specificity, and diagnostic odds ratio as well as the superiority index for ranking the probability of these techniques.

RESULTS

A total of 144 studies involving 14,059 patients (14,212 shoulders) were included in this network meta-analysis. For the detection of full-thickness (FT) tears, partial-thickness (PT) tears, or any tear, MRA had the highest sensitivity, specificity, and superiority index. For the detection of any tear, MRI had better performance than US (sensitivity: 0.84 vs 0.81, specificity: 0.86 vs 0.82, and superiority index: 0.98 vs 0.22, respectively). With regard to FT tears, MRI had a higher sensitivity and superiority index than US (0.91 vs 0.87 and 0.67 vs 0.28, respectively) and a similar specificity (0.88 vs 0.88, respectively). The results for PT tears were similar to the detection of FT tears. A sensitivity analysis was performed by removing studies involving only 1 arm for FT tears, PT tears, or any tear, and the results remained stable.

CONCLUSION

This network meta-analysis of diagnostic tests revealed that high-field MRA had the highest diagnostic value for detecting any tear, followed by low-field MRA, high-field MRI, high-frequency US, low-field MRI, and low-frequency US. These findings can help guide clinicians in deciding on the appropriate imaging modality.

Small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for biceps long head tendon lesions with repair of rotator cuff tears

The curative effect of small-incision open distal subpectoral vs. arthroscopic proximal biceps tenodesis for lesions in the long head of the biceps tendon (LHBT) combined with rotator cuff repairs (RCR) has remained controversial. The aim of the present study was to compare the two surgical methods. A total of 71 patients who received surgical treatment for LHBT lesions accompanied by RC tears were analyzed. Following arthroscopic RCR and tendectomy of the affected LHBT, 35 patients underwent small-incision open distal subpectoral tenodesis through a small incision (the subpectoral group), while the remaining 36 patients received arthroscopic proximal tenodesis (the arthroscopic group). The surgery time and intra-operative blood loss were compared between the two groups. In addition, the clinical outcomes were evaluated using scoring systems for the functional assessment of the shoulder joint. The subpectoral group had a shorter surgery time and less intra-operative blood loss than the arthroscopic group (P<0.05). The functional scores of the two groups significantly improved as time passed (P<0.05). The subpectoral group was significantly superior to the arthroscopic group with regard to the American Shoulder and Elbow Surgeons score at 2 weeks post-operatively and visual analog scale score at 2 weeks and 3 months post-operatively (P<0.05). Small-incision open distal subpectoral and arthroscopic proximal tenodesis were demonstrated to effectively improve the function of the shoulder joint and relieve pain caused by LHBT lesions accompanied by RCR. However, small-incision open distal subpectoral tenodesis had the additional advantage of shorter surgery time, less intra-operative bleeding and encouraging early results compared to arthroscopic proximal tenodesis. The study was registered as a clinical trial in the Chinese Trial Registry (no. ChiCTR1800015643).

Histologic characteristics of the subscapularis tendon from muscle to bone: reference to subscapularis lesions

BACKGROUND

Although subscapularis tendon lesions seem to differ from those of the supraspinatus tendon, the features they have in common suggest that the subscapularis tendon may also have 2 distinct layers. Our aim was therefore to characterize the histologic structure of the subscapularis tendon from its humeral insertion point to the musculotendinous junction.

MATERIAL AND METHODS

A histologic study was performed on 10 autopsy samples. The subscapularis tendon was extracted in one piece from the musculotendinous junction to the humeral insertion point and was prepared using standard (hematoxylin-eosin-saffron) staining.

RESULTS

Histologic analysis revealed 2 fibrous layers, distinguishable by the orientation of the collagen bundles. The deep layer was thinner and composed of parallel longitudinal collagen fibers inserting onto the lesser tuberosity flush with the cartilage. The superficial layer was thicker and composed of interdigitated collagen bundles inserting onto the lesser and the greater tuberosity after splitting into 2 bands, 1 lining the floor of the bicipital groove, and the other extending over the long head of the biceps tendon across the groove. Each layer formed an independent musculotendinous junction in the subscapularis muscle.

CONCLUSIONS

The subscapularis tendon is composed of 2 distinct fibrous layers, just like the supraspinatus tendon, but arranged differently. The superficial layer of the subscapularis tendon passes across the bicipital groove and forms a fibrous ring around the long head of the biceps tendon that stabilizes the latter in the bicipital groove. These results explain some of the specific features of subscapularis tears described in the literature, namely, delamination and biceps subluxation.

Medial Subluxation or Dislocation of the Biceps on Magnetic Resonance Arthrography Is Reliably Correlated with Concurrent Subscapularis Full-Thickness Tears Confirmed Arthroscopically

Background

The purpose of this study was to investigate the relationship between biceps medial subluxation/dislocation on the magnetic resonance arthrography (MRA) imaging and subscapularis full-thickness tear confirmed arthroscopically. We hypothesized that presence of a biceps medial subluxation or dislocation would strongly indicate a subscapularis full-thickness tear.

Methods

A total of 432 consecutive patients who underwent arthroscopic repair for rotator cuff tears with/without subscapularis tears at our institute were retrospectively reviewed. The inclusion criterion of this study was preoperative MRA images taken within 6 months of arthroscopic repair. The presence of medial subluxation/dislocation was evaluated on the preoperative MRA images, and subscapularis tear was confirmed on arthroscopic examination.

Results

Biceps subluxation/dislocation was identified in 46 of the 432 patients on MRA. Forty-five of these 46 patients also had a subscapularis full-thickness tear identified in arthroscopic examination. Among the 386 patients who did not have biceps subluxation or dislocation, 54 patients had a subscapularis full-thickness tear diagnosed arthroscopically. The presence of a biceps subluxation/dislocation could predict a subscapularis full-thickness tear with sensitivity of 45% (45/99), specificity of 99% (332/333), positive predictive value of 98% (45/46), negative predictive value of 86% (332/386), and accuracy of 87% (377(45 +332)/432).

Conclusion

Medial subluxation/dislocation of the biceps on MRA images was highly associated with a concurrent subscapularis full-thickness tear which was confirmed arthroscopically. This association had 99% specificity and 98% positive predictive value. Therefore, if a biceps subluxation/dislocation is identified on MRA images, there is a high chance that a concurrent subscapularis full-thickness tear exists.

The high frequency of superior labrum, biceps tendon, and superior rotator cuff pathologies in patients with subscapularis tears: A cohort study

BACKGROUND

The purpose of this study was to assess the frequency of superior labrum anterior posterior (SLAP) lesions, long head of biceps tendon (LHBT) pathologies, and superior rotator cuff tears accompanying subscapularis tears. We hypothesised that LHBT lesions, superior rotator cuff tears, and especially SLAP lesions were very frequent with subscapularis tears.

METHODS

The digital files of patients who underwent shoulder arthroscopy were reviewed retrospectively. One hundred and eleven patients with subscapularis tears evident on surgery videos were examined. Superior labrum, LHBT, and superior rotator cuff lesions were investigated by the authors of this study. The statistical analyses were made with SPSS statistics software, and significance was set at P < 0.05 value.

RESULTS

There were 111 patients with both subscapularis tears and surgery videos. The mean age was 58.09 ± 10.21, and 63.1% of the patients were female. 98.2% of the 111 patients had a SLAP lesion. 7.2% of those were SLAP I and 91% were SLAP II lesions while 1.8% were healthy. The 75.7% of the patients had a LHBT pathology, and 83.8% had superior cuff tear.

CONCLUSIONS

Subscapularis tears were almost always accompanied by SLAP lesions. On the other hand, biceps tendon pathologies and superior rotator cuff tears were also very frequent with subscapularis tears.

LEVEL OF EVIDENCE

Prognostic study, Level IV (retrospective cohort study).

Subscapularis tears: hidden and forgotten no more

The subscapularis tendon, at one point, was thought of as the forgotten tendon, with “hidden lesions” that referred to partial tears of this tendon. Better understanding of anatomy and biomechanics combined with improved imaging technology and the widespread use of arthroscopy has led to a higher rate of subscapularis tear diagnoses and repairs.

The bulk mass of the subscapularis muscle is more than that of all 3 other rotator cuff muscles combined. It functions as the internal rotator of the shoulder as the stout, rolled border of its tendon inserts onto the superior portion of the lesser tuberosity. A thorough history combined with specific physical examination maneuvers (including the bear hug, lift-off, and belly-press tests) is critical for accurate diagnosis. A systematic approach to advanced shoulder imaging also improves diagnostic capacity.

Once identified, most subscapularis tendon tears can be successfully repaired arthroscopically. The Lafosse classification is useful as part of a treatment algorithm. Type I and II tears may be addressed while viewing from the standard posterior glenohumeral portal; larger Lafosse type III and IV tears are best repaired with anterior visualization at the subacromial or subdeltoid space. Tendon mobilization for larger tears is critical for adequate repair.

In Lafosse type V tears, in which there is glenohumeral imbalance, tendon transfers and reverse replacement are commonly considered salvage options.

Arthroscopic Evaluation of Subluxation of the Long Head of the Biceps Tendon and Its Relationship with Subscapularis Tears

Background

The purpose of this study was to evaluate the angle between the long head of the biceps tendon (LHBT) and the glenoid during arthroscopic surgery and its correlation with biceps subluxation on magnetic resonance imaging (MRI). Furthermore, we evaluated the relationship of this angle with subscapularis tears and biceps pathologies.

Methods

MRI and arthroscopic images of 270 consecutive patients who had undergone arthroscopic surgery were retrospectively evaluated. On MRI, 60 shoulders with biceps subluxation and 210 shoulders without subluxation were identified. On the arthroscopic view from the posterior portal, the angle between the LHBT and the glenoid (biceps-glenoid angle) was measured. The biceps-glenoid angle, tears of the LHBT, degenerative superior labrum anterior to posterior (SLAP) lesions, and presence of a subscapularis tear were compared according to the presence of biceps subluxation on MRI.

Results

In the subluxation group, 51 (85%) had a subscapularis tendon tear and all shoulders showed biceps tendon pathologies. In the non-subluxation group, 116 (55.2%) had a subscapularis tendon tear, 125 (60%) had tears in the biceps tendon, and 191 (91%) had degenerative SLAP lesions. The incidences of subscapularis tears (p < 0.001) and biceps pathologies (p < 0.001) showed significant differences. The mean biceps-glenoid angle was 87.0° (standard deviation [SD], 11.4°) in the subluxation group and 90.0° (SD, 9.6°) in the non-subluxation group, showing a statistically significant difference (p = 0.037).

Conclusions

Shoulders with subluxation of the biceps tendon on the preoperative MRI revealed more pathologies in the subscapularis tendon and biceps tendon during arthroscopy. However, the arthroscopically measured biceps-glenoid angle did not have clinical relevance to the determination of subluxation of the LHBT from the bicipital groove.

Diagnostic Value of the Supine Napoleon Test for Subscapularis Tendon Lesions

PURPOSE

The purpose of this study was to compare the diagnostic value of the supine Napoleon test (a variation of the belly-press test that reduces compensatory motion) with other clinical tests for subscapularis tendon (SSC) tears.

METHODS

One hundred thirty consecutive patients who were scheduled for arthroscopic rotator cuff repair were evaluated preoperatively with the lift-off test, Napoleon test, bear-hug test, and supine Napoleon test. The supine Napoleon test was performed by placing the patient's hand on their belly while they lay supine with an examiner holding their hand and shoulder to prevent compensatory motion. The patient was asked to move their elbow upward and the test was considered positive if they were unable to do so. During surgery, SSC lesions were classified with the Lafosse classification system. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios (LR+, LR-) were calculated for each test. The ability to detect partial SSC tears was compared among the clinical tests.

RESULTS

Fifty-two of 130 patients (40%) had SSC tears confirmed arthroscopically. For diagnosis of these tears, the supine Napoleon test was the most sensitive (84%), followed by the bear-hug test (74%), and the bear-hug test was the most specific (97%), followed by the supine Napoleon test (96%). The LR+ was greatest for the bear-hug test (28.4) and next greatest for the supine Napoleon test (21.9). The LR- was lowest for the supine Napoleon test (0.16) and the bear-hug test was second (0.27). The sensitivity of the supine Napoleon test (65%) was highest for detecting partial tears.

CONCLUSIONS

In comparison with other clinical tests for SSC tears, the supine Napoleon test had the greatest diagnostic value for full-thickness SSC tears and was most able to detect partial tears.

LEVEL OF EVIDENCE

Level III, diagnostic nonrandomized study.