Three-dimensional ultrasonography in the diagnosis of rotator cuff lesions

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.

Evaluation of Tendon Disorders With Ultrasonography and Elastography

The frequency of musculoskeletal system ultrasonography (US) has increased over time. The most common reason for musculoskeletal US is the evaluation of tendons. The superficial location of tendons makes US the most suitable diagnostic tool, and US is generally the initial imaging modality for tendon disorders. The primary advantages of US are its low cost, easy accessibility, rapidity, repeatability, freedom from x-rays, and enabling of a dynamic inspection. In addition, Doppler US and elastography can be performed simultaneously with US. We aimed to demonstrate the US and elastographic findings of tendon disorders that we frequently encounter in different regions.

Detecting Rotator Cuff Tears: A Network Meta-analysis of 144 Diagnostic Studies

BACKGROUND

Many imaging techniques have been developed for the detection of rotator cuff tears (RCTs). Despite numerous quantitative diagnostic studies, their relative accuracy remains inconclusive.

PURPOSE

To determine which of 3 commonly used imaging modalities is optimal for the diagnosis of RCTs.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Studies evaluating the performance of magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA), and ultrasound (US) used in the detection of RCTs were retrieved from the PubMed/MEDLINE and Embase databases. Diagnostic data were extracted from articles that met the inclusion/exclusion criteria. A network meta-analysis was performed using an arm-based model to pool the absolute sensitivity and specificity, relative sensitivity and specificity, and diagnostic odds ratio as well as the superiority index for ranking the probability of these techniques.

RESULTS

A total of 144 studies involving 14,059 patients (14,212 shoulders) were included in this network meta-analysis. For the detection of full-thickness (FT) tears, partial-thickness (PT) tears, or any tear, MRA had the highest sensitivity, specificity, and superiority index. For the detection of any tear, MRI had better performance than US (sensitivity: 0.84 vs 0.81, specificity: 0.86 vs 0.82, and superiority index: 0.98 vs 0.22, respectively). With regard to FT tears, MRI had a higher sensitivity and superiority index than US (0.91 vs 0.87 and 0.67 vs 0.28, respectively) and a similar specificity (0.88 vs 0.88, respectively). The results for PT tears were similar to the detection of FT tears. A sensitivity analysis was performed by removing studies involving only 1 arm for FT tears, PT tears, or any tear, and the results remained stable.

CONCLUSION

This network meta-analysis of diagnostic tests revealed that high-field MRA had the highest diagnostic value for detecting any tear, followed by low-field MRA, high-field MRI, high-frequency US, low-field MRI, and low-frequency US. These findings can help guide clinicians in deciding on the appropriate imaging modality.

Effectiveness of 3-dimensional shoulder ultrasound in the diagnosis of rotator cuff tears: A meta-analysis

BACKGROUND

Numerous quantitatively based studies measuring the accuracy of 3D shoulder ultrasound (US) for the diagnosis of rotator cuff tears remain inconclusive. In order to determine how effective 3D shoulder US is for detecting rotator cuff tears, a meta-analysis was performed systematically.

METHODS

Six electronic databases, PubMed/Medline, Embase, Cochrane Library, CNKI, VIP data, and Wanfang data, were utilized to retrieve articles praising the diagnostic value of 3D shoulder US for use in detecting rotator cuff tears. After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis, the pooled evaluation indexes including sensitivity, specificity, and diagnostic odds ratio (DOR) as well as the summary receiver operating characteristic curve (SROC) were calculated utilizing Meta-Disc v.1.4.

RESULTS

Screening determined that out of 4220, 7 studies involving a total of 282 patients were deemed viable for inclusion in the meta-analysis. The results of the analysis showed that the sensitivity and specificity were at 94% and 83%, respectively, with a DOR of 60.06, Q* index of 0.9058 and the area under SROC of 0.9609. Additionally, a satisfactory accuracy of 3D shoulder US was observed in detecting full- and partial-thickness rotator cuff tears.

CONCLUSION

This meta-analysis suggests that 3D shoulder US is very effective and highly accurate to detect full-thickness rotator cuff tears, but may lack accuracy in the diagnosis of partial tears.

[Kinematic examination of the musculoskeletal system : Use of methods of image and image sequence analyses as well as shape and motion models]

Image-based preoperative planning has become a routine component in surgery on the musculoskeletal system. In joint arthroplasty it is obligatory. Surgeons are increasingly considering new approaches with additional computer-based kinematic examinations that also generate dynamic image analyses. This article describes several of these new examination techniques and discusses their clinical relevance.

A Review on Real-Time 3D Ultrasound Imaging Technology

Real-time three-dimensional (3D) ultrasound (US) has attracted much more attention in medical researches because it provides interactive feedback to help clinicians acquire high-quality images as well as timely spatial information of the scanned area and hence is necessary in intraoperative ultrasound examinations. Plenty of publications have been declared to complete the real-time or near real-time visualization of 3D ultrasound using volumetric probes or the routinely used two-dimensional (2D) probes. So far, a review on how to design an interactive system with appropriate processing algorithms remains missing, resulting in the lack of systematic understanding of the relevant technology. In this article, previous and the latest work on designing a real-time or near real-time 3D ultrasound imaging system are reviewed. Specifically, the data acquisition techniques, reconstruction algorithms, volume rendering methods, and clinical applications are presented. Moreover, the advantages and disadvantages of state-of-the-art approaches are discussed in detail.

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.

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.

Comparative analysis of 2- versus 3-dimensional sonography of the supraspinatus tendon

OBJECTIVES

The purpose of this study was to determine the reliability in the analysis of images acquired using a dedicated 3-dimensional (3D) ultrasound transducer and conventional 2-dimensional (2D) images in the detection and characterization of supraspinatus tendon tears.

METHODS

Images of the supraspinatus tendon in 42 patients who had undergone 2D and 3D sonography were classified by two readers independently as no tear, full-thickness tear, or partial-thickness tear. When present, the tear size and location were recorded. Inter- and intra-rater reliability for the two data sets were calculated.

RESULTS

There was substantial agreement between the two readers in the classification of supraspinatus tendon tears on 2D images (κ = 0.79) but only moderate agreement on 3D images (κ = 0.48). There was moderate to substantial agreement in the classification of tears between the 2D and 3D images for both readers (reader 1, κ = 0.64; reader 2, κ= 0.54). The most common cause of a discordant result was the interpretation of a small hypoechoic region at the footprint as a partial tear on 3D images, compared to a normal appearance on 2D images.

CONCLUSIONS

Use of a dedicated 3D ultrasound transducer has poorer inter- and intra-rater reliability for the assessment of supraspinatus tendon tears compared to 2D sonography because of the interpretation of small partial-thickness tears at the footprint on 3D images, a common region affected by anisotropy.

Shoulder ultrasound

Ultrasound is used increasingly in the investigation of the rotator cuff. It is as accurate as magnetic resonance imaging in the detection of rotator cuff tears and the assessment of tear size and can demonstrate atrophy and fatty infiltration in the rotator cuff muscles. This article reviews the anatomy and technique of shoulder ultrasound, the ultrasound findings in rotator cuff disease, the accuracy of ultrasound and magnetic resonance imaging in the assessment of rotator cuff tears and the role of interventional ultrasound of the shoulder.

What the practising rheumatologist needs to know about the technical fundamentals of ultrasonography

A transducer generates ultrasound waves and emits them into the body. Boundaries in or between tissues reflect the waves, and the transducer receives the reflected waves. A computer converts the information into images that are displayed on a monitor. Image resolution is greater with higher frequencies, and penetration is greater with lower frequencies. Linear probes with frequencies between 5 and 20 MHz are mainly used for musculoskeletal ultrasound. Image quality and resolution have improved significantly. Tissue harmonic imaging and cross-beam technology aid in differentiating between anatomical structures, although borders appear artificially thickened. Three-dimensional ultrasound provides additional coronary planes, and contrast agents increase the sensitivity for synovial blood flow in inflamed joints. This chapter provides further information regarding which ultrasound technology is the best for purchase by a rheumatology unit, how to organize ultrasound clinics, and how best to perform ultrasonography in daily practice, including the most important indications for ultrasound in rheumatology.

Three-dimensional ultrasonography of shoulders with rotator cuff tears

BACKGROUND

It is possible to evaluate the size of rotator cuff tears by ultrasonography (US) or magnetic resonance imaging. However, there are only a few reports on the imaging assessment of the configuration of cuff tears, which could provide important preoperative information that assists performing an optimal anatomical repair. The purpose of this study was to determine quantitatively the reproducibility of three-dimensional US in the assessment of rotator cuff tear configuration.

METHODS

Ten embalmed cadaveric shoulders with rotator cuff tears were examined. After resecting the proximal humerus with the rotator cuff, we put it in water and scanned it using high-resolution US with a three-dimensional linear probe. Actual tear lengths and widths were compared with sonographic measurements (Pearson correlation coefficient). By superimposing the real photographic image on the reconstructed three-dimensional image, we calculated the concordance rate (ratio of the concordance area to the tear area).

RESULTS

The actual tear length (16.6 +/- 7.1 mm; mean +/- SD) and width (8.4 +/- 4.4 mm) were correlated with the tear length (16.4 +/- 7.5 mm) and width (8.2 +/- 4.4 mm) measured from reconstructed three-dimensional ultrasonograms (r = 0.998 and 0.994, respectively). The mean concordance rate was 91.4%, indicating that almost exactly the same configuration was reconstructed by US.

CONCLUSIONS

Three-dimensional US is useful for evaluating the configuration of rotator cuff tears. This is the first report to quantify the similarity between the configuration evaluated by US and the actual configuration. Using this method, we can visualize the configuration of rotator cuff tears preoperatively, facilitating optimal repair design.

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 1: Current controversies and issues in the development of musculoskeletal ultrasound in rheumatology

As we begin the 21st century, musculoskeletal ultrasound (MSUS) is routinely used by an increasing number of rheumatologists throughout Europe and there is a growing interest in the application of MSUS in rheumatological practice in the UK. MSUS allows high-resolution, real-time imaging of articular and periarticular structures and has the advantages of being non-radioactive, inexpensive, portable, highly acceptable to patients and repeatable. There are a number of critical issues that need to be addressed in order to develop the role of MSUS within rheumatology. These include issues of equipment costs, training and certification and the relationship of rheumatologists and radiologists in advancing the field of MSUS. Rheumatologists must demonstrate the relevance of MSUS in their clinical practice through high-quality research. Emerging technologies such as power Doppler and 3D imaging will further improve imaging capabilities and the range of clinical applications of MSUS systems. This paper reviews how MSUS in rheumatology has evolved and the controversies and issues that rheumatologists must now address in developing MSUS as an indispensable, everyday clinical tool.

A ecografia no diagnóstico das lesões músculo-tendinosas do ombro

Este estudo propôs-se a revisar os aspectos relevantes da anatomia, técnica de exame e achados de imagens, com o objetivo de auxiliar o radiologista no diagnóstico diferencial frente às afecções músculo-tendinosas do ombro. Foram realizadas 34 ultra-sonografias da região do ombro, no período de janeiro a dezembro de 2001. A avaliação foi realizada com transdutores de alta freqüência (7,5-10 MHz). O exame foi normal em 23% dos pacientes (oito casos). Dos 26 casos alterados, observaram-se oito com ruptura total (30%), cinco com ruptura parcial (19%), dez com tendinopatia (38%), um com tendinopatia calcificada (3%), um com tenossinovite bicipital (3%) e um com tendinopatia associada a artrite gotosa (3%). A falta de experiência e de conhecimento das principais alterações que acometem o ombro é um dos principais pontos limitantes do diagnóstico ultra-sonográfico das lesões do ombro. Portanto, o estudo dessas alterações deve ser realizado amplamente.