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PubMed2003

MR arthrography of partial thickness tears of the undersurface of the rotator cuff: an arthroscopic correlation.

OBJECTIVE: Partial thickness tears of the undersurface (articular surface) of the rotator cuff (RTC) have been recognized increasingly in recent years as a source of treatable shoulder pain in the athletic population. This study evaluated the efficacy of MR arthrography (MR-ARTH) in diagnosing these tears. DESIGN AND PATIENTS: The study design was a retrospective review of medical records of patients who had presented with refractory shoulder complaints and subsequently undergone MR arthrography with multiple signal MRI sequences followed by shoulder arthroscopy. Of particular interest were patients who had oblique T1 fat suppression (COT1FS), coronal oblique T2 (COT2), and coronal oblique T2 fat suppression (COT2FS) images taken. Seventy-six subjects met the study criteria. Investigators examined the MR-ARTH images from these patients' charts while blinded as to arthroscopic results, clinical signs and symptoms. RESULTS: Based on COT1FS images, investigators identified nine subjects as having had full thickness tears, 28 as having had partial thickness tears of the undersurface of the rotator cuff (PRTC), and 39 as having had intact RTC. These results were compared to actual findings at arthroscopy: nine full thickness tears, 26 of 28 with PRTC and 34 of 39 intact. The sensitivity of MR-ARTH was 84%, with a positive predictive value of 93%. The overall accuracy was 91% (69/76). The specificity was 96%. That is, if a PRTC was not seen on the MR-ARTH images, it was very unlikely to exist. COT2 and COT2FS sequences failed to increase sensitivity and overall efficacy of MRI. CONCLUSION: PRTC can be diagnosed accurately by MR-ARTH with gadopentatate contrast. A COT1FS sequence is recommended for evaluation when tears are suspected.

Adolescent↗
PubMed2005

Acromioclavicular joint cyst: nine cases of a pseudotumor of the shoulder.

OBJECTIVE: (1) To analyse the imaging appearances of nine patients with acromioclavicular joint cysts presenting as shoulder masses for tumor staging with operative, histopathological and joint aspiration findings. DESIGN AND PATIENTS: Retrospective review of imaging and correlation with clinical, operative and surgical notes. Images were reviewed by two musculoskeletal radiologists by consensus. Nine patients who presented clinically with a shoulder mass were evaluated by radiographs (n=9), ultrasound (n=1), conventional arthrography (n=3), MRI (n=6; with direct MR arthrography n=2, indirect MR arthrography n=4). RESULTS: All patients had a focal mass superior to the AC joint, with a size ranging from 1.5 cm to 6 cm and a mean of 3.27 cm. Correlation was available with surgery (n=7), histopathology (n=2) and cyst aspiration (n=2). Two patients were managed conservatively. Geyser sign was positive in all three arthrograms. All MRIs revealed extensive rotator cuff tears with a column of fluid extending from the glenohumeral joint through the rotator cuff tear into the acromioclavicular joint and acromioclavicular cyst. Chondrocalcinosis was seen in the acromioclavicular joint cyst (n=2) and in the glenohumeral joint (n=1). Aspirate in two patients contained calcium pyrophosphate dihydrate crystals. CONCLUSION: Acromioclavicular joint cysts may present as a tumor mass. They are associated with extensive rotator cuff tears and there is usually communication of the cyst with the joint space. This feature excludes a diagnosis of tumor. AC joint cysts may be associated with calcium pyrophosphate dihydrate deposition disease.

Acromioclavicular Joint↗
PubMed2005

Imaging findings of spontaneous detachment of the deltoid muscle as a complication of massive rotator cuff tear.

A tear at the origin of the deltoid muscle is uncommon and usually occurs as a complication of shoulder surgery. We report a case of spontaneous deltoid detachment as a complication of massive rotator cuff tear in a 70-year-old woman evaluated by standard radiographs, ultrasound, arthrography and MR-arthrography. We present the multimodality imaging findings with review of the literature. We found that ultrasound is an accurate modality in detecting and assessing spontaneous detachment of the deltoid muscle. As ultrasound is a noninvasive, low-cost, and universally available imaging modality we suggest using ultrasound as the first modality for evaluation of spontaneous detachment of the deltoid muscle.

Aged↗
PubMed2006

Humeral head cysts and rotator cuff tears: an MR arthrographic study.

OBJECTIVE: Humeral tuberosity cysts are a common finding, with previous reports suggesting they are related to rotator cuff tear or aging. The aim of this study was to investigate the characteristics of cysts in the tuberosities of the humeral head and their relationship with rotator cuff tear and age. DESIGN AND PATIENTS: Shoulder MR arthrograms were reviewed in 120 consecutive patients-83 males (mean age 38.0, range 19-59 years) and 37 females (mean age 41.2, range 15-59 years). Patients were referred for investigation of a variety of conditions, and instability was suspected in only a minority of cases. MR was performed before and after direct arthrography with 0.01% solution of gadolinium. Cysts were defined as well-demarcated circular/ovoid foci in two planes that demonstrated high signal on pre-arthrographic T2W sequences. Location, size and numbers of cysts and post-arthrographic enhancement were documented, along with the location of rotator cuff tears, if present. RESULTS: Cysts in the tuberosities of the humerus were identified in 84 patients (70%), and were seen seven times more frequently in the posterior aspect of the greater tuberosity than anteriorly. Most cysts (94%) demonstrated communication with the joint post-arthrogram. Rotator cuff tears were present in 36 patients, and 79% of all tears occurred in supraspinatus tendon. There was no significant difference in the occurrence of cysts between patients older or younger than age 40 or between genders, but rotator cuff tears were seen significantly more often in the older age group (p<0.01). Tuberosity cysts and rotator cuff tears did not appear to be related (p=0.55). However, whilst this lack of association was quite obvious posteriorly (p=0.84), the trend in the anterior aspect of the greater tuberosity is not as clear (p=0.14). CONCLUSIONS: Humeral cysts are most often located in the posterior aspect of the greater tuberosity, communicate with the joint space and, in this location, are not related to aging or rotator cuff tear.

Adolescent↗
PubMed2007

Magnetic resonance imaging findings associated with surgically proven rotator interval lesions.

OBJECTIVE: To identify shoulder magnetic resonance imaging (MRI) findings associated with surgically proven rotator interval abnormalities. MATERIALS AND METHODS: The preoperative MRI examinations of five patients with surgically proven rotator interval (RI) lesions requiring closure were retrospectively evaluated by three musculoskeletal-trained radiologists in consensus. We assessed the structures in the RI, including the coracohumeral ligament, superior glenohumeral ligament, fat tissue, biceps tendon, and capsule for variations in size and signal alteration. In addition, we noted associated findings of rotator cuff and labral pathology. RESULTS: Three of three of the MR arthrogram studies demonstrated extension of gadolinium to the cortex of the undersurface of the coracoid process compared with the control images, seen best on the sagittal oblique images. Four of five of the studies demonstrated subjective thickening of the coracohumeral ligament, and three of five of the studies demonstrated subjective thickening of the superior glenohumeral ligament. Five of five of the studies demonstrated a labral tear. CONCLUSIONS: The MRI arthrogram finding of gadolinium extending to the cortex of the undersurface of the coracoid process was noted on the studies of those patients with rotator interval lesions at surgery in this series. Noting this finding-especially in the presence of a labral tear and/or thickening of the coracohumeral ligament or superior glenohumeral ligament-may be helpful in the preoperative diagnosis of rotator interval lesions.

Adult↗
PubMed2000

Comparison of supraspinatus tendon and glenohumeral joint axes in MR imaging of the shoulder.

OBJECTIVE: In magnetic resonance (MR) imaging of the shoulder, oblique coronal images are used for evaluating the supraspinatus tendon (SST) of patients with suspected rotator cuff tear or impingement. This study aimed to compare orientation of the SST long axis with planes perpendicular to the glenohumeral joint (GHJ). DESIGN AND PATIENTS: The axial scans of 100 consecutive patients referred for MR imaging or MR arthrography of the shoulder were reviewed. Using the electronic cursors of a computer workstation, the angle of the SST long axis was measured and compared with the angle obtained through the GHJ utilizing three different landmarks: perpendicular to the joint (GHJ-90), joint-humeral head center axis (GHJ-H) and joint-scapular body axis (GHJ-S). RESULTS: Differences in angulation between axes of the SST and the three GHJ axes averaged only about 5 degree [range of means 4.5-5.3 degrees, range of standard deviation (SD) 3.8-4.6 degrees]. In the majority of shoulders, angular differences measured 4 or less for all SST/GHJ comparisons. Similarly, small angular differences in the three GHJ axes were found: 4.5 degrees (SD 3.3 degrees) for GHJ-90/GHJ-S, 5.0 degree (SD 4.0 degrees) for GHJ-S/GHJ-H and 2.9 degrees (SD 3.0 degrees) for GHJ-90/GHJ-H. Correlation between the GHJ-90 and GHJ-H axes was particularly good, with differences of 4 degree or less in 84% of shoulders. The orientations of the GHJ axes and that of the SST long axis are comparable. CONCLUSION: The GHJ may potentially be used as a landmark for obtaining oblique coronal images of the SST.

Adolescent↗
PubMed2001

Radiographic diagnosis of rotator cuff tear based on the supraspinatus muscle radiodensity.

OBJECTIVE: To evaluate the supraspinatus muscle radiodensity on the outlet view as an indication of a tendon tear. DESIGN AND PATIENTS: Plain radiographs and magnetic resonance imaging (MRI) examinations were obtained on both shoulders of 40 subjects aged 23-70 years, including 13 asymptomatic volunteers and 27 patients. Two readers analyzed the superior contour and the heterogeneity of the supraspinatus muscle radiodensity and compared them with the MRI findings. RESULTS AND CONCLUSION: Significant concordances (P < 0.001) were found between the assessments of the superior contour and the heterogeneity of the muscle radiodensity, respectively, on plain radiographs and MR images. For the diagnosis of a full-thickness tear, the analysis of the superior contour and the heterogeneity of the muscle radiodensity reached an accuracy of 85% and 80% respectively. Stepwise discriminant analyses showed low to moderate benefit of considering the contour and the heterogeneity simultaneously. The inter- and intraobserver agreement ranged from moderate to good. We conclude that on the outlet view, modifications in the superior contour and heterogeneity of the supraspinatus muscle radiodensity suggest a full-thickness tear.

Adult↗
PubMed1996

Ultrasonography for diagnosis of rotator cuff tear.

In this study the clinical usefulness of ultrasonography in the diagnosis of rotator cuff tears was assessed. One hundred twenty-two patients undergoing preoperative ultrasonography were evaluated surgically. Three different ultrasonographic machines were applied with a 7.5-MHz linear-array transducer. Surgery confirmed a sensitivity of 79% for full-thickness tears and 50% for partial thickness tears. In 73 patients with negative ultrasonographic findings, the specificity was 100% for full-thickness tears and 90% for partial-thickness tears. The diagnostic sensitivity for full-thickness tears of the Hitachi EUB-340 system was significantly lower than those of Hitachi EUB-415 and EUB-515, and thus the former cannot be recommended for detection of rotator cuff tears. The sensitivity with regard to partial-thickness tears was also significantly lower with the Hitachi EUB-340 system as compared to the Hitachi EUB-515. There were no significant differences in false-positive rate among the three machines used. In conclusion, accurate ultrasonographic diagnosis of rotator cuff tear requires a high-resolution machine, as well as considerable experience in interpretation.

Adult↗
PubMed1996

Rotator cuff strain: a post-traumatic mimicker of tendonitis on MRI.

OBJECTIVE: To determine whether there is a subset of young patients (< 35 years) with acute, post-traumatic insults to the rotator cuff which mimic the early stages of impingement. DESIGN AND PATIENTS: One hundred and ninety-seven consecutive shoulder MR images were retrospectively reviewed, and the results of 83 clinically correlated. Two observers independently evaluated the location of intra-tendon signal and adjacent bone marrow abnormalities on T1- and T2-weighted images. These findings were correlated with age, history of trauma, and surgical or clinical follow-ups. RESULTS: Patients younger than 35 years had signal intensity that was more localized in atypical locations (posterior aspect of the supraspinatus tendon), more commonly associated with marrow abnormalities (presumed bone bruise), and more often associated with trauma. Younger patients also were less likely to require surgery, especially if they showed bone bruises. This differentiated them from older patients (> 45 years), who demonstrated more widespread signal within the tendon, rare bone bruises, and more frequent surgery. CONCLUSIONS: Localized tendon signal in atypical locations of the supraspinatus tendon, particularly when associated with bone bruise and young age, suggests the possibility of a post-traumatic strain.

Adult↗
PubMed1998

Anterior versus posterior, and rim-rent rotator cuff tears: prevalence and MR sensitivity.

PURPOSE: To determine the relative distribution of the locations of rotator cuff tears, and the sensitivity of anterior versus posterior tears on MR images. PATIENTS AND METHODS: We identified 110 consecutive patients who had a shoulder MR and either a partial-thickness or a small full-thickness rotator cuff tear diagnosed at arthroscopy. From the arthroscopy videotapes, we classified the tears as centered in the anterior or posterior half of the cuff, and as either in the critical zone or adjacent to the bony insertion. The original MR interpretation was compared with the arthroscopic findings. MR sensitivity and patient age were compared between patients with tears in the anterior and posterior halves of the cuff. In addition, in patients with partial tears less than 2 cm in diameter, an age comparison between those with tears in the critical zone and those with articular surface tears adjacent to the bony insertion (rim-rent tear) was performed. RESULTS: The tear was centered in the anterior half of the rotator cuff in 79% of the patients younger than 36 years old, and in 89% of the patients 36 years old and over. The average age of the patients with tears in the anterior half (44 years) was not significantly different from the average age of those with posterior tears (40 years) (P = 0.23). The sensitivity of MR for anterior tears was 0.69, and for posterior tears it was 0.56 (P = 0.17). The average age of the 9 patients with rim-rent tears was 31 years, while that of the 28 patients with similarly-sized partial tears not involving the insertion was 40 years old (P = 0.048). Five of the nine rim-rent tears (0.56) were interpreted correctly on the original MR report; two of the other tears were misinterpreted as intratendinous fluid but were diagnosable in retrospect. CONCLUSION: Even in patients less than 36 years old, most partial and small full-thickness rotator cuff tears are centered in the anterior half of the supraspinatus. Although our figure for MR sensitivity for these tears is lower than in recent articles, we found no significant difference between the sensitivity of MR for diagnosing posterior tears versus tears in the anterior half of the supraspinatus tendon. Rim-rent tears can be mistaken for intratendinous signal, and should be carefully looked for in younger patients with shoulder pain.

Adolescent↗
PubMed1999

Subacromial-subdeltoid lipoma arborescens associated with a rotator cuff tear.

A 44-year-old man presented with lipoma arborescens of the right shoulder, associated with a rotator cuff tear. MRI revealed villous proliferations with signal intensity of fat on all pulse sequences. At surgery, this bursa was found to contain moderately yellow cloudy fluid without fat globules. Histological examination of the lesion showed subsynovial accumulation of mature fat cells.

Adult↗
PubMed1999

Internal derangements of the shoulder: decision tree and cost-effectiveness analysis of conventional arthrography, conventional MRI, and MR arthrography.

PURPOSE: In a patient with internal derangement of the shoulder, the diagnostic method of choice is controversial. Conventional arthrography can diagnose most rotator cuff tears accurately; however, in many institutions MR arthrography is usually necessary to diagnose labral tears. We utilized decision tree methodology to compare the cost-effectiveness of conventional arthrography and conventional MRI with a hypothetical algorithm in which a patient underwent arthrography, performed with admixed gadolinium, which if negative, was followed by MRI. DESIGN: The use of double-contrast arthrography alone, conventional MRI alone, and gadolinium-enhanced MRI used as an adjunct to conventional arthrography were modeled for the diagnosis of full-thickness rotator cuff tears (RCT), partial RCTs, labral tears, and the absence of cuff/labral tears using decision analysis methodology. English language medical publications were searched to determine the base probabilities for the accuracy of the diagnostic tests. The outcome utilities ranged from -1 to +1 to reflect the value of correct diagnostic evaluation. Charges for diagnostic tests and appropriate surgical treatments were based on 1997 Medicare reimbursement rates for professional fees and hospital charges in an outpatient setting. Sensitivity analyses were performed to evaluate the effects of uncertainty regarding the prevalence of each disease state and the accuracy of several diagnostic tests. RESULTS: In the base-case analysis, the average effectiveness of double-contrast arthrography alone, MRI alone and arthrography selectively followed by MRI were 0.6610, 0.6715, and 0.7204, respectively. The average costs for each of these strategies were $1090, $2033, and $2339, respectively. CONCLUSION: Arthrography performed with admixed diluted gadolinium, which if negative is immediately followed by MRI, was somewhat more expensive than conventional MRI. However, because of much greater effectiveness, cost-effectiveness was significantly higher for our proposed algorithm. Conventional arthrography without gadolinium, although less expensive, had severely limited effectiveness.

Algorithms↗
PubMed2001

Angled oblique sagittal MR imaging of rotator cuff tears: comparison with standard oblique sagittal images.

OBJECTIVE: To compare the accuracy for diagnosing rotator cuff tears of oblique coronal images supplemented with standard oblique sagittal images versus thinner-section angled oblique sagittal images. DESIGN AND PATIENTS: The study included 75 consecutive patients who had a shoulder MR scan followed by arthroscopy. MR images included oblique coronal, oblique sagittal (4 mm thick, 1 mm interslice gap), and angled oblique sagittal (3 mm/0.2 mm) images perpendicular to the lateral cuff. A musculoskeletal staff radiologist and fellow separately evaluated the cuff for tears on the oblique coronal images supplemented with either the oblique sagittal or the angled sagittal images. RESULTS: For distinguishing a cuff tear from no tear, the staff radiologist had an accuracy of 0.76 (95% confidence interval: 0.67, 0.85) with the standard sagittal set, and 0.88 (0.80, 0.95) with the angled set (P=0.04). There was a nonsignificant improvement in accuracy for the fellow, calculated as 0.73 (0.63, 0.83) on the standard sagittal set and 0.76 (0.67, 0.85) on the angled set. Both readers also improved their diagnostic accuracy for partial-thickness tears with the angled set, although the improvement was statistically significant only for the staff radiologist. CONCLUSION: There is a slight improvement in accuracy for diagnosing rotator cuff tears, particularly partial-thickness tears, for the more experienced radiologist using thinner-section angled oblique sagittal images. These images may be useful as a supplemental sequence in patients where it is important to identify partial-thickness tears accurately.

Adult↗
PubMed2004

Massive tears of the rotator cuff treated with a deltoid flap.

We retrospectively reviewed the charts of 29 patients younger than 65 years at surgery treated with deltoid flap reconstruction for massive postero-superior rotator cuff tears. All tears involved supraspinatus and infraspinatus tendons and were associated with tendon stump retraction to the glenoid rim, a preservable long biceps tendon, and an intact subscapularis tendon. Mean follow-up was 10.5 years. Patient satisfaction rate was 89%. Mean global Constant score improved from 43 to 71.5 points, mean pain score from 6.3 to 13.2, mean anterior flexion from 100 to 157 degrees, and force in elevation from 2.3 to 3 kg. Two thirds of patients had no humeral head migration. Of the 18 patients whose flap was examined by magnetic resonance imaging, 15 had no tear and 12 had a flap signal of muscle intensity; mean flap thickness was 5 mm. Pre-operative factors associated with poorer outcomes were upwards humeral head migration with a subacromial space smaller than 6 mm, presence of glenohumeral osteoarthritis, and supraspinatus amyotrophy greater than 40%. Deltoid flap reconstruction is a valid option in this patient population.

Aged↗
PubMed2006

Inflammatory infiltrate of the edges of a torn rotator cuff.

There is still considerable controversy as to whether or not the inflamed margins of a cuff tear should be excised during surgical suture. We have tried to discover whether anti-inflammatory drugs used before surgical treatment could resolve this issue. Thirty-eight patients were randomly either treated with an anti-inflammatory drug for 2 weeks or not. During the subsequent arthroscopic repair, a few fragments of supraspinatus edge were excised and examined microscopically. No significant differences emerged among samples belonging to the two groups. In all cases, we observed inflammatory infiltrate-lined tear edges. Fibrocytes and newly formed vessels were detected near the margin. Dystrophic calcifications were observed in both groups. Away from the edge, the tendon appeared hypocellular; containing areas with myxoid or fatty degeneration. Our study demonstrates that an anti-inflammatory drug is unable to resolve the inflammatory infiltrate. This failure is probably related to the poor blood supply to the cuff, which, in cases of rupture, is deprived of vessels coming from the humeral periosteum. Further studies are needed to understand how to eliminate the inflammatory process and clarify whether it might inhibit cuff healing and give rise to re-tearing of the sutured cuff.

Aged↗
PubMed2006

Repair of large supraspinatus rotator-cuff defects by infraspinatus and subscapularis tendon transfers in a cadaver model.

Transosseous repair of a supraspinatus tendon (SSP) defect (Patte size II) can be difficult if the tendon is retracted and the muscle atrophied. In this situation alternatives are margin convergence techniques, local tendon transfers or distant tendon transfers in massive tears. The object of this study was to compare two local tendon transfers in terms of the feasibility of the shift, the area covered by the shift and the force needed to accomplish the shift. Thirteen fresh-frozen cadaver shoulders were used. First a supraspinatus defect extending to the apex of the humeral head (Patte size II) was created. Transosseous repair was attempted with the infraspintus (ISP) and with the subscapularis (SCP) in all cases; repair was successful in all ISP cases, while use of the SCP resulted in a successful repair in only 8 of the 13 (61.5%). A significantly (P=0.012) larger defect area was covered by the ISP transfer than by the SCP shift: 89.7+/-8.5% versus 31.2+/-31.1% of the original defect, respectively. The tensile force needed to accomplish the shift was significantly (P=0.004) lower when the ISP was used (15+/-11 N) than with the SCP (37.1+/-15 N). In this cadaver model the ISP shift proved more favourable than the SCP shift for covering a Patte size II SSP defect.

Aged↗
PubMed1996

Partial-thickness tears of the rotator cuff. A clinicopathological review based on 66 surgically verified cases.

This review is based on 66 patients with partial-thickness tears of the rotator cuff, verified at operation. Their average age was 54 years, and all had symptoms of subacromial impingement. The duration of shoulder pain was for between 2 and 108 months (mean 11.4 months). Ultrasonography, arthrography and bursography were helpful in establishing the diagnosis. On exploration, tears were found in the supraspinatus tendon, with 9 extending into the infraspinatus. After anterior acromioplasty, excision of the diseased portion and tenorrhaphy were undertaken. Satisfactory results were obtained in 62 patients (94%) with an average follow-up of 32 months. Spontaneous repair at the torn site was never seen. In addition to Neer's staging of impingement, we propose a new classification based on the integrity of the cuff tendon. We conclude that a partial-thickness cuff tear is an important cause of shoulder disability, which deserves much more clinical attention; misdiagnosis is common and leads to mismanagement. When conservative treatment fails, accurate diagnosis and proper surgical repair are essential.

Adult↗
PubMed2001

Chondrolysis of the glenohumeral joint following a color test using gentian violet.

Two patients developed chondrolysis following injection of 0.4% aqueous gentian violet into the glenohumeral joint to visualize a rotator cuff tear during surgery. In both cases, conventional radiographs revealed joint space narrowing 10-12 months after surgery. Histological examination of the humeral heads revealed loss of the articular cartilage.

Adult↗