Dynamic high-resolution ultrasound of the shoulder: how we do it

Development and Clinical Application of Artificial Intelligence Assistant System for Rotator Cuff Ultrasound Scanning

OBJECTIVE

We developed an intelligent assistance system for shoulder ultrasound imaging, incorporating deep-learning algorithms to facilitate standard plane recognition and automatic tissue segmentation of the rotator cuff and its surrounding structures. We evaluated the system's performance using a dedicated data set of rotator cuff ultrasound images to assess its feasibility in clinical practice.

METHODS

To fulfill the system's primary functions, we designed a standard plane recognition module based on the ResNet50 network and an automatic tissue segmentation module using the Mask R-CNN model. The modules were trained on carefully curated data sets. The standard plane recognition module automatically identifies a specific standard plane based on the ultrasound image characteristics. The automatic tissue segmentation module effectively delineates and segments anatomical structures within the identified standard plane.

RESULTS

With the use of 59,265 shoulder joint ultrasound images, the standard plane recognition model achieved an impressive recognition accuracy of 94.9% in the test set, with an average precision rate of 96.4%, recall rate of 95.4% and F1 score of 95.9%. The automatic tissue segmentation model, tested on 1886 images, exhibited a commendable average intersection over union value of 96.2%, indicating robustness and accuracy. The model achieved mean intersection over union values exceeding 90.0% for all standard planes, indicating its effectiveness in precisely delineating the anatomical structures.

CONCLUSION

Our shoulder joint musculoskeletal intelligence system swiftly and accurately identifies standard planes and performs automatic tissue segmentation.

Comparative study of ultrasonic-guided betamethasone local injection and extracorporeal shock wave therapy in post-stroke hemiplegic shoulder pain: a randomized clinical trial

Objective

This study aimed to compare the efficacy and safety of ultrasound-guided local injection (UGLI) of betamethasone around the shoulder and extracorporeal shock wave therapy (ESWT) in patients with hemiplegic shoulder pain.

Method

Forty-two patients with hemiplegic shoulder pain were randomly divided into the UGLI group (N = 21) and the ESWT group (N = 21). In the UGLI group, betamethasone was injected at the pain point around the shoulder under ultrasonic localization. In the ESWT group, an extracorporeal shock wave was performed at the pain points around the shoulder for 20 min of time, once a week, for 4 consecutive weeks. Both groups received rehabilitation training. The visual analog scale (VAS) evaluation was performed at baseline, 1 h, 1 week, and 1 month after treatment. Furthermore, Neer shoulder joint function scores, upper limb Fugl-Meyer assessment (FMA), modified Barthel index (MBI), Hamilton Depression Scale (HAMD), the MOS-item short-form health survey (SF-36) scores, and serum expression level of cytokine were evaluated at baseline and 1 month after treatment.

Results

After 1-h treatment, the UGLI group showed a greater effect on the degree of pain than the ESWT group (P = 0.017). After 4 consecutive weeks of intervention, the UGLI group showed a significant improvement in the serum level of cytokine expression compared with the ESWT group (P < 0.05). The range of motion (ROM) of the hemiplegic shoulder (P < 0.05) has no difference between the two groups (P > 0.05).

Conclusion

The ultrasonic-guided betamethasone local injection and extracorporeal shock wave both can improve hemiplegic shoulder pain. However, the UGLI can induce a more cytokine expression level.

Adhesive capsulitis and ultrasound diagnosis, an inseparable pair: a novel review

PURPOSE

Adhesive Capsulitis (AC) is a musculoskeletal disorder initially described by Codman in 1934. The disease is characterized by pain-limited restriction in active and passive glenohumeral range of motion (ROM) despite the lack of a structural deficit. In the last decades, arthroscopy and magnetic resonance imaging (MRI) has been the only diagnostic tools able to highlight the characteristic alterations of the glenohumeral capsular-ligament apparatus in AC; nevertheless, both arthroscopy and MRI are burdened by intrinsic limitations. The aim of this narrative review is to summarize the most significant evidence supporting the use of ultrasound (US) for the diagnosis of AC.

METHODS

We extensively searched via PubMed library the terms "frozen-shoulder" and "adhesive capsulitis" each combined with "ultrasound".

RESULTS

We found 3723 papers on PubMed and selected those inherent to AC diagnosis, US imaging, correlation with arthroscopic and MRI findings. Forty papers which were strictly related to the topic of this narrative review were initially chosen, then 20 studies which described and exploited US for AC diagnosis were finally included. Coracohumeral ligament (2.65 ± 0.4 mm) and axillary pouch thickening (3.34 ± 0.8 mm), as well as an increase in vascularity at rotator interval (78/214, 36.44%), represented the commonest US signs useful for AC diagnosis and for which the most significant cut-off values were reported.

CONCLUSIONS

The evidence collected in this review testify that musculoskeletal US is as reliable as MRI for AC diagnosis, therefore we believe that in this context US should be considered a first-line imaging technique.

Differences in Coracohumeral Distance Between the Symptomatic and the Asymptomatic Shoulder in Patients With Unilateral Shoulder Pain and in Healthy Participants: A Cross-Sectional Study

OBJECTIVES

The aim of this study was to analyze whether differences in the coracohumeral distance (CHD) exist between the symptomatic and the asymptomatic shoulder in patients with subacromial pain syndrome and compare with the shoulder of control participants.

METHODS

This was a cross-sectional, observational study. A sample comprising 62 participants with subacromial pain syndrome was recruited from 3 different primary care centers. The CHD was determined from standardized ultrasonography measures performed on both shoulders at 0° and 60° of shoulder abduction, whereas the dominant arm was measured for the control participants.

RESULTS

Statistically significant differences in CHD at 0° and 60° were found between the symptomatic and control shoulders (P = .011/P = .002) and between the contralateral asymptomatic shoulder and controls (P = .026/P = .007).

CONCLUSION

We found differences in CHD at 0° and 60° of shoulder elevation between both the affected and the nonaffected shoulders when compared with healthy shoulders. These results suggest that CHD may be a contributing factor in chronic shoulder pain.

Mid- and Long-Term Results Using 448 kHz Stimulation on the Elasticity of the Supraspinatus Tendon Measured by Quantitative Ultrasound Elastographyin Badminton Professionals: Prospective Randomized Double-Blinded Clinical Trial with Nine Months of Follow-Up

The aim of this study is to analyse the changes that occur in the elasticity of the supraspinatus tendon after the application of a 448 kHz capacitive resistive monopolar radiofrequency (CRMR) at 3, 6 and 9 months in professional badminton players. A randomized double-blinded clinical trial that included 9 months of follow-up was used. A private care practice was used to recruit the participants of this study. They were randomly assigned either the CRMR treatment (n = 19) or the placebo treatment (n = 19). The experimental group received a total of nine treatments of 448 kHz CRMR divided into three treatments per week. The control group received the same regimen but with no radiofrequency. Quantitative ultrasound strain elastography was used to report the main values for three areas of the supraspinatus tendon. These were measured at the start (T1) and directly after (T2), one week after, (T3), three months after (T4), six months after (T5) and nine months after (T6) the completion of the intervention program. There were statistically significant differences in the supraspinatus tendon elasticity immediately after (p ≤ 0.001), one week after (p ≤ 0.001) and three months after (p = 0.01) the intervention program. No significant changes were found six or nine months after the intervention program. A three-week intervention program using 448 kHz produced significant changes in the elasticity of the supraspinatus tendon, with the changes lasting up to approximately three months when compared to the control group.

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Shoulder

ABSTRACT

In this dynamic protocol, ultrasound examination of the shoulder using different maneuvers is described for several/relevant shoulder problems. Scanning videos are coupled with real-time patient examination videos for better understanding. The authors believe that this practical guide prepared by an international consensus of several experts (EURO-MUSCULUS: European Musculoskeletal Ultrasound Study Group and USPRM: Ultrasound Study Group of ISPRM [International Society of Physical and Rehabilitation Medicine]) will help musculoskeletal physicians perform a better and uniform/standard approach.

Ultrasound Versus Magnetic Resonance Imaging in the Evaluation of Shoulder Pain in End Stage Renal Disease Patients on Chronic Hemodialysis

BACKGROUND

Musculoskeletal pain is common in hemodialysis (HD) patients and may be related to articular or periarticular amyloid deposition. The shoulder is one of the most common afflicted joints, but not all causes of shoulder pain are detectable on radiography, and magnetic resonance imaging (MRI) is not always available. The aim of this study was to evaluate the validity of musculoskeletal ultrasound (MSUS) to properly detect shoulder disorders in HD patients by identifying US abnormalities in the shoulder and comparing them to those identified on MRI, with MRI serving as the gold standard test.

METHODS

This cross-sectional observational study was conducted on 28 HD patients (16 males and 12 females, mean age 46.89) with either unilateral or bilateral shoulder pain. Demographic data and clinical characteristics were recruited. All patients were subjected to clinical assessment, MSUS and MRI of both shoulders.

RESULTS

US abnormalities were prevalent in almost all patients. Supraspinatus tendinopathy was the most common abnormality in symptomatic shoulders (92.1%), followed by subacromial-subdeltoid (SASD) bursitis (65.8%), humoral erosions (57.9%), and acromioclavicular joint (ACJ) osteoarthritis (52.6%). MSUS shows high sensitivity and specificity when compared to MRI in all the studied shoulder pathologies except glenohumeral joint (GHJ) effusion (sensitivity, 33.3%) and infraspinatus tendinopathy (sensitivity, 58.3%). The percentage of agreement between MSUS and MRI in detecting biceps tenosynovitis was 82.14% (kappa, 0.64), subscapularis tendinopathy 83.93% (kappa, 0.654), supraspinatus tendinopathy 91.07% (kappa, 0.617), infraspinatus tendinopathy 82.14% (kappa, 0.470), SASD bursitis 80.36% (kappa, 0.569), humeral head erosions 82.14% (kappa, 0.635), GHJ effusion 82.14% (kappa, 0.352), and ACJ osteoarthritis 76.79% (kappa, 0.539).

CONCLUSIONS

Shoulder problems are common in HD patients, even in people who do not have obvious shoulder complaints. MSUS is a valuable imaging technique that assists in the diagnosis of HD patients who report shoulder pain.

Shoulder ultrasound: current concepts and future perspectives

Ultrasonography is an established and effective imaging technique that can be used to evaluate articular and periarticular structures around the shoulder. It has been shown to be useful in a wide range of rotator cuff diseases (e.g. tendon tears, rotator cuff calcific tendinopathy and bursitis) as well as non-rotator cuff abnormalities (instability, synovial joint diseases and nerve entrapment syndrome). A scanning protocol is highly recommended to reduce the rate of operators’ errors by following a standardized scheme including a list of main structures. Shoulder ultrasound has several advantages: it is a relatively cheap and widely available technique, free from ionizing radiation, that can reach excellent diagnostic accuracy even compared to magnetic resonance imaging. Moreover, it is the only imaging technique that allows dynamic evaluation of musculoskeletal structures, which is important for the evaluation of impingement. Also, due to the shoulder’s superficial anatomical position, ultrasound can also be helpful in guiding interventional percutaneous procedures, both for diagnostic (e.g. magnetic resonance arthrography) and therapeutic purposes (e.g. percutaneous treatment of calcific tendonitis). Contrast-enhanced ultrasound and speckle tracking offer complimentary evaluations of shoulder anatomy and biomechanics. Moreover, the advent of ultra-high-frequency US, with probes up to 70 MHz allowing for a resolution as low as 30 μm, is a promising tool for further evaluation of the shoulder anatomy, and diagnostic and therapeutic strategies.

Short-term effects of 448 kilohertz radiofrequency stimulation on supraspinatus tendon elasticity measured by quantitative ultrasound elastography in professional badminton players: a double-blinded randomized clinical trial

OBJECTIVE

To study changes in supraspinatus tendon elasticity after a 448 kHz capacitive resistive monopolar radiofrequency (CRMR) intervention in professional badminton players.

DESIGN

Double-blinded randomized clinical trial.

SETTING

All participants were recruited in a private care practice. Participants were randomized to receive either a CRMR treatment (n = 19) or placebo (n = 19).

SUBJECTS

Professional badminton players (n = 38).

INTERVENTION

A total of nine intervention (three per week) with CRMR at 448 kHz were carried out in the experimental group. The same intervention without an active CRMR current was carried out in the control group.

MAIN MEASURES

Mean values of three different regions of the supraspinatus tendon were reported at baseline (T1), immediately after the intervention (T2) and one week after the end of the whole intervention program (T3) using quantitative ultrasound strain elastography (SEL).

RESULTS

There were statistically significant differences in the supraspinatus tendon elasticity immediately after the intervention (p= <.001) and one week after the end of the whole intervention program (p=.001).

CONCLUSION

CRMR at 448 kHz produces significant changes in supraspinatus tendon elasticity after an intervention program of three weeks and those changes last for a week when compared to control group. Clinical trial registration: NCT04273633 (ClinicalTrials.gov).

Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis

PURPOSE

The purpose of this study was to compare the efficacy of low-dose steroid, high-dose steroid, and low-dose steroid combined with hyaluronidase with respect to intra-articular injection therapy for adhesive capsulitis (AC) of the shoulder.

METHODS

Thirty patients with primary AC in the initial stage were randomly assigned into three groups to receive ultrasound-guided intra-articular injections with 20 mg of triamcinolone acetonide (group A, n=10), 40 mg of triamcinolone acetonide (group B, n=10) and 20 mg of triamcinolone acetonide combined with hyaluronidase (group C, n=10). The outcome measures included a visual analogue scale (VAS), the Shoulder Disability Questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment.

RESULTS

Among the 30 patients, one participant in group B dropped out; therefore, a total of 29 patients completed this study and were successfully injected. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF improved in all groups compared with the preinjection status, regardless of treatment or time point. In the comparison between groups, the SDQ and ISF showed significantly greater improvements in groups B and C than in group A.

CONCLUSION

The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.

The effect of injection volume on long-term outcomes of US-guided subacromial bursa injections

PURPOSE

Limited data exist on the efficacy of high- compared to low-volume US-guided corticosteroid injections (CI) in the subacromial-subdeltoid (SA-SD) bursa. Our purpose was to compare the short- and long-term efficacy of low- and high-volume injections, by using a capacity reference of SA-SD bursa volume, as assessed on cadaveric specimens.

METHOD

Within two years, 136 patients (63 males, 73 females; mean age: 46.11 ± 10.28 years) who underwent SA-SD bursa US-guided CI for subacromial impingement, rotator cuff tendinopathy or shoulder overuse were prospectively included. Patients were randomly assigned to low-volume (1 mL triamcinolone acetonide/40 mg) or high-volume (1 mL triamcinolone acetonide/40 mg, 9 mL anaesthetic agents) groups (67 and 69 patients, respectively). Visual Analogue Scores (VAS) were recorded at baseline, 30 min, 3 weeks, 3 months, 6 months and 1 year post-treatment. Predictors of complete recovery (VAS ≤ 2) at 1 year were analysed with multivariate Cox regression analysis. SA-SD bursa cadaveric dissection in 10 specimens was performed for volume assessment.

RESULTS

Injection volume was the only predictor of complete pain resolution at 1 year. High-volume CI yielded higher chances of early pain recovery (2.837 HR, 95% CI 1.737-4.633, P < .001). Mean VAS scores at baseline and subsequent time-points were 6, 2.6, 2.2, 2, 1.6 and 1 for the high-volume and 7.8, 7.3, 4.7, 3.2, 2.5 and 1.8 for the low-volume group, respectively (P < .001, at all time-points). Cadaveric measurements showed a minimum SA-SD bursa volume of approximately 6.9 mL.

CONCLUSIONS

High-compared to low-volume US-guided CI are superior for achieving early pain recovery.

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.

The arthroscopic triple-row modified suture bridge technique for rotator cuff repair: functional outcome and repair integrity

BACKGROUND

The optimal technique for arthroscopic rotator cuff repair is still controversial. Large tears with a high grade of retraction have an especially high risk of retearing. This study reports the clinical and radiologic results of a triple-row modified suture bridge technique for the treatment of full-thickness rotator cuff tears with medium and high grades of retraction.

METHODS

A total of 101 shoulders in 100 patients underwent a triple-row modified suture bridge reconstruction for full-thickness rotator cuff tears with retraction grade II and grade III according to Patte; 81 patients were reached for follow-up 36.2 months after surgery. At follow-up, clinical outcome was assessed by the American Shoulder and Elbow Surgeons score, subjective shoulder value, visual analog scale score, University of California-Los Angeles shoulder score, and Constant score (CS). At follow-up, an ultrasound examination was performed to determine tendon integrity or retears in all patients.

RESULTS

The overall retear rate was 4.9% (4/81). The clinical outcome was good to excellent (American Shoulder and Elbow Surgeons score, 94 ± 11; subjective shoulder value, 92 ± 12; University of California-Los Angeles shoulder score, 33 ± 5; Constant score, 90 ± 9). In the radiologic follow-up, no retear was found in any of the follow-up patients after an average of 36.2 months. There was no significant difference in clinical outcome parameters between rotator cuff tears Patte II and Patte III (P > .05).

CONCLUSION

For tears with a high grade of retraction, surgical treatment using a triple-row modified suture bridge technique represents a good treatment option with a low rate of retearing and good to excellent clinical results.

[Ultrasound of the Shoulder (Adapted According to SGUM Guidelines)]

Ultrasound of the Shoulder (Adapted According to SGUM Guidelines) Abstract. This review paper explains the simplified ultrasound anatomy of the shoulder. The adapted basic standard planes are described in detail according to SGUM guidelines and illustrated with a selection of high-resolution ultrasound images. A profound knowledge of the sonographic anatomy is essential for the detection of pathologies.

Musculoskeletal ultrasound imaging - An exploration of physiotherapists' interests and use in practice

BACKGROUND

Musculoskeletal ultrasound imaging (MSKUSI) has gained popularity; several professions have expressed an interest in this application but the clinical use by physiotherapists has not been fully researched.

OBJECTIVES

To explore physiotherapists' interests and use of MSKUSI in practice.

DESIGN

Sequential mixed-methods; questionnaire followed by semi-structured interviews.

METHOD

A questionnaire was developed and distributed to gain initial information, (75 responses). Analysis informed topic-guide development and enabled a purposive-sampling strategy for semi-structured interviews that explored physiotherapists' interests, education and clinical use of MSKUSI (n = 11). Interview data were analysed thematically.

RESULTS

Five themes were identified: 1. Professional skill set - physiotherapists' suitability for MSKUSI. 2. Factors that have impacted physiotherapists' ability to use MSKUSI. 3. Physiotherapists' motivation to use ultrasound - improving patient focused care. 4. Quality assurance strategies. 5. Application of biopsychosocial model. Themes revealed links between physiotherapists' core skills, knowledge and professional experiences that align with MSKUSI requirements. Some participants reported support accessing education but many described challenges finding appropriate mentorship. Participants observed education did not always reflect practice typical of physiotherapists. Application of clinical reasoning processes utilised by physiotherapists was regarded as integral to patient-focused scanning.

CONCLUSIONS

Physiotherapists' professional training and musculoskeletal practice are seen as a foundation for education in MSKUSI. Accessing education can be challenging, in particular mentorship that fully incorporates the biopsychosocial model. Proposed roles for MSKUSI for physiotherapists include verification of clinical assessment findings for diagnosis and facilitation of patient education. The potential to streamline patient pathways and optimise resource management warrants investigation.

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.

Imaging the Postsurgical Upper Limb: The Radiologist Perspective

Imaging has a paramount role in postsurgical assessment. Radiologists need to be familiar with the different surgical procedures to be able to identify expected postsurgical appearances and also detect potential complications. This article reviews the indications, normal expected postsurgical appearances, and complications of the most frequently used surgical procedures in the shoulder, elbow, and wrist. The emphasis is on points that should not be overlooked in the surgical planning.

Clinical and Radiological Evaluation of Subscapular Suture Integrity in Reverse Shoulder Arthroplasty

Objective

The aim was to establish a correlation between the integrity of a suture made in the subscapular tendon (SST), as assessed by an ultrasound examination, and its functionality, as assessed by clinical tests during the postoperative period following reverse shoulder arthroplasty (RSA). A secondary goal is to evaluate the presence and viability of the sutured SST.

Methods

This is a retrospective study of 18 RSA patients in whom the SST was repositioned to the anterior face of the humeral osteotomy. The median time of the postoperative evaluation was 31 months. The clinical evaluation consisted of the Gerber lift-off test, the internal rotation (IR) lag sign test, and the abdominal compression test, as well as forward flexion (FF), external rotation (ER), and IR. All patients underwent shoulder ultrasounds to evaluate the SST presence and viability.

Results

The SST was visualized in 13 patients (72.2%; 95% confidence interval [CI], 51.5–92.9). Of these 13 patients, the SST presented an altered fibrillar pattern in 5 patients (38.4%; 95% CI, 12.0–64.9) and was considered nonviable. There were no associations between SST viability and a positive Gerber’s lift-off test (P = .480), a positive IR lag sign test (P = .480), or a positive abdominal compression test (P = .618). There were no significant differences in FF (P = .104), ER (P = .196), or IR (P = .374) mobility between patients with viable SSTs and those without viable SSTs.

Conclusion

It was not possible to demonstrate a correlation between the integrity of the SST repair based on the ultrasound and its functionality as assessed by clinical tests in the postoperative period following an RSA. The SST repair has a high failure rate, as demonstrated by the high incidence of nonviable or absent tendons.

Non-traumatic chronic shoulder pain is not associated with changes in rotator cuff interval tendon thickness

OBJECTIVE

To determine whether the thickness of the rotator interval tendons is different when comparing both symptomatic and non-symptomatic sides in people with chronic shoulder pain, and to those free of pain. Furthermore, to calculate the level of association between the rotator interval tendon thicknesses and perceived shoulder pain-function.

DESIGN

A cross-sectional, observational study.

METHOD

The supraspinatus, subscapularis and biceps brachii tendon thickness of sixty two patients with chronic shoulder pain were determined from standardized ultrasonography measures performed on both shoulders, whereas only the dominant arm was measured for the control subjects.

FINDINGS

Supraspinatus, subscapularis and biceps brachii tendon thickness was comparable between sides in the symptomatic group and was also comparable between the symptomatic and asymptomatic participants. In addition, the correlation between the tendon thickness and shoulder pain-function was non-significant.

INTERPRETATIONS

Tendon thickness was unaltered in people with chronic shoulder pain. These findings do not rule out the possibility that other changes in the tendon are present such as changes in the elastic properties and cell population and this should be explored in future studies.

Ultrasound-guided subacromial-subdeltoid bursa corticosteroid injections: a study of short- and long-term outcomes

AIM

To assess shoulder pain and disability in patients undergoing corticosteroid injection into the subacromial-subdeltoid (SA-SD) bursa under ultrasound guidance, evaluating both short and long-term outcomes.

MATERIALS AND METHODS

In this prospective, longitudinal, analytical study 376 patients referred for SA-SD bursa injection during a 6 month period were asked to complete a questionnaire assessing shoulder pain and disability in the form of the Shoulder Pain and Disability Index (SPADI). Patients were reassessed at 6 weeks and 12 months post-injection. Data were collated and analysed based on the diagnosis made at ultrasound.

RESULTS

Almost two-thirds (63.6%) of patients irrespective of the underlying diagnosis showed improvement in pain and disability 6 weeks after injection, but this figure decreased significantly after 12 months to 27.3%. There was no significant difference in outcome between patients with a rotator cuff tendon tear and without a tear at 6 weeks; however, there was a difference between these two groups at 12 months with significantly fewer patients with a tear receiving benefit.

CONCLUSION

The pattern of good short-term, but poorer long-term outcomes from SA-SD bursa injection is in line with previous studies; however, this study provides additional information on the effect of the underlying diagnosis on the potential outcome, specifically the presence or absence of a rotator cuff tendon tear.

Comparison of acromiohumeral distance in symptomatic and asymptomatic patient shoulders and those of healthy controls

BACKGROUND

The reduction of the subacromial space has traditionally been linked to rotator cuff pathology. The contribution of this narrowing, both in the development and maintenance of rotator cuff tendinopathy, is still under debate. The objective of the present study was compare the acromiohumeral distance at 0 and 60 degrees of active shoulder abduction in scapular plane, static position, in both symptomatic and contralateral shoulders, between participants with unilateral rotator cuff related shoulder pain, and in asymptomatic participants.

METHOD

This was a cross-sectional observational study. Seventy-six participants with chronic shoulder pain were assessed. Forty participants without shoulder pain were also recruited to compare the acromiohumeral distance with symptomatic participants. The acromiohumeral distance was measured at 0 and 60 degrees of active shoulder abduction in all the groups by ultrasound imaging. Mean differences between symptomatic versus contralateral shoulders, and versus healthy controls, were calculated.

FINDINGS

There were no statistical significant differences (p > .05) in the acromiohumeral distance at 0 degrees of shoulder elevation between the groups. However, significant differences were found at 60° between symptomatic and contralateral shoulder groups (0,51 mm; 95% CI: -0.90 to -0.12).

INTERPRETATIONS

Differences in shoulder pain perception at 0° are not attributable to acromiohumeral distance differences. However, treatments focused on increasing AHD at 60° could be prescribed, as a significantly reduced AHD was found in symptomatic shoulders when compared with contralateral shoulders. Further research is needed to determine, not only static differences in AHD, but also dynamic differences.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

[Arthroscopic tenodesis or tenotomy of the long head of the biceps tendon in preselected patients : Does it make a difference?]

BACKGROUND

Are there clinical, cosmetic and/or structural differences between tenotomy and tenodesis of the long head of the biceps tendon (LHB) in patients selected according to commonly used indication criteria?

MATERIAL AND METHODS

A total of 85 patients were included in this study. An LHB tenodesis (LHB-TD) was performed in 49 patients and a tenotomy (LHB-TT) in 36 patients. In addition to a standardized examination, the age and gender adjusted Constant score (aCS), the LHB score and the subjective shoulder value (SSV) were assessed. The cosmetic result was evaluated by both patient and examiner. In all patients the elbow flexion and supination strength were measured and compared between sides and sonography of the affected shoulder was performed.

RESULTS

Both groups showed significant differences concerning age, body mass index (BMI) and requirements for shoulder function. The aCS and the LHB score showed good to excellent results without any significant differences between the groups and the SSV also did not reveal any significant differences between the two groups. In 34 patients of the LHB-TD group and 25 patients of the LHB-TT group a mild upper arm asymmetry could be detected (n. s.). Only three patients of the LHB-TD group and two patients of the LHB-TT group confirmed the presence of a subjective popeye deformity (n. s.). Both flexion and supination strength showed significantly better results for the LHB-TD group in comparison to the LHB-TT group. The LHB could not be sonographically detected in the bicipital groove in five patients of the LHB-TD group and in one patient of the LHB-TT group.

CONCLUSION

In patients preselected according to routinely used indication parameters (e.g. age, BMI and functional requirements of the shoulder) both LHB-TD and LHB-TT can achieve good to very good functional and cosmetic results with high patient satisfaction.

A critical appraisal of the quality of adult musculoskeletal ultrasound guidelines using the AGREE II tool: an EuroAIM initiative

OBJECTIVES

Our aim was to evaluate the quality of published guidelines on musculoskeletal ultrasound (MSK-US) for adults.

METHODS

Between June and July 2016, we conducted an online search for MSK-US guidelines, which were evaluated by four independent readers blinded to each other using the AGREE II tool. A fifth independent reviewer calculated scores per each domain and agreement between reviewers' scores using the intraclass correlation coefficient (ICC).

RESULTS

Five guidelines were included in this appraisal. They were published between 2001 and 2014. Our appraisal showed intermediate results, with four out of five guidelines scoring "average" as overall quality. Domain 1 (scope and purpose) achieved the highest result (total score = 71.1% ± 18.7%). Domain 6 (editorial independence) had the lowest score (total score = 26.3% ± 19.3%). Interobserver agreement was very good for all the evaluated guidelines (ICC ranged between 0.932 and 0.956).

CONCLUSIONS

Overall, quality of MSK-US guidelines ranges from low to average when evaluated using the AGREE II tool. The editorial independence domain was the most critical, thus deserving more attention when developing future guidelines.

MAIN MESSAGES

• Four of five guidelines on MSK-US had an average quality level. • Scope/purpose had the highest score (71.1% ± 18.7%). • Editorial independence had the lowest score (26.3% ± 19.3%). • Interobserver agreement was very good (ranges: 0.932-0.956).

Dynamic ultrasonography of the shoulder

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of shoulder pain. Its low cost, excellent diagnostic accuracy, and capability for dynamic evaluation are also advantages. To assess all possible causes of shoulder pain, it is better to follow a standardized protocol and to perform a comprehensive evaluation of the shoulder than to conduct a focused examination. Moreover, a proper dynamic study can enhance the diagnostic quality of US, especially when the pathology is not revealed by a static evaluation. The purpose of this article is to review the common indications for dynamic US of the shoulder, and to present the basic techniques and characteristic US findings.

The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology

BACKGROUND

In 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines.

OBJECTIVES

To update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology.

METHODS

The project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures).

RESULTS

Structures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts.

CONCLUSIONS

This task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

Rotator Cuff Calcific Tendinopathy: Randomized Comparison of US-guided Percutaneous Treatments by Using One or Two Needles

Purpose To determine whether the use of one or two needles influences procedure performance and patient outcomes for ultrasonography (US)-guided percutaneous irrigation of calcific tendinopathy. Materials and Methods Institutional review board approval and written informed patient consent were obtained. From February 2012 to December 2014, 211 patients (77 men and 134 women; mean age, 41.6 years ± 11.6; range, 24-69 years) with painful calcific tendinopathy diagnosed at US were prospectively enrolled and randomized. Operators subjectively graded calcifications as hard, soft, or fluid according to their appearance at US. US-guided percutaneous irrigation of calcific tendinopathy (local anesthesia, needle lavage, intrabursal steroid injection) was performed in 100 patients by using the single-needle procedure and in 111 patients by using the double-needle procedure. Calcium dissolution was subjectively scored (easy = 1; intermediate = 2; difficult = 3). Procedure duration was recorded. Clinical evaluation was performed by using the Constant score up to 1 year after the procedure. The occurrence of postprocedural bursitis was recorded. Mann-Whitney U, χ², and analysis of variance statistics were used. Results No difference in procedure duration was seen overall (P = .060). Procedure duration was shorter with the double-needle procedure in hard calcifications (P < .001) and with the single-needle procedure in fluid calcifications (P = .024). Ease of calcium dissolution was not different between single- and double-needle procedures, both overall and when considering calcification appearance (P > .089). No clinical differences were found (Constant scores for single-needle group: baseline, 55 ± 7; 1 month, 69 ± 7; 3 month, 90 ± 5; 1 year, 92 ± 4; double-needle group: 57 ± 6; 71 ± 9; 89 ± 7; 92 ± 4, respectively; P = .241). In the single-needle group, nine of 100 cases (9%) of postprocedural bursitis were seen, whereas four of 111 cases (3.6%) were seen in the double-needle group (P = .180). Conclusion The only difference between using the single- or double-needle procedure when performing US-guided percutaneous irrigation of calcific tendinopathy is procedure duration in hard and fluid calcifications. Clinical outcomes are similar up to 1 year. ^© RSNA, 2017.

Reporting rotator cuff tears on magnetic resonance arthrography using the Snyder's arthroscopic classification

AIM

To determine diagnostic performance of magnetic resonance arthrography (MRA) in evaluating rotator cuff tears (RCTs) using Snyder's classification for reporting.

METHODS

One hundred and twenty-six patients (64 males, 62 females; median age 55 years) underwent shoulder MRA and arthroscopy, which represented our reference standard. Surgical arthroscopic reports were reviewed and the reported Snyder's classification was recorded. MRA examinations were evaluated by two independent radiologists (14 and 5 years' experience) using Snyder's classification system, blinded to arthroscopy. Agreement between arthroscopy and MRA on partial- and full-thickness tears was calculated, first regardless of their extent. Then, analysis took into account also the extent of the tear. Interobserver agreement was also calculated the quadratically-weighted Cohen kappa statistics.

RESULTS

On arthroscopy, 71/126 patients (56%) had a full-thickness RCT. The remaining 55/126 patients (44%) had a partial-thickness RCT. Regardless of tear extent, out of 71 patients with arthroscopically-confirmed full-thickness RCTs, 66 (93%) were correctly scored by both readers. All 55 patients with arthroscopic diagnosis of partial-thickness RCT were correctly assigned as having a partial-thickness RCT at MRA by both readers. Interobserver reproducibility analysis showed total agreement between the two readers in distinguishing partial-thickness from full-thickness RCTs, regardless of tear extent (k = 1.000). With regard to tear extent, in patients in whom a complete tear was correctly diagnosed, correct tear extent was detected in 61/66 cases (92%); in the remaining 5/66 cases (8%), tear extent was underestimated. Agreement was k = 0.955. Interobserver agreement was total (k = 1.000).

CONCLUSION

MRA shows high diagnostic accuracy and reproducibility in evaluating RCTs using the Snyder's classification for reporting. Snyder's classification may be adopted for routine reporting of MRA.

Dynamic high-resolution ultrasound of intrinsic and extrinsic ligaments of the wrist: How to make it simple

Wrist ligaments are crucial structures for the maintenance of carpal stability. They are classified into extrinsic ligaments, connecting the carpus with the forearm bones or distal radioulnar ligaments, and intrinsic ligaments, entirely situated within the carpus. Lesions of intrinsic and extrinsic ligaments of the wrist have been demonstrated to occur largely, mostly in patients with history of trauma and carpal instability, or rheumatoid arthritis. Ultrasound allows for rapid, cost-effective, non-invasive and dynamic evaluation of the wrist, and may represent a valuable diagnostic tool. Although promising results have been published, ultrasound of wrist ligaments is not performed in routine clinical practice, maybe due to its technical feasibility regarded as quite complex. This review article aims to enlighten readers about the normal sonographic appearance of intrinsic and extrinsic carpal ligaments, and describe a systematic approach for their sonographic assessment with detailed anatomic landmarks, dynamic manoeuvres and scanning technique.

How is shoulder ultrasound done in Italy? A survey of clinical practice

OBJECTIVES

To define when an ultrasound examination of the shoulder can be considered complete and how many examinations currently performed in Italy are actually complete according to that definition.

MATERIALS AND METHODS

Reports and images of previously performed ultrasound examinations of the shoulder of patients seen in 2014 for interventional procedures were reviewed for the following items, according to guidelines published by the European Society of Musculoskeletal Radiology: long biceps, subscapularis, supraspinatus, external rotators, acromioclavicular joint, subacromial bursa, subacromial space, coraco-acromial ligament, and the posterior recess. The first six items were considered mandatory in a complete shoulder ultrasound examination. The specialization of the performing physician was noted. The number of complete examinations performed by different physicians was compared with the number of incomplete examinations.

RESULTS

We analyzed 324 examinations (212 women, 112 men; mean age = 47 ± 12 years). The most frequently reported item was the supraspinatus tendon (83 %), the least frequently reported was the posterior recess (3 %). The image that was most frequently found was the long head of the biceps tendon (77 %), the least frequently found was the coraco-acromial ligament (3 %). The median number of images/examination was 6 (25th-75th percentiles, range 4-9). The mean number of unrecognizable images was 3 (2-4). A radiologist performed the examination in 269 patients (83 %). The rate of complete examinations was 47 %. The number of complete examinations performed by physicians from different specialties was not significantly different from that of incomplete examinations (P = 0.228).

CONCLUSIONS

Complete shoulder ultrasound examinations account for less than 50 % of those performed in clinical practice in some Italian regions. Standardized scanning protocols and structured reporting may help to improve this figure and consistency among providers performing these examinations.

Association between acromioclavicular joint pain and capsular bulging in adolescent baseball players

PURPOSE

The purpose of this study was to investigate the association between acromioclavicular (AC) joint pain and superior capsular bulging assessed by ultrasound in adolescent baseball players.

METHODS

One hundred and fifty players (1st-8th graders) were examined. All subjects underwent physical examinations, including assessment of tenderness on the AC joint and provocative tests (the Buchberger's test and the cross-body adduction stress test). Bilateral AC joints with the arm in both the resting and the cross-body positions were examined by ultrasound.

RESULTS

Twelve of 150 players (8 %) had AC symptoms with both positive tenderness and positive provocative tests. Interestingly, their prevalence increased with age-one of the 70 (1.4 %) 1st-3rd graders, six of 46 (13 %) 4th-6th graders and five of 34 (15 %) 7th-8th graders. Ultrasonography of AC joints in the cross-body position showed that the difference in superior capsular bulging between the throwing and non-throwing sides was significantly greater in symptomatic players (1.6 ± 1.2 mm) than in asymptomatic players (0.2 ± 0.8 mm) (p = 0.002).

CONCLUSION

The prevalence of superior capsular bulging was significantly higher in adolescent baseball players with AC joint pain than in those without it. In adolescent baseball players with shoulder pain, AC joint symptoms should be considered amongst potential causes. Careful observation of these patients is suggested in cases of superior capsular bulging of the AC joint as determined by ultrasonography.

LEVEL OF EVIDENCE

III.

An orthopedist's guide to shoulder ultrasound: a systematic review of examination protocols

BACKGROUND

The utilization of musculoskeletal ultrasound has expanded within the setting of the orthopedic clinic as a cost-effective, point-of-care diagnostic tool for shoulder pathology. In experienced hands, ultrasound exhibits capabilities equivalent to that of magnetic resonance imaging in the diagnosis of many shoulder diseases including full-thickness and partial-thickness rotator cuff tears. Although similarly effective in identifying additional shoulder disease processes, major obstacles to its widespread use include user dependence and intrinsic limitation to extra-articular diagnosis.

OBJECTIVES

The purpose of this review is to present a step-by-step guide of how to perform a comprehensive shoulder examination and to discuss the appropriate use, economic benefit and implementation of ultrasound within the clinic.

METHODS

A systematic search (June 2016) of PubMed, Scopus, and EMBASE databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for literature presenting shoulder ultrasound examination protocols. Included studies were peer-reviewed articles or academic society endorsed protocols presenting comprehensive sonographic examinations of the adult shoulder. Papers with limited or single structure examination descriptions, non-English language, and publication dates before 1980 were excluded. Final papers meeting criteria were secondarily screened for publication after 2005 to reflect the current state of ultrasound imaging.

RESULTS AND CONCLUSIONS

The search yielded 1,725 unique articles with 17 studies meeting final selection criteria. Information from identified studies was summarized to formulate a 4-part shoulder examination protocol, including steps most pertinent to orthopedic in-office diagnoses. In agreement with previous studies, the inexperienced orthopedic surgeon can be quickly trained to expert level proficiency in shoulder ultrasound diagnosis. Using an established protocol, a comprehensive, yet effective shoulder ultrasound examination can be performed within ten minutes. Further, ultrasound provides opportunity to off-set costs through the engagement of revenue generating activity for the orthopedic practice.

Ultrasound-Guided Percutaneous Tenotomy of Biceps Tendon: Technical Feasibility on Cadavers

We tested the technical feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon (LHBT) in cadavers. Both shoulders of two fresh cadavers were scanned anteriorly to evaluate the extra-articular portion of the LHBT. Under ultrasound monitoring, a scalpel was advanced obliquely up to touch the superficial medial side of the LHBT, cutting it until the tendon was not visible anymore. Ultrasound evaluation was repeated after the procedure, and anatomic dissection was performed. The procedure was 100% feasible: four cuts were made to completely sever the tendon; the duration was less than 1 min. Skin incision measured 5 mm in two cases and 6 mm in two cases. Anatomic dissection confirmed complete tendon cut in all cases with proximal and distal tendon stumps very close to each other. Ultrasound-guided percutaneous LHBT tenotomy was 100% technically feasible in cadavers with a quick procedure and minimal cutaneous incision.

Shoulder Disease Patterns of the Wheelchair Athletes of Table-Tennis and Archery: A Pilot Study

Objective

To investigate the shoulder disease patterns for the table-tennis (TT) and archery (AR) wheelchair athletes via ultrasonographic evaluations.

Methods

A total of 35 wheelchair athletes were enrolled, made up of groups of TT (n=19) and AR (n=16) athletes. They were all paraplegic patients and were investigated for their wheelchair usage duration, careers as sports players, weekly training times, the Wheelchair User's Shoulder Pain Index (WUSPI) scores and ultrasonographic evaluation. Shoulders were divided into playing arm of TT, non-playing arm of TT, bow-arm of AR, and draw arm of AR athletes. Shoulder diseases were classified into five entities of subscapularis tendinopathy, supraspinatus tendinopathy, infraspinatus tendinopathy, biceps long head tendinopathy, and subacromial-subdeltoid bursitis. The pattern of shoulder diseases were compared between the two groups using the Mann-Whitney and the chi-square tests

Results

WSUPI did not significantly correlate with age, wheelchair usage duration, career as players or weekly training times for all the wheelchair athletes. For the non-playing arm of TT athletes, there was a high percentage of subscapularis (45.5%) and supraspinatus (40.9%) tendinopathy. The percentage of subacromial-subdeltoid bursitis showed a tendency to be present in the playing arm of TT athletes (20.0%) compared with their non-playing arm (4.5%), even though this was not statistically significant. Biceps long head tendinopathy was the most common disease of the shoulder in the draw arm of AR athletes, and the difference was significant when compared to the non-playing arm of TT athletes (p<0.05).

Conclusion

There was a high percentage of subscapularis and supraspinatus tendinopathy cases for the non-playing arm of TT wheelchair athletes, and a high percentage of biceps long head tendinopathy for the draw arm for the AR wheelchair athletes. Consideration of the biomechanical properties of each sport may be needed to tailor specific training for wheelchair athletes.

Arthroscopic knotless suprapectoral tenodesis of the long head of biceps: clinical and structural results

INTRODUCTION

Different techniques for tenodesis of the long head of biceps (LHB) have been described. Previous studies focused on intraosseously performed techniques while only little clinical data exists for epiosseously performed knotless LHB tenodesis. The hypothesis is that arthroscopic suprapectoral knotless epiosseous tenodesis of the LHB would have good clinical, cosmetic and structural results.

METHODS

Forty-nine patients [16 women, 33 men; mean age 58; mean follow-up 36.4 months (range 24-57 months)], in whom a tenodesis of the long biceps tendon (LHB) has been performed, were included into this study. The clinical evaluation included the Constant score as well as the LHB score. In addition elbow flexion and supination strength were assessed. The integrity of the tenodesis construct was evaluated indirectly by sonographic detection of the LHB in the bicipital groove.

RESULTS

The overall Constant score did not reveal any significant differences comparing both sides [mean, 86 ± 19 points vs. 89 ± 16 points (p > 0.05)]. The mean LHB score reached 88.3 points (range 54-100 points). Thirty-four patients (69 %) presented an examiner-dependent upper arm deformity although only three patients (6 %) confirmed a subjective cosmetic deformity. Both, flexion and supination strength were significantly decreased compared to the non-operated side (p < 0.05). In five patients (10 %) it was not possible to verify the LHB sonographically in the bicipital groove. Therefore the biceps tenodesis was classified as a failure.

CONCLUSION

The arthroscopic suprapectoral epiosseous knotless tenodesis of the LHB provides good functional results. The high rate of examiner-dependent upper arm deformities can be explained by a non-physiological situation of the primary length-tension relationship or an elongation of the tendon after fixation.

Ultrasound of the coracoacromial ligament in asymptomatic volunteers and patients with shoulder impingement

BACKGROUND

The coracoacromial ligament is part of the coracoacromial arch, which is considered to be involved in shoulder impingement.

PURPOSE

To compare the coracoacromial ligament on ultrasound in asymptomatic volunteers and in patients with subacromial shoulder impingement.

MATERIAL AND METHODS

Twenty-nine asymptomatic volunteers (mean age, 35.5 years) and 29 patients (mean age, 49.9 years) with shoulder impingement, diagnosed by experienced shoulder surgeons, were prospectively included. Two radiologists obtained and analyzed ultrasound images of the coracoacromial ligament in the longitudinal axis.

RESULTS

The ligament thickness was 1.4 ± 0.2 mm at its midportion, 1.8 ± 0.4 mm at the coracoid, and 2.1 ± 0.6 mm at the acromion in asymptomatic volunteers compared with 1.3 ± 0.2 mm, 1.9 ± 0.5 mm, and 1.9 ± 0.5 mm in impingement patients for observer 1. The ligament length was 30.6 ± 2.4 mm in asymptomatic volunteers compared with 30.4 ± 3.6 mm in impingement patients for observer 1. An anteriorly convex shape of the superficial contour of the coracoacromial ligament was significantly more frequent in impingement patients compared with asymptomatic volunteers for both observers (observer 1: 10% (3/29) versus 45% (13/29), P value <0.01; observer 2: 10% (3/29) versus 38% (11/29), P value <0.03). The comparison of the remaining parameters of the coracoacromial ligament, such as the thickness, length, echogenicity, and fibrillation did not reveal significant differences between volunteers and patients.

CONCLUSION

While thickness or length of the coracoacromial ligament were similar in volunteers and patients with shoulder impingement, an anteriorly convex shape of the superficial contour of the coracoacromial ligament was significantly more frequent in impingement patients compared with asymptomatic volunteers.

Ultrasound-guided interventional procedures around the shoulder

Ultrasound is an established modality for shoulder evaluation, being accurate, low cost and radiation free. Different pathological conditions can be diagnosed using ultrasound and can be treated using ultrasound guidance, such as degenerative, traumatic or inflammatory diseases. Subacromial-subdeltoid bursitis is the most common finding on ultrasound evaluation for painful shoulder. Therapeutic injections of corticosteroids are helpful to reduce inflammation and pain. Calcific tendinopathy of rotator cuff affects up to 20% of painful shoulders. Ultrasound-guided treatment may be performed with both single- and double-needle approach. Calcific enthesopathy, a peculiar form of degenerative tendinopathy, is a common and mostly asymptomatic ultrasound finding; dry needling has been proposed in symptomatic patients. An alternative is represented by autologous platelet-rich plasma injections. Intra-articular injections of the shoulder can be performed in the treatment of a variety of inflammatory and degenerative diseases with corticosteroids or hyaluronic acid respectively. Steroid injections around the long head of the biceps brachii tendon are indicated in patients with biceps tendinopathy, reducing pain and humeral tenderness. The most common indication for acromion-clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.