The diagnostic accuracy of MRI for the detection of partial- and full-thickness rotator cuff tears in adults

Evaluation of clinico-radiological outcome of conservative treatment in patients with partial-thickness rotator cuff tears

Objective

While some patients may require surgical treatment a lot of patients do recover on conservative treatment alone while the optimal treatment being unclear. The purpose of this study was to treat the PT-RCTs conservatively for a period of 6 months and to determine its clinical outcome, radiological outcome on MRI and the baseline clinical factors predictive of that outcome.

Methodology

All patients with a partial tear of supraspinatus and/or infraspinatus on their 1st MRI and aged 18-80 years were eligible and 47 patients (22 males, 25 females) were enrolled. Patients were evaluated using a standardised format including clinical history, imaging, and ASES(American Shoulder and Elbow Surgeons) score. Patients underwent a course of physical therapy for a period of minimum of 6 months which was augmented with the use of analgesics and/or anti-inflammatory drugs, multivitamins and supplements which were patient specific. Patients were followed up at 3 months and 6 months, ASES score was calculated, and a follow-up MRI was done at 6 months to determine if their tear had healed, remained the same, or progressed. A patient that had a better ASES score at 6 months was tagged as "clinically improved". Radiologically, patients were considered treated "successfully" if the tear size was reduced or remained the same while some "failed" that had an increased size of tear.

Result

Non-operatively treated patients demonstrated a mean ASES score of 63.45 ± 16.24 at the end of 6 months. Overall, 35 patients (74.5 %) had the same size, seven patients (14.9 %) demonstrated tear progression and 5 (10.6 %) patients showed a decrease in size of their tear on MRI done at 6 months. In the end, 30 (63.8 %) patients improved clinically and 40 (85.1 %) patients improved radiologically. Statistical analysis also showed that patients with their non-dominant side involved and with an atraumatic onset of their injury were more likely to improve clinically.

Conclusion

Conservative treatment of PT-RCTs may lead to a successful clinical outcome but it may or may not reveal itself radiologically. ASES score is an effective tool to evaluate and manage various conditions of the shoulder and not just the rotator cuff. The baseline factors such as onset (traumatic versus atraumatic) and shoulder involved (dominant versus non-dominant) can predict the outcome of conservative treatment.

Deep learning-based screening tool for rotator cuff tears on shoulder radiography

BACKGROUND

Early diagnosis of rotator cuff tears is essential for appropriate and timely treatment. Although radiography is the most used technique in clinical practice, it is difficult to accurately rule out rotator cuff tears as an initial imaging diagnostic modality. Deep learning-based artificial intelligence has recently been applied in medicine, especially diagnostic imaging. This study aimed to develop a deep learning algorithm as a screening tool for rotator cuff tears based on radiography.

METHODS

We used 2803 shoulder radiographs of the true anteroposterior view to develop the deep learning algorithm. Radiographs were labeled 0 and 1 as intact or low-grade partial-thickness rotator cuff tears and high-grade partial or full-thickness rotator cuff tears, respectively. The diagnosis of rotator cuff tears was determined based on arthroscopic findings. The diagnostic performance of the deep learning algorithm was assessed by calculating the area under the curve (AUC), sensitivity, negative predictive value (NPV), and negative likelihood ratio (LR-) of test datasets with a cutoff value of expected high sensitivity determination based on validation datasets. Furthermore, the diagnostic performance for each rotator cuff tear size was evaluated.

RESULTS

The AUC, sensitivity, NPV, and LR- with expected high sensitivity determination were 0.82, 84/92 (91.3%), 102/110 (92.7%), and 0.16, respectively. The sensitivity, NPV, and LR- for full-thickness rotator cuff tears were 69/73 (94.5%), 102/106 (96.2%), and 0.10, respectively, while the diagnostic performance for partial-thickness rotator cuff tears was low at 15/19 (78.9%), NPV of 102/106 (96.2%) and LR- of 0.39.

CONCLUSIONS

Our algorithm had a high diagnostic performance for full-thickness rotator cuff tears. The deep learning algorithm based on shoulder radiography helps screen rotator cuff tears by setting an appropriate cutoff value.

LEVEL OF EVIDENCE

Level III: Diagnostic Study.

Higher Upper Subscapularis Goutallier Grade and Coracohumeral Distance Narrowing Are Predictive of Subscapularis Tears in Patients Undergoing Arthroscopic Rotator Cuff Repair

PURPOSE

To evaluate the relation between subscapularis (SSC) Goutallier grade or coracohumeral distance (CHD) and SSC tears, as well as the relation between these radiographic variables and long head of the biceps tendon lesions.

METHODS

A retrospective analysis was conducted on prospectively maintained data on patients who underwent arthroscopic rotator cuff repair of SSC tears between 2011 and 2021 with at least 6 months of follow-up. Patients with identified subscapularis tears during arthroscopy were included. A control group was established by randomly selecting patients without SSC tears from the same study period. Goutallier grading and CHD were obtained from preoperative magnetic resonance imaging (MRI) scans. Receiver operating characteristic analysis was conducted to define optimal cutoff values for these diagnostic measures.

RESULTS

The study included 735 patients with SSC tears and 249 patients in the control group. Comparing subscapularis tear and intact groups' Goutallier grades revealed significant differences in infraspinatus, upper and lower SSC, and overall SSC (P < .001). No significant difference was detected in supraspinatus Goutallier grade (P = .364). An SSC tear was observed in 58.3% (n = 265) of patients with Goutallier grade 0 of the upper SSC, 77.1% (n = 195) of patients with grade 1 changes, 98.7% (n = 155) with grade 2 changes, and 100% of grade 3 or 4 changes. Goutallier grade of the upper SSC showed a significant correlation with tear size (rs = 0.533; P < .01). CHD measurements were lower in individuals with SSC tears compared to those without tears (6.6 ± 1.7 vs 9.6 ± 1.8; P < .001). Upper SSC Goutallier grade >1 had an acceptable area under the curve (AUC) of 0.742. CHD of 7.96 mm or less had an excellent predictive AUC of 0.879.

CONCLUSIONS

Higher Goutallier grade and CHD narrowing are potential associations predictive of SSC tears. Routine MRI assessment of muscle of the upper SSC and the CHD can contribute to the diagnostic accuracy of SSC tears and offer valuable information regarding the severity of such tears.

LEVEL OF EVIDENCE

Level III, diagnostic study.

A Machine Learning Model Demonstrates Excellent Performance in Predicting Subscapularis Tears Based on Pre-Operative Imaging Parameters Alone

PURPOSE

To develop a machine learning model capable of identifying subscapularis tears before surgery based on imaging and physical examination findings.

METHODS

Between 2010 and 2020, 202 consecutive shoulders underwent arthroscopic rotator cuff repair by a single surgeon. Patient demographics, physical examination findings (including range of motion, weakness with internal rotation, lift/push-off test, belly press test, and bear hug test), and imaging (including direct and indirect signs of tearing, biceps status, fatty atrophy, cystic changes, and other similar findings) were included for model creation.

RESULTS

Sixty percent of the shoulders had partial or full thickness tears of the subscapularis verified during surgery (83% of these were upper third). Using only preoperative imaging-related parameters, the XGBoost model demonstrated excellent performance at predicting subscapularis tears (c-statistic, 0.84; accuracy, 0.85; F1 score, 0.87). The top 5 features included direct signs related to the presence of tearing as evidenced on magnetic resonance imaging (MRI) (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology.

CONCLUSIONS

In this study, machine learning was successful in predicting subscapularis tears by MRI alone in 85% of patients, and this accuracy did not decrease by isolating the model to the top features. The top five features included direct signs related to the presence of tearing as evidenced on MRI (changes in tendon morphology and signal), as well as the quality of the MRI and biceps pathology. Last, in advanced modeling, the addition of physical examination or patient characteristics did not make a significant difference in the predictive ability of this model.

LEVEL OF EVIDENCE

Level III, diagnostic case-control study.

Pre-operative Assessment of Shoulder Pathologies on MRI by a Radiologist and an Orthopaedic Surgeon

Introduction

Pathologies of the shoulder, i.e. rotator cuff tears and labral injuries are very common. Most patients receive MRI examination prior to surgery. A correct assessment of pathologies is significant for a detailed patient education and planning of surgery.

Materials and methods

Sixty-nine patients were identified, who underwent both, a standardised shoulder MRI and following arthroscopic shoulder surgery in our hospital. For this retrospective comparative study, the MRIs were pseudonymised and evaluated separately by an orthopaedic surgeon and a radiologist. A third rater evaluated images and reports of shoulder surgery, which served as positive control. Results of all raters were then compared. The aim was an analysis of agreement rates of diagnostic accuracy of preoperative MRI by a radiologist and an orthopaedic surgeon.

Results

The overall agreement with positive control of detecting transmural cuff tears was high (84% and 89%) and lower for partial tears (70-80%). Subscapularis tears were assessed with moderate rates of agreement (60 - 70%) compared to intra-operative findings. Labral pathologies were detected mostly correctly. SLAP lesions and pulley lesions of the LHB were identified with only moderate agreement (66.4% and 57.2%) and had a high inter-rater disagreement.

Conclusion

This study demonstrated that tears of the rotator cuff (supraspinatus, infraspinatus) and labral pathologies can be assessed in non-contrast pre-operative shoulder MRI images with a high accuracy. This allows a detailed planning of surgery and aftercare. Pathologies of the subscapularis tendon, SLAP lesions and biceps instabilities are more challenging to detect correctly. There were only small differences between a radiologic and orthopaedic interpretation of the images.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

Diagnostic performance of a 3D double-echo steady-state sequence at 3 T using radial reformats for detecting and grading rotator cuff tears: a pilot diagnostic accuracy study with magnetic resonance imaging and arthroscopic correlation

BACKGROUND

In diagnosing rotator cuff tears (RCTs), magnetic resonance imaging (MRI) is the imaging modality of choice, and its accuracy is improving constantly.

PURPOSE

To evaluate the diagnostic performance of a high-resolution 3D double-echo steady-state (DESS) sequence with radial and paracoronal 3-T MRI regarding the grading of RCTs in correlation with conventional 2D MRI and arthroscopic findings.

MATERIAL AND METHODS

We retrospectively compared arthroscopic findings of RCTs with preoperative MRI, including conventional 2D sequences and radial and paracoronal DESS images in 20 patients. Two observers evaluated supraspinatus (SSP), infraspinatus (ISP), and subscapularis (SSC) tendon tears using a grading system. For statistical analysis, arthroscopy was used as the reference standard.

RESULTS

Inter-observer agreement for detecting and grading SSP, ISP, and SSC tendon tears on radial and paracoronal sliced 3D DESS MRI was excellent (intraclass-correlation [ICC] = 0.92-0.98; all P < 0.001). Regarding the detection of SSP lesions, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 93.8%, 50%, 88.2%, and 66.7% for both radial and paracoronal DESS imaging. A sensitivity of 100%, specificity of 61.1%, PPV of 22.2%, and NPV of 100% were noted for detecting ISP tendon tears using radially reformatted DESS images. Regarding detecting SSC tendon tears using radially reformatted DESS images, sensitivity, specificity, PPV, and NPV were 100%, 81.3%, 50%, and 100%, respectively. The results with standard 2D MRI were similar.

CONCLUSION

The DESS technique with radially reformatted images provided excellent sensitivity and high inter-observer agreement in detecting RCTs. It showed a moderate to high correlation between MRI and arthroscopy for diagnosing SSP and SSC tendon tears.

Magnetic resonance imaging could precisely define the mean value of tendon thickness in partial rotator cuff tears

PURPOSE

Rotator Cuff (RC) lesions are classified in full-thickness and partial-thickness tears (PTRCTs). To our knowledge, no studies investigated the mean size of shoulder tendons in healthy and PTRCT patients using MRI scans. The aim of the study was to provide data to obtain and compare the mean value of tendon sizes in healthy and PTRCTs groups.

METHODS

From 2014 to 2020, 500 were included in the study. They were divided into two groups: Group 1 (100 subjects) was composed of people positive for partial-thickness rotator cuff tears (PTRCTs), while the 400 subjects in Group 2 were negative for PTRCTs.

RESULTS

Overall, of the patients included in the study, 231 were females and 269 were males. The mean age of the patients was 49 ± 12.7 years. The mean thickness of the supraspinatus tendon (SSP) was 5.7 ± 0.6 mm in Group 1, 5.9 ± 0.6 mm in Group 2 (p < 0.001). The mean length of the ISP tendon was 27.4 ± 3.2 mm in Group 1, 28.3 ± 3.8 mm in Group 2 (p = 0.004). The mean width of the SSP tendon was 17 ± 1.6 mm in Group 1, 17.6 ± 2 mm in Group 2 (p = 0.004). The mean width of the infraspinatus tendon (ISP) tendon was 17.7 ± 1.4 mm in Group 1, 18.3 ± 2.1 mm in Group 2 (p = 0.02).

CONCLUSION

The anatomical data present in this paper may serve as a tool for surgeons to properly manage PTRCTs. The findings of the present study aimed to set the first step towards reaching unanimity to establish international cut-off values to perform surgery. Additionally, they could widely increase diagnostic accuracy, improving both conservative and surgical approaches. Lastly, further clinical trials using more accurate diagnostic MRI tools are required to better define the anatomical differences between PTRCT and healthy patients.

LEVEL OF EVIDENCE

Level II, Retrospective Comparative Trial.

Anatomic characteristics of shoulder based on MRI accurately predict incomplete rotator cuff injuries in patients: relevance for predictive, preventive, and personalized healthcare strategies

Background and PPPM-related working hypothesis

In the diagnosis of incomplete rotator cuff injuries (IRCI), magnetic resonance imaging (MRI) and ultrasound examination often have false-positive and false-negative results, while arthroscopy is expensive, invasive, and complex. From the strategy of predictive, preventive, and personalized medicine (PPPM), shoulder anatomical characteristics based on MRI have been demonstrated to accurately predict IRCI and their clinical applicability for personalized prediction of IRCI.

Aims

This study aimed to develop and validate a nomogram based on anatomical features of the shoulder on MRI to identify IRCI for PPPM healthcare strategies.

Methods

The medical information of 257 patients undergoing preoperative MRI examination was retrospectively reviewed and served as the primary cohort. Partial-thickness rotator cuff tears (RCTs) and tendinopathy observed under arthroscopy were considered IRCI. Using logistic regression analyses and least absolute shrinkage and selection operator (LASSO), IRCI was identified among various preoperative factors containing shoulder MRI and clinical features. A nomogram was constructed and subjected to internal and external validations (80 patients).

Results

The following eight independent risk factors for IRCI were identified:AgeThe left injured sidesThe Goutallier classification of supraspinatus in oblique coronal positionThe Goutallier classification of supraspinatus in the axial positionAcromial thicknessAcromiohumeral distanceCoracohumeral distanceAbnormal acromioclavicular joint signalsThe nomogram accurately predicted IRCI in the development (C-index, 0.932 (95% CI, 0.891, 0.973)) and validation (C-index, 0.955 (95% CI, 0.918, 0.992)) cohorts. The calibration curve was consistent between the predicted IRCI probability and the actual IRCI ratio of the nomogram. The decision curve analysis and clinical impact curves demonstrated that the model had high clinical applicability.

Conclusions

Eight independent factors that accurately predicted IRCI were determined using MRI anatomical findings. These personalized factors can prevent unnecessary diagnostic interventions (e.g., arthroscopy) and can assist surgeons in implementing individualized clinical decisions in medical practice, thus addressing the goals of PPPM.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-023-00333-5.

Present situation and development prospects of the diagnosis and treatment of rotator cuff tears

Rotator cuff tears are an important cause of shoulder pain and are caused by degeneration or trauma of the shoulder tendon at the anatomical neck of the humeral head. The understanding and research of rotator cuff tears have a history of hundreds of years, and their etiology, diagnosis, and treatment have a complete system, but some detailed rules of diagnosis and treatment still have room for development. This research paper briefly introduces the diagnosis and treatment of rotator cuff tears. The current situation and its valuable research direction are described.

Development and clinical validation of deep learning for auto-diagnosis of supraspinatus tears

BACKGROUND

Accurately diagnosing supraspinatus tears based on magnetic resonance imaging (MRI) is challenging and time-combusting due to the experience level variability of the musculoskeletal radiologists and orthopedic surgeons. We developed a deep learning-based model for automatically diagnosing supraspinatus tears (STs) using shoulder MRI and validated its feasibility in clinical practice.

MATERIALS AND METHODS

A total of 701 shoulder MRI data (2804 images) were retrospectively collected for model training and internal test. An additional 69 shoulder MRIs (276 images) were collected from patients who underwent shoulder arthroplasty and constituted the surgery test set for clinical validation. Two advanced convolutional neural networks (CNN) based on Xception were trained and optimized to detect STs. The diagnostic performance of the CNN was evaluated according to its sensitivity, specificity, precision, accuracy, and F1 score. Subgroup analyses were performed to verify its robustness, and we also compared the CNN's performance with that of 4 radiologists and 4 orthopedic surgeons on the surgery and internal test sets.

RESULTS

Optimal diagnostic performance was achieved on the 2D model, from which F1-scores of 0.824 and 0.75, and areas under the ROC curves of 0.921 (95% confidence interval, 0.841-1.000) and 0.882 (0.817-0.947) were observed on the surgery and internal test sets. For the subgroup analysis, the 2D CNN model demonstrated a sensitivity of 0.33-1.000 and 0.625-1.000 for different degrees of tears on the surgery and internal test sets, and there was no significant performance difference between 1.5 and 3.0 T data. Compared with eight clinicians, the 2D CNN model exhibited better diagnostic performance than the junior clinicians and was equivalent to senior clinicians.

CONCLUSIONS

The proposed 2D CNN model realized the adequate and efficient automatic diagnoses of STs, which achieved a comparable performance of junior musculoskeletal radiologists and orthopedic surgeons. It might be conducive to assisting poor-experienced radiologists, especially in community scenarios lacking consulting experts.

A Systematic Temporal Assessment of Changes in Tendon Stiffness Following Rotator Cuff Repair

OBJECTIVES

How the material properties of the human supraspinatus tendon change following arthroscopic rotator cuff repair is undetermined. Shear wave elastography ultrasound is a relatively new, noninvasive measure of tissue stiffness. We aimed to evaluate any temporal changes in stiffness and/or thickness of supraspinatus tendons in humans following primary arthroscopic rotator cuff repair.

METHODS

Shear wave elastography was performed at three predetermined regions by a single sonographer at 1-, 6-, 12-, 24-, and 52 weeks postoperatively in 50 consecutive single-row inverted mattress primary arthroscopic rotator cuff repairs. One-way ANOVA with Tukey's correction and Spearman's correlation tests was performed.

RESULTS

Of 50 patients, two retore by 1-week and were excluded. Two patients retore at 6 weeks, two at 12 weeks, and one at 24 weeks. The mean tendon stiffness in 48 patients at the tendon footprint increased by 21% (1.32 m/s) at 6 months (P < .001), with the lateral tendon stiffening before the medial tendon. Tendon thickness decreased by 11% (0.6 mm) at 6 weeks (P = .008), then stabilized to 24 weeks. Tendons that were less elastographically stiff at 1 week were more likely to be thinner at 6-weeks (r = .38, P = .010).

CONCLUSIONS

The data supports the hypothesis that rotator cuff tendons repaired using the single-row inverted-mattress technique take 6 weeks to heal to bone. Unlike in other tendons, there was no hypertrophic healing response. Prior to 6 weeks, the tendon may stretch/thin-out, particularly if its material properties, as assessed by shear wave elastography, are inferior. The material properties of the tendon improved at the tendon insertion site first, then medially out to 12 months post-repair.

Shoulder magnetic resonance imaging findings in manual wheelchair users with spinal cord injury

Objective: To investigate the prevalence of rotator cuff and long head of the biceps pathologies in manual wheelchair (MWC) users with spinal cord injury (SCI).Design: Cross-sectional study.Setting: Outpatient clinic at a tertiary medical center.Participants: Forty-four adult MWC users with SCI (36 men and 8 women) with an average age (SD) of 42 (13) years. SCI levels ranged from C6 to L1; complete and incomplete SCI.Outcome Measures: Participants' demographic and anthropometric information, presence of shoulder pain, Wheelchair User's Pain Index (WUSPI) scores, and magnetic resonance imaging findings of shoulder pathologies including tendinopathy, tendon tears, and muscle atrophy.Results: Fifty-nine percent of the participants reported some shoulder pain. The prevalence of any tendinopathy across the rotator cuff and the long head of biceps tendon was 98%. The prevalence of tendinopathy in the supraspinatus was 86%, infraspinatus was 91%, subscapularis was 75%, and biceps was 57%. The majority of tendinopathies had mild or moderate severity. The prevalence of any tears was 68%. The prevalence of tendon tears in the supraspinatus was 48%, infraspinatus was 36%, subscapularis was 43%, and biceps was 12%. The majority of the tears were partial-thickness tears. Participants without tendon tears were significantly younger (P < 0.001) and had been wheelchair user for a significantly shorter time (P = 0.005) than those with tendon tears.Conclusion: Mild and moderate shoulder tendinopathy and partial-thickness tendon tears were highly prevalent in MWC users with SCI. Additionally, the findings of this study suggest that strategies for monitoring shoulder pathologies in this population should not be overly reliant on patient-reported pain, but perhaps more concerned with years of wheelchair use and age.

Isolated bursal-side infraspinatus tear diagnosed by computed tomography bursography: a case series

Background

Partial-thickness rotator cuff tears are commonly found in the articular-side tendon of the supraspinatus; however, isolated lesions, except those occurring in the supraspinatus tendons, are rare. We report three cases of isolated bursal-side infraspinatus tears that were difficult to detect by magnetic resonance imaging but could be visualized by computed tomography bursography.

Case presentation

Three Asian patients (59–71 years old) with shoulder pain ranging from 1 month to 3 years in duration were each diagnosed with shoulder impingement syndrome. Magnetic resonance imaging studies failed to show a tear of the rotator cuff tendon complex. However, computed tomography bursography showed a longitudinal infraspinatus partial-thickness tear on the bursal side in each case. Arthroscopic decompression of the subacromial space and debridement of the infraspinatus tendon tear successfully alleviated the shoulder pain in two of the three patients; the third patient did not undergo surgery and remained symptomatic at follow-up.

Conclusions

In patients with chronic shoulder pain but normal magnetic resonance imaging findings, computed tomography bursography should be considered, as bursal-side infraspinatus tears may be found in these patients. Furthermore, our findings provide a basis for larger studies to further establish the accuracy of computed tomography bursography for these lesions.

Recurrence in traumatic anterior shoulder dislocations increases the prevalence of Hill-Sachs and Bankart lesions: a systematic review and meta-analysis

PURPOSE

The extent of shoulder instability and the indication for surgery may be determined by the prevalence or size of associated lesions. However, a varying prevalence is reported and the actual values are therefore unclear. In addition, it is unclear whether these lesions are present after the first dislocation and whether or not these lesions increase in size after recurrence. The aim of this systematic review was (1) to determine the prevalence of lesions associated with traumatic anterior shoulder dislocations, (2) to determine if the prevalence is higher following recurrent dislocations compared to first-time dislocations and (3) to determine if the prevalence is higher following complete dislocations compared to subluxations.

METHODS

PubMed, EMBASE, Cochrane and Web of Science were searched. Studies examining shoulders after traumatic anterior dislocations during arthroscopy or with MRI/MRA or CT published after 1999 were included. A total of 22 studies (1920 shoulders) were included.

RESULTS

The proportion of Hill-Sachs and Bankart lesions was higher in recurrent dislocations (85%; 66%) compared to first-time dislocations (71%; 59%) and this was statistically significant (P < 0.01; P = 0.05). No significant difference between recurrent and first-time dislocations was observed for SLAP lesions, rotator-cuff tears, bony Bankart lesions, HAGL lesions and ALPSA lesions. The proportion of Hill-Sachs lesions was significantly higher in complete dislocations (82%) compared to subluxations (54%; P < 0.01).

CONCLUSION

Higher proportions of Hill-Sachs and Bankart were observed in recurrent dislocations compared to first-time dislocations. No difference was observed for bony Bankart, HAGL, SLAP, rotator-cuff tear and ALPSA. Especially when a Hill-Sachs or Bankart is present after first-time dislocation, early surgical stabilization may need to be considered as other lesions may not be expected after recurrence and to limit lesion growth. However, results should be interpreted with caution due to substantial heterogeneity and large variance.

LEVEL OF EVIDENCE

IV.

Diagnosis and Management of Partial Thickness Rotator Cuff Tears: A Comprehensive Review

Partial thickness rotator cuff tears (PRCTs) are a challenging disease entity. Optimal management of PRCTs continues to be controversial. Although advances in magnetic resonance imaging and ultrasonography have aided in early diagnosis, arthroscopic evaluation remains the benchmark for diagnosis. Conservative treatment is often the first line of management for most patients; however, evidence suggests that surgical intervention may limit tear progression and the long-term sequelae. Surgical decision making is driven by factors such as age, arm dominance, etiology, activity level, tear thickness, and tear location. Many surgical options have been described in the literature to treat PRCTs including arthroscopic débridement, transosseous, in situ repair techniques, and tear completion and repair. Biologic supplements have also become an attractive alternative to aid in healing; however, the long-term efficacy of these modalities is largely unknown. This article will provide a detailed review of the etiology and natural history of PRCTs, as well as diagnosis, and current management to guide clinical decision-making and formulate an algorithm for management of PRCTs for the orthopaedic surgeon.

Correlation of magnetic resonance and arthroscopy in the diagnosis of shoulder injury

BACKGROUND

Advances in shoulder magnetic resonance imaging (MRI) and arthrography (MRA) have revolutionised musculoskeletal diagnosis and surgical planning. Despite this, the overall accuracy of MRI, with or without intra-articular contrast, can be variable.

METHODS

In this prospective non-randomised analysis, 200 participants (74.5% males) with suspected shoulder injuries underwent MRI (41.0%) or MRA followed by arthroscopy. A study specific proforma was developed to ensure consistency of reporting by radiologists and surgeons. The reports were compared to assess the predictive power of MRI/MRA. Specific assessment of rotator cuff tendon appearance, long head of biceps (LHB) tendon appearance, position and anchor, subacromial space, glenoid labrum and humeral cartilage grade were included.

RESULTS

Shoulder MRA demonstrated a higher agreement with arthroscopy than MRI for supraspinatus, infraspinatus and subscapularis tendon appearance (κ = 0.77 vs. κ = 0.61, κ = 0.55 vs. κ = 0.53 and κ = 0.58 vs. κ = 0.46 respectively). There were also superior agreement rates with MRA compared to MRI for LHB tendon appearance (κ = 0.70 vs. κ =0.54) and position (κ = 0.89 vs. κ = 0.72). As an overall assessor of shoulder pathology we found significantly higher total agreement scores when MRA was used (p = 0.002).

DISCUSSION

Whilst magnetic resonance imaging with arthrography is an extremely useful tool to assess underlying pathological shoulder states it does not confer 100% accuracy. In cases whereby this modality is inconclusive, an examination under anaesthesia and diagnostic arthroscopic assessment for the detection of intra-articular shoulder pathology may be considered.

Rotator Cuff Injuries in Tennis Players

PURPOSE OF REVIEW

This review presents epidemiology, etiology, management, and surgical outcomes of rotator cuff injuries in tennis players.

RECENT FINDINGS

Rotator cuff injuries in tennis players are usually progressive overuse injuries ranging from partial-thickness articular- or bursal-sided tears to full-thickness tears. Most injuries are partial-thickness articular-sided tears, while full-thickness tears tend to occur in older-aged players. The serve is the most energy-demanding motion in the sport, and it accounts for 45 to 60% of all strokes performed in a tennis match, putting the shoulder at increased risk of overuse injury and rotator cuff tears. Studies have shown deficits in shoulder range of motion and scapular dyskinesia to occur even acutely after a tennis match. First-line treatment for rotator cuff injuries in any overhead athlete consists of conservative non-operative management with appropriate rest, anti-inflammatory drugs, followed by a specific rehabilitation program. Operative treatment is usually reserved for older-aged players and to those who fail to return to play after conservative measures. Surgical options include rotator cuff debridement with or without tendon repair, biceps tenodesis, and labral procedures. Unlike rotator cuff repairs in the general population, repairs in the elite tennis athlete have less than ideal rates of return to sport to the same level of performance. Rotator cuff injuries are a common cause of pain and dysfunction in tennis players and other overhead athletes. The etiology of rotator cuff tears in tennis players is multifactorial and usually results from microtrauma and internal impingement in the younger athlete leading to partial tearing and degenerative full-thickness tears in older players. Surgical treatment is pursued in athletes who are still symptomatic despite an extensive course of non-operative treatment as outcomes with regard to returning to sport to the same pre-injury level are modest at best. Debridement alone is usually preferred over rotator cuff repairs for partial tears in younger players due to potential over-constraining of the shoulder joint and decreased rates of return to sport after rotator cuff repairs.

Diagnostic accuracy of preoperative magnetic resonance imaging for detecting subscapularis tendon tears: a diagnostic test study

BACKGROUND

The accuracy of magnetic resonance imaging (MRI) for making the diagnosis of subscapularis tears presents wide variation in the literature and there are few prospective studies.

OBJECTIVE

To compare the findings from MRI and arthroscopy for diagnosing subscapularis tears.

DESIGN AND SETTING

Diagnostic test study performed in a tertiary care hospital.

METHODS

We included patients who underwent arthroscopic rotator cuff repair and who had firstly undergone high magnetic field MRI without contrast. The images were independently evaluated by a shoulder surgeon and two musculoskeletal radiologists. Sensitivity, specificity, positive and negative predictive values, accuracy and inter and intra-observer agreement were calculated.

RESULTS

MRIs on 200 shoulders were evaluated. The incidence of subscapularis tears was 69.5% (41.5% partial and 28.0% full-thickness). The inter and intra-observer agreement was moderate for detection of subscapularis tears. The shoulder surgeon presented sensitivity of 51.1% to 59.0% and specificity of 91.7% to 94.4%. The radiologists showed sensitivity of 83.5% to 87.1% and specificity of 41% to 45.9%. Accuracy ranged from 60.5% to 73.0%.

CONCLUSION

The 1.5-T MRIs without contrast showed mean sensitivity of 70.2% and mean specificity of 61.9% for detection of subscapularis tears. Sensitivity was higher for the musculoskeletal radiologists, while specificity was higher for the shoulder surgeon. The mean accuracy was 67.6%, i.e. lower than that of rotator cuff tears overall.

7-T clinical MRI of the shoulder in patients with suspected lesions of the rotator cuff

Background

To evaluate feasibility and diagnostic performance of clinical 7-T magnetic resonance imaging (MRI) of the shoulder.

Methods

Eight patients with suspected lesions of the rotator cuff underwent 7-T MRI before arthroscopy. Image quality was scored for artifacts, B₁⁺ inhomogeneities, and assessability of anatomical structures. A structured radiological report was compared to arthroscopy. In four patients, a visual comparison with pre-existing 1.5-T examinations was performed.

Results

Regarding image quality, the majority of the sequences reached values above the middle of each scoring scale. Fat-saturated proton density sequences showed least artifacts and best structure assessability. The most homogenous B₁⁺ field was reached with gradient-echo sequences. Arthroscopy did not confirm tendinopathy/partial tear of supraspinatus in 5/8 patients, of subscapularis in 5/6, and of infraspinatus in one patient; only a partial lesion of the subscapularis tendon was missed. Pathologic findings of long bicipital tendon, acromioclavicular joint, glenohumeral cartilage, labrum, and subacromial subdeltoideal bursa were mainly confirmed; exceptions were one lesion of the long bicipital tendon, one subacromial bursitis, and one superior glenoid labrum anterior-to-posterior lesion, missed on 7-T MRI. Evaluating all structures together, sensitivity was 86%, and specificity 74%. A better contrast and higher image resolution was noted in comparison to previous 1.5-T examinations.

Conclusions

7-T MRI of the shoulder with diagnostic image quality is feasible. Overrating of tendon signal alterations was the main limitation. Although the diagnostic performance did not reach the current results of 3-T MRI, our study marks the way to implement clinical 7-T MRI of the shoulder.

Diagnostic accuracy of MRI for detection of tears and instability of proximal long head of biceps tendon: an evaluation of 100 shoulders compared with arthroscopy

OBJECTIVE

To evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) for detection of instability and tears of the proximal long head of biceps tendon (LHBT). To assess intraobserver and interobserver agreement.

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data of 100 consecutive shoulders who underwent non-contrast 1.5-T MRI prior to arthroscopic surgery due to rotator cuff injury. Images were independently analyzed by two musculoskeletal radiologists. LHBT was evaluated for presence of tearing (intact, longitudinal split, partial-thickness, or full-thickness) and position (normal, subluxated, and dislocated). Anterosuperior rotator cuff tears were also assessed. The reference standard was arthroscopic surgery. The ramp test was performed in order to evaluate LHBT stability. Diagnostic performance measures were determined and Kappa coefficients assessed agreement.

RESULTS

Concerning the detection of overall tears, sensitivity ranged from 71 to 73% and specificity was 73%. The specificity for full-thickness tears ranged from 75 to 96%. Overall displacement showed sensitivity ranging from 51 to 58% and specificity ranging from 70 to 86%. The specificity of overall displacement combined with anterosuperior rotator cuff tears ranged from 73 to 91%. Interobserver Kappa values were between 0.59 and 0.69. Intraobserver Kappa values were between 0.74 and 0.82.

CONCLUSIONS

MRI has moderate accuracy and good agreement for detection of LHBT tears and instability. There is a tendency for increased specificity for full-thickness tears and for instability in the coexistence of anterosuperior rotator cuff tears.

Ultrasound versus magnetic resonance imaging in the evaluation of shoulder joint pathologies in a cohort of rheumatoid arthritis patients

BACKGROUND

Rheumatoid arthritis (RA) is a systemic autoimmune disease that has a great impact on different joints, may result in their destruction and loss of function. Although the shoulder is affected in a large portion of patients with RA, it does not receive much attention during the follow up of RA. The precise diagnosis of shoulder pain in RA is a clinical challenge and benefits from a reliable imaging modality to detect its exact origin.

AIM

To determine the diagnostic accuracy of ultrasound (US) in detecting shoulder joint pathologies in RA, considering magnetic resonance imaging (MRI) as the gold standard.

MATERIALS AND METHODS

This cross-sectional, observational study was carried out on 30 RA patients complaining of unilateral or bilateral shoulder pain. Patients were subjected to history taking, clinical shoulder examination, plain X-ray, US examination following a standardized protocol, and MRI. The results were correlated with each other.

RESULTS

In comparison with the MRI findings, US showed high accuracy in terms of sensitivity (Sn) and specificity (Sp) in supraspinatus tendinopathy (Sn 96.6%; Sp 93.3%), biceps tenosynovitis (Sn 87.5%; Sp 97.6%), subacromial-subdeltoid bursitis (Sn 72.7%; Sp 95.7%), humeral erosions (Sn 90.5%; Sp 97.3%), and acromioclavicular osteoarthritis (Sn 85.7%; Sp 95.7%). In terms of reliability, the agreement between US and MRI was almost perfect (κ = .9, P < .001).

CONCLUSION

US may have a role as the initial imaging modality in RA patients with shoulder pain, as it is highly sensitive and specific in detecting different pathological abnormalities of the shoulder.

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.

The accuracy of plain radiographs in diagnosing degenerate rotator cuff disease

BACKGROUND

A number of radiographic signs have been previously demonstrated to be associated with degenerative rotator cuff tears. An ability to predict the presence of a tear by radiography would permit the early commencement of appropriate treatment and the avoidance of unnecessary invasive investigations. The aim of the present study was to determine the accuracy of using radiographic signs to predict the presence of a cuff tear on arthroscopy.

METHODS

Fifty consecutive patients who had undergone shoulder arthroscopy and had pre-operative plain radiographs were included. Pre-operative radiographs were reviewed by a consultant shoulder surgeon, a consultant radiologist and a senior clinical fellow for the following signs: acromial spur; subjective reduction of subacromial space; sourcil sign; acromial acetabularization; os acromiale; greater tuberosity cortical irregularity; greater tuberosity sclerosis; humeral head rounding; cyst; and reduction in acromiohumeral head distance.

RESULTS

The presence of tuberosity sclerosis (p < 0.0001), tuberosity irregularities (p < 0.0001), tuberosity cyst (p = 0.004) and sourcil sign (p = 0.019) was associated with the presence of a rotator cuff tear. The combined sensitivity of prediction of tear by the observers following radiographic review was 91.7%, with a combined negative predictive value of 80%.

CONCLUSIONS

The assessment of radiographs by senior clinicians is a useful tool for confirming the absence of a rotator cuff tear.

Accuracy of magnetic resonance imaging (MRI) for subscapularis tear: a systematic review and meta-analysis of diagnostic studies

INTRODUCTION

The accuracy of MRI for subscapularis tear is lower than that of overall rotator cuff tears. Until now, no systematic reviews and meta-analysis have been conducted to compile these data. The purpose of this study was to determine, through a systematic review and meta-analysis, the diagnostic accuracy of MRI in the detection of subscapularis tendon tears.

MATERIALS AND METHODS

A systematic review of PubMed, EMBASE, and MEDLINE databases up to April 2017 was performed. All studies assessing the sensitivity and specificity of the MRI (index test) compared to arthroscopic surgical findings (reference test) for subscapularis tendon tear were included. A meta-analysis was performed to calculate pooled sensitivity, specificity, sROC curve, and diagnostic odds ratio values.

RESULTS

A total of 497 citations were identified. After applying the eligibility criteria, 14 articles were included, including 1858 shoulders with 613 subscapularis tears. For overall subscapularis tears, sensitivity was 0.68 (95% CI 0.64-0.72) and specificity was 0.90 (95% CI 0.89-0.92). Sensitivity was 0.93 (95% CI 0.83-0.98) for full-thickness tears and 0.74 (95% CI 0.66-0.82) for partial tears. Specificity was 0.97 (95% CI 0.94-0.98) for full-thickness tears and 0.88 (95% CI 0.85-0.91) for partial tears. Analyzing only studies with field of strength ≥ 1.5 T, sensitivity was 0.80 (95% CI 0.76-0.84) and specificity 0.84 (95% CI 0.81-0.87).

CONCLUSION

MRI is an accurate method for diagnosing subscapularis tendon tears; however, its accuracy is lower than that of overall rotator cuff tears, due to its lower sensitivity.

LEVEL OF EVIDENCE

III, systematic review of Level II and III studies.

A novel diagnostic method to predict subscapularis tendon tear with sagittal oblique view magnetic resonance imaging

PURPOSE

To find novel measurement guidelines correlating with known tear size on two sagittal oblique views (en-face view and Y-view).

METHODS

From a series of arthroscopic rotator cuff repair cases between 2012 and 2015, 50 patients were randomly selected from each of six subscapularis tear classifications. Due to rarity of type IV lesions, 272 shoulders were included. En-face view and Y-view in sagittal plane MRI were selected. Image evaluation was retrospectively performed by two researchers independently. In en-face view, anatomical line connecting the coracoid tip to the glenoid base designated as the base-to-tip line was used for thickness measurement and classification. Grading according to base-to-tip line, overlapped segment of base-to-tip line, thickness of subscapularis, and fluid accumulation were measured. In Y-view, a tangent line was drawn through the scapular spine and the coracoid. Parallel lines were then made. Grading according to tangent line, vertical length, cephalic width, caudal width, and fluid accumulation was measured.

RESULTS

In en-face view, grading according to base-to-tip line and overlapped segment of base-to-tip line showed differences in subscapularis tendon tear types IIB, III, and IV compared to the normal group. Thickness of subscapularis showed differences in types III and IV. No significant difference was observed in fluid accumulation. In Y-view, grading according to tangent line, vertical length, cephalic width, and fluid accumulation showed significant differences in types III and IV. Caudal width in Y-view was significantly different only in type IV.

CONCLUSION

Several measurement parameters in two additional views in sagittal-oblique MRI (en-face view and Y-view) showed different degrees of subscapularis tendon tears. Grading of base-to-tip line is easy to use and helps diagnose partial subscapularis tear.

LEVEL OF EVIDENCE

III.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Interstitial tears of the rotator cuff: difficulty in preoperative diagnosis

BACKGROUND

Few studies have investigated the characteristic findings of preoperative magnetic resonance imaging (MRI) and the clinical and radiologic outcomes of interstitial tear of the rotator cuff treated with arthroscopic repair after tear completion.

METHODS

Forty-one patients (14 men and 27 women; mean age, 56.5 years) with arthroscopically confirmed interstitial tears underwent single-row repair after tear completion. The minimum follow-up period was 2 years.

RESULTS

Twenty-eight patients (68.3%) were properly evaluated with MRI before surgery. Seven cases (17.1%) were misdiagnosed as bursal-sided tears and 5 cases (12.2%) were misdiagnosed as articular-sided tears on the basis of presurgical MRI findings. Arthroscopy revealed fibrillation and dimpling of the tendon surface in all cases and congestion within the defect in 36 cases (87.8%). At the final follow-up, the visual analog scale score for pain during motion decreased to 0.8 from a preoperative mean of 6.1 (P <.001). Moreover, at the final follow-up, the mean University of California-Los Angeles score and Constant score improved from 15.7 and 51.8 to 32.1 and 83.8, respectively (P <.001 for all). At 9 months after surgery, MRI revealed no cases of retear.

CONCLUSION

Interstitial tears are difficult to diagnose before surgery because MRI findings may lead to the misdiagnosis of interstitial tears as articular- or bursal-sided tears. If MRI-based diagnosis is indicative of articular- or bursal-sided tears but arthroscopy reveals fibrillation and dimpling of the tendon surface, interstitial tears should be suspected. The defective sites in interstitial tears are usually accompanied by congestion.

Structural Evolution of Nonoperatively Treated High-Grade Partial-Thickness Tears of the Supraspinatus Tendon

BACKGROUND

High-grade partial-thickness rotator cuff tears (hPTRCTs) are frequently encountered in the shoulder. However, little information is available on the prevalence or timing of tear progression. Purpose/Hypothesis: The purpose was to prospectively evaluate the structural progression of hPTRCTs with a minimum follow-up of 1 year using magnetic resonance imaging (MRI). The hypothesis was that a substantial portion of hPTRCT patients would experience tear progression or evolution to a full-thickness rotator cuff tear.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between May 2010 and December 2015, 362 patients were diagnosed with hPTRCT (tear involvement >50% of the mediolateral length of the footprint) of the supraspinatus and were treated nonoperatively. Among these patients, 81 underwent follow-up MRI at least 1 year after initial presentation, and these patients were included in the final analysis. Initial and follow-up MRIs were used to determine whether tears had improved, had not changed, or had progressed. A change in tear involvement of >20% was defined as a significant change. Patients were categorized as follows: (1) a decrease in tear involvement of >20% (improved), (2) an increase or decrease of ≤20% (no change), or (3) an increase in tear involvement of >20% (progressed). Demographic data and morphologic data were analyzed to identify variables related to tear progression. Among them, severity of tendinosis was graded using MRIs: grade 1 (mild tendinosis), mild focal increase in tendon signal; grade 2 (moderate tendinosis), moderate focal increase in tendon signal; and grade 3 (marked tendinosis), marked generalized increase in tendon signal.

RESULTS

At initial diagnosis, 23 were articular-side (28%) and 58 were bursal-side (72%) hPTRCTs. The study cohort was composed of 51 women and 30 men, and the mean patient age was 62.3 years (range, 41-77 years). Follow-up MRI was performed at a mean 19.9 ± 10.9 months (range, 12-52 months). A significant change in tear involvement was observed at follow-up. In 13 patients (16%, 2 articular-side and 11 bursal-side tears), tears were classified as progressed (the progressed group); in 48 patients (59%), tears exhibited no change (the unchanged group); and in 20 patients (25%, 9 articular-side and 11 bursal-side tears), tears were improved (the improved group). Univariate analysis showed initial tendinosis grade was significantly different in the 3 groups (grade 1, 2, and 3: 5, 4, and 4 in progressed; 36, 11, and 1 in unchanged; 10, 8, and 2 in improved group, respectively, P = .007).

CONCLUSION

Although progression of hPTRCT in the long term is uncertain, after 1-year follow-up with MRI, tears progressed in 16% of the tears in this study. Furthermore, some tears were healed or reduced in size, which indicates that decisions to undertake surgical repair at time of presentation may be excessive.

Transtendon repair in partial articular supraspinatus tendon tear

INTRODUCTION

Partial thickness rotator cuff tears (PTRCTs) are common, with an incidence between 17% and 37%, and a high prevalence in throwing athletes. Different surgical procedures are suggested when partial tears involve the articular portion of the rotator cuff, including arthroscopic debridement of the tear, debridement with acromioplasty, tear completion and repair, and lately transtendon repair. This systematic review describes the transtendon repair and examines indications, contraindications, complications and clinical outcome.

SOURCE OF DATA

We identified clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English and Italian concerning the clinical outcomes following treatment of partial articular supraspinatus tendon tear using transtendon surgical repair.

AREAS OF AGREEMENT

Eighteen studies fulfilled our inclusion criteria. All were published between 2005 and 2016, three were retrospective, and 15 prospective. The total number of patients was 507 with a mean age of 50.8 years.

AREAS OF CONTROVERSY

Tear completion and repair and transtendon repair alone produce similar results.

GROWING POINTS

Transtendon surgical repair allows to obtain good-excellent results in the treatment of partial articular supraspinatus tendon tears.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to produce clear guidelines in the treatment of partial articular supraspinatus tendon tears.

LEVEL OF EVIDENCE

IV.

Fosbury flop tear of the rotator cuff: diagnostic assessment with magnetic resonance arthrography

OBJECTIVES

The aim was to assess the diagnostic performance of magnetic resonance arthrography (MRA) of the shoulder for the detection of "Fosbury flop" tears.

METHODS

All patients undergoing arthroscopic rotator cuff repair were considered as potentially eligible for inclusion in this prospective case series. Preoperative MRAs were consecutively performed and compared with intraoperative findings being the gold standard control. Two experienced musculoskeletal radiologists, blinded to the arthroscopic findings, independently analysed all MRAs for the presence of typical signs of Fosbury flop tears.

RESULTS

423 patients were included. Among this group, 11 presented a Fosbury flop tear with a prevalence of 2.6%. Interobserver agreement was considered as excellent for thickened tendon, tendon stump, fluid accumulation, abnormal fibres orientationand adherences between tendon and bursa. The most sensitive and specific criterion was the tendon thickness[90.9% CI(62.3-98.4) and97.1% CI(95.0-98.3), respectively].  Conclusions: Fosbury flop tear is an uncommon condition that should be recognized to allow optimal anatomic repair. MRA is a valuable tool in making the diagnosing of this lesser recognized type of rotator cuff tear. An abnormally thickened supraspinatus tendon tear should especially raise suspicion for a Fosbury flop tear of the posterosuperior rotator cuff. Advances in knowledge: MRA is a valuable tool in making the diagnosing of Fosbury flop tears. An abnormally thickened supraspinatus tendon tear should especially raise suspicion for such lesion.

Accuracy of sagittal oblique view in preoperative indirect magnetic resonance arthrography for diagnosis of tears involving the upper third of the subscapularis tendon

BACKGROUND

The purpose of this study was to investigate the accuracy of sagittal oblique view (SOV) magnetic resonance imaging grading for tears involving the upper third of the subscapularis tendons in correlation with arthroscopic findings. We also propose a schematic classification in the SOV for upper-third subscapularis tears.

METHODS

The study analyzed 364 patients with an average age of 56.0 years. All patients underwent indirect magnetic resonance arthrography (MRA) before surgery. A slightly different magnetic resonance grading was introduced with SOV by musculoskeletal radiologists (Y.C.Y. and J.Y.Y.) and an orthopedic shoulder surgeon (H.Y.R.) who had no information about the clinical data. Subscapularis tendon tear classifications were all prospectively analyzed. Magnetic resonance grading was compared with the arthroscopic findings.

RESULTS

The sensitivity, specificity, and accuracy of subscapularis tendon tear detection were 0.72, 0.77, and 0.75, respectively, for the radiologists. For the orthopedic surgeon, the corresponding values were 0.73, 0.83, and 0.79, respectively. The κ coefficients for interobserver agreement comparing magnetic resonance grade of the musculoskeletal radiologists with the arthroscopic grading showed fair values (κ value, 0.301). Interobserver agreement between the magnetic resonance grade of the orthopedic surgeon and arthroscopic grades was fair (κ value, 0.377). Interobserver agreement between the musculoskeletal radiologists and the orthopedic surgeon was moderate (κ value, 0.591).

CONCLUSIONS

The accuracy of SOV indirect MRA for detecting tears was 0.75 to 0.79. Although the correlation between magnetic resonance and arthroscopic grading was only fair, for most of the magnetic resonancegrading on SOV, the first facet view showed similar results compared with arthroscopy. The accuracy of determining whether subscapularis repair is indicated was 0.82 to 0.83 with SOV indirect MRA.

Accuracy of preoperative MRI in the diagnosis of subscapularis tears

INTRODUCTION

The subscapularis has received little attention in the orthopedic literature, although such lesions are evident in up to 40 % of arthroscopies. An accurate diagnosis is important in clinical practice, as it affects both patient prognosis and surgical planning. The aim of this study was to evaluate the accuracy of preoperative MRI for the identification of subscapularis tears. Our secondary aim involved the identification of factors that may be predictive for the presence of subscapularis tears.

MATERIALS AND METHODS

This retrospective case series included patients undergoing shoulder arthroscopy due to rotator cuff injury. MRI was performed using a 1.5 T unit, and the results were assessed by a musculoskeletal radiologist. The findings were compared to those of arthroscopic inspection.

RESULTS

A total of 93 shoulders were analyzed. The overall accuracy was 82 %, with values of 79 % for partial tears and 89 % for full-thickness tears. Tears requiring repair demonstrated an accuracy of 88 %. Infraspinatus tears, fatty degeneration of the subscapularis, biceps instability and age were identified as predictive factors for the presence of injury.

CONCLUSIONS

MRI of the shoulder demonstrated an accuracy of 82 % for the diagnosis of subscapularis tears. The accuracy values for partial and full-thickness tears were 79 and 89 %, respectively.

LEVEL DE EVIDENCE

III, development of diagnostic criteria with universally applied reference-nonconsecutive patients.

Quantitative diffusion-weighted magnetic resonance imaging for the diagnosis of partial-thickness rotator cuff tears

BACKGROUND

This study investigated diffusion-weighted (DWI) magnetic resonance imaging (MRI) as an alternative to fat-suppressed T2-weighted imaging (FS-T2WI) for assessment of partial-thickness rotator cuff tears (RCTs).

METHODS

Patients with arthroscopy proven partial-thickness RCTs who also received MRI (FS-T2WI and DWI) before surgery were prospectively included. Receiver operating characteristic curves were used to compare DWI vs. FS-T2WI using lesion-to-muscle signal intensity ratios. A cutoff point for predicting partial-thickness tears was determined using the Youden index.

RESULTS

Included were 146 patients, with a mean age of 48.3 years (range, 19-86 years), of whom 43 had full-thickness RCTs, 67 had partial-thickness RCTs, and 36 had no tears. Areas under receiver operating characteristic curves for diagnosing partial-thickness tears were significantly higher for DWI (0.910) than for FS-T2WI (0.822, P = .016). Lesion-to-muscle signal intensity ratio cutoff values were 1.06 for DWI vs. 1.65 for FS-T2WI, respectively. The sensitivity and accuracy of DWI (89.1% [98 of 110] and 87.7% [128 of 146], respectively) for diagnosing partial-thickness and full-thickness tears were higher than for FS-T2WI (65.5% [72 of 110] and 72.6% [106 of 146], respectively). FS-T2WI, however, had higher specificity (94.4% [34 of 36]) than DWI (83.3% [30 of 36]).

CONCLUSIONS

DWI is more accurate and sensitive than FS-T2WI for diagnosing partial-thickness RCTs.

RETRACTED: Abduction external rotation position in magnetic resonance arthrography for the diagnosis of rotator cuff tears

OBJECTIVE

This article aims at evaluating the effectiveness of abduction and external rotation (ABER) position used in magnetic resonance (MR) arthrography for diagnosing rotator cuff tears.

METHODS

A retrospective analysis was performed using 183 MR arthrography images of shoulder joint. Each patient was either examined in a neutral position or ABER position. Then the imaging results were compared with those diagnostic results obtained from shoulder arthroscopy. Also the specificity, sensitivity, negative predictive value, positive predictive value, and accuracy of MR arthrography in the two positions described above were evaluated.

RESULTS

A total of 64 patients were diagnosed with rotator cuff tears using arthroscopy and the diagnostic results include 16 complete rotator cuff tears and 48 partial tears; 47 supraspinatus tendon tears and 17 posterosuperior cuff tears; 22 delamination tears and 26 tears complicated with anteroinferior labrum-ligament complex injuries. The differences in specificity, sensitivity, negative predictive value, positive predictive value and accuracy between neutral position and ABER position using MR arthrography were not statistically significant (all P > 0.05). For diagnosing posterosuperior cuff tears, the sensitivity of ABER position was significantly higher than that of the neutral position (94.12% vs. 64.71%, P = 0.034). For diagnosing delamination tears, the sensitivity and negative predictive value of ABER position were significantly higher than those of the neutral position (P = 0.009 and P = 0.036 respectively). For diagnosing rotator cuff tears complicated with anteroinferior labrum-ligament complex injuries, the sensitivity of ABER position was statistically higher than that of the neutral position (96.15% vs. 73.08%, P = 0.021).

CONCLUSION

This study suggests that MR arthrography in ABER position is a superior tool for diagnosing certain types of rotator cuff tears. Apart from that, MR arthrography in ABER position improved the detection rate of posterosuperior cuff tears, delamination tears and rotator cuff tears complicated with anteroinferior labrum-ligament complex injuries.

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

PURPOSE

The purpose of the present study was to determine the value of shoulder magnetic resonance imaging (MRI) obtained in the community setting interpreted by musculoskeletal radiologists in patients with shoulder pain initiated by a single non-dislocating shoulder trauma.

METHODS

In 56 of 61 consecutive patients who underwent shoulder arthroscopy due to pain after a single non-dislocating shoulder trauma, the data sets of non-contrast MRI were complete. These were retrospectively interpreted by three radiologists specialized on musculoskeletal MRI who were blinded for patients' history and who did not have access to the reports of arthroscopy. Standard evaluation forms were used to assess the MRIs for superior labrum anterior and posterior (SLAP) lesions, anterior or posterior labrum lesions, lesions of the long head of biceps tendon (LHB) and for partial tears of the supraspinatus tendon and the upper quarter of the subscapularis tendon. Quality of the MRI was assessed by each radiologist on a four-point scale.

RESULTS

The pooled sensitivity for the three radiologists for the detection of SLAP lesions was 45.0 %, for anterior or posterior labrum tears 77.8 and 66.7 %, for lesions of the LHB 63.2 % and for partial tears of the supraspinatus or subscapularis tendon tears 84.8 and 33.3 %. Corresponding inter-rater reliabilities were poor (SLAP lesions) to substantial (anterior labrum tears). Quality of MRI only influenced the accuracy for the detection of posterior labrum tears.

CONCLUSION

A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. Accuracy is dependent on the observer and not on the assessed quality.

LEVEL OF EVIDENCE

Case series, Level IV.

Serial structural MRI evaluation of arthroscopy rotator cuff repair: does Sugaya's classification correlate with the postoperative clinical outcomes?

INTRODUCTION

Sugaya's classification is the most commonly used for postoperative evaluation of rotator cuff repairs. However, the correlation between this classification and clinical outcomes after supraspinatus tendon repair were not performed with serial MRI examinations in standardized time intervals.

MATERIALS AND METHODS

This prospective case series involved 54 patients undergoing repair of the supraspinatus tendon tear. Magnetic resonance imaging (MRI, 1.5 T) was used to determine the Sugaya's classifications at 3, 6, and 12 months, and these data were correlated with the visual analog scale for pain (VAS), Constant and University of California at Los Angeles (UCLA) assessments.

RESULTS

Patients with types I, II, and ≥III of Sugaya's classification experienced pain of 1.27 ± 1.95, 1.00 ± 1.40, and 3.43 ± 3.36, respectively (p = 0.010), according to the VAS. The Constant and UCLA scales did not differ significantly. Type II predominated, though their percentage decreased over time (from 77.8 to 66.7 %), whereas type I became more frequent (from 1.9 to 20.4 %).

CONCLUSIONS

The pain was more intense in patients classified as types III, IV, or V of Sugaya's classification. The postoperative appearance of the supraspinatus tendon was not correlated with the Constant and UCLA scales. The occurrence of type II, the most prevalent, decreased over time, whereas the occurrence of type I increased; these differences were not significant. Level de evidence: prospective cohort evaluation-level III.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Diagnosis of rotator cuff tears using 3-Tesla MRI versus 3-Tesla MRA: a systematic review and meta-analysis

OBJECTIVE

To compare the diagnostic accuracy of magnetic resonance imaging (MRI), 2-dimensional magnetic resonance arthrogram (MRA) and 3-dimensional isotropic MRA in the diagnosis of rotator cuff tears when performed exclusively at 3-T.

MATERIALS AND METHODS

A systematic review was undertaken of the Cochrane, MEDLINE and PubMed databases in accordance with the PRISMA guidelines. Studies comparing 3-T MRI or 3-T MRA (index tests) to arthroscopic surgical findings (reference test) were included. Methodological appraisal was performed using QUADAS 2. Pooled sensitivity and specificity were calculated and summary receiver-operating curves generated. Kappa coefficients quantified inter-observer reliability.

RESULTS

Fourteen studies comprising 1332 patients were identified for inclusion. Twelve studies were retrospective and there were concerns regarding index test bias and applicability in nine and six studies respectively. Reference test bias was a concern in all studies. Both 3-T MRI and 3-T MRA showed similar excellent diagnostic accuracy for full-thickness supraspinatus tears. Concerning partial-thickness supraspinatus tears, 3-T 2D MRA was significantly more sensitive (86.6 vs. 80.5 %, p = 0.014) but significantly less specific (95.2 vs. 100 %, p < 0.001). There was a trend towards greater accuracy in the diagnosis of subscapularis tears with 3-T MRA. Three-Tesla 3D isotropic MRA showed similar accuracy to 3-T conventional 2D MRA.

CONCLUSION

Three-Tesla MRI appeared equivalent to 3-T MRA in the diagnosis of full- and partial-thickness tears, although there was a trend towards greater accuracy in the diagnosis of subscapularis tears with 3-T MRA. Three-Tesla 3D isotropic MRA appears equivalent to 3-T 2D MRA for all types of tears.

Asymptomatic Elite Adolescent Tennis Players' Signs of Tendinosis in Their Dominant Shoulder Compared With Their Nondominant Shoulder

CONTEXT

Tennis is an asymmetric overhead sport with specific muscle-activation patterns, especially eccentrically in the rotator cuff. Magnetic resonance imaging (MRI) findings in asymptomatic adolescent elite tennis players have not previously been reported.

OBJECTIVE

The first aim of the study was to describe MRI findings regarding adaptations or abnormalities, as well as muscle cross-sectional area (CSA), of the rotator cuff. The second aim of the study was to investigate the rotator cuff based on the interpretation of the MRI scans as normal versus abnormal, with the subdivision based on the grade of tendinosis, and its association with eccentric rotator cuff strength in the dominant arm (DA) of the asymptomatic elite adolescent tennis player.

SETTING

Testing environment at the radiology department of Medicinsk Röntgen AB.

PATIENTS OR OTHER PARTICIPANTS

Thirty-five asymptomatic elite tennis players (age = 17.4 ± 2.7 years) were selected based on ranking and exposure time.

INTERVENTION(S)

We assessed MRI scans and measured the CSA of the rotator cuff muscle. The non-DA (NDA) was used as a control. In addition, eccentric testing of the external rotators of the DA was performed with a handheld dynamometer.

RESULTS

The DA and NDA displayed different frequencies of infraspinatus tendinosis (grade 1 changes) (P < .05). Rotator cuff measurements revealed larger infraspinatus and teres minor CSA (P < .05) in the DA than in the NDA. Mean eccentric external-rotation strength in the DA stratified by normal tendon and tendinosis was not different between groups (P = .723).

CONCLUSIONS

Asymptomatic adolescent elite tennis players demonstrated infraspinatus tendinosis more frequently in the DA than in the NDA. Clinicians must recognize these tendon changes in order to modify conditioning and performance programs appropriately.

Accuracy of preoperative MRI in the diagnosis of disorders of the long head of the biceps tendon

OBJETIVES

To evaluate the accuracy of magnetic resonance imaging (MRI) in the detection of disorders of the long head of the biceps tendon (LHBT). The secondary objective was to investigate predictive factors for tears and instability.

METHODS

This retrospective case series involved patients undergoing shoulder arthroscopy due to rotator cuff injury. MRI was performed in a 1.5T scanner and was evaluated by a musculoskeletal radiologist. The findings were compared with those of arthroscopic inspection.

RESULTS

A total of 90 shoulders were analyzed. Regarding tears, there was 67% sensitivity and 98% specificity. Regarding instabilities, the values were 53% and 72%, respectively. Tears and fatty degeneration of the infraspinatus are predictive factors for tears of the LHBT. Tears of the subscapularis and infraspinatus, retraction of the supraspinatus and infraspinatus equal to or greater than 30mm, and fatty degeneration of the infraspinatus and subscapularis are predictive factors for instability.

CONCLUSION

Compared to arthroscopy, the shoulder MRI has a sensitivity of 67% and a specificity of 98% for the detection of complete tears of the LHBT. For instability, the values are 53% and 72%, respectively.

Predicting Pain and Disability After Shoulder Arthroscopy: Rotator Cuff Tear Severity and Concomitant Arthroscopic Procedures

OBJECTIVES

Study the influence of concomitant arthroscopic procedures and rotator cuff tear (RCT) severity on daily pain intensity and disability after shoulder arthroscopy.

MATERIALS AND METHODS

A sample of 145 patients (mean age, 42.66±17.6; number of males=96) completed daily pain intensity and disability measures before shoulder arthroscopy. RCT severity was assessed on a 7-point scale based on operative report. Operative procedures were categorized based on anatomic location and invasiveness to calculate a weighted concomitant procedure estimate. Postoperative daily pain and disability were assessed 3 months, 6 months, and 1 year status after surgery.

RESULTS

Only concomitant procedures were associated with 3-month daily pain intensity after adjusting for age, sex, pain duration, and baseline daily pain intensity (R=0.03; standardized β=0.203; P=0.036). Moreover, post hoc analysis revealed concomitant procedures remained predictive of 3-month daily pain intensity when the estimate was calculated independent of RCT procedures (R=0.05; standardized β=0.233; P=0.007), and when accounting for postoperative factors of physical therapy and analgesic medication (R=0.05; standardized β=0.237; P=0.007). Neither RCT severity nor concomitant procedures were predictive of daily pain intensity at 6 months and 1 year, or disability at any time-point, in the adjusted models (P>0.05).

DISCUSSION

This study introduces a novel means for estimating concurrent procedures for use as a prognostic factor. Our findings are similar to previous research of RCT severity that was found to have limited influence on postoperative outcomes. In contrast, this study highlights the potential importance of accounting for concomitant arthroscopic procedures as a predictor of early postoperative pain intensity outcomes.

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis

Background

Different diagnostic imaging modalities, such as ultrasonography (US), MRI, MR arthrography (MRA) are commonly used for the characterisation of rotator cuff (RC) disorders. Since the most recent systematic reviews on medical imaging, multiple diagnostic studies have been published, most using more advanced technological characteristics. The first objective was to perform a meta-analysis on the diagnostic accuracy of medical imaging for characterisation of RC disorders. Since US is used at the point of care in environments such as sports medicine, a secondary analysis assessed accuracy by radiologists and non-radiologists.

Methods

A systematic search in three databases was conducted. Two raters performed data extraction and evaluation of risk of bias independently, and agreement was achieved by consensus. Hierarchical summary receiver-operating characteristic package was used to calculate pooled estimates of included diagnostic studies.

Results

Diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears was high with overall estimates of sensitivity and specificity over 0.90. As for partial RC tears and tendinopathy, overall estimates of specificity were also high (>0.90), while sensitivity was lower (0.67–0.83). Diagnostic accuracy of US was similar whether a trained radiologist, sonographer or orthopaedist performed it.

Conclusions

Our results show the diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears. Since full thickness tear constitutes a key consideration for surgical repair, this is an important characteristic when selecting an imaging modality for RC disorder. When considering accuracy, cost, and safety, US is the best option.

Labrum and rotator cuff injuries in the throwing athlete

The large amount of force imparted across the shoulder during the act of throwing makes the glenohumeral joint highly susceptible to injury in the athlete performing overhead throwing motions. The bony incongruity of the shoulder enables greater range of motion than any other joint in the body, but it also results in significant strain on the surrounding soft tissues during the throwing motion. Throwers can present with acute injuries, but more commonly they suffer from chronic overuse conditions resulting from repetitive overload. Proper management requires early recognition with treatment directed toward the athlete's safe return to sports. Failure to institute an appropriate management strategy may result in significant complications, including prolonged disability, progression of symptoms, and further injury. We discuss the functional anatomy, pathophysiology, clinical presentation, evaluation, and treatment of common injuries of the glenoid labrum and rotator cuff in the overhead throwing athlete.

The evaluation and treatment of rotator cuff pathology

Rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. History and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. Treatment options include nonsteroidal anti-inflammatory agents, subacromial corticosteroid injections, and exercise therapy. Surgical intervention is generally reserved for those failing nonoperative measures and/or healthy, young, and middle-aged adults with full-thickness rotator cuff tears. No surgical technique has proved to be superior. Despite surgery, about 20% of patients experience retears, more likely occurring in those with larger tears.

Magnetic resonance anatomy of the superior part of the rotator cuff in normal shoulders, assessment and practical implication

OBJECTIVES

The superior part of the rotator cuff consists of the anterior (SSa) and posterior (SSp) parts of the supraspinatus tendon, the infraspinatus (IS) tendon plus the articular capsule. An overlap of the distal SSp tendon by the anterior part of the IS one has been anatomically demonstrated; the insertion area of the IS is more anterior than currently believed. The aim of our study was to assess this complex architecture through standard MRI scans.

METHODS

Twenty-five healthy volunteers underwent a shoulder MRI. Three planes T2 fat saturation sequences were read in consensus by two radiologists. The SSa, the SSp, the IS tendons and the articular capsule were assessed for visibility. The patterns of demarcation of each structure from adjacent ones were assessed. The width and the thickness of each tendinous band were measured on sagittal images.

RESULTS

The SSa, the SSp and the IS tendons were distinguishable in all patients. The anterior part of the IS tendon overlapped the SSp tendon to reach a quite anterior insertion into the greater tuberosity of the humerus. The SSa, the SSp and the IS tendons were 6.5-3.4, 15.1-2.8 and 26.8-2.2 mm wide and thick, respectively.

CONCLUSION

MR images of the normal superior rotator cuff are consistent with latest anatomical descriptions. The distal superposition of the IS over the SSp tendon should be considered regarding the linear increased signal areas and the commonly named "partial thickness ruptures" of the superior rotator cuff as well as the fatty infiltration of the IS muscle.

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.