Prediction of Rotator Cuff Injury Associated with Acromial Morphology: A Three-Dimensional Measurement Study

Acromioplasty combined with arthroscopic rotator cuff repair can reduce the risk of reoperation: a systematic review and meta-analysis

BACKGROUND

Whether to perform acromioplasty in arthroscopic rotator cuff repair (ARCR) is controversial, and the optimal surgical approach for rotator cuff tear repair is unknown. The purpose of this study was to compare the reoperation rate, retear rate and patient-reported outcomes (PROs) of ARCR with those of ARCR combined with acromioplasty (ARCR-A).

METHODS

PubMed, Embase and Cochrane Library were searched for relevant literature dated between database inception and 4 December 2023. The primary outcomes of this study were the reoperation rate and the retear rate. The secondary outcomes were PROs, including the visual analogue scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the University of California-Los Angeles (UCLA) score, the Constant score and the Western Ontario Rotator Cuff (WORC) score. The quality of the included studies was evaluated by using the risk of bias assessment tool. RevMan 5.3 software was used for meta-analysis. Fixed (I2 <50%) or random (I2 ≥50%) effects models were applied to calculate the effect size.

RESULTS

Meta-analysis revealed that ARCR-A had a lower reoperation rate (OR = 0.35, 95%CI: 0.15-0.85, p = 0.02), but the difference in the retear rate between ARCR-A and ARCR was not significant (p = 0.25). In type 2 acromion patients, the reoperation rate was not significantly different between ARCR and ARCR-A (p = 0.12), but, for type 3 acromion patients, the retear rate was lower for ARCR-A than for ARCR (OR = 0.12, 95%CI: 0.01-0.94, p = 0.04). There were statistically significant differences in the 6-month postoperative Constant scores (p < 0.001), VAS pain scores (p = 0.003) 12-month postoperative ASES scores (p = 0.02) and 24-month postoperative WORC scores (p = 0.04), but these differences were not clinically significant.

CONCLUSIONS

Combining ARCR with acromioplasty can reduce the rate of reoperation, especially in patients with type 3 acromion, but it provides no clinically important change in the retear rate and postoperative PRO compared with ARCR.

Reliability of Magnetic Resonance Imaging Criteria for the Preoperative Assessment of Rotator Cuff Tears: A Systematic Review

BACKGROUND

Magnetic resonance (MR) imaging is the most common modality for assessment of the rotator cuff before and after surgery. Several classifications have been described aiming to define main tear characteristics. However, there is still confusion when it comes to the reliability of those classifications.

PURPOSE

(1) To identify all MR classifications available in the literature for preoperative assessment of rotator cuff tears, (2) to summarize available data on the reliability of identified classifications, and (3) to assess the methodological quality of reliability studies.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies reporting MR assessment in patients with a superior or posterosuperior rotator cuff tear were included. After identification of the available MR criteria, reliability studies were analyzed. Descriptive statistics were used to summarize findings. Methodological quality was assessed using the Quality Appraisal of Reliability Studies checklist.

RESULTS

A total of 75 studies were included in this review. Eight categories of outcomes could be identified. Of the total, 62 studies reported interobserver reliability whereas 32 reported intraobserver reliability of some of the identified criteria. Each category reflected a variety of reliability, ranging from poor to excellent agreement. MR proved to be a reliable imaging modality to detect the structural integrity of the posterosuperior cuff, especially in cases of full-thickness tear; it was also reliable in terms of tear width and length and muscle atrophy based on a tangent sign or Thomazeau classification. All other classifications did not prove acceptable reliability. Methodological quality was high for 23 articles and moderate for 14.

CONCLUSION

Preoperative MR is a reliable imaging modality to identify full-thickness tears, measure tear size and morphology, and identify muscle atrophy with tangent sign or Thomazeau classification. All other outcomes and classifications did not show acceptable reliability; therefore, caution is needed when using them for preoperative evaluation of a rotator cuff tear.

Clinical value of three-dimensional ultrasonography in the morphologic evaluation of rotator cuff tear: a prospective study

OBJECTIVE

To study the clinical value of three-dimensional ultrasonography (3D-US) in the morphological evaluation of rotator cuff tears (RCTs).

METHODS

Based on previously published literature, RCT patterns in our study were divided into crescent, L-shaped with the remnant tendon retracted to the anterior rotator cuff (aL-shaped), L-shaped with the remnant tendon retracted to the posterior rotator cuff (pL-shaped), T-shaped (a tear pattern that is a combination of aL-shaped and pL-shaped), U-shaped, and massive type. Two radiologists prospectively assessed the tear patterns using 3D-US as well as magnetic resonance imaging (MRI) and compared these results using arthroscopy to calculate diagnostic accuracy.

RESULT

Fifty-two patients (52 shoulders) were enrolled. The overall diagnostic accuracy of 3D-US in evaluating RCT patterns (82.7%, 43/52; 95% CI: 72.1-93.3%) was significantly higher (p = 0.008) than that of the MRI (57.7%, 31/52; 95% CI: 45.8-73.4%). The accuracy of 3D-US was higher than that of MRI for most types of tears (crescent: 95.0% vs. 55.0%, aL-shaped: 83.3% vs. 77.8%, pL-shaped: 50.0% vs. 25.0%, T-shaped: 75.0% vs. 0.0%, and massive type: 80.0% vs. 100.0%). The accuracies of 3D-US with respect to evaluation by the two radiologists were 84.6% (44/52) and 76.9% (40/52), and there was substantial agreement evident (κ = 0.709). The time taken by the two radiologists to reconstruct the 3D-US images and evaluate the tear pattern was < 5 min.

CONCLUSION

The 3D-US can be used for the preoperative evaluation of RCT patterns, and thus be useful for the correct selection of the surgical repair technique for RCTs.

KEY POINTS

• Few studies have been found exploring the value of 3D-US for the morphological evaluation of RCTs and correlated with the arthroscopic findings. • Based on previous studies on the morphological classification, anterior L shape (aL-shaped), and posterior L shape (pL-shaped) were used for the first time to describe the torn patterns of RCT.

Anterolateral Acromioplasty Does Not Change the Critical Shoulder Angle and Acromion Index in a Clinically Relevant Amount

PURPOSE

Assessment on whether radiographic parameters of the acromion measured in radiographs change significantly after anterolateral acromioplasty.

METHODS

This retrospective study included patients that underwent an arthroscopic anterolateral acromioplasty between January 2014 and September 2020. n = 435 subjects with high-quality preoperative and postoperative radiographs according to Suter-Henninger criteria were included in the final assessment. All measurements were independently performed by the first and second author in a blinded fashion using dicomPACS software: acromion index (AI), critical shoulder angle (CSA), lateral acromial angle (LAA), beta angle, acromio-humeral distance (AHD), Aoki angle, frontal supraspinatus outlet angle (FSOW), and acromion type, according to Bigliani. SPSS software was used for statistical analysis.

RESULTS

The beta angle and the CSA did not significantly change after operation (alpha power 0.32 and 0.11, respectively). In a subgroup analysis of patients with a pathological CSA >35° (n = 194), the CSA changed from 38.62 (range: 35.08-47.52, SD 2.83) to 38.04 (range: 29.18-48.12, SD 3.77) postoperatively (P = .028) (Fig 8). All other parameters changed significantly after operation (AI, AHD, FSOW, and Aoki; P = .001, LAA; P = .039) (Fig. 9). The interobserver and intraobserver reliability was good to excellent in the majority of measured values. Mean patient age was 59.2 years (range: 18.1-87.1; SD 11.3), mean height was 1.73 meters (range: 1,50-1.98, SD 0.09), mean weight was 80.2 kg (range: 37.0-133.0, SD 16.68), and mean body mass index was 26.6 (range: 0.0-46.1, SD 4.73).

CONCLUSION

Anterolateral acromioplasty producing a flat acromion undersurface did not result in a significant change of the CSA in the study population. Pathological preoperative CSA values of >35° were significantly reduced but not to normal values, but only by a small amount that puts the clinical relevance into question.

LEVEL OF EVIDENCE

IV, diagnostic study, case series.