Sonography of the rotator cuff in painful shoulders performed without knowledge of clinical information: results from 58 sonographic examinations with surgical correlation

PURPOSE: To assess the value of sonography as an isolated diagnostic test for the detection and quantification of rotator cuff tears. METHODS: Preoperative sonographic examination was performed on 58 shoulders. Key biases on sonographic interpretation such as history-taking, physical examination, or concurrent imaging examinations were excluded by way of blinding. Tears of the rotator cuff were the positive findings of interest. Assessment of tear size and localization was done sonographically, and the results were compared with operative findings. RESULTS: All 24 full-thickness tears observed at surgery had been diagnosed correctly via sonography. In 19 of 20 cases with an intact rotator cuff, preoperative sonography was negative. Thirteen of 14 partial-thickness tears were not detected via sonography; 1 was misinterpreted as a full-thickness tear. Location of the tears relative to the rotator cuff tendons was described correctly in 21 of 25 cases. For tear size measurement, the 95% range of agreement was less than +/-1 cm. CONCLUSIONS: Blinded sonographic examination is effective in the detection and quantification of full-thickness tears of the rotator cuff but lacks sensitivity in the detection of partial-thickness tears.     

Association of shoulder sonographic findings with subsequent surgical treatment for rotator cuff injury.

OBJECTIVE: To identify any clinical and radiologic findings of rotator cuff injury that predict whether patients will undergo shoulder surgery. METHODS: We retrospectively studied all shoulder sonograms obtained at a single institution over 12 months. Possible predictors of surgical treatment were documented, including patient age and sex, duration and types of symptoms, and the location and severity of tendon damage on sonography. One hundred twenty-eight patients underwent shoulder sonography; 34 patients eventually underwent shoulder surgery. Multivariate logistic regression was performed to identify clinical and sonographic factors associated with the use of surgical therapy. RESULTS: The only statistically significant predictor of surgical intervention was the finding of full-thickness tears (with or without tendon retraction) on sonography (P = .03). Patients with full-thickness tears were 4.3 times more likely to undergo surgery than those with no tears (odds ratio, 4.3). CONCLUSIONS: The sonographic diagnosis of full-thickness rotator cuff tears is the only finding statistically associated with the use of surgical treatment. No single clinical variable was consistently associated with subsequent surgery. Partial-thickness tears on sonography also do not show any statistical association with the eventual use of surgery for rotator cuff symptoms.     

关节镜下治疗肩袖损伤21例报告

目的探讨运用关节镜治疗肩袖损伤方面的作用。方法在关节镜下对肩袖损伤进行缝合,同时行肩关节前肩峰成形术。结果本组21例根据美国UCLA功能评分标准进行评定,优良率达95.24%。结论关节镜下治疗肩袖损伤能明确诊断、探查盂肱关节的其他疾患、不损伤三角肌止点、无张力缝合肩袖、术后疼痛轻、可以早期功能锻炼、术后肩关节粘连少、瘢痕少。     

Clinical significance of sonographic findings in the abnormal but intact rotator cuff: a preliminary report

Shoulder pain is a common orthopedic problem. Clinical examination is often nonspecific and arthrography is normal in those patients with the most frequent cause of shoulder pain--noncalcific tendonitis secondary to impingement. Ultrasonography has recently shown itself to be of value in the diagnosis of rotator cuff tears. In addition to the diagnosis of tears, however, sonography can demonstrate abnormalities within the intact rotator cuff tendon. These abnormalities consist of changes in echogenicity and thickness of the tendon. The patterns of abnormality demonstrated correlate with pathologic changes seen in tendonitis. This preliminary study suggests that the ability to demonstrate an abnormal rotator cuff tendon has potential for becoming a valuable aid to the orthopedist in allowing confident diagnosis of rotator cuff disease in the presence of nonspecific symptomatology and an intact tendon.     

肩袖损伤与关节镜手术后康复

肩袖损伤是肩关节的多发病。关节镜下肩袖缝合术因具有创伤小、恢复快的优点而成为目前治疗肩袖损伤的主要方法之一。术后肩关节康复亦是手术成功的关键。     

关节镜下肩袖间隙滑移技术在巨大肩袖撕裂中的应用

目的观察关节镜下使用肩袖间隙滑移技术修补巨大肩袖撕裂的临床疗效。方法采用回顾性研究方法,选取2015年1月至2019年3月北京市平谷区医院收治的巨大肩袖撕裂患者42例,按照手术方式不同将患者分为切开修复组和关节镜修复组,每组各21例。切开修复组患者使用改良切开修复巨大肩袖撕裂,关节镜修复组患者使用关节镜下肩袖滑移技术修复巨大肩袖。记录并比较患者术前情况,包括患者的VAS评分、肩关节UCLA评分、肩关节Constant-Murley评分、肩袖受伤情况、受伤至手术的时间等。所有患者术后3个月和6个月门诊随访,记录并比较两组患者VAS评分、肩关节UCLA评分、肩关节Constant-Murley评分和末次随访患者满意度评分以评价两种手术疗效。结果两组患者术前各观察指标比较差异均无统计学意义(P>0.05)。术后3个月关节镜修复组VAS评分、肩关节UCLA评分和肩关节Constant-Murley评分分别是4.9±1.2分、29.1±4.5分和72.4±13.9分,而切开修复组上述指标分别为6.3±1.6分、21.7±3.9分和61.8±10.6分。关节镜修复组患者的疼痛VAS评分低于切开修复组,差异具有统计学意义(P<0.05);关节镜修复组患者的肩关节UCLA评分和肩关节Constant-Murley评分均高于切开修复组,差异具有统计学意义(P<0.05)。术后6个月,关节镜修复组VAS评分、肩关节UCLA评分和肩关节Constant-Murley评分分别是3.7±1.3分、32.6±4.7分和82.1±10.8分,而切开修复组上述指标分别为3.9±1.4分、32.8±4.5分和81.5±11.3分,差异均无统计学意义(P>0.05)。术后末次随访时,关节镜修复组患者的满意度评分(84.3±15.1分)显著高于切开修复组(72.9±12.3分),差异具有统计学意义(P<0.05)。结论关节镜下肩袖间隙滑移技术能够有效地修复巨大肩袖撕裂,比切开肩袖修复巨大肩袖撕裂术后康复得更快。     

肩袖超声成像研究

检查３０例正常人的６０个肩袖，对肩袖各肌腱的大小、形态及成像特点等进行了一系列的观察和分析，获得了有价值的资料和数据，为进一步研究超声检查肩袖疾病奠定了基础。     

超声诊断类风湿性肩关节炎肩袖损伤：与关节镜手术对照

目的 探讨超声检查对类风湿性肩关节炎肩袖损伤的诊断价值。方法 应用超声对47例临床拟诊肩袖损伤的类风湿性肩关节炎患者的47侧肩袖进行扫查,依次观察肩胛下肌腱、冈上肌腱、冈下肌腱、小圆肌腱在静止状态和运动状态下有无损伤及撕裂。 在超声检查1周内对所有患者行肩关节镜手术治疗,将超声结果与手术结果进行对照。结果 超声可清晰显示类风湿性肩关节炎肩袖病变的形态学特征,包括有无撕裂和厚度改变;共检出31侧肩袖损伤,其中不完全撕裂18侧,完全撕裂7侧,肩袖肌腱厚度变薄6侧。与关节镜手术结果比较,超声诊断肩袖损伤的总体敏感度为90.62%(29/32),特异度为86.67%(13/15),准确率为89.36%(42/47)。超声对肩袖完全撕裂的诊断准确率为100%(7/7)。结论 超声对检出和判断类风湿性肩关节炎肩袖损伤程度有较高价值,尤其对显示完全撕裂和肩袖肌腱厚度变薄意义更显著。     

EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE

The incidence of rotator cuff tears increases with age, with full-thickness rotator cuff tears present in approximately 25% of individuals in their sixties, and more than 50% of those in their eighties. While surgery is considered an effective treatment, recurrent tears at the insertion site are common, especially with degenerative tears, which are frequent in the older population. More recently, there has been increasing interest in exercise rehabilitation and physical therapy as a means to manage partial and full thickness tears of the rotator cuff by addressing weakness and functional deficits. Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery. When considering the increasing rate of shoulder surgery and the associated economic and social burden rotator cuff surgery places on both the patient and the health care system, non-surgical management such as physical therapy and exercise may, in selected cases, be a treatment alternative to surgical repair. The purpose of this clinical commentary is to provide an overview of rotator cuff pathology and pathogenesis, and to present an evidence-based case for the role of conservative rehabilitation in the management of rotator cuff injuries.

Level of Evidence

Level 5     

肩袖撕裂的超声诊断

目的：评价超声检查肩袖撕裂的应用价值。方法：对55例（57个肩关节 ）临床怀疑肩袖损伤者行超声检查,诊断标准包括。（1）、肩袖部分缺损;（2）、肩袖不显示;（3）肩袖内局灶性回声异常;（4）、肩袖部发变薄,超声检查结果与手术、肩关节造影或MR结果比较。结果：超声诊断敏感性94％（33／35）,特异性86％（19／22）,准确性91％（52／57）。结论：超声检查肩袖撕裂具有很高的应用价值,作为首选的检查方法。     

Comparison Between Exclusively Long‐Axis and Multiple‐Axis Sonographic Protocols for Screening of Rotator Cuff Lesions in Symptomatic Shoulders

Objective. The purpose of this study was to determine whether exclusively long‐axis sonography differs from a multiple‐axis scanning protocol as a screening tool for rotator cuff lesions in symptomatic shoulders when compared with magnetic resonance imaging (MRI). Methods. A total of 509 consecutive patients (mean age, 52.8 years) referred for MRI were also routinely evaluated by sonography. We initially performed exclusively long‐axis sonography and graded the rotator cuff as normal or abnormal. Patients subsequently underwent a full sonographic protocol using multiple‐axis views. Magnetic resonance imaging findings were compared with sonographic findings for both techniques. Results. The overall accuracy of sonography was greater than 90%. We found divergent results from different sonographic techniques in 34 patients. Of these, 8 were multiple‐axis false‐negative; 14 were exclusively long‐axis false‐negative; 6 were exclusively long‐axis false‐positive; and 6 were multiple‐axis false‐positive. All cases with divergent false‐negative findings on multiple‐axis sonography showed tendinosis on MRI. Causes for false‐negative findings on exclusively long‐axis sonography included tendinosis and partial‐thickness tears of the supraspinatus. No statistically significant difference was seen between both sonographic techniques compared with MRI in terms of accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (P > .05). Conclusions. Sonography is reliable for detecting rotator cuff abnormalities. Exclusively long‐axis sonography seems appropriate as a screening tool for rotator cuff lesions in symptomatic shoulders.     

Sonography of the shoulder after arthrography (arthrosonography): preliminary results.

PURPOSE: The purpose of this study was to verify whether arthrosonography improves diagnostic accuracy in diseases of the shoulder and provides additional information for therapeutic planning, compared with conventional sonography. METHODS: We prospectively studied 113 consecutive patients with chronic shoulder pain. Sonography was performed before and after arthrography, with the radiologist blinded to the results of arthrography. When a rotator cuff tear was detected sonographically, its type, location, and size were recorded; we also evaluated any changes in the subacromial-subdeltoid bursa and any abnormalities in the biceps tendon sheath. The diagnostic accuracy of conventional sonography and arthrosonography was compared with that of arthrography for rotator cuff tear. Changes in the subacromial-subdeltoid bursa and biceps tendon sheath seen on conventional sonography were also compared with those seen on arthrosonography. RESULTS: The sensitivity and specificity of conventional sonography in the diagnosis of rotator cuff tear were 86% (25/29) and 95% (80/84), respectively; for arthrosonography, the values were 97% (28/29) and 95% (80/84), respectively. The differences in sensitivity and specificity for the 2 sonographic techniques were not statistically significant (p > 0.05). The accuracy in localizing the tear was also not significantly different between the 2 sonographic techniques. Synovial proliferation was more easily detected with arthrosonography than it was with conventional sonography in the subacromial-subdeltoid bursa (p < 0.01) and in the biceps tendon sheath (p < 0.0001). CONCLUSIONS: Our preliminary results suggest that although arthrosonography was not superior to conventional sonography in the diagnosis of rotator cuff tears, it may provide a better assessment of the size of tears and additional information about synovial proliferation in the subacromial-subdeltoid bursa and the biceps tendon sheath.     

巨大肩袖撕裂的机制与修复方法的研究进展

巨大肩袖撕裂因其损伤机制复杂,目前仍是骨科难题。对于其最佳治疗方法及术后效果,各学者报道也不尽相同。其主要的治疗方法包括保守治疗、肩关节清理及肩峰成形术、肱二头肌长头键切断或固定术、撕裂肌腱修复术、肌腱转位术及比较热门的上关节囊重建及反肩关节置换术。本文着重对巨大肩袖撕裂的机制和治疗方法的研究成果作一综述,以期为临床治疗提供参考。     

肩关节镜下肩袖修复术治疗肩袖损伤的临床效果

目的探讨肩关节镜下肩袖修复术治疗肩袖损伤的临床效果。方法将我院2018年2月至2019年2月收治的52例肩袖损伤患者随机分为对照组(26例,开放式肩袖修复术)和观察组(26例,全肩关节镜下肩袖修复术)。比较两组的治疗效果。结果治疗后,两组的肩关节前屈、内旋、外旋活动度及Constant-Muley肩关节评分均增加,数字评估量表(NRS)评分均降低,且观察组显著优于对照组(P<0.05);观察组的治疗优良率显著高于对照组(P<0.05)。结论肩关节镜下肩袖修复术治疗肩袖损伤的临床效果显著,能够有效减轻患者疼痛,加快患者术后肩关节功能的恢复,值得临床推广应用。     

急性创伤致肩袖撕裂的超声诊断

目的探讨肩袖撕裂的超声特征，评价超声检查肩袖撕裂的应用价值。方法对33例急性创伤后疑诊肩袖损伤者行超声检查，并与磁共振、肩关节造影或手术结果进行比较。结果肩袖撕裂的超声主要表现为：肩袖不显示，肩袖部分缺失，肩袖内局灶性异常回声，肩袖局部变薄。超声诊断的敏感性92％(22／24)，特异性82％(9／11)，准确性94％(31／33)。结论超声诊断肩袖撕裂有较高的应用价值，可作为急性肩部创伤而X线检查正常患者的首选检查方法。     

Detection and quantification of rotator cuff tears with ultrasonography and magnetic resonance imaging - a prospective study in 77 consecutive patients with a surgical reference

The aim of this study was to compare the accuracy of ultrasonography (US) and magnetic resonance artrography (MRA) for the detection and measurement of rotator cuff tears, using surgical findings as a standard. A total of 77 consecutive patients with suspected rotator cuff tears were prospectively studied with US and MRA. Rotator cuff tears were identified by US with sensitivity, specificity, positive predictive and negative predictive values of 92%, 45%, 91% and 50%, respectively, and by MRA with values of 97%, 82%, 97% and 82%, respectively. US was not reliable for differentiating between partial and full thickness tears. US and MRA underestimated the tear sizes by an average of 15 mm and 4 mm, respectively. Our results suggest that US could be used as a screening test to confirm a suspected rotator cuff tear. In patients with negative findings, an MRA should be considered for substantiation.     

Treatment Options for Massive Irreparable Rotator Cuff Tears

Purpose of ReviewMassive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.Recent FindingsPartial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands.SummaryIrreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.     

Treatment of irreparable rotator cuff tears

Irreparable rotator cuff tears are a challenging problem for patients and surgeons. There are several treatment options, but deciding the correct one for each patient can be difficult. Treatment options include physical therapy, arthroscopy, muscle transfers, reverse shoulder arthroplasty, and hemiarthroplasty. An understanding of the patient’s chief complaint and their functional ability to elevate their arm above horizontal should guide the treatment. This article reviews the current literature on various treatment options for irreparable rotator cuff tears, then outlines an algorithm for determining treatment.     

Interobserver variation in sonography of the painful shoulder

PURPOSE: This study was conducted as a prospective assessment of interobserver variability in the sonographic evaluation of the rotator cuff. METHODS: Three musculoskeletal radiologists who had different levels of scanning experience each performed shoulder sonography on 24 consecutive patients during 1 patient visit. The diagnostic criteria full-thickness rotator cuff tear, tendon calcification, tendinosis of the supraspinatus, subacromial fluid, subacromial synovial/bursal thickening, dynamic signs of impingement, and abnormality in the long head of biceps tendon were scored, with independent observers recording the data. Statistical analysis was performed using Cohen's kappa test, with significance assessed at p values of less than 0.05. RESULTS: There was good agreement (kappa >0.60, p <0.01) between the experienced operators for full-thickness rotator cuff tear, tendon calcification, dynamic signs of impingement, and abnormality of the long head of biceps tendon. There was no significant agreement between the experienced operators and the less experienced operator in several categories, including (and importantly) full-thickness rotator cuff tears (kappa=0.18-0.21). CONCLUSIONS: In experienced hands sonography of the rotator cuff is a reproducible diagnostic test, but agreement is poor when there is marked disparity between the operators' experience levels. Our findings suggest a need for a more clearly defined training curriculum for sonography of the shoulder in radiology training programs.     

关节镜下缝线桥技术治疗老年创伤性肩关节脱位合并肩袖损伤的疗效评价

目的比较关节镜下缝线桥技术肩袖修补与保守方法治疗老年创伤性肩关节脱位合并肩袖损伤的疗效。方法前瞻性研究2010年8月-2013年8月采用关节镜下缝线桥技术肩袖修补或保守方法治疗老年创伤性肩关节脱位合并肩袖损伤患者共63例,根据患者治疗方法将其分为关节镜下缝线桥技术肩袖修补治疗组(手术组)和保守方法治疗组(对照组)。手术组完整随访30例,男16例,女14例;年龄66~83岁,平均74.5岁;参照DEORIO和COFIELD的分级标准,中撕裂27例,大撕裂3例。对照组完整随访30例,男17例,女13例;年龄65~82岁,平均74.2岁;参照DEORIO和COFIELD的分级标准,中撕裂27例,大撕裂3例。比较两组患者分组时、治疗1年后视觉模拟评分(VAS)、关节活动范围、简明肩关节功能测试(SST)评分、欧洲肩关节协会的Constant肩关节评分,并记录随访期间肩关节脱位复发例数。结果 60例患者获得至少1年的完整随访,手术组30例,对照组30例。分组时两组患者VAS评分、肩关节活动范围、SST评分、Constant评分组间差异无统计学意义(P0.05);随访1年时手术组患者的VAS评分、肩关节活动范围、SST评分和Constant评分均明显优于对照组,差异有统计学意义(P0.05)。随访期间手术组无肩关节脱位复发,对照组5例发生肩关节脱位复发,差异有统计学意义(P0.05)。结论采用关节镜下缝线桥技术肩袖修补治疗合并肩袖中、大型撕裂的老年创伤性肩关节脱位患者,可以明显改善患者肩关节功能,降低肩关节脱位复发率,长期随访结果有待进一步研究。