A comparison of the degree of retraction of full-thickness supraspinatus tears with the Goutallier grading system

Cost analysis of dermal allograft patch utilization in rotator cuff repair

Background

To perform an analysis of intraoperative costs associated with arthroscopic rotator cuff repair (RCR) acellular dermal allograft patch augmentation and interposition.

Methods

This was a matched cohort retrospective cost identification analysis. We identified patients who underwent arthroscopic RCR with acellular dermal allograft patch augmentation or interposition between 2014 and 2023 at a single academic center. These were matched based on age and tear size to a cohort of patients who underwent arthroscopic RCR without a patch. Patients without preoperative MRI data were excluded. Via chart review, we collected demographics, medical comorbidities, tear characteristics, and intraoperative repair characteristics. Patch and control patients were compared with paired t tests. Differences in costs between patch and control patients were assessed using multivariable regression controlling for observable covariates.

Results

One hundred and thirty-two (132) total patients were included: 66 patch patients and 66 control patients. The patch group demonstrated more tear retraction and utilized single row medial repair more frequently. Multivariable analysis revealed that there was a $4930 total direct cost increase with the utilization of a patch (P <.001) after controlling for age, body mass index, American Society of Anesthesiologists (ASA), Charlson comorbidity index, gender, surgeon, tear width, number of anchors, occupation, biceps treatment, prior surgery, and repair construct. The multivariable analysis also revealed that a higher ASA was associated with a $1440 increase in cost (P =.012). Biceps tenotomy was associated with a $3303 decrease in cost compared to tenodesis (P =.001). Additionally, single row medial repair demonstrated a $1745 decrease in total direct cost when compared to a double row repair construct (P =.019).

Conclusion

The addition of a patch increases the total direct cost by $4930 when compared to arthroscopic RCR without a patch. Increased ASA, biceps tenodesis, and use of a double row repair construct were also associated with increased cost.

Patient, imaging, and surgical factors associated with supraspinatus re-tear pattern after rotator cuff repair

Background

This study aimed to characterize patient, imaging, and surgical factors associated with re-tear patterns after rotator cuff repair, as well as to identify predictors of type 2 failure in a large patient cohort.

Methods

A retrospective case-control study was performed at a single urban academic institution. All patients who underwent an arthroscopic rotator cuff repair by 2 fellowship-trained shoulder and elbow surgeons between 2005 and 2022 and were subsequently found to have a symptomatic re-tear on magnetic resonance imaging were included. Patients were characterized as either a type 1 (failure at bone-tendon interface) or type 2 (failure medial to the bone-tendon junction) re-tear based on the Cho classification. Chart review was performed to collect demographic, imaging, and intraoperative surgical factors. Multivariable analysis was performed to determine patient and imaging factors associated with type 2 failure.

Results

Fifty-seven patients were included in the study. Overall, 33 (57.9%) patients were classified as a Cho 1 re-tear and 24 (42.1%) were classified as Cho 2 re-tear. No differences in preoperative tear characteristics (tear width, tear retraction, and tendon length) or fatty infiltration were found between Cho 1 and Cho 2 re-tears. Bivariate analysis comparing Cho 1 vs. Cho 2 found male sex was associated with a higher incidence of a Cho 2 re-tear (79.2% vs. 20.8%; P = .033). No significant differences in repair construct (single row vs. double row) (P = .816), biceps treatment (P = .552), concomitant subscapularis repair (P = .306), number of medial anchors (P = .533), or number of lateral anchors (P = .776) were noted between re-tear types. After controlling for potential confounding factors, multivariable regression analysis demonstrated that male sex was predictive of developing a Cho 2 re-tear (odds ratio 3.8; 95% confidence interval 1.1-13.3; P = .039). Repair construct was not found to be predictive of re-tear pattern (P = .580).

Conclusion

Repair construct used during rotator cuff repair does not appear to influence re-tear pattern. Male sex was associated with a higher rate of type 2 failure.

The relationship between the duration and the retraction and atrophy grades in traumatic isolated full-thickness supraspinatus tears in young patients

BACKGROUND

The study aimed to determine the grade of retraction and atrophy according to the time elapsed in traumatic isolated full-thickness supraspinatus (SS) tears in young patients.

METHODS

One thousand twenty-six patients, who underwent arthroscopic shoulder surgery, were retrospectively reviewed. Pre-operative magnetic resonance imaging (MRI) of 69 patients aged 18 to 40 years with isolated traumatic full-thickness SS lesions remaining after exclusion criteria were evaluated for tendon retraction and atrophy grades. SS retraction was determined from a T2-weighted oblique coronal MRI slice, and the atrophy grade was determined from the T1-weighted oblique sagittal MRI slice. The patients were divided into four groups 0-1 month, 1-3 months, 3-6 months, and 6-12 months according to the time between trauma and MRI. The relationship of tendon retraction and muscle atrophy with elapsed time was evaluated, in addition, comparisons between groups were made.

RESULTS

Thirty-one (45%) of the patients were female and their mean age was 30 ± 7.3 (18-40) years. The mean age of men was 30.5 ± 6.9 (18-39) years (p = 0.880). The time between rupture and MRI was moderately correlated with retraction and strongly correlated with atrophy grades (r = 0.599, 0.751, respectively). It was observed that there was a statistically significant difference between the 1st (0-1 month) and 2nd (1-3 months) groups (p = 0.003, 0.001, respectively), and between the 2nd and 3rd (3-6 months) groups (p = 0.032, 0.002, respectively), but there was no significant difference between the 3rd and 4th (6-12 months) groups (p = 0.118, 0.057, respectively). In addition, there was a moderate correlation between tendon retraction and atrophy grades (r = 0.668). Power (1- b) in post hoc analysis was calculated as 0.826.

CONCLUSIONS

The current study, supported by arthroscopy, showed that there is a moderate and strong positive correlation between the time elapsed after trauma and the level of retraction and degree of atrophy in traumatic full-thickness SS tears, and demonstrated the importance of early surgical intervention in young patients.

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.

Multidimensional risk factor analysis of acute low back pain progressing to chronicity: a longitudinal cohort study protocol

Introduction

Approximately 40% of patients with acute low back pain (LBP) develop chronic low back pain, which significantly increases the risk of poor prognosis. To reduce the risk of acute LBP becoming chronic, effective preventive strategies are needed. Early identification of risk factors for the development of chronic LBP can help clinicians choose appropriate treatment options and improve patient outcomes. However, previous screening tools have not considered medical imaging findings. The aim of this study is to identify factors that can predict the risk of acute LBP becoming chronic based on clinical information, pain and disability assessment, and MRI imaging findings. This protocol describes the methodology and plan for investigating multidimensional risk factors for acute LBP becoming chronic, in order to better understand the development of acute LBP and prevent chronic LBP.

Methods

This is a prospective multicenter study. We plan to recruit 1,000 adult patients with acute low back pain from four centers. In order to select four representative centers, we find the larger hospitals from different regions in Yunnan Province. The study will use a longitudinal cohort design. Patients will undergo baseline assessments upon admission and will be followed up for 5 years to collect the time of chronicity and associated risk factors. Upon admission, patients will be collected detailed demographic information, subjective and objective pain scores, disability scale, and lumbar spine MRI scanning. In addition, patient's medical history, lifestyle, psychological factors will be collected. Patients will be followed up at 3 months, 6 months, 1 year, 2 years and up for 5 years after admission to collect the time of chronicity and associated factors. Multivariate analysis will be used to explore the multidimensional risk factors affecting the chronicity of acute LBP patients (such as age, gender, BMI, degree of intervertebral disc degeneration, etc.), and survival analysis will be performed to explore the impact of each factor on the time of chronicity.

Ethics and dissemination

The study has been approved by the institutional research ethics committee of each study center (main center number: 2022-L-305). Results will be disseminated through scientific conferences and peer-reviewed publications, as well as meetings with stakeholders.

A novel MRI index for paraspinal muscle fatty infiltration: reliability and relation to pain and disability in lumbar spinal stenosis: results from a multicentre study

BACKGROUND

Fatty infiltration of the paraspinal muscles may play a role in pain and disability in lumbar spinal stenosis. We assessed the reliability and association with clinical symptoms of a method for assessing fatty infiltration, a simplified muscle fat index (MFI).

METHODS

Preoperative axial T2-weighted magnetic resonance imaging (MRI) scans of 243 patients aged 66.6 ± 8.5 years (mean ± standard deviation), 119 females (49%), with symptomatic lumbar spinal stenosis were assessed. Fatty infiltration was assessed using both the MFI and the Goutallier classification system (GCS). The MFI was calculated as the signal intensity of the psoas muscle divided by that of the multifidus and erector spinae. Observer reliability was assessed in 102 consecutive patients for three independent investigators by intraclass correlation coefficient (ICC) and 95% limits of agreement (LoA) for continuous variables and Gwet's agreement coefficient (AC1) for categorical variables. Associations with patient-reported pain and disability were assessed using univariate and multivariate regression analyses.

RESULTS

Interobserver reliability was good for the MFI (ICC 0.79) and fair for the GCS (AC1 0.33). Intraobserver reliability was good or excellent for the MFI (ICC range 0.86-0.91) and moderate to almost perfect for the GCS (AC1 range 0.55-0.92). Mean interobserver differences of MFI measurements ranged from -0.09 to -0.04 (LoA -0.32 to 0.18). Adjusted for potential confounders, none of the disability or pain parameters was significantly associated with MFI or GCS.

CONCLUSION

The proposed MFI demonstrated high observer reliability but was not associated with preoperative pain or disability.

Efficacy of Imaging Modalities Assessing Fatty Infiltration in Rotator Cuff Tears

BACKGROUND

Fatty atrophy is a diagnosis characterized by the combination of fatty infiltration and muscle atrophy of the rotator cuff. Studies have shown a strong positive correlation between the level of fatty infiltration and the risk of experiencing a chronic rotator cuff tear. Therefore, the purpose of the present study was to review the current literature on radiographic imaging of fatty infiltration and fatty atrophy to better aid surgeons in predicting functional outcome and to help guide patient decisions.

METHODS

We conducted a literature search in PubMed. The exact search queries included "rotator cuff" in the MeSH Terms field; "fatty atrophy," fatty infiltration," and "fatty muscle degeneration" in the Title/Abstract field; and various combinations of these searches. We initially found 184 articles using these keywords, including both human and animal studies. The 25 animal studies were excluded, leaving 159 articles. The abstracts of all remaining articles were reviewed and selected on the basis of our inclusion criteria of focusing on patients with rotator cuff tears (preoperatively and postoperatively), fatty infiltration, fatty atrophy, and imaging modalities. We excluded an additional 127 articles, leaving 32 articles that were selected for the final review and inclusion in this study.

RESULTS

Among 45 shoulder specialists across different studies, interrater agreement for Goutallier staging with use of magnetic resonance imaging (MRI) ranged from 0.24 to 0.82 and intrarater agreement for supraspinatus fatty changes ranged from 0.34 to 0.89. Our review also showed strong positive correlations when assessing the severity of fatty atrophy of the rotator cuff between MRI and ultrasound or ultrasound modalities such as sonoelastography.

CONCLUSIONS

Increasing fatty infiltration of the rotator cuff is associated with greater repair failure rates and hence poorer overall clinical outcomes. MRI remains the gold standard for the imaging of rotator cuff tears and postoperative healing. Ultrasound can decrease health-care expenditures associated with the assessment of repair integrity postoperatively, although ultrasound is not as precise and has some limitations compared with MRI.

The influence of full-thickness supraspinatus tears on abduction moments: the importance of the central tendon

BACKGROUND

Detachment of the central tendon of the supraspinatus from its insertion is considered to be crucial to functional deficit. The aim of the present study was to assess the function of the supraspinatus in terms of abduction moments by introducing different tear configurations to assess the functional effect of the central tendon insertion.

METHODS

Ten fresh frozen shoulders from five cadavers were prepared for testing. A testing protocol was established to measure the abduction moment of the supraspinatus under physiological loading tailored to the anthropometrics of each specimen. Four conditions were tested: intact supraspinatus; complete detachment of portion of the supraspinatus tendon anterior to the main central tendon; detachment of the main central tendon; and detachment of the region of the supraspinatus posterior to the main central tendon.

RESULTS

There was a significant and large reduction in abduction moment when the central tendon was sectioned (p < 0.05). A smaller reduction in abduction moment was found when the regions anterior and posterior to the main central tendon were sectioned (p < 0.05).

CONCLUSIONS

The central tendon is vital in the role of functional arm abduction through force transmission through the intact rotator cuff. Reinsertion of the central tendon in the correct anatomical location is desirable to optimize functional outcome of surgery.

The natural history of donor hamstrings unit after anterior cruciate ligament reconstruction: a prospective MRI scan assessment

PURPOSE

The aim of this prospective study was to assess the natural history of the donor hamstrings, compared to the contralateral knee and thigh.

METHODS

In 47 patients who had ACL reconstruction (hamstrings technique), bilateral knees and thighs were investigated using MRI scans, up to 2 years post-operatively.

RESULTS

Tendon regeneration below the knee joint line of the semitendinosus occurred in 30/47 (64 %) patients and of the gracilis tendon in 17/47 (36 %) patients. Insertion of both tendons at the "pes anserinus", with normal anatomic relations, was observed in 5/47 (11 %) patients. Semitendinosus and gracilis donor muscles were found retracted in 41/47 (87 %) patients. In 25/47 (53 %) patients, there was evidence of fatty infiltration of the semitendinosus muscle. All (47/47) (100 %) patients showed semitendinosus muscle atrophy and 41/47 (87 %) patients showed gracilis muscle atrophy, compared to the contralateral limb. High signal intensity on STIR images was observed in the semitendinosus in 22/47 (46 %) patients and in the gracilis muscle in 30/47 (64 %) patients, on MRI examination performed up to 24 months post-operatively.

CONCLUSIONS

The "regenerated" hamstrings tendons most commonly do not regenerate fully anatomically, so they should not be considered as a first choice for re-harvesting in revision ACL reconstruction. The "donor hamstrings muscles" are found to be shorter, contracted, thinner and with a long-term abnormal MRI signal, features which are considered to be related to reduced muscle performance (knee flexion and internal rotation) post-operatively.

LEVEL OF EVIDENCE

II.

Magnetic resonance rotator cuff fat fraction and its relationship with tendon tear severity and subject characteristics

BACKGROUND

Compared with the Goutallier classification, chemical shift-based magnetic resonance (MR) fat quantification has superior reliability and accuracy in evaluation of muscle fatty infiltration. We used this method to assess the relationship between rotator cuff (RC) muscle fat fractions, tendon disease severity, and subject characteristics.

METHODS

In total, 182 subjects with shoulder symptoms underwent shoulder MR imaging including additional sequences for fat quantitation. Then, fat fraction maps were manually segmented, and custom software was used to compute the fat fraction. Goutallier scores were also obtained. The relationship between fat fraction and tendon tear severity and subject characteristics was assessed with descriptive statistics, analysis of variance, Student t test of different subgroups, and simple and multiple linear regression analysis.

RESULTS

Statistically higher supraspinatus fat fractions were observed in subgroups with tendon tears >3 cm, retraction >1 cm, age >50 years, body mass index (BMI) >30, higher Goutallier score, female gender, and longer symptom duration. A significant linear relationship was seen between RC fat fraction and tendon disease severity, age, and BMI but not symptom duration. Multiple regression models with fat fraction and tendon disease, age, BMI, and gender were significant for all 4 muscles (P < .001). The slope of fatty infiltration increase with age was reduced after adjustment for tendon disease, BMI, and gender.

CONCLUSION

RC fat fraction assessed by chemical shift MR demonstrated a significant linear relationship with tendon tear severity, age, BMI, and gender but not with symptom duration.

Complete Fatty infiltration of intact rotator cuffs caused by suprascapular neuropathy

Suprascapular neuropathy is generally considered to be a diagnosis of exclusion, although it has been described in association with several activities and conditions. To our knowledge, this is the first description of suprascapular neuropathy with complete neurogenic fatty replacement in patients with intact rotator cuff tendons in the absence of traction or compression mechanisms. We present 4 cases of patients who presented with complete fatty infiltration of the supraspinatus (1 patient), infraspinatus (2 patients), and both (1 patient) resulting from suprascapular neuropathy. Each of these patients underwent arthroscopic suprascapular nerve decompression and subsequently had immediate improvement in pain and subjective shoulder value.

Quantitative assessment of fat infiltration in the rotator cuff muscles using water-fat MRI

PURPOSE

To evaluate a chemical shift-based fat quantification technique in the rotator cuff muscles in comparison with the semiquantitative Goutallier fat infiltration classification (GC) and to assess their relationship with clinical parameters.

MATERIALS AND METHODS

The shoulders of 57 patients were imaged using a 3T MR scanner. The rotator cuff muscles were assessed for fat infiltration using GC by two radiologists and an orthopedic surgeon. Sequences included oblique-sagittal T1-, T2-, and proton density-weighted fast spin echo, and six-echo gradient echo. The iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) was used to measure fat fraction. Pain and range of motion of the shoulder were recorded.

RESULTS

Fat fraction values were significantly correlated with GC grades (P < 0.0001, κ >0.9) showing consistent increase with GC grades (grade = 0, 0%-5.59%; grade = 1, 1.1%-9.70%; grade = 2, 6.44%-14.86%; grade = 3, 15.25%-17.77%; grade = 4, 19.85%-29.63%). A significant correlation between fat infiltration of the subscapularis muscle quantified with IDEAL versus 1) deficit in internal rotation (Spearman Rank Correlation Coefficient [SRC] = 0.39, 95% confidence interval [CI] 0.13-0.60, P < 0.01) and 2) pain (SRC coefficient = 0.313, 95% CI 0.049-0.536, P = 0.02) was found but was not seen between the clinical parameters and GC grades. Additionally, only quantitative fat infiltration measures of the supraspinatus muscle were significantly correlated with a deficit in abduction (SRC coefficient = 0.45, 95% CI 0.20-0.60, P < 0.01).

CONCLUSION

An accurate and highly reproducible fat quantification in the rotator cuff muscles using water-fat magnetic resonance imaging (MRI) techniques is possible and significantly correlates with shoulder pain and range of motion.

Intra- and inter-rater reliability of the detection of tears of the supraspinatus central tendon on MRI by shoulder surgeons

BACKGROUND

The purpose of this study was to determine the intra- and inter-rater reliability of detecting full- and partial-thickness tears of the supraspinatus intramuscular central tendon on magnetic resonance imaging (MRI) by orthopaedic shoulder surgeons. Full-thickness tears of this tendon have previously been associated with the failure of nonsurgical management of rotator cuff tears.

METHODS

Shoulder MRIs from 40 patients entered into a prospective rotator cuff disease database were independently reviewed by two musculoskeletal (MSK) radiologists in order to determine if there was a partial- or full-thickness tear of the supraspinatus central tendon. The MRIs were randomly sorted and distributed to 16 fellowship-trained shoulder surgeons. The surgeons then similarly diagnosed each patient. After a 1-month interval, surgeons repeated the evaluation with the same set of randomly reordered MRIs. Surgeon intra- and inter-rater reliability was determined with the kappa statistic. Agreement and inter-rater reliability were also determined between the shoulder surgeons and MSK radiologists.

RESULTS

For full-thickness tears, the intra-rater reliability was excellent (0.86 ± 0.1, 95% confidence interval (CI): 0.81, 0.91) and the agreement was 93.4% ± 4.6, 95% CI: 91.1, 95.8. Inter-rater reliability for both rounds was also excellent (0.77 and 0.74). The agreement between the shoulder surgeons and MSK radiologists was 92.9% ± 3.9, 95% CI: 90.9, 94.9, and the kappa was 0.85 ± 0.08, 95% CI: 0.81, 0.89. Including partial-thickness tears resulted in agreement of 65-92% and kappa values of 0.59-0.72.

CONCLUSION

The reliability for the MRI detection of full thickness tears of the supraspinatus central tendon among shoulder surgeons and between shoulder surgeons and MSK radiologists was excellent.