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PubMed1997

Diagnosis of rotator cuff lesions: comparison of US and MRI on 38 joint specimens.

An experimental study was performed on cadaveric joint specimens of the shoulder to determine the accuracy of US and MRI in diagnosis of abnormalities of the rotator cuff. The value of different morphological criteria was evaluated for discrimination of degeneration as well as partial and complete disruption. A total of 38 surgically exposed specimens of the shoulder joint were examined by US, MRI and pathological methods visualising the tendons of the rotator cuff in same axial and longitudinal orientations. The three imaging modalities were reviewed separately by experienced examiners, respectively, who were blind to other results. Evaluation criteria consisted of signs of shape (thinning, thickening, discontinuity and absence of rotator cuff) and structure (changes in echogenicity in US, increased signal intensity in MRI, tissue changes in pathology). Findings in US and MRI were finally compared with pathology to assess sensitivity and specificity. Pathology demonstrated 4 full-thickness tears, 6 partial-thickness tears, 16 cases with degeneration and 12 normal rotator cuffs. Ultrasound showed pathological signs in all abnormal cuffs, and one MRI report was false negative. Specificity was 67 % in US (4 of 12 cases were false positive) and 100 % in MRI (no abnormal findings in healthy tendons). Discrimination of different pathological disorders of the rotator cuff was reduced in both methods. Using US only 10 of 16 cases of degeneration, 2 of 6 partial tears and 3 of 4 complete tears were correctly defined. Using MRI 13 of 16 degenerations, 3 of 6 partial tears and 3 of 4 complete tears were detected. The MRI technique failed to visualise intratendinous calcifications in all 3 cases. We conclude that MRI and US are both sensitive in detection of abnormalities of the rotator cuff. Ultrasound should be the primary diagnostic method in screening of shoulder pain because it is economic and fast. The MRI technique should be used secondary because it provides more information about extent of tendons and has lower risk of artefacts.

Adult↗
PubMed1988

[Rupture of the rotator cuff. Quantification of indirect signs in standard radiology and the Leclercq maneuver].

The roentgenograms and the "Leclercq's manoeuvre" of 105 patients who had a shoulder arthrography were reviewed. We differentiated two groups: One with a rotator cuff tear. The other without a rotator cuff tear. The space between the acromion and the head of the humerus was measured on rotation zero degree and external rotational roentgenograms. When the acromio-humeral space was less than 8 mm, it was always correlated with a rotator cuff tear (specificity = 1). If at least tow of the following signs were present, there was in most cases a rotator cuff tear (specificity = 0.96): Sclerosed acromion. Spur of the acromion. Cystic changes around the greater tuberosity. Rounded tuberosities. Inferior gleno-humeral spur. The "Leclercq's manoeuvre" was considered positive either when there was an acromio-humeral space narrowing compared with the other side, or when there was an upward subluxation of the head of the humerus. When positive there was always a rotator cuff tear (sensibility = 0.7; specificity = 1).

Arthrography↗
PubMedDate not supplied

The molecular pathophysiology of subacromial bursitis in rotator cuff disease.

Little information exists on the molecular and biochemical pathophysiology of subacromial bursitis and rotator cuff disease. We investigated the pattern of expression of cytokines (interleukin [IL]-1beta, IL-1, IL-6, tumor necrosis factor [TNF] alpha, small inducible cytokines), metalloproteases, and cyclooxygenases in the subacromial bursa in patients with rotator cuff disease. Subacromial bursa specimens were prepared for molecular and biochemical analysis in patients undergoing shoulder surgery following an institutional review board-approved protocol. Specimens were analyzed for the presence of cytokines, metalloproteases, and cyclooxygenases by use of microarray for gene expression and immunohistocytochemistry. Microarray analysis for gene expression and immunohistochemistry demonstrated that the expression of several cytokine genes (TNF, IL-1alpha, IL-1beta, and IL-6) was increased in patients with subacromial bursitis compared with control specimens. Furthermore, the expression of metalloproteases (MMP-1 and MMP-9) and cyclooxygenases (COX-1 and COX-2) in the bursitis group was found to be increased as compared with controls. Although further investigation is required, these studies suggest that inflammation of the subacromial bursa does occur in patients with rotator cuff disease. These findings support the role of anti-inflammatory agents in the treatment of subacromial impingement and emphasize the importance of subacromial bursectomy to reduce inflammation in rotator cuff disease.

Bursitis↗
PubMed2003

Biomechanical effect of patch graft for large rotator cuff tears: a cadaver study.

It is not possible for some rotator cuff tears to be repaired because of a large defect associated with muscle retraction. The purpose of the current study was to investigate the use of a synthetic patch graft to restore abduction force transmission in the glenohumeral joint with a rotator cuff defect. Shoulders from cadavers (n = 10) were fixed in the hanging arm and in neutral rotation, and loading was applied to the rotator cuff tendons and middle deltoid. After a simulated supraspinatus tendon defect and retraction, a patch graft was inserted into the defect and the effects of reattachment to the greater tuberosity, narrowing of the defect by using a smaller graft, and anterior graft attachment (rotator interval tissue versus subscapularis) were investigated. Abduction torque generation was measured and normalized to the intact condition. Compared with torque generation after creation of a supraspinatus defect (61% of normal torque), abduction torque increased with a graft between the infraspinatus and either the rotator interval (68% of normal) or subscapularis (80% of normal). The optimum grafting technique for abduction torque restoration occurred with a reduced size patch connected anteriorly to the subscapularis and sutured to the greater tuberosity (107% of normal). The patch graft acts to redirect force transmission, thereby providing a potential treatment option for otherwise irreparable defects. These same principles can be applied when tendon transfers are used to reconstruct large or massive cuff tears.

Aged↗
PubMed2003

Comparison of surgical outcome between bursal and articular partial thickness rotator cuff tears.

Surgical outcomes after arthroscopic subacromial decompression and debridement in bursal and articular partial thickness rotator cuff tears with a tear depth of < 50% were compared. Twenty-four articular and 13 bursal partial thickness rotator cuff tears were evaluated for pain relief and functional recovery. At 6 months postoperatively, the average pain score decreased from 6.2 to 1.7 in patients with articular tears and from 7.1 to 0.9 in patients with bursal tears. Although pain relief and functional recovery were excellent in both groups, the results were better in patients with bursal partial thickness rotator cuff tears at 6 months postoperatively.

Activities of Daily Living↗
PubMed2000

Three-dimensional ultrasound imaging of the rotator cuff: spatial compounding and tendon thickness measurement.

Three-dimensional (3-D) volume reconstructions of the shoulder rotator cuff were generated from freehand ultrasound (US) scans acquired with a magnetic tracking system. Image stacks acquired with lateral overlap from multiple acoustic windows were spatially compounded to provide an extended representation of the rotator cuff tendons. A semiautomated technique was developed for measuring rotator cuff thickness from the 3-D compound volumes. Scans of phantoms and volunteer subjects were used to evaluate the accuracy and repeatability of the thickness measurements. For an in vitro phantom with known thickness, the mean difference between the true value and the automatic measurements was 0.05 +/- 0.28 mm. Thickness measurements made manually from 2-D images and automatically from 3-D volumes were different by 0.03 +/- 0.44 mm in vitro and -0.06 +/- 0.36 in vivo. Repeated thickness measurements in vivo differed by 0.06 +/- 0.36 mm. The 3-D measurement technique offers a promising method for evaluating rotator cuff tendons.

Adult↗
PubMed1989

Clinical presentation of complete tears of the rotator cuff.

To determine whether the presence and extent of a tear of the rotator cuff could be predicted on the basis of a patient's history, physical examination, and radiographic findings, detailed data from the histories and physical examinations of 103 patients who were known to have a tear of the rotator cuff were correlated with the radiographic and operative findings on these patients. An age-matched control group of fifty-one patients who had similar symptoms, but whose arthrograms showed normal results, was used to establish a baseline incidence of ten specific radiographic findings in the shoulder. Two discrete groups of patients who had a tear of the rotator cuff were identified. Twenty-eight patients (27 per cent) had a tear of a single tendon; the histories and the physical and radiographic findings in this group were consistent with a symptomatic local mechanical-impingement process in the shoulder. Sixty (80 per cent) of the seventy-five patients in the other group had a history of acute trauma to a shoulder. The patients in this second group were older and were non-athletic, and had not previously had symptoms that were severe enough to need treatment. These patients were subsequently found to have a complete tear of more than one of the tendons of the rotator cuff. Multiple radiographic findings in the shoulder and other coexisting orthopaedic conditions also were more common in these patients. In this group, we believe that acute trauma in a shoulder that had chronic degenerative changes, rather than localized mechanical impingement, caused the tendons to rupture.

Adolescent↗
PubMedDate not supplied

The manual muscle examination for rotator cuff strength. An electromyographic investigation.

The electromyographic activity of eight muscles of the rotator cuff and shoulder girdle (supraspinatus, infraspinatus, subscapularis, pectoralis, latissimus dorsi, and the anterior, middle, and posterior deltoid) was measured from the nondominant shoulders of 11 subjects during a series of 29 isometric contractions. The contractions simulated different positions used for strength testing of the rotator cuff and involved elevation, external rotation, and internal rotation at three degrees of initial humeral rotation (-45 degrees of internal rotation, 0 degree, +45 degrees of external rotation) and scapular elevation (0 degree, 45 degrees, 90 degrees). Isolation of the supraspinatus muscle was best achieved with the test position of elevation at 90 degrees of scapular elevation and +45 degrees (external rotation) of humeral rotation. Isolation of the infraspinatus muscle was best achieved with external rotation at 0 degree of scapular elevation and -45 degrees (internal rotation) of humeral rotation. Isolation of the subscapularis muscle was best achieved with the Gerber push-off test. This study used four criteria for identifying the optimal manual muscle test for each rotator cuff muscle: 1) maximal activation of the cuff muscle, 2) minimal contribution from involved shoulder synergists, 3) minimal provocation of pain, and 4) good test-retest reliability. Based on the results of this study and known painful arcs of motion, an objective identification of the optimal tests for the manual muscle testing of the cuff was elucidated.

Adult↗
PubMed2001

[MRI of the shoulder. Degenerative changes and rotator cuff tears].

MRI currently offers the best imaging information for the diagnosis of subacromial pain syndrome, rotator cuff tears and osteoarthritis of the shoulder. The excellent anatomical and tissue specific imaging allows a detailed evaluation of the rotator cuff as well as the adjacent bony structures. If the cause of subacromial pain can not be determined despite extensive clinical, sonographical and radiological examination, MRI is indicated if there is a suspected pathology of the bony structures or the glenohumeral joint that could influence the further therapeutic procedures. In addition, MRI evaluation of muscular atrophy has become an important factor for determining appropriate therapy, particularly in cases of massive rotator cuff tears.

Acromion↗
PubMed2005

Changes in rotator cuff muscle volume, fat content, and passive mechanics after chronic detachment in a canine model.

BACKGROUND: Long-standing tears of the rotator cuff can lead to substantial and perhaps irreversible changes in the affected rotator cuff muscles. We developed a chronic rotator cuff tear in a canine model to investigate and quantify the time-related changes in passive mechanics, volume, and fat of the infraspinatus muscle. We hypothesized that infraspinatus muscle stiffness would increase, volume would decrease, and fat content would increase at twelve weeks following tendon detachment. METHODS: The right infraspinatus tendon of eight adult mongrel dogs were surgically detached from the proximal part of the humerus. The uninvolved left shoulder served as a control. Muscle volume changes were quantified with use of magnetic resonance imaging. At twelve weeks, the passive mechanical properties of the chronically detached and control muscles were determined intraoperatively with use of a custom-designed device. Intramuscular fat was evaluated histologically at the time that the animals were killed. RESULTS: After twelve weeks of detachment, the stiffness was significantly increased in the detached infraspinatus muscles relative to that in the controls (p < 0.0001). Magnetic resonance image analysis demonstrated that the detached muscle volumes decreased by an average of 32% in the first six weeks and remained constant thereafter. Intramuscular fat increased significantly in the detached muscles and to a greater extent in the lateral regions (p < 0.05). CONCLUSIONS: The chronically detached muscle is not merely a smaller version of the original muscle but, rather, a different muscle. The detached muscle becomes stiffer, and the passive loads required to repair it can become excessive. A significant reduction in muscle volume occurs within days to weeks following tendon detachment (p < 0.0001). The nonuniformity of changes in muscle fat suggests that fat content should be used cautiously as an indicator of muscle quality.

Adipose Tissue↗
PubMed1997

MR imaging of rotator cuff tendon tears: comparison of T2*-weighted gradient-echo and conventional dual-echo sequences.

OBJECTIVE: Although MR imaging evaluation of the rotator cuff is usually done with proton density- and T2-weighted spin-echo techniques, interest also exists in T2*-weighted gradient-recalled echo techniques. The shorter scan times of T2*-weighted sequences can be used to increase the number of signal averages and thus improve the signal-to-noise ratio. Our purpose in this study was to compare the sensitivity and specificity of oblique coronal T2*-weighted MR image interpretations with conventional dual-echo T2-weighted MR image interpretations when diagnosing rotator cuff tears. SUBJECTS AND METHODS: Forty-seven consecutive patients who underwent both MR imaging and shoulder arthroscopy were included in this study. The MR examination included both a 7 min 20 sec acquisition time proton density- and T2-weighted oblique coronal sequence and a 7 min 5 sec T2*-weighted oblique coronal sequence. The oblique coronal dual-echo T2-weighted images were evaluated by two of the authors independently, who were unaware of the arthroscopic findings. Each of the two observers graded each cuff as being intact, having a partial-thickness tear, or having a full-thickness tear. After a 3-week interval, each of the two observers then interpreted the T2*-weighted oblique coronal MR images in the same manner. Sensitivity and specificity for the two sets of interpretations were calculated in terms of the ability of the observers to use the two sequences to distinguish an intact cuff from a rotator cuff tear and to distinguish a partial-thickness cuff tear from an intact cuff or full-thickness tear. The results were then compared using Student's t test calculations. RESULTS: For distinguishing an intact cuff from a torn cuff, the sensitivity of the observers' interpretations was lower for the T2*-weighted images than for the conventional dual-echo T2-weighted images. The specificity also decreased with interpretation of the T2*-weighted images for one observer and was unchanged for the second observer. For distinguishing a partial-thickness cuff tear from a non-partial-thickness cuff tear (intact or full-thickness tear), the sensitivity and specificity of both observers decreased with interpretations of the T2*-weighted images when compared with the conventional dual-echo T2-weighted images. The results did not reach statistical significance. CONCLUSION: In this small study evaluating the ability of observers to diagnose rotator cuff tears on oblique coronal MR images only, interpretations of T2*-weighted images tended to be less sensitive and specific than interpretations of standard dual-echo T2-weighted images.

Adult↗
PubMed2000

[Arthroscopic rotator cuff repair: a multicentric retrospective study of 87 cases with anatomical assessment].

PURPOSE OF THE STUDY: The aim of this study was to evaluate the anatomical and technical limits of endoscopic rotator cuff repair. Anatomical results were also compared with functional assessment of the shoulder. MATERIAL AND METHODS: A multicentric serie of 87 patients presenting a full thickness rotator cuff tear repaired endoscopically was retrospectively reviewed at 25.4 months (mean) post surgery. Limits of the surgical technique were studied in correlation with functional results and anatomic radiographic evaluation (arthroscans in 93 p. 100). RESULTS: Anatomical repair (normal thickness and no contrast in the subacromial space on arthroscan) was achieved in 83 p. 100 of the rotator cuffs with limited damage to the frontal part of the supra spinatus tendon. This percentage fell to 57.8 p. 100 in case of posterior extension of the tear to the supra spinatus tendon and further dropped to 40.8 p. 100 in case of retraction to the apex of the humeral head. Functional outcome evaluated with the Constant score was strongly related to the radiographic cuff condition (p <0.05). For distal and anterior tears of the supra spinatus tendon, the Constant score at revision was 89.8 points in cases with anatomic repair at revision. This score fell to 75 when the rotator cuff tear was evidenced radiographically (p <0.0001). For tears involving the entire supra spinatus tendon repaired by arthroscopy, the functional difference at revision was 8 points on the Constant scale. Objective and subjective analysis of the surgical procedure identified significant peroperative elements predictive of clinical and anatomical outcome (difficult reduction, p <0.05; subjective degree of solidity, p <0.0001; anatomical aspect of the repaired cuff, p <0.05). DISCUSSION: A comparison of our findings with data on equivalent lesions reported in the literature suggests that endoscopic surgery for rotator cuff tears offers both functional and anatomic results equivalent to those achieved with conventional open surgery. This assumes that the surgical procedure is carried out by surgeons experienced in shoulder arthroscopy who can precisely gauge the posterior/anterior extension of the tears and the limits of the surgical technique.

Adult↗
PubMedDate not supplied

[Surgical treatment of the impingement syndrome and of the rotator cuff tears: personal experience in 134 cases].

The time-course covered by the original definition of scapulo-humeral periarthritis suggested by Duplay through the more recent term of subacromial impingement syndrome coined by Neer, follows the identification of the pathogenetic mechanisms leading to chronic subacromial impingement and degenerative tears of the rotator cuff. The Authors recall the functional-anatomic development evolution of the shoulder and the disequilibrium between the depressor and the elevator muscles which may promote the chronic friction against the acromion. However, the actual pathogenesis of the impingement still remains controversial. We evaluated 134 patients (81F, 53M, mean age 56.4 years) with chronic subacromial impingement syndrome. In 92 cases (69%) non traumatic tears of the rotator cuff were also present as confirmed by ultrasonography in 94 cases, CT in18 cases and magnetic resonance in 102 cases. The different tear patterns of the rotator cuff were classified as suggested by Ellman (L shaped, L reverse, triangular, trapezoidal and massive with retraction) and clinical results were analyzed following Sahlstrand clinical criteria and Costant numerical scale. According to the anatomical damage, patients were divided into those with impingement without severe cuff tendinopathy (42 cases), those with rotator cuff tears without loss of motion of the shoulder (32 cases) and those with cuff tears and loss of active motion (60 cases). The different surgical techniques and rehabilitation procedures after surgery are also reported. After a mean follow-up of 1.3 years (range 8 months - 2 years), good or excellent results were obtained in 91% of the patients without rotator cuff tears, in 87% of the patients with tears but without loss of motion and in 75% of the cases with loss of active motion. Our data demonstrate that in the majority of patients with chronic impingement syndrome and rotator cuff tears, surgical treatment shows high success rates. When surgery is associated with a careful rehabilitation programme it may frequently allow patients to return to their baseline function.

Adult↗
PubMed2006

Rotator cuff tears: assessment with MR arthrography in 275 patients with arthroscopic correlation.

We assessed the diagnostic performance of magnetic resonance (MR) arthrography in the diagnosis of articular-sided partial-thickness and full-thickness rotator cuff tears in a large symptomatic population. MR arthrograms obtained in 275 patients including a study group of 139 patients with rotator cuff tears proved by arthroscopy and a control group of 136 patients with arthroscopically intact rotator cuff tendons were reviewed in random order. MR imaging was performed on a 1.0 T system (Magnetom Expert, Siemens). MR arthrograms were analyzed by two radiologists in consensus for articular-sided partial-thickness and full-thickness tears of the supraspinatus, infraspinatus, and subscapularis tendons. At arthroscopy, 197 rotator cuff tears were diagnosed, including 105 partial-thickness (93 supraspinatus, nine infraspinatus, three subscapularis) and 92 full-thickness (43 supraspinatus, 20 infraspinatus, 29 subscapularis) tendon tears. For full-thickness tears, sensitivity, specificity, and accuracy were 96%, 99%, and 98%, respectively, and for partial tears 80%, 97%, and 95%, respectively. False negative and positive assessments in the diagnosis of articular-sided partial-thickness tears were predominantly [78% (35/45)] observed with small articular-sided (Ellman grade1) tendon tears. MR arthrography is highly accurate in the diagnosis of full-thickness rotator cuff tears and is accurate in the diagnosis of articular-sided partial-thickness tears. Limitations in the diagnosis of partial-thickness tears are mainly restricted to small articular-sided tears (Ellman grade 1) due to difficulties in differentiation between fiber tearing, tendinitis, synovitic changes, and superficial fraying at tendon margins.

Adolescent↗
PubMed1990

Rotator cuff tears: diagnosis with sonography.

The purpose of this study was to determine the accuracy of sonography in the detection of rotator cuff tears. Eighty-one patients were referred by orthopedic specialists because of a clinical suspicion of rotator cuff tear. The standards of comparison were arthrography in 79 cases and surgery in two cases. The sonographic technique used was based on a review of the literature and experience gained by scanning normal subjects. The sonographic criteria for the diagnosis of a complete rotator cuff tear were a focal defect in the cuff or complete absence or nonvisualization of the cuff. All sonograms were interpreted prospectively without knowledge of arthrographic or surgical results. With arthrography as the standard of comparison for the diagnosis of rotator cuff tear, sonographic results included 15 true-positives, 52 true-negatives, eight false-negatives, and four false-positives. With surgery as the standard of comparison, the results were one true-positive and one true-negative sonogram. The sensitivity of sonography in detecting rotator cuff tear was 0.67, the specificity was 0.93, and the accuracy was 0.85. Our study found lower sensitivity and accuracy results for shoulder sonography than have been previously reported.

Arthrography↗
PubMed2003

A modified Mason-Allen technique for rotator cuff repair using suture anchors.

An adequate restoration of the muscle-tendon-bone unit is essential for a successful outcome after rotator cuff reconstruction. We describe a suture grasping technique for rotator cuff repair using suture anchors that can be performed either arthroscopically or during open rotator cuff refixation. The technique we use is a combination of a mattress and a single suture, thus representing the principles of a Mason-Allen suture technique. The modified Mason-Allen technique for suture anchor repair is easy to perform and provides excellent initial fixation strength allowing durable osteofibroblastic integration of the reinserted cuff.

Absorbable Implants↗
PubMedDate not supplied

Arthroscopic repair of medium to large full-thickness rotator cuff tears: outcome at 2- to 6-year follow-up.

Medium-term follow-up of arthroscopic rotator cuff repair was evaluated in 48 consecutive arthroscopic repairs of medium to large rotator cuff tears. Mean rotator cuff tear size was 2.4 cm (range, 2-4 cm), mean age at surgery was 57.6 years (range, 38-80 years), and mean follow-up was 39 months (range, 24-66 months). Mean University of California at Los Angeles End-Result Scores were 17.2 preoperatively and 33.7 postoperatively (P <.001). American Shoulder and Elbow Surgeons mean scores were 42.2 and 94.9, respectively. There were no complications requiring reoperation. There were 35 excellent, 11 good, 2 fair, and no poor results; however, 1 patient had clinical evidence of a failed repair. Forty-four of 45 patients (47/48 repairs) were satisfied with their results.

Adult↗
PubMed2006

Diagnosis and management of massive rotator cuff tears: the surgeon's dilemma.

Several studies have documented high success rates following the surgical treatment of full-thickness rotator cuff tears. Historically, however, less favorable and predictable results have been found in the treatment of massive tears (>5 cm) compared with small and medium sized tears. Determining the most appropriate treatment for a patient with a massive rotator cuff tear can be challenging because of inconsistent outcome results. Some patients function well with nonsurgical treatment of massive tears, some have initially favorable results from surgical débridement of tears without repair that then deteriorate over time, and other patients who are surgically treated continue to maintain good function despite documented retears. Nonsurgical treatment of massive rotator cuff tears may be suitable for elderly patients with chronic tears and limited functional goals below shoulder level. Surgical débridement without repair of the tear may be considered for patients with low physical demands whose predominant symptom is pain. Surgical repair is recommended for patients who require maximal postoperative function, particularly for overhead activities. Open repairs have a lower rate of rerupture than arthroscopic repairs; however, arthroscopic repair offers the benefits of decreased morbidity and decreased risk of postoperative deltoid detachment. Early studies of arthroscopic repairs have shown good functional results; however, there has been a high incidence of retears. Tendon transfers and other reconstruction techniques may offer improvements in certain salvage cases, but results of these procedures are inferior to those for primary repair. Preservation of the coracoacromial arch should be considered in all forms of treatment of massive rotator cuff tears to avoid the devastating complication of superior humeral head escape.

Decision Making↗