Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: comparison with magnetic resonance imaging with arthroscopic correlation

Variability in quantifying the Hill-Sachs lesion: A scoping review

Background

Currently, is there no consensus on a widely accepted measurement technique for calculating the Hill-Sachs lesion (HSL). The purpose of this review is to provide an overview of the techniques and imaging modalities to assess the HSL pre-operatively.

Methods

Four online databases (PubMed, Embase, MEDLINE, and COCHRANE) were searched for literature on the various modalities and measurement techniques used for quantifying HSLs, from data inception to 20 November 2021. The Methodological Index for Non-Randomized Studies tool was used to assess study quality.

Results

Forty-five studies encompassing 3413 patients were included in this review. MRA and MRI showed the highest sensitivity, specificity, and accuracy values. Intrarater and interrater agreement was shown to be the highest amongst MRA. The most common reference tests for measuring the HSL were arthroscopy, radiography, arthro-CT, and surgical techniques.

Conclusion

MRA and MRI are reliable imaging modalities with good test diagnostic properties for assessment of HSLs. There is a wide variety of measurement techniques and imaging modalities for HSL assessment, however a lack of comparative studies exists. Thus, it is not possible to comment on the superiority of one technique over another. Future studies comparing imaging modalities and measurement techniques are needed that incorporate a cost-benefit analysis.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Dual-layer spectral detector CT arthrography of the shoulder: assessment of image quality and value in differentiating calcium from iodine

BACKGROUND

Dual-layer spectral detector computed tomography (DLCT) may potentially improve CT arthrography through enhanced image quality and analysis of the chemical composition of tissue.

PURPOSE

To evaluate the image quality of monoenergetic reconstructions from DLCT arthrography of the shoulder and assess the additional diagnostic value in differentiating calcium from iodine.

MATERIAL AND METHODS

Images from consecutive shoulder DLCT arthrography examinations performed between December 2016 and February 2018 were retrospectively reviewed for hyperattenuating lesions within the labrum and tendons. The mean attenuation of the target lesion, noise, contrast-to-noise ratio (CNR), and signal-to-noise ratio (SNR) of the virtual monoenergetic images obtained at 40-200 keV were compared with conventional 140-kVp images. Two evaluators independently classified each target lesion as contrast media or calcification, without and with DLCT spectral data. Receiver operating curve (ROC) analysis was performed to assess the diagnostic performance of shoulder DLCT arthrography, without and with the aid of spectral data.

RESULTS

The study included 20 target lesions (18 DLCT arthrography examinations of 17 patients). The SNRs of the monoenergetic images at 40-60 keV were significantly higher than those of conventional images (P < 0.05). The CNRs of the monoenergetic images at 40-70 keV were significantly higher than those of conventional images (P < 0.001). The ability to differentiate calcium from iodine, without and with DLCT spectral data, did not significantly differ (P = 0.441 and P = 0.257 for reviewers 1 and 2, respectively).

CONCLUSION

DLCT had no additive value in differentiating calcium from iodine in small, hyperattenuating lesions in the labrum and tendons.

Clinical Outcomes of Revision Arthroscopic Capsulolabral Repair for Recurrent Anterior Shoulder Instability With Moderate Glenoid Bone Defects: A Comparison With Primary Surgery

Background:

The optimal revision surgery for failed primary arthroscopic capsulolabral repair (ACR) has yet to be determined. Revision ACR has shown promising results.

Purpose:

To compare the functional, strength, and radiological outcomes of revision ACR and primary ACR for anterior shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between March 2007 and April 2017, a total of 85 patients underwent ACR (revision: n = 23; primary: n = 62). Functional outcome scores and positive apprehension signs were evaluated preoperatively, at 1 year, and then annually. Isokinetic internal and external rotation strengths were evaluated preoperatively and at 1 year after surgery.

Results:

The mean follow-up was 36.5 ± 10.2 months (range, 24-105 months). There was no significant difference between the revision and primary groups in the glenoid bone defect size at the time of surgery (17.3% ± 4.8% vs 15.4% ± 5.1%, respectively; P = .197). At the final follow-up, no significant differences were found in the American Shoulder and Elbow Surgeons score (97.6 ± 3.1 vs 98.0 ± 6.2, respectively; P = .573), Western Ontario Shoulder Instability Index score (636.7 ± 278.1 vs 551.1 ± 305.4, respectively; P = .584), or patients with a positive apprehension sign (17.4% [4/23] vs 11.3% [7/62], respectively; P = .479) between the revision and primary groups. There was no significant difference between the revision and primary groups for returning to sports at the same preoperative level (65.2% vs 80.6%, respectively; P = .136) and anatomic healing failure at 1 year after surgery (13.0% vs 3.2%, respectively; P = .120). Both groups recovered external rotation strength at 1 year after surgery (vs before surgery), although the strength was weaker than in the uninvolved shoulder. In the revision group, a larger glenoid bone defect was significantly related to a positive apprehension sign (22.0% ± 3.8%) vs a negative apprehension sign (16.0% ± 3.2%; cutoff = 20.5%; P = .003).

Conclusion:

In patients with moderate glenoid bone defect sizes (10%-25%), clinical outcomes after revision ACR were comparable to those after primary ACR. However, significant glenoid bone loss was related to a positive remaining apprehension sign in the revision group. Surgeons should consider these findings when selecting their revision strategy for patients with failed anterior shoulder stabilization.

Dual-energy CT arthrography: a feasibility study

OBJECTIVE

To evaluate the feasibility of producing 2-dimensional (2D) virtual noncontrast images and 3-dimensional (3D) bone models from dual-energy computed tomography (DECT) arthrograms and to determine whether this is best accomplished using 190 keV virtual monoenergetic images (VMI) or virtual unenhanced (VUE) images.

MATERIALS AND METHODS

VMI and VUE images were retrospectively reconstructed from patients with internal derangement of the shoulder or knee joint who underwent DECT arthrography between September 2017 and August 2019. A region of interest was placed in the area of brightest contrast, and the mean attenuation (in Hounsfield units [HUs]) was recorded. Two blinded musculoskeletal radiologists qualitatively graded the 2D images and 3D models using scores ranging from 0 to 3 (0 considered optimal).

RESULTS

Twenty-six patients (mean age ± SD, 57.5 ± 16.8 years; 6 women) were included in the study. The contrast attenuation on VUE images (overall mean ± SD, 10.5 ± 16.4 HU; knee, 19.3 ± 10.7 HU; shoulder, 5.0 ± 17.2 HU) was significantly lower (p < 0.001 for all comparisons) than on VMI (overall mean ± SD, 107.7 ± 43.8 HU; knee, 104.6 ± 31.1 HU; shoulder, 109.6 ± 51.0 HU). The proportion of cases with optimal scores (0 or 1) was significantly higher with VUE than with VMI for both 2D and 3D images (p < 0.001).

CONCLUSIONS

DECT arthrography can be used to produce 2D virtual noncontrast images and to generate 3D bone models. The VUE technique is superior to VMI in producing virtual noncontrast images.

Accuracy and Reliability of Imaging Modalities for the Diagnosis and Quantification of Hill-Sachs Lesions: A Systematic Review

PURPOSE

To determine the reliability and accuracy of different imaging modalities in assessing Hill-Sachs lesions within the setting of anterior shoulder instability.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the PubMed, Scopus, Embase, and Cochrane Library databases. The inclusion criteria were clinical trials or cadaveric studies that assessed the accuracy of humeral head bone loss imaging or reliability and English-language articles. The exclusion criteria were animal studies; imaging studies without measures of accuracy, reliability, or clinical predictive power; studies of shoulder injuries without humeral head bone loss; editorials; abstracts; reviews; case reports; and surveys. The search terms included "imaging" OR "radiographic" OR "CT" OR "MRI" AND "Hill-Sachs" OR "humeral head bone loss." Assessment of the methodologic quality of the included studies was performed using the original Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool.

RESULTS

Forty studies (2,560 shoulders) met the inclusion criteria and were assessed. For diagnosing the presence of Hill-Sachs lesions, computed tomography (CT) arthrography had the highest reported accuracy (median, 91%; range, 66%-100%). For the same assessment, CT arthrography also had the greatest reported sensitivity (median, 94%; range, 50%-100%). For the quantification of Hill-Sachs lesion parameters, reported intraobserver reliabilities were highest for 3-dimensional (3D) CT (intraclass correlation coefficient [ICC] range, 0.916-0.999), followed by 2-dimensional CT (ICC range, 0.858-0.861) and magnetic resonance imaging (MRI) (ICC range, 0.28-0.97). For the same quantification parameters, interobserver reliabilities were also reported for 3D CT (ICC range, 0.772-0.996), 2-dimensional CT (ICC range, 0.721-0.879), and MRI (κ range, 0.444-0.700). Intraobserver reliabilities for determining glenoid tracking were only reported for 3D CT (κ range, 0.730-1.00; ICC range, 0.803-0.901) and MRI (ICC range, 0.770-0.790).

CONCLUSIONS

This study shows that the current literature supports a variety of different imaging modalities that provide clinically acceptable accuracy in diagnosing and quantifying Hill-Sachs lesions, as well as determining whether they will cause persistent anterior shoulder instability. Furthermore, this systematic review justifies that further research is needed to help develop a treatment algorithm on the proper imaging modalities needed to help treat patients with anterior shoulder instability that is both reliable and financially acceptable.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Comparison of Functional and Radiological Outcomes of Tears Involving the Subscapularis: Isolated Subscapularis Versus Combined Anterosuperior Rotator Cuff Tears

Background:

Few studies have compared the clinical and radiological characteristics and outcomes in isolated subscapularis (SSC) and combined anterosuperior (AS) rotator cuff tears (RCTs). Furthermore, risk factors for retear after SSC repair and the effect of preoperative fatty degeneration require further evaluation.

Purpose:

To compare the functional and radiological outcomes of isolated SSC with combined AS RCTs after arthroscopic repair and to determine the risk factors for SSC retear in these 2 groups.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data from 30 patients in the isolated SSC group were compared with data from 110 patients in the combined AS group. All patients underwent primary arthroscopic rotator cuff repair between 2010 and 2016. Clinical outcomes were assessed through use of the visual analog scale for pain, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test at a mean follow-up of 26.7 months (range, 24-96 months). SSC tendon integrity was examined via magnetic resonance imaging, computed tomography arthrogram, or ultrasonography at least 1 year after surgery.

Results:

The isolated SSC group had a greater proportion of males and the patients were younger compared with the combined AS group (both P < .050). The incidence of trauma was high but not significantly different between groups (56.7% vs 40.9%; P = .180). Clinical outcome measures and radiological outcomes in terms of retear were not statistically different between both groups (16.7% vs 8/5%; P = .337). The optimal cutoff values for the risk of SSC tendon retear in both groups were 19-mm retraction and 16-mm superoinferior dimension (P = .048). Unfavorable preoperative fatty degeneration of the SSC muscle (grades 3 and 4) was a significant risk factor for retear (odds ratio, 9.8; P < .001).

Conclusion:

Isolated SSC and combined AS RCTs were comparable except for patient age and sex; both had a high incidence of traumatic history. The current data suggest that the risk factors for retear after SSC repair in RCTs involving the SSC were tear size greater than 19 mm of retraction and unfavorable fatty degeneration (grade 3 or higher) of the SSC muscle.

Evaluation of glenoid labral tears: comparison between dual-energy CT arthrography and MR arthrography of the shoulder

OBJECTIVE

To compare the diagnostic accuracy of dual-energy computed tomography arthrography (DE-CTA) and magnetic resonance arthrography (MRA) of the shoulder in depicting glenoid labral tears.

METHODS

This prospective institutional review board-approved study included 47 consecutive patients (28 males, 19 females; mean age of 34.2 years) studied between January 2017 and October 2018. All patients underwent DE-CTA and MRA the same day. Two radiologists (25 and 11 years of experience, respectively), blinded to clinical data, evaluated the presence labral tears on virtual-blended 120 kV standard CTA and on DE-CTA images. A third radiologist (18 years of experience) evaluated the MRA images. Diagnostic accuracy values were calculated by using surgery as standard of reference. Inter-observer and intra-observer agreements were calculated with k statistics. A value of p < 0.05 was considered statistically significant.

RESULTS

Surgery revealed the presence of labral tears in 38/47 patients (80.9%). Sensitivity and specificity values in diagnosing labral tears were 84.2% and 77.8% for MRA (Reader 3), 84.2% and 77.8% for CTA (Reader 1), 84.2% and 88.9% for CTA (Reader 2), 89.5% and 88.9% for DE-CTA (Reader 1), and 92.1% and 88.9% for DE-CTA (Reader 2). A nonsignificant increase in AUC values with respect to MRA was obtained by reading the CTA (p = 0.470) and DE-CTA dataset (p = 0.217), respectively. Inter-observer agreements were near perfect for CTA (k = 0.84) and substantial for DE-CTA reading (k = 0.76). Intra-observer agreements were near perfect both for CTA (k = 0.88) and for DE-CTA reading (k = 0.82).

CONCLUSION

DE-CTA and MRA were not different in terms of diagnostic performance.

Comparative Study between Multi-slice Computed Tomographic Arthrography and Arthroscopy in the Evaluation of Rotator Cuff Tears

Objective  To compare the imaging findings of anatomical alterations using multi-slice computed tomographic arthrography in the evaluation of rotator cuff tears in the shoulder, correlating them with the arthroscopy (the gold standard diagnostic test) findings. Materials and Methods  A longitudinal, prospective, comparative study of diagnostic accuracy performed in the period between June 2016 and June 2017 in patients of both sexes, aged between 40 and 70 years, with shoulder rotator cuff tendon tears and therapeutic need to undergo shoulder arthroscopy. Patients with contraindication to magnetic resonance imaging were included. After multi-slice computed tomographic arthrography, all patients underwent arthroscopy. Results  To obtain the results, the following parameters were determined: sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and Kappa coefficient, and contrast between the imaging method and arthroscopy. Conclusion  In the impossibility of performing magnetic resonance imaging (the gold standard imaging technique), multi-slice computed tomographic arthrography is an imaging examination capable of evaluating/diagnosing rotator cuff tears.

Role of Ultrasound in the Detection of Rotator-Cuff Syndrome: An Observational Study

Background

Physical tests are usually preferred to assess rotator-cuff syndrome but are insufficient to predict the morphology and size of the rotator-cuff. The objective of the study was to rate the ultrasound findings for patients with sudden shoulder pain and to determine potential predictors of the same.

Material/Methods

A total of 112 patients with sudden shoulder pain with rotator-cuff syndrome, suspected by orthopedic doctors, were subjected to ultrasonography. Real-time ultrasonography was done for the acromioclavicular joint, biceps, infraspinatus, posterior labrum, subscapularis, supraspinatus, teres minor tendon, and the sub-acromial-subdeltoid bursa. Each tendon was assessed via scanning planes in orientation as per longer and shorter axis, and from their myotendinous junction shoulder to bony insertions. Linear and logistic regression analysis were performed to predict the associations of medical history with rotator-cuff injury.

Results

Ultrasonography identified that 82% of the enrolled patients had at least one particular cause of the rotator-cuff disorder. Among the rotator-cuff disorders, calcific tendonitis (54%) was observed more frequently followed by tendinopathy (32%), subacromial-subdeltoid bursitis (22%), and partial thickness tear (21%). Also, 46 patients (41%) had multiple findings. Older age (older than 40 years) was a strong predicting factor of rotator-cuff disorder (r²=0.36, P=0.0004).

Conclusions

Ultrasonography is a vital diagnostic procedure used by orthopedic surgeons for diagnosis of the rotator-cuff disorder(s) in patients with sudden shoulder pain.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Shoulder Pain-Traumatic

Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Predictors of Pain and Discomfort Associated with CT Arthrography of the Shoulder

RATIONALE AND OBJECTIVES

The objective of this study was to investigate predictors of pain associated with computed tomographic arthrography of the shoulder.

MATERIALS AND METHODS

Before shoulder arthrography, all participants were assessed with the Hospital Anxiety and Depression Scale (HADS) and the World Health Organization Quality of Life Short Version Instrument (WHOQOL-BREF). The participants were nonrandomized into two groups: the anesthesia group, who underwent prior local infiltration anesthesia before shoulder arthrography, and the nonanesthesia group, who did not undergo prior local infiltration anesthesia. The pain levels at intraprocedure, at 1, 2, 6, and 12 hours, and at 1 and 2 days after injection were assessed by using a visual analog scale. Univariate and multivariate generalized linear model analyses were conducted.

RESULTS

Sixty participants in the anesthesia group and 60 participants in the nonanesthesia group were included. The pain level at intraprocedure (3.37 ± 1.94 in the anesthesia group and 3.20 ± 1.34 in the nonanesthesia group) was the highest of the whole pain course. The psychological domain (P = .0013) of WHOQOL-BREF, gender (P = .042), body mass index (P = .0001), and the total number of reinsertion and redirection of needle (P< .0001) were independent predictors of arthrography-related pain.

CONCLUSIONS

The pain associated with shoulder computed tomographic arthrography depends on the psychological domain of WHOQOL-BREF, gender, body mass index, and the total number of reinsertion and redirection of needle.

The Clinical Outcomes and Their Associated Factors in Staged Bilateral Arthroscopic Rotator Cuff Repair

PURPOSE

To compare perioperative characteristics and postoperative outcomes of both shoulders in patients who underwent arthroscopic bilateral rotator cuff repair sequentially and to assess the associated factors that would affect the anatomic healing in staged bilateral rotator cuff repair.

METHODS

The study enrolled 64 patients who underwent bilateral rotator cuff repair with follow-up imaging at least 12 months postoperatively. We allocated the shoulders operated on first to the surgery I group and those operated on second to the surgery II group. Visual analog scale (VAS) pain and satisfaction scores, range of motion, the American Shoulder and Elbow Surgeons score, the Simple Shoulder Test score, and healing failure were evaluated.

RESULTS

Range of motion improved with no significant between-group differences (all P > .05). In the surgery II group, VAS pain and VAS satisfaction scores were significantly worse at 6 months postoperatively (P = .048 and P = .041, respectively) but were comparable at final follow-up (P = .598 and P = .065, respectively). American Shoulder and Elbow Surgeons and Simple Shoulder Test scores at 6 months were worse in the surgery II group (P = .038 and P = .048, respectively) but similar at final follow-up (P = .786 and P = .087, respectively). Tear size was similar between the 2 surgical procedures (κ = 0.537, P < .001). Of the 11 patients with nonhealing in the surgery I group, 7 (63.6%) had subsequent failure in the other shoulder, and if one shoulder had healing failure, the other shoulder had a high possibility of healing failure as well (κ = 0.373, P = .004).

CONCLUSIONS

Bilateral arthroscopic rotator cuff repair showed good outcomes at final follow-up on both sides. Tear size was closely related in both shoulders, and healing failure after the first rotator cuff repair was an associated factor with healing failure after the second operation.

LEVEL OF EVIDENCE

Level IV, case series.

Is Anatomical Healing Essential for Better Clinical Outcome in Type II SLAP Repair? Clinico-Radiological Outcome after Type II SLAP Repair

Background

We hypothesized that anatomical healing in superior labrum anterior to posterior (SLAP) repair is associated with good clinical outcome. The purposes of this study were to assess the failure rate of anatomical healing after arthroscopic repair of SLAP lesions using computed tomography arthrography (CTA), investigate correlation of the rate with clinical outcomes, and identify prognostic factors for anatomical failure following SLAP repair.

Methods

We retrospectively evaluated the outcome of 43 patients at a minimum follow-up of 1 year after arthroscopic surgery for SLAP lesions or SLAP lesions associated with Bankart lesions. Twenty-eight patients underwent isolated SLAP repair and 15 patients underwent Bankart repair with SLAP repair. The anatomical outcome was assessed using CTA at 1 year after surgery. Clinical outcomes including visual analogue scale for pain and satisfaction and Constant score were assessed at the final follow-up. We investigated clinical failure that was defined as stiffness, loss of maximum rotation, deterioration of pain, and/or need for revision of surgery.

Results

Anatomical failure occurred in 32.6% of patients (14/43), whereas 16.3% of patients (7/43) had clinical failure. Clinicoradiological assessment revealed that clinical failure occurred only in 7.1% of patients (1/14) with unhealed SLAP lesions, whereas it occurred in 20.7% of patients (6/29) with healed SLAP lesions. Isolated SLAP repair resulted in a higher risk of anatomical failure (risk ratio, 7.0) than combined SLAP repair (p = 0.015). Nonoverhead activities were associated with higher risk of anatomical failure (risk ratio, 2.9; p = 0.041). Patients above 35 years of age had more risk of anatomical failure (risk ratio, 3.5; p = 0.010). Clinical outcomes significantly improved regardless of anatomical failure (p < 0.001) and were not significantly different between unhealed and healed repairs (all p > 0.05).

Conclusions

Since patients with unhealed SLAP lesions had less clinical failure than patients with healed SLAP lesions, anatomical healing does not seem essential for better clinical outcome of SLAP II repair, especially in patients with higher healing failure risk (isolated SLAP repair, nonoverhead activities, and above 35 years of age). Therefore, we believe the indications of SLAP repair should be narrowed to avoid overtreatment.

Computed tomographic arthrography is a useful adjunct to survey computed tomography and arthroscopic evaluation of the canine shoulder joint

The aim of this retrospective, methods comparison study was to assess the diagnostic utility of computed tomographic arthrography in the assessment of various intraarticular shoulder pathologies in dogs in comparison with survey computed tomography (CT), using arthroscopic examination as the reference standard. Computed tomography, computed tomographic arthrography, and arthroscopic findings of 46 scapulohumeral joints of dogs with forelimb lameness were reviewed retrospectively. Predefined sites were assessed for the presence or absence of disease. If a lesion was present, a prespecified pathology was designated. Computed tomographic arthrography was found to be a safe technique which provided a superior diagnostic efficacy relative to survey CT for the assessment of the biceps tendon and biceps tendon sheath (sensitivity 71%, specificity 75%, positive likelihood ratio 2.9, negative likelihood ratio 0.38) and humeral head cartilage (sensitivity 65%, specificity 97%, positive likelihood ratio 19, negative likelihood ratio 0.37). Computed tomography and computed tomographic arthrography provided additional diagnostic information to arthroscopy in regard to osteophytosis, subchondral defects, and joint mice. Computed tomographic arthrography alone was of limited diagnostic value for assessment of the medial and lateral glenohumeral ligaments (sensitivity 13% and 0%, specificity 1% and 78%, positive likelihood ratios unmeasurable and 0, negative likelihood ratios 0.88 and 1.29, respectively) and the subscapularis tendon (sensitivity 14%, specificity 98%, positive likelihood ratio 5.7, negative likelihood ratio 0.88). Computed tomographic arthrography is therefore a useful adjunct to survey CT and arthroscopic evaluation of the canine shoulder joint, however, is not a replacement for these techniques.

Volume Manipulation Based on 3D Reconstructed Surfaces for Joint Function Evaluation and Surgery Simulation

In joint surgery, evaluation of the relative positions and angles among joint structures (bones, ligaments, muscle, and cartilages, etc.) in range of motion, lifting and weight bearing of the joint is required. However, current volume visualization techniques provide only static 3D images of anatomic structures in volume data. We propose a method to manipulate (reposition, resize and bend) the joint structures in a volume, by which surgeons can visualize and evaluate the critical positions or angles of the joint structures, and thus plan surgery to correct the morphologic pathology of the joint structures. We also propose a system with a real-time cutting simulation function together with the proposed structure manipulation functions by which surgeons can rehearse and verify joint surgery.

Seizure-induced unilateral posterior dislocation of the shoulder: a diagnosis not to be missed

A man in his mid-50s with a history of bladder carcinoma presented to the Emergency Department (ED) following a witnessed tonic-clonic seizure. Computed Tomography (CT) scanning of his brain revealed an indeterminate mass lesion in the left parietal region. The patient described bilateral shoulder pain prompting plain film radiographs with axial views, but no obvious abnormality was identified by the ED staff. Staging CT scanning did not reveal any evidence of underlying malignancy but revealed dislocation of the left humeral head with a large reverse Hill-Sachs lesion and posteriorly displaced reverse Bankart lesion. Manipulation under anaesthesia and closed reduction of the left shoulder was undertaken successfully. This case report reminds the clinician to maintain a high index of suspicion for posterior dislocation of the shoulder following seizures and to perform appropriate imaging promptly.

The Repaired Rotator Cuff: MRI and Ultrasound Evaluation

PURPOSE OF REVIEW

The purposes of this review were to provide an overview of the current practice of evaluating the postoperative rotator cuff on imaging and to review the salient imaging findings of the normal and abnormal postoperative rotator cuff, as well as of postoperative complications.

RECENT FINDINGS

The repaired rotator cuff frequently appears abnormal on magnetic resonance imaging (MRI) and ultrasound (US). Recent studies have shown that while the tendons typically normalize, they can demonstrate clinically insignificant abnormal imaging appearances for longer than 6 months. Features of capsular thickening or subacromial-subdeltoid bursal thickening and fluid distension were found to decrease substantially in the first 6-month postoperative period. MRI and US were found to be highly comparable in the postoperative assessment of the rotator cuff, although they had a lower sensitivity for partial thickness tears. Imaging evaluation of newer techniques such as patch augmentation and superior capsular reconstruction needs to be further investigated. MRI and US are useful in the postoperative assessment of the rotator cuff, not only for evaluation of the integrity of the rotator cuff, but also for detecting hardware complications and other etiologies of shoulder pain.

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PURPOSE

(1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score.

METHODS

From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value.

RESULTS

The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears.

CONCLUSIONS

The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy.

LEVEL OF EVIDENCE

Comparative case series, Level IV.

Critical period and risk factors for retear following arthroscopic repair of the rotator cuff

PURPOSE

The incidence of retear following rotator cuff repair remains a major concern, and the cause and timing of retear remain unclear. The aim of this study was to prospectively investigate the timing of retears following rotator cuff repair at multiple time intervals. The hypothesis was that the 'critical period' for retears extends beyond the first three post-operative months.

METHODS

The authors prospectively studied 206 shoulders that underwent arthroscopic double-row (without suture bridge) suture anchor repair for rotator cuff tears. Patients were recalled to three follow-up visits at the following post-operative time intervals: 3, 6, and 12 months or longer. Ultrasonography was performed at each visit, and Constant score was collected during the last visit.

RESULTS

A total of 176 shoulders attended all required follow-up visits with mean age 56.0 years. Ultrasonography revealed retears in 16 shoulders (9.1 %) at 3 months, in 6 shoulders (3.4 %) at 6 months, and in 5 others (2.8 %) at the last follow-up, while it confirmed intact rotator cuffs in 149 shoulders (84.7 %) at the last follow-up (median 35.5; range 12-61). The incidence of retears was significantly associated with tear size (p = 0.001) and tendon degeneration (p = 0.003).

CONCLUSION

The 'critical period' for healing following rotator cuff repair, during which risks of retears are high, extends to the first 6 months. The risk of retear is greatest for massive 3-tendon tears, which may require longer periods of protection. The clinical relevance of this study is the identification of patients at risk of retear and the adjustment of their rehabilitation strategy and time for return to work.

LEVEL OF EVIDENCE

III.

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

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

Mean Glenoid Defect Size and Location Associated With Anterior Shoulder Instability: A Systematic Review

BACKGROUND

There is a strong correlation between glenoid defect size and recurrent anterior shoulder instability. A better understanding of glenoid defects could lead to improved treatments and outcomes.

PURPOSE

To (1) determine the rate of reporting numeric measurements for glenoid defect size, (2) determine the consistency of glenoid defect size and location reported within the literature, (3) define the typical size and location of glenoid defects, and (4) determine whether a correlation exists between defect size and treatment outcome.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

PubMed, Ovid, and Cochrane databases were searched for clinical studies measuring glenoid defect size or location. We excluded studies with defect size requirements or pathology other than anterior instability and studies that included patients with known prior surgery. Our search produced 83 studies; 38 studies provided numeric measurements for glenoid defect size and 2 for defect location.

RESULTS

From 1981 to 2000, a total of 5.6% (1 of 18) of the studies reported numeric measurements for glenoid defect size; from 2001 to 2014, the rate of reporting glenoid defects increased to 58.7% (37 of 63). Fourteen studies (n = 1363 shoulders) reported defect size ranges for percentage loss of glenoid width, and 9 studies (n = 570 shoulders) reported defect size ranges for percentage loss of glenoid surface area. According to 2 studies, the mean glenoid defect orientation was pointing toward the 3:01 and 3:20 positions on the glenoid clock face.

CONCLUSION

Since 2001, the rate of reporting numeric measurements for glenoid defect size was only 58.7%. Among studies reporting the percentage loss of glenoid width, 23.6% of shoulders had a defect between 10% and 25%, and among studies reporting the percentage loss of glenoid surface area, 44.7% of shoulders had a defect between 5% and 20%. There is significant variability in the way glenoid bone loss is measured, calculated, and reported.

Magnetic resonance imaging evaluation of meniscoid superior labrum: normal variant or superior labral tear

Objective

The objective of this study was to determine the incidence of a "meniscoid" superior labrum.

Materials and Methods

This was a retrospective analysis of 582 magnetic resonance imaging examinations of shoulders. Of those 582 examinations, 110 were excluded, for a variety of reasons, and the final analysis therefore included 472 cases. Consensus readings were performed by three musculoskeletal radiologists using specific criteria to diagnose meniscoid labra.

Results

A meniscoid superior labrum was identified in 48 (10.2%) of the 472 cases evaluated. Arthroscopic proof was available in 21 cases (43.8%). In 10 (47.6%) of those 21 cases, the operative report did not include the mention a superior labral tear, thus suggesting the presence of a meniscoid labrum. In only one of those cases were there specific comments about a mobile superior labrum (i.e., meniscoid labrum). In the remaining 11 (52.4%), surgical correlation demonstrated superior labral tears.

Conclusion

A meniscoid superior labrum is not an infrequent finding. Depending upon assumptions and the requirement of surgical proof, the prevalence of a meniscoid superior labrum in this study was between 2.1% (surgically proven) and 4.8% (projected). However, superior labral tears are just as common and are often confused with meniscoid labra.

MR-arthrography and CT-arthrography in sports-related glenolabral injuries: a matched descriptive illustration

The combination of a large range of motion and insufficient bony stabilization makes the glenohumeral joint susceptible to injuries including dislocation in young athletes. Magnetic resonance arthrography (MR-arthrography) and computed tomography arthrography (CT-arthrography) play an important role in the preoperative workup of labroligametous injuries. This paper illustrates MR-arthrography and CT-arthrography findings acquired at the same time on the same subjects to illustrate common causes and sequelae of shoulder instability. Teaching Points • MR-arthrography and CT-arthrography are equivalent for SLAP and full-thickness rotator cuff tears.• CT-arthrography is superior in evaluating osseous defects and cartilage surface lesions.• MR-arthrography is superior in evaluating intrasubstance and extra-articular tendinous injuries.

Prognostic Factors Affecting Rotator Cuff Healing After Arthroscopic Repair in Small to Medium-sized Tears

BACKGROUND

Small and medium-sized rotator cuff tears usually have good clinical and anatomic outcomes. However, healing failure still occurs in some cases.

PURPOSE

To evaluate prognostic factors for rotator cuff healing in patients with only small to medium-sized rotator cuff tears.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected from 339 patients with small to medium-sized rotator cuff tears who underwent arthroscopic repair by a single surgeon between March 2004 and August 2012 and who underwent magnetic resonance imaging or computed tomographic arthrography at least 1 year after surgery. The mean age of the patients was 59.8 years (range, 39-80 years), and the mean follow-up time was 20.8 months (range, 12-66 months). The functional evaluation included the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons score, Constant-Murley score, and Simple Shoulder Test.

RESULTS

Postoperative VAS for pain and functional scores improved significantly compared with preoperative values (P < .001). Forty-five healing failures occurred (13.3%), and fatty degeneration of the infraspinatus muscle, tear size (anteroposterior dimension), and age were significant factors affecting rotator cuff healing (P < .001, = .018, and = .011, respectively) in multivariate logistic regression analysis. Grade II and higher infraspinatus fatty degeneration correlated with a higher failure rate. The failure rate was also significantly higher in patients with a tear >2 cm in size (34.2%) compared with patients with a tear ≤2 cm (10.6%) (P < .001). A receiver operating characteristic curve was used to determine the predictive cut-off value for the oldest age and the largest tear size for successful healing, which were calculated as 69 years and 2 cm, respectively, with a specificity of 90%.

CONCLUSION

In small to medium-sized rotator cuff tears, grade II fatty degeneration of the infraspinatus muscle according to the Goutallier classification could be a reference point for successful healing, and anatomic outcomes might be better if repair is performed before the patient is 69 years old and the tear size exceeds 2 cm.

Are radiologists superior to orthopaedic surgeons in diagnosing instability-related shoulder lesions on magnetic resonance arthrography? A multicenter reproducibility and accuracy study

BACKGROUND

We compared the diagnostic reproducibility and accuracy of musculoskeletal radiologists with orthopaedic shoulder surgeons in 2 large medical centers in assessing magnetic resonance arthrograms (MRAs) of patients with traumatic anterior shoulder instability.

METHODS

Forty-five surgically confirmed MRAs were assessed by 4 radiologists, 4 orthopaedic surgeons, 2 radiologic teams, and 2 orthopaedic teams. During MRA assessment and surgery, the same 7-lesion scoring form was used. κ Coefficients, sensitivity, specificity, and differences in percentage of agreement or correct diagnosis (P < .05, McNemar test) were calculated per lesion and overall per the 7 lesion types.

RESULTS

The overall κ between the individual radiologists (κ = 0.51, κ = 0.46) and orthopaedic surgeons (κ = 0.46, κ = 0.41) was moderate. Although the overall percentage of agreement between the radiologists was slightly higher than that between the orthopaedic surgeons in both centers (80.0% vs 77.5% and 75.2% vs 73.7%), there was no significant difference. In each medical center, however, the most experienced orthopaedic surgeon was exceedingly more accurate than both radiologists per the 7 lesion types (81.9% vs 72.4%/74.6% and 76.5% vs 67.3%/73.7%). In 3 of 4 cases, this difference was significant. Overall accuracy improvement through consensus assessment was merely established for the weakest member of each team.

CONCLUSION

Experienced orthopaedic surgeons are more accurate than radiologists in assessing traumatic anterior shoulder instability-related lesions on MRA. In case of diagnosis disagreement, these orthopaedic surgeons should base their treatment decision on their own MRA interpretation.

Arthroscopic repair of type II SLAP lesions: Clinical and anatomic follow-up

Aims:

The aim was to evaluate the clinical and anatomic outcome of arthroscopic repair of type II SLAP lesions.

Materials and Methods:

The senior author performed isolated repairs of 25 type II SLAP lesions in 25 patients with a mean age of 40.0 ± 12 years. All tears were repaired using standard arthroscopic suture anchor repair to bone. All patients were reviewed using a standardized clinical examination by a blinded, independent observer, and using several shoulder outcome measures. Patients were evaluated by magnetic resonance imaging arthrogram at a minimum of 1-year postoperatively.

Statistical Analysis Used:

Two-tailed paired t-test were used to determine significant differences in preoperative and postoperative clinical outcomes scores. In addition, a Fisher's exact test was used.

Results:

At a mean follow-up of 54-month, the mean American Shoulder and Elbow Surgeons Shoulder Index (ASES) scores improved from 52.1 preoperatively to 86.1 postoperatively (P < 0.0001) and the Simple Shoulder Test (SST) scores from 7.7 to 10.6 (P < 0.0002). Twenty-two out of the 25 patients (88%) stated that they would have surgery again. Of the 21 patients who had postoperative magnetic resonance imaging arthrographys (MRAs), 9 patients (43%) demonstrated dye tracking between the labrum bone interface suggestive of a recurrent tear and 12 patients (57%) had a completely intact repair. There was no significant difference in ASES, SST, and patient satisfaction scores in patients with recurrent or intact repairs.

Conclusions:

Arthroscopic repair of type II SLAP lesions demonstrated improvements in clinical outcomes. However, MRA imaging demonstrated 43% of patients with recurrent tears. MRA results do not necessarily correlate with clinical outcome.

Superior Labral Cleft after Superior Labral Anterior-to-Posterior Tear Repair: CT Arthrographic Features and Correlation with Clinical Outcome

PURPOSE

To evaluate the presence of a superior labral cleft at postoperative computed tomographic (CT) arthrography after superior labral anterior-to-posterior lesion (SLAP) repair and to correlate CT arthrographic appearance with clinical outcomes.

MATERIALS AND METHODS

The institutional review board approved this retrospective study, and the requirement to obtain informed consent was waived. Fifty-six patients who underwent CT arthrography after arthroscopic SLAP repair were included. Two musculoskeletal radiologists retrospectively reviewed CT arthrographic images for the presence, size, location, direction, and shape of a superior labral cleft, which was defined as a detectable contrast material-filled focal discontinuity of the labrum within anchor fixation sites of the glenoid. In addition, the glenoid osteolysis ratio was calculated on the basis of the CT arthrographic images. Clinical outcome was evaluated with use of the American Shoulder and Elbow Surgeons (ASES) scoring system. Continuous variables, such as patient age, interval between imaging and surgery, ASES score, and osteolysis ratio, were compared by using the Mann-Whitney U test.

RESULTS

A superior labral cleft was observed in 27 of the 56 patients (48%). The mean width and depth of the superior labral clefts was 2.1 mm ± 1.1 and 2.8 mm ± 0.8, respectively. The superior labral clefts extended posterior to the biceps anchor in 16 of the 27 patients (59%), were curved medially in 24 (89%), and had a smooth margin in 22 (81%). No significant association was observed between the presence of a superior labral cleft and the ASES score (P = .805) or patient age (P = .290). Superior labral clefts were observed more commonly in cases with a long interval since surgery (P = .007) and a high osteolysis ratio (P = .011).

CONCLUSION

Superior labral clefts are frequently observed on CT arthrographic images after arthroscopic SLAP repair and do not correlate with clinical outcome.

Arthroscopic repair of partial-thickness and small full-thickness rotator cuff tears: tendon quality as a prognostic factor for repair integrity

BACKGROUND

The healing failure rate is high for partial-thickness or small full-thickness rotator cuff tears.

PURPOSE

To retrospectively evaluate and compare outcomes after arthroscopic repair of high-grade partial-thickness and small full-thickness rotator cuff tears and factors affecting rotator cuff healing.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Included in the study were 55 consecutive patients (mean age, 57.9 ± 7.2 years) who underwent arthroscopic repair for high-grade partial-thickness (n = 34) and small full-thickness (n = 21) rotator cuff tears. The study patients also underwent magnetic resonance imaging (MRI) preoperatively and computed tomography arthrography (CTA) at least 6 months postoperatively, and their functional outcomes were evaluated preoperatively and at the last follow-up (>24 months). All partial-thickness tears were repaired after being converted to full-thickness tears; thus, the repair process was almost the same as for small full-thickness tears. The tendinosis of the torn tendon was graded from the MRI images using a 4-point scale, and the reliabilities were assessed. The outcomes between high-grade partial-thickness tears that were converted to small full-thickness tears and initially small full-thickness tears were compared, and factors affecting outcomes were evaluated.

RESULTS

The inter- and intraobserver reliabilities of the tendinosis grade were good (intraclass correlation coefficient, 0.706 and 0.777, respectively). Failure to heal as determined by CTA was observed in 12 patients with a high-grade partial-thickness tear (35.3%; complete failure in 4 and partial failure in 8) and in 3 patients with a small full-thickness tear (14.3%; complete failure in 1 and partial failure in 2). The patients with high-grade partial-thickness rotator cuff tears showed a higher tendinosis grade than did those with small full-thickness tears (P = .014), and the severity of the tendinosis was related to the failure to heal (P = .037). Tears with a higher tendinosis grade showed a 7.64-times higher failure rate (95% CI, 1.43-36.04) than did those with a lower tendinosis grade (P = .013). All functional outcome scores improved after surgery (all P < .001); however, there was no difference between groups.

CONCLUSION

The high-grade partial-thickness rotator cuff tears showed more severe tendinosis compared with the small full-thickness tears in this study. Contrary to previous impressions that tear size or fatty infiltration is the factor that most influences healing, tendinosis severity assessed by preoperative MRI was the only factor associated with failure to heal, given the numbers available for analysis, in patients with partial-thickness and small full-thickness rotator cuff tears. Surgeons should pay more attention to tendon quality during repair surgery or rehabilitation in smaller rotator cuff tears, especially in high-grade partial-thickness tears with severe tendinosis.

Ultrasonic evaluation of the repair integrity can predict functional outcomes after arthroscopic double-row rotator cuff repair

PURPOSE

Despite proven accuracy of US for the evaluation of rotator cuff integrity, there is no US-based classification for this purpose. This study aimed to assess US for the evaluation of rotator cuff repair integrity in accordance with a well-established MRI classification.

METHODS

The authors retrospectively reviewed 257 patients who underwent arthroscopic double-row suture anchor repair for rotator cuff tears. Post-operative function was rated using the Constant score, the UCLA rating and the SSV, whereas repair integrity was assessed using US as described in the MRI classification of Sugaya et al.

RESULTS

A total of 212 patients aged 55.6 ± 9.8 years had complete functional and radiographic assessments at a mean follow-up of 36.8 ± 11.6 months. Using all three ratings, repairs of Type I had highest scores, repairs of Type II had discernibly lower scores, whereas repairs of Types III, IV and V had similar intermediate scores.

CONCLUSION

Comparison of the UCLA scores with those of Sugaya et al. revealed similar scores for repairs of Type I and of Type V. The scores are less comparable for repairs of Types II, III and IV, because US does not allow identification of partial tears if shielded by bony structures and because partial tears correspond to minimal impairment. The study reveals that US is an adequate imaging modality to classify rotator cuff repair integrity, which could reduce economic and practical burdens of CTA, MRI or MRA. The results also confirm that post-operative repair integrity and functional outcome depend on pre-operative tear size and fatty infiltration, which provides clinicians with reasoning for early surgical repair and warning of the risks of strenuous activity for patients with larger tears.

LEVEL OF EVIDENCE

Prognostic study, Level IV.

Comparison of image quality of shoulder CT arthrography conducted using 120 kVp and 140 kVp protocols

OBJECTIVE

To compare the image quality of shoulder CT arthrography performed using 120 kVp and 140 kVp protocols.

MATERIALS AND METHODS

Fifty-four CT examinations were prospectively included. CT scans were performed on each patient at 120 kVp and 140 kVp; other scanning parameters were kept constant. Image qualities were qualitatively and quantitatively compared with respect to noise, contrast, and diagnostic acceptability. Diagnostic acceptabilities were graded using a one to five scale as follows: 1, suboptimal; 2, below average; 3, acceptable; 4, above average; and 5, superior. Radiation doses were also compared.

RESULTS

Contrast was better at 120 kVp, but noise was greater. No significant differences were observed between the 120 kVp and 140 kVp protocols in terms of diagnostic acceptability, signal-to-noise ratio, or contrast-to-noise ratio. Lowering tube voltage from 140 kVp to 120 kVp reduced the radiation dose by 33%.

CONCLUSION

The use of 120 kVp during shoulder CT arthrography reduces radiation dose versus 140 kVp without significant loss of image quality.

Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study

BACKGROUND

The failure of subacromial decompression may be attributed to persistent symptoms of acromioclavicular joint (ACJ) arthritis, while inferior clavicular spurs of the ACJ may be associated with failed healing of repaired rotator cuffs.

PURPOSE

To evaluate the clinical effectiveness of arthroscopic distal clavicle resection (DCR) in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis who were scheduled for arthroscopic rotator cuff repair were prospectively randomized into 2 groups. Patients underwent arthroscopic rotator cuff repair with acromioplasty. Patients in group 1 (39 patients) underwent additional arthroscopic DCR, while patients in group 2 (39 patients) did not. Clinical outcomes of the 2 groups were compared using the visual analog scale (VAS) for pain, range of motion, Constant score, and American Shoulder and Elbow Surgeons (ASES) score up to at least 24 months. The structural integrity of repaired rotator cuffs was assessed using ultrasonography, computed tomography arthrography, or MRI at least 6 months after surgery. To evaluate ACJ instability, weighted stress radiography of the ACJ was studied at 6 and 12 months postoperatively.

RESULTS

Patients in both groups showed significant improvement in the VAS score and all functional scores at final follow-up (mean, 29.2 months; range, 24-46 months) without significant differences between the 2 groups (P > .05). Results (mean ± SD) for preoperative group 1/group 2 and postoperative group 1/group 2 were as follows, respectively: 7.2 ± 1.8/6.1 ± 1.9 (P = .02) and 0.6 ± 1.8/0.6 ± 0.9 (P = .97) for the VAS score, 74.1 ± 5.7/73.8 ± 8.0 (P = .87) and 96.3 ± 5.7/95.7 ± 4.6 (P = .77) for the Constant score, and 47.0 ± 10.3/50.8 ± 14.1 (P = .22) and 91.5 ± 15.5/94.5 ± 11.8 (P = .55) for the ASES score. Failed cuff healing occurred in 9 patients (23%) in group 1 and 10 patients (26%) in group 2, with no significant difference (P = .95). In group 1, there were 2 patients (5.0%) with ACJ subluxation on weighted stress radiography at 6 months postoperatively. These patients complained of gross protrusion and ACJ tenderness.

CONCLUSION

Preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and it did lead to symptomatic ACJ instability in some patients. Preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis. Further long-term follow-up is needed to confirm the development of symptoms in ACJ arthritis.

Does the experience level of the radiologist, assessment in consensus, or the addition of the abduction and external rotation view improve the diagnostic reproducibility and accuracy of MRA of the shoulder?

AIM

To prospectively evaluate the influence of observer experience, consensus assessment, and abduction and external rotation (ABER) view on the diagnostic performance of magnetic resonance arthrography (MRA) in patients with traumatic anterior-shoulder instability (TASI).

MATERIALS AND METHODS

Fifty-eight MRA examinations (of which 51 had additional ABER views) were assessed by six radiologists (R1-R6) and three teams (T1-T3) with different experience levels, using a seven-lesion standardized scoring form. Forty-five out of 58 MRA examination findings were surgically confirmed. Kappa coefficients, sensitivity, specificity, and differences in percent agreement or correct diagnosis (p-value, McNemar's test) were calculated per lesion and overall per seven lesion types to assess diagnostic reproducibility and accuracy.

RESULTS

Overall kappa ranged from poor (k = 0.17) to moderate (k = 0.53), sensitivity from 30.6-63.5%, and specificity from 73.6-89.9%. Overall, the most experienced radiologists (R1-R2) and teams (T2-T3) agreed significantly more than the lesser experienced radiologists (R3-R4: p = 0.014, R5-R6; p = 0.018) and teams (T2-T3: p = 0.007). The most experienced radiologist (R1, R2, R3) and teams (T1, T2) were also consistently more accurate than the lesser experienced radiologists (R4, R5, R6) and team (T3). Significant differences were found between R1-R4 (p = 0.012), R3-R4 (p = 0.03), and T2-T3 (p = 0.014). The overall performance of consensus assessment was systematically higher than individual assessment. Significant differences were established between T1-T2 and radiologists R3-R4 (p<0.001, p = 0.001) and between T2 and R3 (p<0.001/p = 0.001) or R4 (p = 0.050). No overall significant differences were found between the radiologists' assessments with and without ABER.

CONCLUSION

The addition of ABER does not significantly improve overall diagnostic performance. The radiologist's experience level and consensus assessment do contribute to higher reproducibility and accuracy.

Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management

After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.

Morphological Characteristics of the Repaired Labrum According to Glenoid Location and Its Clinical Relevance After Arthroscopic Bankart Repair: Postoperative Evaluation With Computed Tomography Arthrography

BACKGROUND

There have been no studies on the postoperative morphological characteristics of the restored labrum at different glenoid locations and its clinical relevance after arthroscopic Bankart repair with suture anchors.

PURPOSE

To analyze the morphological characteristics of the restored labrum at different locations of the glenoid and their relevance to clinical outcomes as well as affecting factors and to trace the inserted suture anchors after arthroscopic Bankart repair using computed tomography arthrography (CTA).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 46 patients (mean age, 26.5 ± 6.8 years) who underwent arthroscopic Bankart repair with absorbable suture anchors were enrolled in this study. Patients underwent CTA preoperatively and 6 months postoperatively as well as functional outcome evaluation preoperatively and at the last follow-up (>24 months) with the Rowe score and visual analog scale for pain. Labral height and width were measured on conventional axial CTA images at the 3-, 4-, and 5-o'clock positions twice by 2 raters. The postoperative measurements were also compared with those of the healthy anterior labrum, acquired from the same CTA examination of 32 consecutive patients (mean age, 26.5 ± 8.5 years) with superior labral lesions in the same study period. The postoperative difference in the measurements and between clock positions, and the relationship between the measurements and the clinical factors and functional outcomes, were evaluated. In addition, the locations of all suture anchors were traced on each CTA image, and outcomes according to the locations of the most inferior suture anchors were assessed.

RESULTS

The interobserver and intraobserver reliabilities of measurements at each location were excellent (Pearson correlation coefficient = 0.773-0.988). Of the 46 patients, 2 (4.35%) had redislocations after surgery. Postoperative labral height and width were significantly increased at all locations (all P < .001) up to a level similar to the healthy anterior labrum, with significantly larger values at the inferior location compared with the superior location (all P < .05). Patients who had a greater frequency of dislocations before surgery showed a lower postoperative labral height at the 5-o'clock position (P = .012), and this correlated with postoperative instability and poor functional outcomes by the Rowe score (P = .036). In most patients (41/46; 89.1%), the tips of the lowest suture anchors perforated the far cortex, and these anchors were mostly located below the 5-o'clock position (32/41; 78.0%). However, perforation of the far cortex did not affect functional outcomes.

CONCLUSION

Surgeons should be cautious of restoring labral height at the inferior glenoid location for successful arthroscopic Bankart repair. In addition, attention should be given to inserting the lowest suture anchor regardless of clinical significance.

Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered

BACKGROUND

Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability. Magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US) are increasingly being used to assess the presence and size of rotator cuff tears to assist in planning surgical treatment. It is not known whether one imaging method is superior to any of the others.

OBJECTIVES

To compare the diagnostic test accuracy of MRI, MRA and US for detecting any rotator cuff tears (i.e. partial or full thickness) in people with suspected rotator cuff tears for whom surgery is being considered.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, MEDLINE, EMBASE, and LILACS from inception to February 2011. We also searched trial registers, conference proceedings and reference lists of articles to identify additional studies. No language or publication restrictions were applied.

SELECTION CRITERIA

We included all prospective diagnostic accuracy studies that assessed MRI, MRA or US against arthroscopy or open surgery as the reference standard, in people suspected of having a partial or full thickness rotator cuff tear. We excluded studies that selected a healthy control group, or participants who had been previously diagnosed with other specific causes of shoulder pain such as osteoarthritis or rheumatoid arthritis. Studies with an excessively long period (a year or longer) between the index and reference tests were also excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study characteristics and results of included studies, and performed quality assessment according to QUADAS criteria. Our unit of analysis was the shoulder. For each test, estimates of sensitivity and specificity from each study were plotted in ROC space and forest plots were constructed for visual examination of variation in test accuracy. Meta-analyses were performed using the bivariate model to produce summary estimates of sensitivity and specificity. We were unable to formally investigate potential sources of heterogeneity because of the small number of studies.

MAIN RESULTS

We included 20 studies of people with suspected rotator cuff tears (1147 shoulders), of which six evaluated MRI and US (252 shoulders), or MRA and US (127 shoulders) in the same people. Many studies had design flaws, with the potential for bias, thus limiting the reliability of their findings. Overall, the methodological quality of the studies was judged to be low or unclear. For each test, we observed considerable heterogeneity in study results, especially between studies that evaluated US for the detection of full thickness tears and studies that evaluated MRA for the detection of partial thickness tears. The criteria for a positive diagnostic test (index tests and reference standard) varied between studies.Meta-analyses were not possible for studies that assessed MRA for detection of any rotator cuff tears or partial thickness tears. We found no statistically significant differences in sensitivity or specificity between MRI and US for detecting any rotator cuff tears (P = 0.13), or for detecting partial thickness tears (P = 1.0). Similarly, for the comparison between MRI, MRA and US for detecting full thickness tears, there was no statistically significant difference in diagnostic performance (P = 0.7). For any rotator cuff tears, the summary sensitivity and specificity were 98% (95% CI 92% to 99%) and 79% (95% CI 68% to 87%) respectively for MRI (6 studies, 347 shoulders), and 91% (95% CI 83% to 95%) and 85% (95% CI 74% to 92%) respectively for US (13 studies, 854 shoulders). For full thickness tears, the summary sensitivity and specificity were 94% (95% CI 85% to 98%) and 93% (95% CI 83% to 97%) respectively for MRI (7 studies, 368 shoulders); 94% (95% CI 80% to 98%) and 92% (95% CI 83% to 97%) respectively for MRA (3 studies, 183 shoulders); and 92% (95% CI 82% to 96%) and 93% (95% CI 81% to 97%) respectively for US (10 studies, 729 shoulders).Because few studies were direct head-to-head comparisons, we could not perform meta-analyses restricted to these studies. The test comparisons for each of the three classifications of the target condition were therefore based on indirect comparisons which may be prone to bias due to confounding.

AUTHORS' CONCLUSIONS

MRI, MRA and US have good diagnostic accuracy and any of these tests could equally be used for detection of full thickness tears in people with shoulder pain for whom surgery is being considered. The diagnostic performance of MRI and US may be similar for detection of any rotator cuff tears. However, both MRI and US may have poor sensitivity for detecting partial thickness tears, and the sensitivity of US may be much lower than that of MRI. The strength of evidence for all test comparisons is limited because most studies were small, heterogeneous and methodologically flawed, and there were few comparative studies. Well designed studies that directly compare MRI, MRA and US for detection of rotator cuff tears are needed.

Fatty degeneration of the rotator cuff muscles on pre- and postoperative CT arthrography (CTA): is the Goutallier grading system reliable?

OBJECTIVES

To retrospectively evaluate fatty degeneration (FD) of rotator cuff muscles on CTA using Goutallier's grading system and quantitative measurements with comparison between pre- and postoperative states.

MATERIALS AND METHODS

IRB approval was obtained for this study. Two radiologists independently reviewed pre- and postoperative CTAs of 43 patients (24 males and 19 females, mean age, 58.1 years) with 46 shoulders confirmed as full-thickness tears with random distribution. FD of supraspinatus, infraspinatus/teres minor, and subscapularis was assessed using Goutallier's system and by quantitative measurements of Hounsfield units (HUs) on sagittal images. Changes in FD grades and HUs were compared between pre- and postoperative CTAs and analyzed with respect to preoperative tear size and postoperative cuff integrity. The correlations between qualitative grades and quantitative measurements and their inter-observer reliabilities were also assessed.

RESULTS

There was statistically significant correlation between FD grades and HU measurements of all muscles on pre- and postoperative CTA (p < 0.05). Inter-observer reliability of fatty degeneration grades were excellent to substantial on both pre- and postoperative CTA in supraspinatus (0.8685 and 0.8535) and subscapularis muscles (0.7777 and 0.7972), but fair in infraspinatus/teres minor muscles (0.5791 and 0.5740); however, quantitative Hounsfield units measurements showed excellent reliability for all muscles (ICC: 0.7950 and 0.9346 for SST, 0.7922 and 0.8492 for SSC, and 0.9254 and 0.9052 for IST/TM). No muscle showed improvement of fatty degeneration after surgical repair on qualitative and quantitative assessments; there was no difference in changes of fatty degeneration after surgical repair according to preoperative tear size and post-operative cuff integrity (p > 0.05). The average dose-length product (DLP, mGy · cm) was 365.2 mGy · cm (range, 323.8-417.2 mGy · cm) and estimated average effective dose was 5.1 mSv.

CONCLUSIONS

Goutallier grades correlated well with HUs of rotator cuff muscles. Reliability was excellent for both systems, except for FD grade of IST/TM muscles, which may be more reliably assessed using quantitative measurements.

Management of the athlete with a failed shoulder instability procedure

The athlete with a failed instability procedure requires a thoughtful and systematic approach to achieve a good outcome. Goals of treatment should be defined and realistic expectations should be set. Revision stabilization has a high rate of recurrent instability, low rates of return to play, and low clinical outcome scores. Fundamental to successful revision surgery is choosing the correct procedure. The decision is straightforward in athletes with clear factors that predict recurrence (significant glenoid bone loss, engaging Hill-Sachs lesions) because only a bony procedure can restore the articular arc of the glenoid. Arthroscopic revision Bankart repair may be appropriate in those athletes who have an obvious Bankart tear and no bone loss after a traumatic reinjury. The challenge for the shoulder surgeon is identifying the best surgery for the athlete who does not have such clear-cut indications. Each factor that has the potential to lead to a poor outcome needs to be collected and calculated. Patient factors (age, laxity, type and level of sport), injury factors (mechanism of injury, capsulolabral injury, glenoid bone loss, Hill-Sachs lesion), and technical factors (previous surgery performed, integrity of repair, scarring) must be integrated into the treatment algorithm. Based on this collection of factors, the shoulder surgeon should be prepared to provide the athlete with the surgery that provides the best chance to return to playing sports and the lowest risk of recurrent instability.

Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function

BACKGROUND

Many patients with an unhealed cuff after repair show functional improvement.

PURPOSE

To evaluate outcomes of arthroscopically repaired massive rotator cuff tears and to identify prognostic factors affecting rotator cuff healing and functional outcome, especially in patients with failed rotator cuff healing.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Among 173 patients who underwent arthroscopic repair of a massive rotator cuff tear, 108 patients with a mean age of 63.7 years were included. Outcome evaluation was completed both anatomically (CT arthrography or ultrasonography) and functionally at a minimum of 1 year postoperatively; mean follow-up period was 31.68 ± 15.81 months. Various factors affecting cuff healing were analyzed, and factors affecting functional outcome were evaluated in patients with failed repairs using both univariate and multivariate analyses.

RESULTS

The anatomic failure rate was 39.8% in arthroscopically repaired massive rotator cuff tears; however, functional status significantly improved regardless of cuff healing (P < .05). Several factors were associated with failure of cuff healing in the univariate analysis, but only fatty infiltration (FI) of the infraspinatus was significantly related to healing failure in the multivariate analysis (P = .04). Among patients with failed rotator cuff healing, only reduced postoperative acromiohumeral distance (AHD) was related to poor functional outcome in the multivariate analysis (P = .01), with a cutoff value of 4.1 mm.

CONCLUSION

Despite a high rate of healing failures, arthroscopic repair can be recommended in patients with massive rotator cuff tears because of the functional gain at midterm follow-up. Higher FI of the infraspinatus was the single most important factor negatively affecting cuff healing. In cases of failed massive rotator cuff repair, no preoperative factor was able to predict poor functional outcome; reduced postoperative AHD was the only relevant functional determinant in the patients' eventual functional outcome and should be considered when ascertaining a prognosis and planning further treatment strategies.

Is the supraspinatus muscle atrophy truly irreversible after surgical repair of rotator cuff tears?

BACKGROUND

Atrophy of rotator cuff muscles has been considered an irreversible phenomenon. The purpose of this study is to evaluate whether atrophy is truly irreversible after rotator cuff repair.

METHODS

We measured supraspinatus muscle atrophy of 191 patients with full-thickness rotator cuff tears on preoperative magnetic resonance imaging and postoperative multidetector computed tomography images, taken at least 1 year after operation. The occupation ratio was calculated using Photoshop CS3 software. We compared the change between pre- and postoperative occupation ratios after modifying the preoperative occupation ratio. In addition, possible relationship between various clinical factors and the change of atrophy, and between the change of atrophy and cuff integrity after surgical repair were evaluated.

RESULTS

The mean occupation ratio was significantly increased postoperatively from 0.44 ± 0.17 to 0.52 ± 0.17 (p < 0.001). Among 191 patients, 81 (42.4%) showed improvement of atrophy (more than a 10% increase in occupation ratio) and 33 (17.3%) worsening (more than a 10% decrease). Various clinical factors such as age tear size, or initial degree of atrophy did not affect the change of atrophy. However, the change of atrophy was related to repair integrity: cuff healing failure rate of 48.5% (16 of 33) in worsened atrophy; and 22.2% (18 of 81) in improved atrophy (p = 0.007).

CONCLUSIONS

The supraspinatus muscle atrophy as measured by occupation ratio could be improved postoperatively in case of successful cuff repair.