Imaging modality for measuring the presence and extent of the labral lesions of the shoulder: a systematic review and meta-analysis

Three-dimensional sonography has satisfied accuracy for detecting rotator cuff tears

Background

Rotator cuff injuries and tears are common causes of shoulder pain and dysfunction, necessitating accurate diagnostic methods to guide clinical decision-making. This study evaluates the diagnostic utility of three-dimensional (3D) shoulder sonography in identifying rotator cuff injury and tear patterns.

Methods

A comprehensive search across seven electronic databases, which included Cochrane Library, Embase, PubMed, Cochrane Library, China Biology Medicine (CBM) database, CNKI, Wanfang, and VIP database. These databases were utilized to retrieve articles that assess the diagnostic value of 3D shoulder sonography for identifying rotator cuff injuries and tear patterns. The effectiveness of 3D shoulder sonography was assessed in terms of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). For each parameter, the 95% confidence intervals were calculated. Additionally, summary receiver operating characteristic curves (SROCs) were constructed, allowing for a comprehensive evaluation of diagnostic accuracy, which is reflected in the area under the SROC curve (AUC).

Results

Screening of 8,508 identified nine literatures eligible for inclusion in the meta-analysis, encompassing a total of 366 patients. The analysis of detecting any rotator cuff tear revealed a sensitivity of 0.97 and specificity of 0.87, yielding a DOR of 90.03 and an AUC of 0.98. Furthermore, 3D shoulder sonography demonstrated satisfactory accuracy in detecting both full and partial-thickness rotator cuff tears (Sensitivity: 0.92 vs. 0.83, specificity: 0.94 vs. 097, and AUC: 0.96 vs. 0.95).

Conclusion

This study indicates that three-dimensional sonography has satisfied accuracy for detecting rotator cuff tears.

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.

Magnetic Resonance Arthrogram Outperforms Standard Magnetic Resonance Imaging 2 Weeks After First Shoulder Dislocation for Labral Tear Diagnosis

PURPOSE

To determine the comparative accuracy and precision of routine magnetic resonance imaging (MRI) versus magnetic resonance (MR) arthrogram in measuring labral tear size as a function of time from a shoulder dislocation.

METHODS

We retrospectively evaluated consecutive patients who underwent primary arthroscopic stabilization between 2012 and 2021 in a single academic center. All patients completed a preoperative MRI or MR arthrogram of the shoulder within 60 days of injury and subsequently underwent arthroscopic repair within 6 months of imaging. Intraoperative labral tear size and location were used as standards for comparison. Three musculoskeletal radiologists independently interpreted tear extent using a clock-face convention. Accuracy and precision of MR labral tear measurements were defined based on location and size of the tear, respectively. Accuracy and precision were compared between MRI and MR arthrogram as a function of time from dislocation.

RESULTS

In total, 32 MRIs and 65 MR arthrograms (total n = 97) were assessed. Multivariate analysis demonstrated that intraoperative tear size, early imaging, and arthrogram status were associated with increased MR accuracy and precision (P < .05). Ordering surgeons preferred arthrogram for delayed imaging (P = .018). For routine MRI, error in accuracy increased by 3.4° per day and error in precision increased by 2.3° per day (P < .001) from time of injury. MR arthrogram, however, was not temporally influenced. Significant loss of accuracy and precision of MRI compared with MR arthrogram occurred at 2 weeks after an acute shoulder dislocation.

CONCLUSIONS

Compared with MR arthrogram, conventional MRI demonstrates time-dependent loss of accuracy and precision in determining shoulder labral tear extent after dislocation, with statistical divergence occurring at 2 weeks.

LEVEL OF EVIDENCE

Level II, retrospective radiographic diagnostic study.

Understanding Shoulder and Elbow Injuries in the Windmill Softball Pitcher

Although pitching-related injuries in the overhead athlete have been studied extensively, injuries associated with windmill pitching are not as clearly elucidated. Windmill pitching produces high forces and torques in the upper extremity, and studies have shown it creates similar shoulder and elbow joint loads to those reported in baseball pitchers. Studies have shown that the windmill pitching motion generates high levels of biceps activation with an eccentric load, placing the biceps at increased risk for overuse injuries. Although the American Orthopaedic Society for Sports Medicine published prevention guidelines including recommendations for maximum pitch counts in softball, these recommendations have not been adopted by most United States softball governing bodies. The repetitive windmill motion in conjunction with high pitch count demands in competitive softball creates notable challenges for the sports medicine physician. As with overhead throwing athletes, identifying and preventing overuse is crucial in preventing injuries in the windmill pitcher, and prevention and rehabilitation should focus on optimizing mechanics and kinematics, core, hip, and lower body strength, and recognition of muscle fatigue. With more than two million fastpitch softball participants in the United States, it is essential to better understand the etiology, evaluation, and prevention of injuries in the windmill pitching athlete.

Glenohumeral osteoarthritis: what the surgeon needs from the radiologist

Glenohumeral osteoarthritis (GHOA) is a widely prevalent disease with increasing frequency due to population aging. Both clinical manifestations and radiography play key roles in the initial diagnosis, staging, and management decisions. Radiographic disease progression evaluation is performed using validated staging systems, such as Kellgren and Lawrence, Samilson, and Hamada. For young patients with mild to moderate GHOA and failed conservative treatment, arthroscopic preservation surgery (APS) is usually considered. Older patients and those with severe GHOA benefit from different types of arthroplasties. Preoperative magnetic resonance imaging (MRI) is essential for APS surgical planning, as it maps repairable labral, cartilage, and rotator cuff lesions. For arthroplasty planning, the status of glenoid cartilage and intactness of rotator cuff as well as glenoid morphology represent key factors guiding the decision regarding the most suitable hardware design, whether resurfacing, partial, total, or reverse joint replacement. Pre-surgical MRI or alternatively computed tomography arthrogram is employed to evaluate the cartilage and rotator cuff. Finally, three-dimensional computed tomography (3D CT) is indicated to optimally assess the glenoid morphology (to determine Walch classification, version, inclination, and bone loss) and analyze the necessity for glenoid osteotomy or graft augmentation to correct the glenoid structural abnormalities for future success and longevity of the shoulder implants or chosen constructs. Understanding the purpose of each imaging and treatment modality allows more efficient image interpretation. This article reviews the above concepts and details what a surgeon needs from a radiologist and could benefit from accurate reporting of preoperative imaging studies.

Diagnostic Needle Arthroscopy of the Shoulder: A Validation Study

Background

Diagnostic needle arthroscopy offers an alternative imaging modality to magnetic resonance imaging (MRI) for the diagnosis of intra-articular pathology.

Purpose

To compare the accuracy of a needle arthroscopy device (Mi-eye2) versus MRI in identifying intra-articular anatomic abnormalities in the glenohumeral joint, with formal arthroscopy as the gold standard.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 22 patients underwent diagnostic needle arthroscopy of the shoulder, of whom 20 had preoperative MRI scans. A standardized 12-point noninstrumented diagnostic arthroscopy was performed on each patient using the 0° needle arthroscope, followed by a 30°, 4 mm-diameter conventional arthroscope. Intraoperative images were randomized and reviewed by 2 independent blinded fellowship-trained shoulder surgeons for identification of key pathology and anatomic structures. The MRI scans were reviewed by a single musculoskeletal radiologist to identify pathology in the same key areas.

Results

For the identification of rotator cuff pathology, needle arthroscopy (sensitivity, 0.75; specificity, 1.00) was superior to MRI (sensitivity, 0.75; specificity, 0.75) with an interobserver reliability (κ) of 0.703. For long head of the biceps pathology, needle arthroscopy (sensitivity, 0.67; specificity, 0.95) was superior to MRI (sensitivity, 0.00; specificity, 0.83). It was less accurate for labral (sensitivity, 0.33; specificity, 0.50; κ = 0.522) and articular cartilage pathology (sensitivity, 0.00; specificity, 0.94; κ = 0.353). The number of anatomic structures that could be clearly identified was 8.35 of 12 (69.58%) for needle arthroscopy versus 10.35 of 12 (86.25%) for standard arthroscopy.

Conclusion

Diagnostic needle arthroscopy was found to be more accurate than MRI for the diagnosis of rotator cuff and long head of the biceps pathology but was less accurate for diagnosing labral and cartilage pathology. Although the field of view of a 0° needle arthroscope is not equivalent to a 30° conventional arthroscope, it presents an alternative with potential for use in an outpatient setting.

Outcomes After Open Latarjet in Patients With or Without SLAP Lesions

Background

Up to 20% of shoulders with anterior instability are associated with superior labrum anterior-posterior (SLAP) lesions, and they remain untreated after an open Latarjet procedure. SLAP lesions can be responsible for pain and feelings of instability in high-demand patients.

Purpose/Hypothesis

The aim of this study was to compare the early functional outcomes and return to sport rates in athletes after the Latarjet procedure with versus without associated SLAP lesions. It was hypothesized that untreated SLAP lesions would not influence clinical results.

Study Design

Cohort study; Level of evidence, 3.

Methods

Inclusion criteria were athletes with anterior shoulder instability treated with Latarjet procedure, a minimum follow-up of 1 year, and an available preoperative computed tomography arthrogram. We recorded patient characteristics; type of sport; bone loss; Rowe, Single Assessment Numeric Evaluation (SANE), and 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; 5-point pain and satisfaction scores; reported apprehension; and return to sport. Patients with and without a preoperative type 5 SLAP lesion on imaging were compared.

Results

Fifty patients were included (mean age, 22 ± 5 years [range, 16-36 years]; mean follow-up, 27 ± 9 months [range, 12-42 months]). Thirty-four patients practiced contact sports, including 20 rugby players. Twelve patients (24%) had a preoperative SLAP lesion. Groups with (+) and without (-) a SLAP lesion were comparable in terms of age, sex, number of instability episodes, type of sport, and glenoid and humeral bone loss. The SLAP+ group had significantly worse outcomes with a lower Rowe score (79 ± 23 vs 91 ± 15; P = .018) and painless rate (50% vs 77%; P = .04). There were no significant differences between the groups in SANE score (SLAP+ vs SLAP-: 80% vs 87%), QuickDASH score (8% vs 8%), return to sport (83% vs 91%), apprehension (79% vs 50%), and reported satisfaction. There was 1 episode of postoperative subluxation in each group.

Conclusion

Patients who underwent an open Latarjet procedure with an associated SLAP tear more frequently reported postoperative pain than those without a SLAP lesion. Patients with untreated SLAP tears had significantly lower Rowe scores, although SANE score and return to sport were not significantly different between the groups.

Shoulder Magnetic Resonance Arthrography with the Internal and External Rotation Positions of the Humeral Head in the Evaluation of SLAP Lesions

We aimed to evaluate the diagnostic performance of shoulder MR arthrography (MRA) acquired in the neutral (N), internal rotation (IR), and external rotation (ER) positions of the shoulder to detect SLAP lesions. Three observers evaluated 130 MRAs to detect SLAP lesions and to calculate labral diastasis in this triple-blinded study. Sensitivity was much higher in the ER (92.5–97.5%) than in the N (60–72.5%) and IR (42.5–52.5%) positions, and the specificity of all the reviewers was 100% in all the positions. The diagnostic accuracy was higher in the ER too (97.7–99.2%). The diastasis length was significantly higher in the ER (median = 2.5–2.8 mm) than in the N (1 mm) and IR (0 mm) positions and was also significantly higher in those patients requiring surgery (p = 0.001). The highest inter-rater agreement values were observed in the ER both in SLAP detection (k = 0.982) and the diastasis length evaluation (ICC = 0.962). The diastasis length threshold in the ER that best separated the patients who did and did not require surgery was 3.1 mm (AUC = 0.833). In 14.6% of the cases, ER enabled the detection of SLAP lesions not identified in the N position. MRA with the ER improves the diagnosis of SLAP lesions and, together with the IR position, provides additional dynamic information about the diastasis of the lesions. It is recommended to perform additional ER and IR scans in the shoulder MRA protocol.

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.

An assessment of SLAP type 5 lesions using proton density oblique sagittal imaging in magnetic resonance arthrography

BACKGROUND

Bankart lesions accompany superior labrum anteroposterior (SLAP) lesions; these are called SLAP type 5.

PURPOSE

To compare SLAP type 5 lesions using routine magnetic resonance arthrography (MRA) and thin-slice oblique sagittal proton density (PDW) sequences and correlation operation results.

MATERIAL AND METHODS

In total, 181 patients were admitted with shoulder instability. The study was completed with 44 patients. The presence or absence of isolated Bankart and SLAP type 5 lesions in routine MRA and PDW oblique sagittal images were evaluated separately. Absence of rupture scored 0 points, suspected ruptures scored 1 point, and apparent ruptures scored 2 points. The two scores were compared with the shoulder arthroscopy findings.

RESULTS

According to the findings in the shoulder arthroscopy, 40 patients had Bankart lesions and 17 patients had accompanying SLAP type 5 lesions. To detect a Bankart lesion, there was no significant difference between routine MRA sequences and PDW oblique sagittal images (P = 0.061). Routine MRA sensitivity was 95%, specificity 25%, positive predictive value (PPV) 92%, negative predictive value (NPV) 33%, while for PDW oblique sagittal images, sensitivity was 75%, specificity 100%, PPV 100%, and NPV 28.5%. In 8/17 type 5 SLAP lesions, routine MRA detected sensitivity 47%, specificity 92.6%, PPV 80%, and NPV 73.5%; in 14/17 SLAP type 5 lesions, PDW oblique sagittal images detected sensitivity 82%, specificity 100%, PPV 100%, and NPV 90% (P = 0.015).

CONCLUSION

The PDW oblique sagittal images may play a significant role in assessing the anterior and superior extent of the tears.

The Value of 3 Tesla Field Strength for Musculoskeletal Magnetic Resonance Imaging

ABSTRACT

Musculoskeletal magnetic resonance imaging (MRI) is a careful negotiation between spatial, temporal, and contrast resolution, which builds the foundation for diagnostic performance and value. Many aspects of musculoskeletal MRI can improve the image quality and increase the acquisition speed; however, 3.0-T field strength has the highest impact within the current diagnostic range. In addition to the favorable attributes of 3.0-T field strength translating into high temporal, spatial, and contrast resolution, many 3.0-T MRI systems yield additional gains through high-performance gradients systems and radiofrequency pulse transmission technology, advanced multichannel receiver technology, and high-end surface coils. Compared with 1.5 T, 3.0-T MRI systems yield approximately 2-fold higher signal-to-noise ratios, enabling 4 times faster data acquisition or double the matrix size. Clinically, 3.0-T field strength translates into markedly higher scan efficiency, better image quality, more accurate visualization of small anatomic structures and abnormalities, and the ability to offer high-end applications, such as quantitative MRI and magnetic resonance neurography. Challenges of 3.0-T MRI include higher magnetic susceptibility, chemical shift, dielectric effects, and higher radiofrequency energy deposition, which can be managed successfully. The higher total cost of ownership of 3.0-T MRI systems can be offset by shorter musculoskeletal MRI examinations, higher-quality examinations, and utilization of advanced MRI techniques, which then can achieve higher gains and value than lower field systems. We provide a practice-focused review of the value of 3.0-T field strength for musculoskeletal MRI, practical solutions to challenges, and illustrations of a wide spectrum of gainful clinical applications.

MRA improves sensitivity than MRI for the articular-sided partial-thickness rotator cuff tears

BACKGROUND

This study aims to compare the diagnostic accuracy of magnetic resonance imaging (MRI) and MR arthrography (MRA) for the articular-sided partial-thickness rotator cuff tear (PTRCT).

METHODS

Three electronic databases, PubMed/Medline, Embase and Cochrane Library, were utilized to retrieve articles comparing the diagnostic value of MRA and MRI for detecting articular-sided PTRCTs. The pooled statistical indexes included sensitivity, specificity, positive/negative predictive value, diagnostic odds ratio (DOR) and the area under the receiver operating characteristic curve (AUC).

RESULTS

Eleven studies involving 1703 patients and 1704 shoulders were included. The pooled sensitivity, specificity, DOR and AUC and their 95% CIs of MRA to diagnose articular-sided PTRCTs were 0.81 (95% CI, 0.65-0.90), 0.96 (95% CI, 0.91-0.98), 68.14 (95% CI, 33.20-139.84) and 0.96 (95% CI, 0.94-0.97), respectively. The pooled sensitivity, specificity, DOR and AUC and their 95% CIs of MRI were 0.78 (95% CI, 0.65-0.87) and 0.97 (95% CI, 0.84-0.99), 47.82 (95% CI, 8.29-275.89) and 0.89 (95% CI, 0.86-0.92), respectively.

CONCLUSIONS

This meta-analysis reveals that MRA has a better diagnostic value than that of MRI for the diagnosis of articular-sided partial-thickness rotator cuff tears because of an improvement of sensitivity.

Glenohumeral Joint Instability: A Review of Anatomy, Clinical Presentation, and Imaging

The glenohumeral joint is intrinsically predisposed to instability because of the bony anatomy but maintained in alignment by many important structures, including the glenoid labrum, glenohumeral ligaments (GHLs), and muscles and tendons. Trauma and overuse can damage these stabilizers, which may then lead to subluxation or dislocation and eventually recurrent instability. This is most common in the anterior direction, which has several recognizable patterns of injury on advanced imaging, including humeral Hill Sachs deformities, bony Bankart lesion of the anteroinferior glenoid, soft tissue Bankart lesions, Bankart variant lesions (Perthes and ALPSA lesions), and HAGL/GAGL lesions. Similar reverse lesions are seen, as well as unique posterior lesions, such as Bennett and Kim's lesions. When symptoms of apprehension and instability in more than one direction are seen, one should consider multidirectional instability, which often presents with a patulous joint capsule. Finally, owing to significant impacts of daily activities and quality of life, surgical correction of labral tears, bony Bankart defects, Hill Sachs defects, and capsular laxity, may be considered.

Arthroscopic Treatment of Luxatio Erecta Humeri Associated with Greater Tuberosity Fracture, Bankart Lesion, and Partial Rotator Cuff Tear: A Case Report

BACKGROUND Luxatio erecta humeri (LEH) is a rare injury present in only 0.5% of shoulder dislocations. Much of the relevant literature is focused on the initial management and proper reduction techniques, although the prevalence of associated injuries can reach 80%. A case of LEH associated with greater tuberosity (GT) fracture and rotator cuff (RC) tear in a young laborer managed with closed reduction and arthroscopic repair of the labrum and rotator cuff is presented. CASE REPORT A 28-year-old man presented to our hospital with severe pain in his right shoulder after a high-impact motor vehicle accident. Standard anteroposterior radiographs revealed an inferior dislocation (LEH) of the right shoulder and a fracture of the GT. The patient was initially managed with closed reduction under mild intravenous sedation, using a 2-step maneuver followed by arthroscopic evaluation of the joint the next day. During arthroscopic evaluation, an anterior-inferior Bankart lesion, impaction of the humeral head with a minimal displaced GT fracture, and a partial RC tear were identified and successfully treated arthroscopically. The patient had immobilization in a simple sling for 6 weeks and he followed a standard 3-month physiotherapy protocol for rotator cuff, finally regaining almost normal range of shoulder motion at 1 year. CONCLUSIONS Although very good results of non-operative treatment of LEH have been reported in the literature, the co-existence of intra-articular lesions such as labral and rotator cuff tears makes arthroscopic repair an attractive alternative in individual cases.