MR evaluation of rotator cuff pathology using T2-weighted fast spin-echo technique with and without fat suppression

Development and clinical validation of deep learning for auto-diagnosis of supraspinatus tears

BACKGROUND

Accurately diagnosing supraspinatus tears based on magnetic resonance imaging (MRI) is challenging and time-combusting due to the experience level variability of the musculoskeletal radiologists and orthopedic surgeons. We developed a deep learning-based model for automatically diagnosing supraspinatus tears (STs) using shoulder MRI and validated its feasibility in clinical practice.

MATERIALS AND METHODS

A total of 701 shoulder MRI data (2804 images) were retrospectively collected for model training and internal test. An additional 69 shoulder MRIs (276 images) were collected from patients who underwent shoulder arthroplasty and constituted the surgery test set for clinical validation. Two advanced convolutional neural networks (CNN) based on Xception were trained and optimized to detect STs. The diagnostic performance of the CNN was evaluated according to its sensitivity, specificity, precision, accuracy, and F1 score. Subgroup analyses were performed to verify its robustness, and we also compared the CNN's performance with that of 4 radiologists and 4 orthopedic surgeons on the surgery and internal test sets.

RESULTS

Optimal diagnostic performance was achieved on the 2D model, from which F1-scores of 0.824 and 0.75, and areas under the ROC curves of 0.921 (95% confidence interval, 0.841-1.000) and 0.882 (0.817-0.947) were observed on the surgery and internal test sets. For the subgroup analysis, the 2D CNN model demonstrated a sensitivity of 0.33-1.000 and 0.625-1.000 for different degrees of tears on the surgery and internal test sets, and there was no significant performance difference between 1.5 and 3.0 T data. Compared with eight clinicians, the 2D CNN model exhibited better diagnostic performance than the junior clinicians and was equivalent to senior clinicians.

CONCLUSIONS

The proposed 2D CNN model realized the adequate and efficient automatic diagnoses of STs, which achieved a comparable performance of junior musculoskeletal radiologists and orthopedic surgeons. It might be conducive to assisting poor-experienced radiologists, especially in community scenarios lacking consulting experts.

Isolated bursal-side infraspinatus tear diagnosed by computed tomography bursography: a case series

Background

Partial-thickness rotator cuff tears are commonly found in the articular-side tendon of the supraspinatus; however, isolated lesions, except those occurring in the supraspinatus tendons, are rare. We report three cases of isolated bursal-side infraspinatus tears that were difficult to detect by magnetic resonance imaging but could be visualized by computed tomography bursography.

Case presentation

Three Asian patients (59–71 years old) with shoulder pain ranging from 1 month to 3 years in duration were each diagnosed with shoulder impingement syndrome. Magnetic resonance imaging studies failed to show a tear of the rotator cuff tendon complex. However, computed tomography bursography showed a longitudinal infraspinatus partial-thickness tear on the bursal side in each case. Arthroscopic decompression of the subacromial space and debridement of the infraspinatus tendon tear successfully alleviated the shoulder pain in two of the three patients; the third patient did not undergo surgery and remained symptomatic at follow-up.

Conclusions

In patients with chronic shoulder pain but normal magnetic resonance imaging findings, computed tomography bursography should be considered, as bursal-side infraspinatus tears may be found in these patients. Furthermore, our findings provide a basis for larger studies to further establish the accuracy of computed tomography bursography for these lesions.

Inter-rater agreement of rotator cuff tendon and muscle magnetic resonance imaging parameters evaluated preoperatively and during the first postoperative year following rotator cuff repair

BACKGROUND

Magnetic resonance imaging (MRI) is standard of care for rotator cuff evaluation, with clinical interpretation usually limited to qualitative judgments. The reliability of MRI-based measurements and scoring systems has been evaluated only preoperatively or ≥6 months following rotator cuff repair, when repairs are in the later stages of healing. This study describes the MRI assessments and inter-rater agreement of various rotator cuff tendon and muscle parameters evaluated preoperatively and 4 times during the first postoperative year.

METHODS

Two musculoskeletal radiologists independently assessed MRI scans of 42 patients preoperatively and 3, 12, 26, and 52 weeks after rotator cuff repair. Using standardized reading rules, readers assessed tendon integrity (5-point Sugaya classification), tear dimensions, muscle fat (5-point Goutallier classification) and atrophy (4-point Warner classification), muscle cross-sectional areas, and myotendinous junction distance. Raw exact agreement proportions, κ statistics, and correlation coefficients were used to quantify inter-rater agreement.

RESULTS

Readers showed moderate to substantial above-chance agreement in scoring rotator cuff tendon integrity and supraspinatus muscle atrophy and good to excellent agreement on tear dimensions and muscle cross-sectional areas but only fair to moderate agreement for fatty infiltration and myotendinous junction distance. Only fatty infiltration grades evidenced observer bias. Inter-rater agreement did not appear time dependent.

CONCLUSION

By use of defined reading rules in a research setting, MRI evaluations of rotator cuff tendon integrity, tear dimensions, muscle atrophy, and cross-sectional areas have reasonable reliability at all time points in the first postoperative year. However, the presence of clinically significant disagreements, even in such favorable circumstances, indicates the need for improved imaging tools for precise rotator cuff evaluation.

Diagnostic Ultrasound Shows Reversal of Supraspinatus Muscle Atrophy Following Arthroscopic Rotator Cuff Repair

PURPOSE

Prospective study to assess ultrasonography (US) utility as an imaging tool for supraspinatus muscle atrophy diagnosis, establishing if there is any relationship between repairing supraspinatus tears and its eventual muscular recovery.

METHODS

Observational study.

SELECTION CRITERIA

adults with a full-thickness reparable supraspinatus tear confirmed arthroscopically. Clinical and imaging data pre- and postoperatively with 12 months of follow-up were recorded, including demographic data, Constant scale, Patte classification, repair type, and supraspinatus muscle belly US images in both shoulders, recording height, diameter, echogenicity (mean number of pixels between 0-black and 255-white), and central tendon pennate angle (PA).

RESULTS

In total, 110 supraspinatus tears underwent arthroscopic repair (2015-2018). Mean age was 61 ± 8 years (46-77). We detected a correlation between atrophy and age in terms of echogenicity and PA (P = .01). Echogenicity improved from 54.5 to 51.0 (P = .365) and slightly deteriorated on the contralateral side from 51.6 to 52.9 (P = .351). Supraspinatus echogenicity compared to trapezius muscle reduced from 0.43 to 0.36 (P < .001). PA augmented from 5.8 to 8.6 (P < .001). Mean PA on the contralateral side was 8.6 preoperatively. Patte II cases showed the most significant improvement in terms of imaging evaluation of atrophy. Although Patte III cases almost did not improve in terms of atrophy, they improved clinically. We observed improvement after surgery in Constant score from 35 to 85 (P < .001). Minimal clinically important differences for Constant and visual analog scale were 44.45 ± 12.87 and 6.54 ± 1.41, respectively. Recurrence of symptoms was 13%, related to worse results of PA and echogenicity compared to nonrecurrences.

CONCLUSIONS

Supraspinatus atrophic muscle changes after repair can be reversed. It can be quantified using US imaging (histogram, histogram ratio and echogenicity reduction, pennate pattern, and PA augmentation). Patte II cases showed the best results after repair, demonstrated by US. The faster the repair, the better the results without being influenced by repair type. The bigger the tear and retraction, the more echogenicity and less PA, with worse clinical and US results.

LEVEL OF EVIDENCE

Level III, prospective therapeutic study.

Evaluation of Diagnostic Precision of Ultrasound for Rotator Cuff Disorders in Patients with Shoulder Pain

Background

Rotator cuff disorders are a leading cause of shoulder symptoms. Accurate imaging, detecting the type of the involved muscle, and severity of the injury have important effects on the choice of treatment. Accordingly, the current study was conducted to evaluate the diagnostic accuracy of ultrasound for rotator cuff disorders in patients suffering from shoulder pain and to explore the precision of ultrasound in determining the exact dimensions of a tear in comparison with magnetic resonance imaging (MRI).

Methods

This prospective research was performed on patients clinically suspected of rotator cuff tendinopathy. An ultrasound of the shoulder was initially performed for the candidates. In this study, MRI was regarded as the modality of choice for examining the images of shoulder disorders. The European Society of Musculoskeletal Radiology (ESSR) guidelines were used to design the protocols and implement imaging measures. Based on the reference standard of MRI, the specificity and sensitivity as well as positive and negative predictive values of ultrasound in detection of rotator cuff disorders were calculated.

Results

A total of48 patients (22 women, 23 dominant right hands) with an average age of 51.6±8.3 years were enrolled in this study. Based on MRI findings, rotator cuff disorders were detected in 43 patients (89.5%). The most commonly observed disorders were partial-thickness rotator cuff tear (n=17, 35.4%), full-thickness rotator cuff tear (n=16, 33.3%), and tendinopathy (n=10, 20.8%). Among rotator cuff disorders, the highest sensitivity of ultrasound was observed in the detection of full-thickness tear (93.7%) and rotator cuff tendinopathy (90%). The highest specificity was found in the detection of full-thickness rotator cuff tear (100%) and partial-thickness rotator cuff tear (96.7%).

Conclusion

Based on our findings, ultrasound could be considered as a high-quality diagnostic tool to rule in partial and full-thickness rotator cuff tears and rule out the rotator cuff pathologies.

Magnetic resonance imaging reproducibility for rotator cuff partial tears in patients up to 60 years

Background

Magnetic resonance imaging (MRI) is the gold standard in diagnosing rotator cuff pathology; however, there is a lack of studies investigating the reliability agreement for supraspinatus partial-thickness tears among orthopaedic surgeons and musculoskeletal (MSK) radiologists.

Methods

Sixty digital MRI scans (1.5 Tesla) were reviewed by two orthopaedic shoulder surgeons, two MSK radiologists, two fellowship-trained shoulder surgeons, and two fellowship-trained orthopaedic surgeons at two distinct times. Thirty-two scans of partial-thickness tears and twenty-eight scans of the supraspinatus tendon with no tears were included. Supraspinatus tendonosis and tears, long head of the biceps pathology, acromial morphology, acromioclavicular joint pathology and muscle fatty infiltration were assessed and interpreted according to the Goutallier system. After a four-week interval, the evaluators were asked to review the same scans in a different random order. The statistical analyses for the intra- and interobserver agreement results were calculated using the kappa value and 95% confidence intervals.

Results

The intraobserver agreement for supraspinatus tears was moderate among the MSK radiologists (k = 0.589; 95% CI, 0.446–0.732) and the orthopaedic shoulder surgeons (k = 0.509; 95% CI, 0.324–0.694) and was fair among the fellowship-trained shoulder surgeons (k = 0.27; 95% CI, 0.048–0.492) and the fellowship-trained orthopaedic surgeons (k = 0.372; 95% CI, 0.152–0.592). The overall intraobserver agreement was good (k = 0.627; 95% CI, 0.576–0.678). The intraobserver agreement was moderate for biceps tendonosis (k = 0.491), acromial morphology (k = 0.526), acromioclavicular joint arthrosis (k = 0.491) and muscle fatty infiltration (k = 0.505). The interobserver agreement results for supraspinatus tears were fair and poor among the evaluators: the MSK radiologists and the orthopaedic shoulder surgeons had the highest agreement (k = 0.245; 95% CI, 0.055–0.435).

Conclusions

In this sample of digital MRI scans, there was an overall good intraobserver agreement for supraspinatus partial tears; however, there were also poor and fair interobserver agreement results. The evaluators with higher levels of experience (the orthopaedic shoulder surgeons and the MSK radiologists) demonstrated better results than evaluators with lower levels of experience.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2760-4) contains supplementary material, which is available to authorized users.

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.

Are non-steroidal anti-inflammatory drug injections an alternative to steroid injections for musculoskeletal pain?: A systematic review

Background

Given the potential side effect profile of steroids, the need for an alternative injectable anti-inflammatory is needed. The purpose of this systematic review was to compare corticosteroid injections with non-steroidal anti-inflammatory drug (NSAID) injections for musculoskeletal pain.

Methods

Reviewers with methodological and content expertise searched three databases: PUBMED, Medline and EMBASE. Two blinded reviewers searched, screened, and evaluated the data quality. Data was abstracted in duplicate. Agreement and descriptive statistics are presented.

Results

Four studies were included. All four studies found no statistically significant differences in improvements on the visual analog scale. The follow-up period within the four studies ranged between 2 weeks and 3 months. No statistically significant differences were demonstrated between the two groups with regards to functional outcomes.

Interpretation

The studies reviewed, while limited in quantity, show that compared with corticosteroids, NSAIDs provide equivalent, if not better, pain relief from the musculoskeletal ailments assessed. Further, there is weak evidence supporting a lower recurrence rate of symptoms with NSAIDs when compared to corticosteroids. There is a need for more long-term high-quality studies on this topic.

Level of evidence

Level II (Systematic review of Level II and III studies).

Role and Correlation of High Resolution Ultrasound and Magnetic Resonance Imaging in Evaluation of Patients with Shoulder Pain

Background

The study aimed to evaluate of the role of high-resolution ultrasound and magnetic resonance imaging in patients with shoulder pain.

Material/Methods

This prospective study included 50 patients referred for ultrasound and MRI because of shoulder pain. All patients were examined clinically, followed by radiography of the affected shoulder. High-resolution ultrasound examination of the involved shoulder was performed together with an examination of the contralateral normal shoulder, followed by MRI of the symptomatic shoulder in all 50 patients.

Results

In the present study, the majority of patients were in age group 56–65 years, 56% were males and 44% were females (of a total of 50 patients). A total of 40 patients were diagnosed as having rotator cuff tears on ultrasound (USG) and MRI. USG showed complete-thickness tears in 25 patients and partial-thickness tears in 15 patients. MRI detected 28 complete- and 12 partial-thickness tears of the rotator cuff. In the diagnosis of rotator cuff tears, the strength of agreement between ultrasound and magnetic resonance imaging was good (kappa coefficient=0.79).

Conclusions

Ultrasonography of the shoulder shows promising results in the diagnosis of rotator cuff tears and in differentiating partial from complete tears. A wide availability, cost effectiveness and better tolerability of ultrasonography make it a modality of first choice for evaluating rotator cuff tears.

Characterization of Rotator Cuff Tears: Ultrasound Versus Magnetic Resonance Imaging

Ultrasound and magnetic resonance imaging (MRI) are both capable of diagnosing full-thickness rotator cuff tears. However, it is unknown which imaging modality is more accurate and precise in evaluating the characteristics of full-thickness rotator cuff tears in a surgical population. This study reviewed 114 patients who underwent arthroscopic repair of a full-thickness rotator cuff tear over a 1-year period. Of these patients, 61 had both preoperative MRI and ultrasound for review. Three musculoskeletal radiologists evaluated each ultrasound and MRI in a randomized and blinded fashion on 2 separate occasions. Tear size, retraction status, muscle atrophy, and fatty infiltration were analyzed and compared between the 2 modalities. Ultrasound measurements were statistically smaller in both tear size (P=.001) and retraction status (P=.001) compared with MRI. The 2 image modalities showed comparable intraobserver reliability in assessment of tear size and retraction status. However, MRI showed greater interobserver reliability in assessment of tear size, retraction status, and atrophy. Independent observers are more likely to agree on measurements of the characteristics of rotator cuff tears when using MRI compared with ultrasound. As tear size increases, the 2 image modalities show greater differences in measurement of tear size and retraction status. Additionally, compared with MRI, ultrasound shows consistently low reliability in detecting subtle, but clinically important, degeneration of the soft tissue envelope. Although it is inexpensive and convenient, ultrasound may be best used to identify a tear, and MRI is superior for use in surgical planning for larger tears. [Orthopedics. 2017; 40(1):e124-e130.].

Intra- and Inter-rater Agreement on Magnetic Resonance Imaging Evaluation of Rotator Cuff Integrity After Repair

PURPOSE

To investigate the intra- and inter-rater agreement of magnetic resonance imaging (MRI) evaluations of rotator cuff integrity at 6 and 24 months after arthroscopic rotator cuff repair (ARCR).

METHODS

Three shoulder surgeons reviewed 68 MRI scans from 34 patients who had undergone ARCR and MRI examination at both 6 and 24 months after surgery. Postoperative rotator cuff integrity was investigated by using Owen, Sugaya, and Hayashida classifications to determine whether the rotator cuff was intact or whether there was a partial-thickness retear or full-thickness retear and Burks score to assess tendon appearance. Multirater kappa statistics were used to measure intra- and inter-rater agreement. Kappa values were interpreted according to guidelines adapted from the work of Landis and Koch.

RESULTS

All classifications had similar intra- and inter-rater agreement (κ = 0.14 to 0.67, 0.23 to 0.60, respectively), but no intra- or inter-rater agreement scored "excellent." Inter-rater agreement after ARCR was higher at 24 months (κ = 0.31 to 0.60) than at 6 months (κ = 0.23 to 0.44) in all evaluations. Reviewers identified full-thickness retears with a moderate to good degree of inter-rater agreement in all evaluations, at both 6 months (κ = 0.42 to 0.73) and 24 months (κ = 0.61 to 0.80) after ARCR. However, poor inter-rater agreement (κ = 0.13 to 0.19) was found in the identification of partial-thickness retears in all evaluations at 6 months after ARCR.

CONCLUSIONS

Shoulder surgeons showed better intra- and inter-rater agreement in predicting full-thickness tears compared with partial-thickness tears. The inter-rater agreement at 24 months after ARCR was superior to that at 6 months in predicting not only full-thickness retear but also partial-thickness retear. MRI evaluation of rotator cuff integrity at 6 months after ARCR may be less reliable, regardless of which classification system is used.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

The evaluation and treatment of rotator cuff pathology

Rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. History and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. Treatment options include nonsteroidal anti-inflammatory agents, subacromial corticosteroid injections, and exercise therapy. Surgical intervention is generally reserved for those failing nonoperative measures and/or healthy, young, and middle-aged adults with full-thickness rotator cuff tears. No surgical technique has proved to be superior. Despite surgery, about 20% of patients experience retears, more likely occurring in those with larger tears.

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.

Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft

PURPOSE

This study presents a retrospective case series of the clinical and structural outcomes (1.5 T MRI) of arthroscopic rotator cuff repair with acellular human dermal graft reinforcement performed by a single surgeon in patients with large, massive, and previously repaired rotator cuff tears.

MATERIALS AND METHODS

Fourteen patients with mean anterior to posterior tear size 3.87 ± 0.99 cm (median 4 cm, range 2.5-6 cm) were enrolled in the study and were evaluated for structural integrity using a high-field (1.5 T) MRI at an average of 16.8 months after surgery. The Constant-Murley scores, the Flexilevel Scale of Shoulder Function (Flex SF), scapular plane abduction, and strength were analyzed.

RESULTS

MRI results showed that the rotator cuff repair was intact in 85.7% (12/14) of the patients studied. Two patients had a Sugaya Type IV recurrent tear (2 of 14; 14.3%), which were both less than 1 cm. The Constant score increased from a preoperative mean of 49.72 (range 13-74) to a postoperative mean of 81.07 (range 45-92) (P value = 0.009). Flexilevel Scale of Shoulder Function (Flex SF) Score normalized to a 100-point scale improved from a preoperative mean of 53.69 to a postoperative mean of 79.71 (P value = 0.003). The Pain Score improved from a preoperative mean of 7.73 to a postoperative mean of 13.57 (P value = 0.008). Scapular plane abduction improved from a preoperative mean of 113.64° to a postoperative mean of 166.43° (P value = 0.010). The strength subset score improved from a preoperative mean of 1.73 kg to a postoperative mean of 7.52 kg (P value = 0.006).

CONCLUSIONS

This study presents a safe and effective technique that may help improve the healing rates of large, massive, and revision rotator cuff tears with the use of an acellular human dermal allograft. This technique demonstrated favorable structural healing rates and statistically improved functional outcomes in the near term.

LEVEL OF EVIDENCE

4. Retrospective case series.

Magnetic resonance imaging identification of rotator cuff retears after repair: interobserver and intraobserver agreement

BACKGROUND

Magnetic resonance imaging (MRI) is the most commonly used imaging modality to assess the rotator cuff. Currently, there are a limited number of studies assessing the interobserver and intraobserver reliability of MRI after rotator cuff repair.

HYPOTHESIS

Fellowship-trained orthopaedic shoulder surgeons will have good inter- and intraobserver agreement with regard to features of the repaired rotator cuff (repair integrity, fat content, muscle volume, number of tendons involved, tear size, and retract) on MRI.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Seven fellowship-trained orthopaedic shoulder surgeons reviewed 31 MRI scans from 31 shoulders from patients who had previous rotator cuff repair. The scans were evaluated for the following characteristics: rotator cuff repair status (full-thickness retear vs intact repair), tear location, tendon thickness, fatty infiltration, atrophy, number of tendons involved in retear, tendon retraction, status of the long head of the biceps tendon, and bone marrow edema in the humeral head. Surgeons were asked to review images at 2 separate time points approximately 9 months apart and complete an evaluation form for each scan at each time point. Multirater kappa (κ) statistics were used to assess inter- and intraobserver reliability.

RESULTS

The interobserver agreement was highest (80%, κ = 0.60) for identifying full-thickness retears, tendon retear retraction (64%, κ = 0.45), and cysts in the greater tuberosity (72%, κ = 0.43). All other variables were found to have fair to poor agreement. The worst interobserver agreement was associated with identifying rotator cuff footprint coverage (47%, κ = -0.21) and tendon signal intensity (29%, κ = -0.01). The mean intraobserver reproducibility was also highest (77%-90%, κ = 0.71) for full-thickness retears, quality of the supraspinatus (47%-83%, κ = 0.52), tears of the long head of the biceps tendon (58%-94%, κ = 0.49), presence of bone marrow edema in the humeral head (63%-87%, κ = 0.48), cysts in the greater tuberosity (70%-83%, κ = 0.47), signal in the long head of the biceps tendon (60%-80%, κ = 0.43), and quality of the infraspinatus (37-90%, κ = 0.43). The worst intraobserver reproducibility was found in identification of the location of bone marrow edema (22%-83%, κ = -0.03).

CONCLUSION

The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. Intact rotator cuff repairs or full-thickness retears can be identified with moderate reliability. These findings indicate that additional imaging modalities may be needed for accurate assessment of the repaired rotator cuff.

Magnetic resonance imaging of rotator cuff disease and external impingement

Magnetic resonance (MR) imaging plays a major role in helping to identify rotator cuff disease and in demonstrating the pathology associated with external impingement. Many surgeons rely on MR imaging to assist in decision making and presurgical planning for patients with rotator cuff pain. This article reviews the etiology of external impingement and rotator cuff tears, and describes the MR imaging appearance of the normal and the pathologic rotator cuffs. It focuses on the supraspinatus tendon because this is the tendon involved in 95% of rotator cuff tears.

Technical update on magnetic resonance imaging of the shoulder

Improvement in both hardware and software has opened up new opportunities in magnetic resonance (MR) imaging of the shoulder. MR imaging at 3-T has become a reality, with the prospect of 7-T imaging on the horizon. The art of MR arthrography continues to improve, aided by the use of novel imaging positions. New techniques for three-dimensional imaging, the reduction of metal artifact, and biochemical imaging of cartilage hold great promise.

MRI versus radiography of acromioclavicular joint dislocation

OBJECTIVE

Acromioclavicular joint injuries are usually diagnosed by clinical and radiographic assessment with the Rockwood classification, which is crucial for treatment planning. In view of the implementation of MRI for visualization of the acromioclavicular joint, the purpose of this study was to describe the MRI findings of acromioclavicular joint dislocation in comparison with the radiographic findings.

SUBJECTS AND METHODS

Forty-four patients with suspected unilateral acromioclavicular joint dislocation after acute trauma were enrolled in this prospective study. All patients underwent digital radiography and 1-T MRI with a surface phased-array coil. MRI included coronal proton density-weighted turbo spin-echo and coronal 3D T1-weighted fast field-echo water-selective sequences. The Rockwood classification was used to assess acromioclavicular joint injuries at radiography and MRI. An adapted Rockwood classification was used for MRI evaluation of the acromioclavicular joint ligaments. The classifications of acromioclavicular joint dislocations diagnosed with radiography and MRI were compared.

RESULTS

Among 44 patients with Rockwood type I-IV injuries on radiographs, classification on radiographs and MR images was concordant in 23 (52.2%) patients. At MRI, the injury was reclassified to a less severe type in 16 (36.4%) patients and to a more severe type in five (11.4%) patients. Compared with the findings according to the original Rockwood system, with the adapted system that included MRI findings, additional ligamentous lesions were found in 11 (25%) patients.

CONCLUSION

In a considerable number of patients, the MRI findings change the Rockwood type determined with radiography. In addition to clinical assessment and radiography, MRI may yield important findings on ligaments that may influence management.

High-resolution magnetic resonance imaging of rotator cuff tears using a microscopy coil: noninvasive detection without intraarticular contrast material

PURPOSE

The aim of this study was to evaluate the feasibility of high-resolution magnetic resonance imaging (MRI) using a microscopy coil for the diagnosis of rotator cuff tears by comparing the method to conventional MRI and MRI arthrography.

MATERIALS AND METHODS

A total of 68 shoulders were prospectively studied using a 1.5-T MRI unit. Conventional MRI scans were obtained with a surface coil and high-resolution MRI scans with a microscopy coil. MRI arthrography was performed in 28 shoulders using a surface coil. MRI evaluation of tears of rotator cuff tendons was compared with arthroscopic findings and surgical results.

RESULTS

The surgery revealed 40 full-thickness tears, 13 partial-thickness tears, and 15 intact cuffs. In all, 35 (88%) full-thickness tears were correctly diagnosed on conventional MRI and 40 (100%) on high-resolution MRI. MR arthrography delineated 11 of 12 (92%) full-thickness tears. Altogether, 5 (38%) of the partial-thickness tears were detected on conventional MRI, and 12 (92%) were clearly demonstrated on high-resolution MRI. MRI arthrography depicted three (60%) of five partial-thickness tears. High-resolution MRI showed higher sensitivity than conventional MRI (P < 0.05) and had values equivalent to those of MRI arthrography for diagnosing partial-thickness tears.

CONCLUSION

High-resolution MRI with a microscopy coil is a feasible, noninvasive technique for diagnosing rotator cuff tears.

Accuracy of ultrasonography and magnetic resonance imaging for detection of full thickness rotator cuff tears

Background:

Rotator cuff problems are frequently seen by orthopedic surgeons and accurate diagnosis is essential for appropriate management. Value of the clinical assessment of a shoulder is often limited, therefore, imaging studies have important implications in the management of rotator cuff pathologies.

Aim:

The purpose of this retrospective study is to compare the accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for detection of full-thickness rotator cuff tears.

Materials and Methods:

We reviewed 91 consecutive cases of shoulder arthroscopy and open rotator cuff repair, who had undergone preoperative investigation in the form of either an ultrasound or MRI. Thirty-six patients had an ultrasound and 55 had an MRI for their affected shoulders. We compared the accuracy of US and MRI for detection of full-thickness rotator cuff tears, using the operative findings as the ‘gold standard’. Data regarding a supraspinatus tear was assessed for the purpose of this study.

Results:

Ultrasonography correctly diagnosed 15 out of 17 tears (sensitivity of 0.88). There were 17 true-negative and two false-positive ultrasounds (specificity of 0.89). MRI accurately identified 33 of the 36 tears (sensitivity of 0.91). There were 16 true-negative and three false-positive tears on MRI (specificity of 0.84). The positive predictive value (PPV) was 88% for US and 92% for MRI. The negative predictive value (NPV) was 89% for US and 84% for MRI. The overall accuracy of the ultrasound was 88.89% (95% confidence interval (CI) = 74.09 to 96.18) as compared to 89.09% (95% CI = 77.82% to 95.26%) for the MRI.

Conclusion:

Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy. US being a dynamic study and better tolerated by the patient, can therefore be used as the first-line investigation for rotator cuff tear, where appropriate skills are available to reduce the waiting time and cost of investigation.

Supraspinatus tendon tears: comparison of 3D US and MR arthrography with surgical correlation

OBJECTIVE

The objective of the study was to compare the diagnostic reliability of 3D US with MR arthrography in diagnosing supraspinatus tendon tears, with arthroscopic findings used as the standard.

MATERIALS AND METHODS

In a prospective study 50 patients who later underwent arthroscopic surgery of the rotator cuff were examined pre-operatively by 3D US with MR arthrography. The presence or absence of a full- or partial-thickness supraspinatus tendon tear and the tear size as demonstrated by each imaging and arthroscopy was recorded. The tear size was divided into three grades: small (<1 cm), medium (1-3 cm), and large (>3 cm).

RESULTS

The arthroscopic diagnosis was a full-thickness tear in 40 patients, partial-thickness tears in 5, and intact supraspinatus tendon in 5. 3D US correctly diagnosed 35 out of 40 full-thickness tears and MR arthrography 39 out of 40 full-thickness tears. Regarding partial-thickness tears, 3D US underestimated 2 cases as no tear and overestimated 1 case as a full-thickness tear. MR arthrography underestimated 1 case as a partial-thickness tear and overestimated 2 cases as full-thickness and partial-thickness tears respectively. 3D US and MR arthrography yield a sensitivity for full-thickness tears of 87.5% and 97.5% with specificity of 90.0% and 90.0%. Based on the grading system, 3D US measurements correctly predicted the tear size of 23 (65.7%) of the 35 full-thickness tears and MR arthrography 30 (75.0%) of the 39 full-thickness tears.

CONCLUSION

Three-dimensional ultrasound seems to be a promising imaging modality comparable to MR arthrography for the assessment of the supraspinatus tendon tears.

[Rotator cuff tears: value of 3.0T MRI]

PURPOSE

To demonstrate the value of 3.0T MR imaging for the detection of rotator cuff tendon tears and surgical planning by correlating imaging findings to surgical findings. Materials and methods. Prospective follow-up of patients who underwent 3.0T MR imaging of the shoulder in our department between November 2005 and June 2007. Surgical findings were correlated to imaging findings for 48 patients who underwent surgery: detection, size, partial thickness or complete, and tendon edges.

RESULTS

In this patient group, the positive predictive value of MRI for detecting surgical tears was 100% (100% of complete tears and 92% of partial thickness tears). No change in surgical management was recorded when arthroscopy was performed based on MRI findings (size of tear).

CONCLUSION

3.0 T MRI is valuable for the detection of small tears, especially for partial thickness tears due to increased spatial resolution. The identification of surgical candidates and surgical planning are improved due to more accurate measurements of tear size and quality of the tendon edges.

Clinical update: MR imaging of the shoulder

Magnetic resonance imaging has become an important diagnostic adjunct in the evaluation of shoulder conditions, and the technology continues to evolve. Direct magnetic resonance arthrography can improve detection of labral and rotator cuff pathology, especially partial thickness tears of the rotator cuff. Special positioning, such as abducted-externally rotated views, improves visualization of the rotator cuff and posterior superior labrum in throwing athletes. Diagnosis-specific sequencing such as fat suppression, spin-echo and proton-density techniques, and higher power magnets (3.0 T) allow for an unprecedented level of soft tissue detail. Clinical expertize is required to differentiate between normal anatomic variants, incidental findings, and true pathology. Although magnetic resonance imaging findings may be diagnostic in some cases, clinical correlation with history and physical examination findings is critical.

The pathogenesis and surgical treatment of tears of the rotator cuff

This review discusses the pathogenesis and surgical treatment of tears of the rotator cuff.

Interobserver agreement in the classification of rotator cuff tears using magnetic resonance imaging

BACKGROUND

Although magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease.

HYPOTHESIS

Fellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Ten fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived.

RESULTS

Interobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was -0.11.

CONCLUSIONS

Fellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

Ultrasonography of symptomatic rotator cuff tears compared with MR imaging and surgery

PURPOSE

To compare the accuracy of ultrasonography and magnetic resonance imaging in the detection of rotator cuff tears.

MATERIALS AND METHODS

Ninety-six patients with clinically suspected rotator cuff pathology underwent ultrasonography and magnetic resonance imaging of the shoulder. The findings in 88 patients were compared with arthroscopy or open surgery.

RESULTS

Full-thickness tear was confirmed in 57 cases, partial-thickness tear in 30 cases and degenerative changes without tear in 1. In all 57 cases of full-thickness tear and in 28 out of 30 cases of partial-thickness tear the supraspinatus tendon was involved. The accuracy in the detection of full-thickness tears was 98 and 100% for ultrasonography and magnetic resonance imaging, respectively. The accuracy in the detection of bursal or articular partial-thickness tears was 87 and 90% for ultrasonography and magnetic resonance imaging, respectively.

CONCLUSIONS

In experienced hands ultrasonography should be considered as an accurate modality for the initial investigation of rotator cuff, especially supraspinatus, tears.

Rim-Rent Tear of the Rotator Cuff: A Common and Easily Overlooked Partial Tear

OBJECTIVE

The purpose of this study was to determine the incidence of rim-rent rotator cuff tears in a population of patients referred for shoulder MRI and to determine the sensitivity of MRI for the detection of these tears.

CONCLUSION

Rim-rent tears are a common type of partial-thickness rotator cuff tear, much more commonly present than has been previously reported. In particular, infraspinatus rim-rent tears are more common than previously believed. Rim-rent tears of the infraspinatus tendon and those involving the anterior-most fibers of the supraspinatus tendon are commonly overlooked on MRI, possibly because of failure to appreciate the high incidence of these types of tears and failure to inspect the anterior-most fibers of the rotator cuff.

Efficacy and cost-effectiveness of a physiotherapy program for chronic rotator cuff pathology: a protocol for a randomised, double-blind, placebo-controlled trial

BACKGROUND

Chronic rotator cuff pathology (CRCP) is a common shoulder condition causing pain and disability. Physiotherapy is often the first line of management for CRCP yet there is little conclusive evidence to support or refute its effectiveness and no formal evaluation of its cost-effectiveness.

METHODS/DESIGN

This randomised, double-blind, placebo-controlled trial will involve 200 participants with CRCP recruited from medical practices, outpatient departments and the community via print and radio media. Participants will be randomly allocated to a physiotherapy or placebo group using concealed allocation stratified by treating physiotherapist. Both groups will receive 10 sessions of individual standardised treatment over 10 weeks from one of 10 project physiotherapists. For the following 12 weeks, the physiotherapy group will continue a home exercise program and the placebo group will receive no treatment. The physiotherapy program will comprise shoulder joint and spinal mobilisation, soft tissue massage, postural taping, and home exercises for scapular control, posture and rotator cuff strengthening. The placebo group will receive inactive ultrasound and gentle application of an inert gel over the shoulder region. Blinded assessment will be conducted at baseline and at 10 weeks and 22 weeks after randomisation. The primary outcome measures are self reported questionnaires including the shoulder pain and disability index (SPADI), average pain on an 11-point numeric rating scale and participant perceived global rating of change. Secondary measures include Medical Outcomes Study 36-item short form (SF-36), Assessment of Quality of Life index, numeric rating scales for shoulder pain and stiffness, participant perceived rating of change for pain, strength and stiffness, and manual muscle testing for shoulder strength using a handheld dynamometer. To evaluate cost-effectiveness, participants will record the use of all health-related treatments in a log-book returned to the assessor monthly. To test the effect of the intervention using an intention-to-treat analysis, linear regression modelling will be applied adjusting for baseline outcome values and other demographic characteristics. Participant measures of perceived change will be compared between groups by calculating the relative risks and their 95% confidence intervals at each time point using log binomial regression.

DISCUSSION

Results from this trial will contribute to the evidence regarding the effectiveness of a physiotherapy program for the management of CRCP.

Diagnostic accuracy of shoulder ultrasound performed by a single operator

Both diagnostic ultrasound and magnetic resonance imaging (MRI) are used for investigation of the presence and severity of rotator cuff lesions. There is no consensus as to which is the more accurate and cost-effective study. We sought to examine the sensitivity of ultrasound, when used by one experienced radiologist with modern equipment. We compared the ultrasound and surgical results obtained from 68 patients. Ultrasound showed a sensitivity of 89% and specificity of 100% (Positive Predictive Value 100%) for full-thickness tears, and a sensitivity of 79% and specificity of 94% (Positive Predictive Value 87%) for partial-thickness tears. We found that shoulder ultrasound, in the hands of an experienced radiologist with the use of modern high-resolution equipment, is highly sensitive in differentiating complete tears and partial-thickness tears. Our results are similar to the best published results for MRI and given that ultrasound is significantly cheaper and more available, ultrasound by an experienced radiologist should be considered as a primary diagnostic tool for imaging the rotator cuff.

3.0-T MRI of the supraspinatus tendon

OBJECTIVE

MRI of the shoulder has been found to be highly sensitive and specific for detection of full-thickness supraspinatus tendon tears at 1.5-T or lower field strength compared with arthroscopy. MRI of the shoulder at 3.0 T has not been specifically assessed. This study assesses the sensitivity and specificity of MRI at 3.0 T for supraspinatus tendon tears compared with arthroscopy.

MATERIALS AND METHODS

Two experienced musculoskeletal radiologists retrospectively reviewed MR images of the shoulder in 150 consecutive patients who had subsequent arthroscopy. All patients had oblique coronal and sagittal T1-weighted and fat-saturated T2-weighted axial, oblique coronal, and sagittal imaging performed. The radiologists interpreted the MR images by consensus without knowledge of the arthroscopy results. Scans were interpreted for full-thickness or partial-thickness supraspinatus tendon tears. If partial-thickness supraspinatus tendon tears were seen on MRI, the reviewers noted whether the partial-thickness tear was articular or bursal in location. The radiologists also separated the supraspinatus tendon tears into small (< 1 cm retraction from the humeral head) and large (> 1 cm retraction from the humeral head). All 150 patients went on to arthroscopy. After consensus review of the MR images, arthroscopy results were compared with consensus MR interpretations.

RESULTS

Ninety-eight of the 150 patients had full-thickness supraspinatus tendon tears at arthroscopy. Twenty-six of the 150 patients had partial-thickness supraspinatus tendon tears. Seventeen of these 26 partial-thickness tears were along the articular surface and nine were along the bursal surface. Ninety-six of 98 full-thickness tears seen at arthroscopy were seen on consensus MRI interpretation. All 26 partial-thickness tears seen at arthroscopy were seen at consensus MR interpretation; however, two of the partial-thickness articular surface tears seen at arthroscopy were interpreted as full-thickness tears on consensus MRI interpretation. Twenty-eight of the 98 full-thickness supraspinatus tendon tears were small tears (< 1 cm retraction from the humeral head) on arthroscopy. Two of these 28 small tears seen on arthroscopy were not seen on consensus MRI interpretation. Twenty-six patients had intact supraspinatus tendons on both retrospective consensus MRI interpretation and at arthroscopy.

CONCLUSION

MRI of the shoulder at 3.0 T is highly sensitive and specific compared with arthroscopy in the detection of full-thickness and partial-thickness supraspinatus tendon tears.

Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect full- and partial-thickness tears of the supraspinatus tendon

PURPOSE

To evaluate prospectively the accuracy of indirect magnetic resonance (MR) arthrography for supraspinatus tendon tears during neutral positioning or abduction and external rotation (ABER) and neutral positioning.

MATERIALS AND METHODS

Informed consent was obtained in all patients, and the study was approved by the institutional review board. Indirect MR arthrography of the shoulder was performed in 51 symptomatic patients (14 female, 37 male; mean age, 47 years) in the neutral position (set 1) and in the neutral and ABER positions (set 2). Two readers independently interpreted both sets, and diagnoses were compared with arthroscopic findings. Diagnostic accuracy was calculated, and 95% confidence intervals were used to detect significant differences between sets. Diagnostic confidence was recorded by using a three-level confidence score. Differences between sets were evaluated by using the Wilcoxon signed rank test. Interobserver agreement was determined separately for each set and for all diagnoses, full-thickness tears, and partial-thickness tears.

RESULTS

For full-thickness tears, there was no benefit to reading set 2. For reader 1, sensitivity and specificity were 95% and 100%, respectively, for set 1 and 100% and 100%, respectively, for set 2. For reader 2, sensitivity and specificity were 80% and 100%, respectively, for set 1 and 100% and 100%, respectively, for set 2. For partial-thickness tears, sensitivity was significantly higher after reading set 2. For reader 1, sensitivity and specificity were 71% and 88%, respectively, for set 1 and 93% and 100%, respectively, for set 2. For reader 2, sensitivity and specificity were 50% and 88%, respectively, for set 1 and 86% and 94%, respectively, for set 2. For both readers, diagnostic confidence for partial-thickness tears was significantly higher after reading set 2. After the interpretation of set 2, kappa values increased from 0.35 to 1.00 for full-thickness tears and from 0.12 to 0.63 for partial-thickness tears.

CONCLUSION

Indirect MR arthrography with supplementary images obtained with patients in the ABER position significantly improved sensitivity and increased diagnostic confidence for partial-thickness tears of the supraspinatus tendon. Interobserver agreement was improved for both full- and partial-thickness tears.

Use of preoperative magnetic resonance imaging to predict rotator cuff tear pattern and method of repair

PURPOSE

To determine the magnetic resonance imaging (MRI) criteria for predicting rotator cuff tear pattern and method of repair.

TYPE OF STUDY

Retrospective MRI/arthroscopy correlation.

METHODS

Sixty-six preoperative MRI scans were evaluated. The maximum medial to lateral length (L) of the tear was measured on T2-weighted coronal cuts. The maximum anterior to posterior width (W) was measured on T2-weighted sagittal cuts. The cases were divided into 3 groups: group 1, short-wide tears, L < or = W, L < 2 cm; group 2, long-narrow tears, L > W, W < 2 cm; and group 3, long-wide tears, L > or = 2 cm, W > or = 2 cm.

RESULTS

Of the 66 MRI scans, 55 were adequate for standardized measurement. Group 1, 16 cases: 15 were found at arthroscopy to be crescent-shaped tears repaired end-to-bone; 1 was repaired with interval slides. Group 2, 22 cases: all 22 were repaired side-to-side/margin convergence. Group 3, 17 cases: 12 required interval slides, 1 partial repair was performed, and 4 were repaired side-to-side/margin convergence.

CONCLUSIONS

Tear pattern and method of repair can be predicted on high-quality MRI scan. Group 1, L < or = W and L < 2 cm, predicts a crescent-shaped tear and end-to-bone repair (positive predictive value, 93.8%). Group 2, L > W and W < 2 cm, predicts a longitudinal tear and side-to-side/margin convergence repair (positive predictive value 100%). Group 3, L > or = 2 cm and W > or = 2 cm, predicts a massive contracted tear and that primary end-to-bone or side-to-side repairs are usually not possible and that interval slides or partial repair may be necessary (positive predictive value, 76.5%). The overall diagnostic model based on usable MRI scans significantly predicted arthroscopic findings (P < .001 for chi-square test).

LEVEL OF EVIDENCE

Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).

Comparison of fat-suppressed T2-weighted fast spin-echo sequence and modified STIR sequence in the evaluation of the rotator cuff tendon

OBJECTIVE

This study was performed to determine whether a modified version of the classic STIR sequence provides similar information about the integrity of the rotator cuff tendon as the commonly used fat-suppressed T2-weighted fast spin-echo sequence.

SUBJECTS AND METHODS

Sixty-one consecutive MRI examinations of the shoulder in 57 patients were performed using a coronal oblique T1-weighted spin-echo sequence, a modified version of the STIR sequence, and a fat-suppressed T2-weighted fast spin-echo sequence. Three reviewers independently assessed the rotator cuff tendon using the coronal oblique modified inversion recovery sequence and T1-weighted spin-echo sequence. After a minimum of 4 weeks, reviewers assessed the rotator cuff tendon using the fat-suppressed T2-weighted fast spin-echo sequence and T1-weighted spin-echo sequence. The kappa statistic was used to measure the degree of concordance between interpretations when each sequence was used independently. The conditional probability that a full- and a partial-thickness tear would be diagnosed on both sequences was calculated. Image quality was assessed in a side-by-side comparison.

RESULTS

The overall weighted kappa score was 0.82, which indicates excellent concordance between the two sequences. If a full-thickness tear of the rotator cuff tendon was found on the fat-suppressed T2-weighted fast spin-echo sequence, there was a 94.1% probability that the same conclusion would be reached using the modified inversion recovery sequence. If a partial-thickness tear was found on the fat-suppressed T2-weighted fast spin-echo sequence, there was an 80.3% probability that the same conclusion would be reached with the modified inversion recovery sequence. Fat suppression in the modified inversion recovery sequence was superior to that in the T2-weighted fast spin-echo sequence in 26-39% of the examinations.

CONCLUSION

The modified inversion recovery sequence and fat-suppressed T2-weighted fast spin-echo sequence provide similar information about the integrity of the rotator cuff tendon.

Evaluation of rotator cuff tears with magnetic resonance arthrography

The size and morphologic features of rotator cuff tears may influence treatment selection and affect final outcomes. Magnetic resonance arthrography allows observation of these features and other intraarticular structures. To assess the utility of magnetic resonance imaging in assessing size and morphologic features, we retrospectively reviewed observations on 41 shoulders in 37 consecutive surgically treated patients (mean age, 63.2 years) who had magnetic resonance imaging followed by magnetic resonance arthrography. The maximum rotator cuff defect size in the anteroposterior direction defined transverse size, and the maximum rotator cuff defect size in the mediolateral direction defined longitudinal size. Sensitivities for detecting full-thickness rotator cuff tears by magnetic resonance imaging and magnetic resonance arthrography were 90.2% and 100%, respectively. Maximum longitudinal and transverse dimensions of the tear as shown by magnetic resonance arthrography correlated better with intraoperative measurements (r2 = 0.85 transversely, 0.92 longitudinally) than magnetic resonance imaging measurements (r2 = 0.47 transversely, 0.26 longitudinally). The reproducibility of the two methods is similar. Magnetic resonance arthrography also allowed morphologic classification of the torn tendon as blunt end, tapering end, indistinct end, horizontal tear, and global tear. There was good agreement in classifying torn edges; the imaging findings agreed with findings at surgery. Magnetic resonance arthrography was more accurate in evaluating rotator cuff tear size and morphologic features than conventional magnetic resonance imaging.

Ruptures hyperéchogènes de la coiffe des rotateurs

PURPOSE

To describe unusual rotator cuff tendon tears which are hyperechoic at ultrasonography (US).

MATERIALS AND METHOD

We retrospectively reviewed the shoulder US examinations of 100 patients with rotator cuff tear demonstrated by CT arthrogram with bursography. We included in this study hyperechoic foci without surrounding hypoechoic zone. A second US examination was performed after bursal distension.

RESULTS

Six (6%) hyperechoic foci were detected. The initial US diagnosis was tendinosis in five cases (n=5) and full thickness tear in one case (n=1). At repeat US examination, the hyperechoic area was completely or partially hypoechoic, probably because the tears were filled with the injected hypoechoic fluid.

CONCLUSION

Some rotator cuff tears, filled with fibrinoid fragments, are probably underdiagnosed at US.

Work above shoulder level and degenerative alterations of the rotator cuff tendons: A magnetic resonance imaging study

OBJECTIVE

To determine whether work performed with the arms in a highly elevated position is associated with alterations in the rotator cuff tendons as assessed by magnetic resonance imaging (MRI).

METHODS

A cross-sectional study was performed in a historical cohort of male machinists, car mechanics, and house painters. The participants were right-handed, ages 40-50 years, and had been employed in their trades for not less than 10 years. Seventy-one percent of invited subjects participated (136 of 192). Lifetime upper arm elevation was assessed by direct measurements combined with individual work histories obtained by questionnaire and from registry data. Supraspinatus tendinopathy was evidenced by MRI signal intensity changes and morphologic alterations. Infraspinatus and subscapularis tendinopathy were also assessed. Additional outcomes were acromioclavicular joint degeneration and humeral head cysts. The MRI findings were evaluated by radiologists who were blinded to exposure status and symptoms.

RESULTS

An exposure-response relationship was found between lifetime upper arm elevation and supraspinatus tendinopathy, with an age-adjusted odds ratio of 1.27 (95% confidence interval 1.02-1.60) for a 5-month increase in the total number of full-time working months spent with the arm elevated >90 degrees .

CONCLUSION

Work with the arms in a highly elevated position is associated with MRI-diagnosed alterations in the supraspinatus tendon. By demonstrating the first part of a possible biologic pathway, the study corroborates the work-relatedness of rotator cuff disorders.

Suspected rotator cuff lesions: tissue harmonic imaging versus conventional US of the shoulder

PURPOSE

To compare tissue harmonic imaging (THI) of the shoulder with conventional ultrasonography (US) in patients suspected of having rotator cuff lesions.

MATERIALS AND METHODS

THI and conventional US images were obtained in 50 patients suspected of having rotator cuff lesions. Images were graded for visibility of acromioclavicular (AC) joint surfaces and rotator cuff tendon contours and substances: Grade 1 meant poor; grade 2, moderate; and grade 3, good visibility. Accuracy, sensitivity, and specificity of the diagnosis of AC joint osteoarthritis and accuracy of the diagnosis and rates of underestimation and overestimation of the extent of rotator cuff tears were evaluated. Visibility grade differences were evaluated with the Wilcoxon signed rank test. The McNemar test was used to assess differences in diagnoses. Magnetic resonance (MR) arthrography was the reference standard.

RESULTS

Mean visibility grades for readers 1 and 2, respectively, were as follows: for AC joint bone surfaces, 2.1 and 2.0 with THI and 1.7 (P =.010) and 1.7 (P =.16) with conventional US; for AC joint capsule surfaces, 2.2 and 1.9 with THI and 1.8 (P =.005) and 1.8 (P =.34) with US; for supraspinatus tendon contour, 2.6 and 2.2 with THI and 2.1 (P =.001) and 1.9 (P =.055) with US; for supraspinatus tendon substance, 2.2 and 1.9 with THI and 2.0 (P =.036) and 1.7 (P =.070) with US; for subscapularis tendon contour, 2.4 and 2.1 with THI and 2.2 (P =.07) and 2.0 (P =.25) with US; and for subscapularis tendon substance, 1.8 and 1.7 with THI and 2.0 (P =.86) and 1.7 (P =.91) with US. Diagnostic accuracies for the supraspinatus tendon for readers 1 and 2, respectively, were 84% and 74% with THI and 86% and 70% with US (P >.99 for both readers). Corresponding values for the subscapularis tendon were 78% and 72% with THI and 64% (P =.27) and 52% (P =.006) with US.

CONCLUSION

Joint and tendon surface visibility improves with THI, as compared with the visibility achieved with conventional US. THI is superior to conventional US for diagnosis of subscapularis tendon abnormalities.

Dynamic enhanced MRI of the subacromial bursa: correlation with arthroscopic and histological findings

OBJECTIVE

To assess dynamic MRI with Gd-DTPA enhancement for evaluating inflammatory changes in the subacromial bursa.

DESIGN AND PATIENTS

We detected the signal intensity changes in dynamic MRI of the subacromial bursa, and confirmed these macroscopically by arthroscopy and histologically. The signal intensity was measured using built-in software, and the enhancement ratio (E ratio) was calculated from dynamic MR images. In addition, as a parameter of the rate of the increase in the signal intensity from 0 to 80 s, the mean increase per second in the E ratio was obtained as the coefficient of enhancement (CE). The correlation was studied of the E ratio and CE with the arthroscopic findings (redness, villous formation, thickening and adhesion), and of the E ratio and CE with the histological findings (capillary proliferation, papillary hyperplasia, fibrosis and inflammatory cell infiltration) of the subacromial bursa. Of patients with shoulder pain, this study included those with rotator cuff injury; patients with rheumatoid arthritis or pitching shoulder disorders were excluded. There were 27 patients (15 men, 12 women) ranging in age from 25 to 73 years (mean 49.1 years). Dynamic MRI of the shoulder was also performed on the healthy side of 10 patients and in five normal young volunteers.

RESULTS AND CONCLUSIONS

Changes in signal intensity on dynamic MRI were measured in the subacromial bursa. The E ratio (80 s) and CE (0-80 s) were significantly correlated with redness and villous formation as arthroscopic findings, positively correlated with capillary proliferation and papillary hyperplasia as histological findings (p < 0.05), and negatively correlated with fibrosis as a histological finding (p < 0.05) in the subacromial bursa. The patterns of dynamic curves were well correlated with the bursoscopic and histological findings of the synovium of the subacromial bursa. Dynamic MRI appears to correlate with inflammatory activity of synovium of the subacromial bursa. Clarifying the state of the synovium of the subacromial bursa may be useful in determining therapeutic strategies (e.g., indicating topical infusion of hyaluronic acid or steroids for preservative treatment and selecting the site). Furthermore, the evaluation may be useful for indicating surgery, selecting the technique, and evaluating preoperative and postoperative inflammatory changes.