MR assessment of the repaired rotator cuff: prevalence, size, location, and clinical relevance of tendon rerupture

The objectives of this study were to use magnetic resonance (MR) imaging to evaluate the prevalence, size, location, and clinical relevance of tendon rerupture following complete repair of full-thickness rotator cuff tear (RCT). A total of 78 surgically proven full-thickness rotator cuff tears in 74 patients were retrospectively included in the study. Clinical assessment was performed using the University of California at Los Angeles score. Postoperative MR imaging was evaluated to determine prevalence, size, and location of tendon rerupture. At a mean 48.4 months' follow-up, 62 shoulders (79.5%) had favorable outcomes and 45 shoulders (57.6%) showed rerupture on MR imaging studies. Reruptures were significantly more prevalent among patients with intermediate-to-bad outcomes (81.3%), with surgically demonstrated two-tendon tears (78.9%) or three-tendon tears (100%), and with preoperative fatty degeneration of the supraspinatus muscle greater than 1 (91.6%). Reruptures were also significantly larger in those subgroups. Complete repair of RCT of all sizes may have favorable outcomes in a significant proportion of patients in spite of a high prevalence of reruptures. Preoperative tear size and degree of muscle fatty degeneration influence the prevalence and rerupture size. After repair of supraspinatus tears, reruptures tend to invade the posterior aspect of the tendon.

Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings

OBJECTIVE

Our goal in this study was to evaluate by means of MRI the clinical significance of tendon integrity, muscle fatty degeneration, and muscle atrophy in surgically repaired massive rotator cuff tears and to correlate these and other prognostic factors with intraoperative and clinical findings.

MATERIALS AND METHODS

Twenty-eight surgically proven massive rotator cuff tears were retrospectively included in the study. Twenty-two patients underwent complete repair, and six patients underwent partial repair. Preoperative and postoperative clinical assessment was performed by using the University of California at Los Angeles score. Preoperative and postoperative MRI studies were evaluated for the presence and extent of rotator cuff tear and for the degree of fatty degeneration and atrophy of the rotator cuff muscles.

RESULTS

At a mean 44.4 months' follow-up, 20 patients (71.4%) had a favorable result. A total of 25 patients (89.2%) showed postoperative full-thickness rotator cuff tear, 19 of which were reruptures. A sagittal preoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 100% for predicting a favorable outcome. A coronal postoperative rotator cuff tear of less than or equal to 34 mm showed a specificity of 85.7% and a positive predictive value of 92.9% for predicting a favorable outcome. A postoperative fatty degeneration of infraspinatus muscle less than or equal to 2 had a specificity of 87.5% and a positive predictive value of 90.9% for predicting a favorable outcome.

CONCLUSION

Open repair of massive rotator cuff tears may reach a favorable outcome in a significant proportion of patients, despite a high rate of recurrent or residual tears. Oblique coronal sizes of the recurrent or residual tear of less than or equal to 34 mm and postoperative fatty degenerations of infraspinatus muscle of less than or equal to 2 may allow a favorable outcome.

Analgesic effect of intra-articular ketorolac in knee arthroscopy: comparison of morphine and bupivacaine

This prospective study assessed the postoperative analgesic effect of intra-articular ketorolac, morphine, and bupivacaine during arthroscopic outpatient partial meniscectomy. Group 1 patients (n=20) received postoperative injection of 60 mg intra-articular ketorolac, group 2 patients (n=20) 10 cc intra-articular bupivacaine 0.25%, group 3 patients (n=20) 1 mg intra-articular morphine diluted in 10 cc saline, and group 4 patients (n=20, controls) only 10 cc saline. We evaluated the postoperative analgesic effect (period measured from the end of the surgery until further analgesia was demanded), the level of postoperative pain (by visual analog scale 1, 2, 3, 12, and 24 h after surgery), and the need for additional pain medication (during the first 24 h after surgery). The best analgesic effect was in patients treated with intra-articular ketorolac, and this was statistically significant in: postoperative analgesic effect and the need for additional pain medication immediately after surgery, and after 24 h. No complications were found related to the intra-articular treatment. We conclude that 60 mg intra-articular ketorolac provides better analgesic effect than 10 cc intra-articular bupivacaine 0.25% or 1 mg intra-articular morphine.

Early intrathoracic migration of Kirschner wires used for percutaneous osteosynthesis of a two-part humeral neck fracture: a case report

We present an unusual case of early migration of three Kirschner wires used for percutaneous osteosynthesis of a two-part humeral neck fracture, causing hemothorax. An 85-year-old woman was admitted to the emergency room after casual accident. She was found to have suffered a two-part fracture of the surgical neck of the right humerus. The humeral fracture was treated by closed reduction and percutaneous osteosynthesis with three threaded Kirschner wires, which were bent subcutaneously. Ten days after the accident the patient presented with dyspnea and laterocervical pain. Plain X-rays and complementary CT demonstrated intrathoracic migration of the three Kirschner wires with hemothorax. Two of the wires were seen under the right clavicle and adjacent to the C7 vertebra. The third wire reached the lateral chest wall. Immediate surgery was performed, with withdrawal of the wires and placement of a drainage tube. The patient had an uneventful recovery after surgery. The humeral fracture resulted in a nonunion, which was well tolerated by the patient and was left untreated. The use of Kirschner wires for osteosynthesis of proximal humeral fractures may cause significant thoracic morbidity, even if various prophylactic measures, including the use of threaded wires, subcutaneous bending, and close radiographic follow-up, are adopted. The use of Kirschner wires should anyway be restricted to carefully selected cases, in order to avoid major complications.

Open bicondylar Hoffa fracture associated with extensor mechanism injury

Two cases of open bicondylar Hoffa fracture of the knee associated with extensor mechanism injury are described in two active young patients with multiple fractures. The level of the fracture was determined by the proximal insertion of the posterior cruciate ligament and anterior cruciate ligament in the medial and lateral condyle. The level of the extensor mechanism injury was determined by the degree of flexion of the knee at the moment of impact. No ligament or meniscal tears were found. Open reduction and internal fixation with four lag screws and bone-to-tendon repair of the patellar and quadriceps tendon gave excellent results after more than 2 years of follow-up. The mechanism of injury and the therapeutic implications are discussed, and the literature is reviewed.

Magnetic resonance imaging of anterior cruciate ligament tears: reevaluation of quantitative parameters and imaging findings including a simplified method for measuring the anterior cruciate ligament angle

We evaluated the diagnostic utility of magnetic resonance imaging (MRI) for predicting anterior cruciate ligament (ACL) tears using both quantitative parameters and nonquantitative imaging findings. MRI examinations were retrospectively evaluated in a group of patients with arthroscopically confirmed complete ACL tear and in a control group with arthroscopically confirmed intact ACL. We evaluated multiple MRI features to compare their sensitivity and specificity for detecting ACL tears. Particular emphasis is put on the evaluation of three different quantitative parameters, including a simplified method for measuring the ACL angle. With a threshold value of 45 degrees the ACL angle reached a sensitivity and specificity of 100% for detecting ACL tears. With a threshold value of 0 degrees the Blumensaat angle had a sensitivity of 90% and a specificity of 98%. Finally, a threshold value of 115 degrees gave the posterior cruciate ligament angle a sensitivity of 70% and a specificity of 82%. Discontinuity was found to be the most useful of the ACL abnormalities. Of the secondary findings anterior tibial displacement was the best predictor of ligamentous injury. However, ACL abnormalities and secondary findings, alone or combined, failed to surpass the diagnostic value of the ACL angle for predicting ACL tears. Quantitative parameters are thus good predictors of ACL tears and may increase the overall sensitivity and specificity of MRI. The ACL angle may be confidently measured in a single MRI section and can be considered to be the most reliable quantitative parameter for detecting ACL tears.

Antioxidant status in a squirrel monkey (Saimiri sciureus) with chronic pancreatitis and degenerative myopathy

A squirrel monkey (Saimiri sciureus) presented with wasting, vomiting and diarrhoea. Haematology revealed elevation of creatinine phosphokinase, lactic dehydrogenase, alanine aminotransferase, amylase and lipase, together with azotaemia and hypoalbuminaemia. Prominent findings were chronic pancreatitis with acinar and ductal plugs, granulomatous and necrotizing peripancreatic steatitis, degenerative myopathy, testicular atrophy, candidiasis and bacterial necrotizing glossitis. Antioxidant analyses revealed low concentrations of serum vitamin E (and apparently A), hepatic selenium and hair zinc. Pancreatitis may have caused malabsorption and maldigestion, associated with deficiency of multiple antioxidants.

Intraosseous neurilemmoma of the radius: a case report

Neurilemmomas are benign tumors that arise from Schwann cells. They are rarely found on bone. We describe a neurilemmoma in a 45-year-old patient that affected the distal metaphysis of the radius. Only 1 previous case has been described in the literature. We discuss the clinical presentation, the radiographic aspect, particularly the magnetic resonance imaging characteristics, and the microscopic findings.

[Creatine phosphokinase in leptospirosis]

Leptospirosis is a widely-distributed infectious disease, that usually presents with fever, headache and myalgia. Organ involvement could have very different severity degree. We evaluate 21 patients with leptospirosis looking for prognostic and diagnostic value of myalgia and/or elevated creatine-phosphokinase serum levels. Myalgia was recorded in nearly all patients (91%). Creatine-phosphokinase levels above normal limits were seen in 37% of cases, either in severe forms of leptospirosis with organ involvement or in mild forms of disease. We conclude that creatine-phosphokinase elevated levels could be of early diagnosis interest but they are not solely seen in the more severe forms of the disease.