Imaging of Usual and Unusual Complication of Rotator Cuff Repair

Can We Apply Snyder's Arthroscopic Classification to Ultrasound for Evaluating Rotator Cuff Tears? A Comparative Study with MR Arthrography

We aimed to demonstrate the applicability of Snyder's arthroscopic classification of rotator cuff tears (RCT) in shoulder ultrasound (US) and to compare it with MR arthrography (MRA). Forty-six patients (34 males; mean age:34 ± 14 years) underwent shoulder US and MRA. Two radiologists (R1 = 25 years of experience; R2 = 2 years of experience) assigned A1-4, B1-4, or C1-4 values depending on the extent of RCT in both US and MRA. Inter-reader intra-modality and intra-reader inter-modality agreement were calculated using Cohen's kappa coefficient. US sensitivity and specificity of both readers were calculated using MRA as the gold standard. Patients were divided into intact cuff vs. tears, mild (A1/B1) vs. moderate (A2-3/B2-3) tears, mild-moderate (A2/B2) vs. high-moderate (A3/B3) cuff tears, moderate (A2-3/B2-3) vs. advanced (A4/B4) and full-thickness (C) tears. The highest agreement values in inter-reader US evaluation were observed for mild-moderate vs. high-moderate RCT (K = 0.745), in inter-reader MRA evaluation for mild vs. moderate RCT (K = 0.821), in R1 inter-modality (US-MRA) for mild-moderate vs. high-moderate and moderate vs. advanced/full-thickness RCT (K = 1.000), in R2 inter-modality (US-MRA) for moderate vs. advanced/full-thickness RCT (K = 1.000). US sensitivity ranged from 88.89%(R1)-84.62%(R2) to 100% (both readers), while specificity from 77.78%(R1)-90.00%(R2) to 100% (both readers). Snyder's classification can be used in US to ensure the correct detection and characterization of RCT.

Efficacy and Safety of Tranexamic Acid in Shoulder Arthroscopic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Visual clarity during shoulder arthroscopy can ensure an efficient and effective performance of the procedure, and it is highly related to bleeding without a tourniquet. Tranexamic acid (TXA) is widely used in adult reconstruction procedures; however, its use in shoulder arthroscopic operations is a relatively novel topic.

PURPOSE

To analyze the available literature on visual clarity, blood loss, pain control, functional outcomes, and complications after the administration of tranexamic acid in shoulder arthroscopic surgery.

METHODS

A literature search was performed to retrieve randomized controlled trials examining the use of tranexamic acid at the time of shoulder arthroscopic surgery. The literature search included the MEDLINE, Embase, Web of Science, and Cochrane Library databases. The primary outcomes included visual clarity, blood loss, and visual analog scale scores for pain. Secondary outcomes were operative time, irrigation amount used, postoperative shoulder swelling, the need for pressure increase, mean arterial pressure (MAP), functional outcomes, postoperative adverse effects such as deep venous thrombosis, and pulmonary embolism. The outcomes were pooled to perform a meta-analysis.

RESULTS

Seven prospective randomized controlled trials met the inclusion criteria for analysis. All of the included studies performed arthroscopic rotator cuff repair. No significant difference in visual clarity was observed (SMD (standardized mean difference), 0.45 [95% CI(confidence interval), -0.68, 1.59]; p = 0.44) nor in pain score (MD (mean difference), -0.46 [95% CI, -0.97, 0.05]; p = 0.08) between the TXA group and the control group. Two studies found no significant difference in blood loss between the TXA group and the control group. The meta-analysis from five studies demonstrated no significant difference between the TXA and control groups in operative time (MD, -3.51 [95% CI, -15.82, 8.80]; p = 0.58) or irrigation amount used (MD, -2.53 [95% CI, -5.93, 0.87]; p = 0.14). Two trials reported different statistical results in postoperative shoulder swelling. No significant differences regarding the need for pressure increase and MAP were reported between groups. No wound complications or infections or cardiac, thrombotic, or thromboembolic complications were recorded in either group.

CONCLUSION

The use of intravenous or local TXA in shoulder arthroscopic surgery did not increase complications or thromboembolic events, but TXA had no obviously effect of reducing bleeding to obtain a clear visual field or pain release in patients undergoing shoulder arthroscopic surgery.

Ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinosis. What radiologist should know

Rotator cuff calcific tendinopathy is a common condition caused by the presence of calcification into the rotator cuff or in the subacromial-subdeltoid bursa. The pathogenetic mechanism of this pathology is still debated. Calcific tendinitis frequently affects the rotator cuff and may cause shoulder pain and reduction of range of motion. It can be diagnosed with conventional radiography, ultrasound, or magnetic resonance imaging. The first therapeutic option includes conservative management based on rest, physical therapy, and oral non-steroid anti-inflammatory administration. Extracorporeal shock wave therapy is a noninvasive technique that can be useful for the fragmentation of calcific deposits. Imaging-guided percutaneous irrigation is currently considered the gold standard technique for the treatment of calcific tendinitis due to its minimal invasiveness and its success rate of about 80%.

Quantitative T2 mapping of glenohumeral joint osteoarthritis: a case-control study

Background

T2 relaxometry is a highly sensitive technique used to assess morphological changes in the cartilage prior to anatomical changes; it provides the quantification of the disparate components of cartilage such as water, proteoglycans, and collagen. This study aims to assess T2 values of glenohumeral joint cartilage using 1.5 T magnetic resonance imaging (MRI) and comparing T2 relaxation time values between two groups—the control group and the group of patients with osteoarthritis (OA). The study was conducted among 35 OA patients (27 females and eight males; median age, 60 years; age range, 43–69 years). This group was divided into primary OA (n = 15) and secondary OA (n = 20). The control group had 30 patients (25 females and five males; median age, 46 years; age range, 30–56 years). All patients were assessed using plain radiography to determine the grade of osteoarthritis followed by a multi-echo spin pulse sequence (T2 mapping) of the coronal plane. Three areas were considered to evaluate the cartilage-humeral zone, glenoid zone, and central zones by manually drawing the region of interest (ROI). The values were compared statistically by using Mann-Whitney U tests.

Results

Median T2 values differed significantly between the control group (43.4 ms [interquartile ranges, 41.54-45.33 ms]) and the OA patients for grades I (59.2 ms [interquartile ranges, 57.54-63.33 ms]), II (64.7 ms [interquartile ranges, 62.54-67.39 ms]), and III (61.9 ms, [interquartile ranges, 57.54-64.53 ms]). Mean T2 values were significantly higher in the different zones when comparing the OA patients whatever the cause primary or secondary (p value < 0.05) with the control group; no significant difference was noticed between the primary and secondary OA (p value > 0.05).

Conclusion

T2 relaxometry is a reliable, quantitative method for the assessment of the glenohumeral cartilage for significant differences in T2 values between the control group and the OA patients.

Imaging of calcific tendinopathy around the shoulder: usual and unusual presentations and common pitfalls

Rotator cuff calcific tendinopathy (RCCT) is a very common condition, characterized by calcium deposition over fibrocartilaginous metaplasia of tenocytes, mainly occurring in the supraspinatus tendon. RCCT has a typical imaging presentation: in most cases, calcific deposits appear as a dense opacity around the humeral head on conventional radiography, as hyperechoic foci with or without acoustic shadow at ultrasound and as a signal void at magnetic resonance imaging. However, radiologists have to keep in mind the possible unusual presentations of RCCT and the key imaging features to correctly differentiate RCCT from other RC conditions, such as calcific enthesopathy or RC tears. Other presentations of RCCT to be considered are intrabursal, intraosseous, and intramuscular migration of calcific deposits that may mimic infectious processes or malignancies. While intrabursal and intraosseous migration are quite common, intramuscular migration is an unusual evolution of RCCT. It is important also to know atypical regions affected by calcific tendinopathy as biceps brachii, pectoralis major, and deltoid tendons. Unusual presentations of RCCT may lead to diagnostic challenge and mistakes. The aim of this review is to illustrate the usual and unusual imaging findings of RCCT that radiologists should know to reach the correct diagnosis and to exclude other entities with the purpose of preventing further unnecessary imaging examinations or interventional procedures.

Ultrasound-Guided Percutaneous Tenotomy of the Long Head of Biceps Tendon in Patients with Symptomatic Complete Rotator Cuff Tear: In Vivo Non-contRolled Prospective Study

Background: We prospectively tested technical feasibility and clinical outcome of percutaneous ultrasound-guided tenotomy of long head of biceps tendon (LHBT). Methods: We included 11 patients (6 women; age: 73 ± 8.6 years) with symptomatic full-thickness rotator cuff tear and intact LHBT, in whom surgical repair was not possible/refused. After ultrasound-guided injection of local anesthetic, the LHBT was cut with a scalpel under continuous ultrasound monitoring until it became no longer visible. Pain was recorded before and at least six months after procedure. An eight-item questionnaire was administered to patients at follow-up. Results: A median of 4 tendon cuts were needed to ensure complete tenotomy. Mean procedure duration was 65 ± 5.7 s. Mean length of skin incision was 5.8 ± 0.6 mm. Pre-tenotomy VAS score was 8.2 ± 0.7, post-tenotomy VAS was 2.8 ± 0.6 (p < 0.001). At follow-up, 5/11 patients were very satisfied, 5/11 satisfied and 1/11 neutral. One patient experienced cramping and very minimal pain in the biceps. Six patients had still moderate shoulder pain, 1/11 minimal pain, 2/11 very minimal pain, while 2/11 had no pain. No patients had weakness in elbow flexion nor limits of daily activities due to LHBT. One patient showed Popeye deformity. All patients would undergo ultrasound-guided tenotomy again. Conclusion: ultrasound-guided percutaneous LHBT tenotomy is technically feasible and effective.

Ultrasound-Guided Percutaneous Irrigation of Rotator Cuff Calcific Tendinopathy (US-PICT): Patient Experience

Purpose

To assess patients' experience of ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinopathy (US-PICT).

Methods

Ninety-one patients (58 females; mean age: 50.5 ± 8.3 years) treated by US-PICT (local anesthesia, single-needle lavage, and intrabursal steroid injection) answered to a list of questions regarding their experience of the procedure before treatment, immediately after treatment, and three months later. The Borg CR10 scale was used to evaluate perceived pain, discomfort during anesthetic injection, and anxiety. The Wilcoxon, Spearman's rho, linear regression, and chi-square statistics were used.

Results

81/91 patients complained mild discomfort during the injection of anesthetics (2, 1-2). Pain scores during US-PICT were very low (0, 0-1), with 70% patients having not experienced pain. After treatment, we found a significant reduction of pain (before: 8, 7-8; 3-month: 3, 1-6; p < .001) and anxiety (before: 5, 2-7; during treatment: 2, 1-7; p = 0.010), with high overall satisfaction (immediately after: 10, 9-10; 3-month: 9, 7-10) and confidence in the possibility of recovery (immediately after: 9, 8-10; 3-month: 10, 8-10), respectively. Treatments performed before US-PICT were not statistically associated with pain relief (p = 0.389) and clinical improvement (p = 0.937). We found a correlation between satisfaction immediately postprocedure and confidence in the possibility of recovery (p = 0.002) and between satisfaction three months after treatment and clinical improvement (p < 0.001) and patients' reminds about the description of the procedure (p = 0.005) and of the potential complications (p = 0.035).

Conclusions

US-PICT is a mildly painful, comfortable, and well-tolerated procedure, regardless of any previous treatments. Patients' satisfaction is correlated with clinical benefit and full explanation of the procedure and its complications.

Posterior Shoulder Instability: What to Look for

Posterior shoulder instability is often hard to diagnose with clinical examination. Patients generally present with vague pain, weakness, and/or joint clicking but less frequently complaining of frank sensation of instability. Imaging examinations, especially MR imaging and magnetic resonance arthrography, have a pivotal role in the identification and management of this condition. This review describes the pathologic micro/macrotraumatic magnetic resonance features of posterior shoulder instability as well as the underlying joint abnormalities predisposing to this condition, including developmental anomalies of the glenoid fossa, humeral head, posterior labrum, and capsular and ligamentous structures.

Diagnostic performance of 3D-multi-Echo-data-image-combination (MEDIC) for evaluating SLAP lesions of the shoulder

Background

Superior labral anterior to posterior (SLAP) lesions remain a clinical and diagnostic challenge in routine (non-arthrographic) MR examinations of the shoulder. This study prospectively evaluated the ability of 3D-Multi-Echo-Data-Image-Combination (MEDIC) compared to that of routine high resolution 2D-proton-density weighted fat-saturated (PD fs) sequence using 3 T-MRI to detect SLAP lesions using arthroscopy as gold standard.

Methods

Seventeen consecutive patients (mean age, 51.6 ± 14.8 years, 11 males) with shoulder pain underwent 3 T MRI including 3D-MEDIC and 2D-PD fs followed by arthroscopy. The presence or absence of SLAP lesions was evaluated using both sequences by two independent raters with 4 and 14 years of experience in musculoskeletal MRI, respectively. During arthroscopy, SLAP lesions were classified according to Snyder’s criteria by two certified orthopedic shoulder surgeons. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 3D-MEDIC and 2D-PD fs for detection of SLAP lesions were calculated with reference to arthroscopy as a gold standard. Interreader agreement and sequence correlation were analyzed using Cohen’s kappa coefficient.

Figure 1 demonstrates the excellent visibility of a proven SLAP lesion using the 3D-MEDIC and Fig. 2 demonstrates a false-positive case.

Results

Arthroscopy revealed SLAP lesions in 11/17 patients. Using 3D-MEDIC, SLAP lesions were diagnosed in 14/17 patients by reader 1 and in 13/17 patients by reader 2. Using 2D-PD fs, SLAP lesions were diagnosed in 11/17 patients by reader 1 and 12/17 patients for reader 2. Sensitivity, specificity, PPV, and NPV of 3D-MEDIC were 100.0, 50.0, 78.6, and 100.0% for reader 1; and 100.0, 66.7, 84.6, and 100% for reader 2, respectively. Sensitivity, specificity, PPV, and NPV of 2D-PD fs were 90.9, 83.3, 90.9, and 83.3% for reader 1 and 100.0, 83.3, 91.7, and 100.0% for reader 2. The combination of 2D-PD fs and 3D-MEDIC increased specificity from 50.0 to 83.3% for reader 1 and from 66.7 to 100.0% for reader 2. Interreader agreement was almost perfect with a Cohen’s kappa of 0.82 for 3D-MEDIC and 0.87 for PD fs.

Conclusions

With its high sensitivity and NPV, 3D-MEDIC is a valuable tool for the evaluation of SLAP lesions. As the combination with routine 2D-PD fs further increases specificity, we recommend incorporation of 3D-MEDIC as an additional sequence in conventional shoulder protocols in patients with non-specific shoulder pain.

Potential use of a diluted high-relaxivity gadolinium-based intra-articular contrast agent for magnetic resonance arthrography: an in-vitro study

Background

Magnetic resonance arthrography (MRA) requires intra-articular injection of gadolinium-based diluted paramagnetic contrast material. To our knowledge, gadobenate dimeglumine (Gd-BOPTA) has never been used for intra-articular applications. Our aim was to test in vitro different concentrations of Gd-BOPTA to be potentially used to perform MRA.

Methods

Gd-BOPTA was diluted in saline (NaCl 0.9%) to achieve different concentrations (4 mmol/l; 2 mmol/l; 1 mmol/l; 0.67 mmol/l; 0.5 mmol/l). Six sets of five sterile pipes were prepared with 5 ml of each solution, five sets added with 0.5 ml of fresh synovial fluid. Two separate pipes were prepared with 5 ml of gadopentetate dimeglumine (Gd-DTPA) at 2 mmol/l, one pipe added with 0.5 ml of synovial fluid. Pipes were imaged using a T1-weighted sequence at 1.5 T. For each pipe, signal intensity (SI) in arbitrary units (au) was measured.

Results

SI reproducibility range was 86–99%. Mean Gd-BOPTA SI in pipes containing synovial fluid increased from 1236 ± 8au (0.5 mmol/l) up to 1610 ± 44au (1 mmol/l) and down to 1405 ± 33au (4 mmol/l). Mean Gd-BOPTA SI in pipes without synovial fluid increased from 1184 ± 29au (0.5 mmol/l) up to 1530 ± 38au (1 mmol/l), and down to 1347 ± 39au (4 mmol/l). SI of pipes without synovial fluid was lower than that of pipes with synovial fluid for both Gd-BOPTA and Gd-DTPA (P ≤ 0.002). Regarding pipes with synovial fluid, mean Gd-DTPA SI at 2 mmol/l was 1246 ± 27au. Compared with Gd-BOPTA, SI was not different at 0.5 mmol/l (− 0.2%, P = 0.587) while it was higher (P < 0.001) at all other concentrations (range + 13.3%[4 mmol/l] − + 28.3%[1 mmol/l]). Regarding pipes without synovial fluid, mean Gd-DTPA SI at 2 mmol/l was 1275 ± 56au. Compared with Gd-BOPTA, SI was lower at 0.5 mmol/l (− 6.8%,P < 0.001), while it was higher (P < 0.001) at all other concentrations (range + 6.1%[4 mmol/l] − + 19.6% [1 mmol/l]).

Conclusions

In vitro, Gd-BOPTA at 1 mmol/ had a + 28% SI increase in comparison to Gd-DTPA 2 mmol/l. SI similar to Gd-DTPA can be obtained using one fourth concentration of Gd-BOPTA.

Imaging of long head biceps tendon. A multimodality pictorial essay

The aim of this is article is to provide an  imaging review of normal anatomy, most common anatomical variants and pathologies of the long head of the biceps tendon (LHB) encountered during the daily practice.