MR imaging of rotator interval, long biceps, and associated injuries in the overhead-throwing athlete

The rotator interval between supraspinatus and subscapularis is proving to be an important anatomic and functional region of the shoulder. Appreciation of the anatomic structures, functional importance, and mechanisms of injury are invaluable in appropriate assessment, both by physical examination and diagnostic MR imaging. The long biceps tendon; the superior labrum and labral-biceps anchor; the coracohumeral ligament merging with the rotator interval capsule and the superior glenohumeral ligament; the ligamentous reflection pulley for the long biceps tendon at the far lateral margin of the interval extending to the lesser tuberosity and proximal bicipital groove, bounded by the distal superior margin of the subscapularis and anterior margin of the supraspinatus tendons; and the transverse humeral ligament extending between the lesser and greater tuberosities along the proximal bicipital groove all are intimately associated in this region and may be injured together. Understanding of the anatomy and function of the rotator interval continues to evolve. Rotator interval injury may be better understood as a complex or spectrum rather than an isolated lesion. When any one of the spectrum of associated injuries is suspected or found, all of the other possible associated injuries should be considered and evaluated, both on clinical and MR imaging evaluations.     

Indikation,Technik und Ergebnisse von Sehnentransferoperationen

Background

In the last few decades, tendon transfer procedures have become established for the treatment of younger patients with irreparable rotator cuff tears.

Objectives

Indication, predictive factors and clinical results of tendon transfer procedures in rotator cuff surgery and modified surgical techniques are discussed.

Methods

The current literature and expert opinions are discussed in association with our own case series.

Results

In recent years a number of predictive factors, important to consider for surgical indication, have been analyzed for M. latissimus dorsi transfer (postero-superior defects) and M. pectoralis major transfer (anterior defects). Because the indication is restricted to the short time interval between reparable tear and apparent cuff arthropathy, the number of cases is limited. Clinical results in currently published case series show on average a significant functional improvement, but not complete restoration of shoulder function. Larger case series have been published for M. latissimus dorsi transfer and this technique presents superior clinical results compared to the results observed in patients after M. pectoralis major transfer.

Conclusion

Tendon transfer techniques offer an additional therapeutic option during the time interval between still reparable rotator cuff tear and cuff arthropathy; however, clinical results are highly dependent on correct indication.     

Risk factors for rotator cuff disease: A systematic review and meta-analysis of diabetes,hypertension, and hyperlipidemia

BackgroundRotator cuff disease is a common cause of shoulder pain. Comorbidities such as diabetes, hypertension, and hyperlipidemia may be associated with rotator cuff disease, likely because of mechanisms related to vascular insufficiency.ObjectivesWe performed a systematic review of the association of diabetes, hypertension, and hyperlipidemia with the diagnosis of rotator cuff disease.MethodsFollowing systematic queries of PubMed, Embase, Cochrane, CINAHL, and Science Direct, articles meeting eligibility criteria and reporting on the association of one or more risk factors (diabetes, hypertension, and hyperlipidemia) and rotator cuff disease were considered. Meta-analysis was performed to quantitatively summarize the associations between each risk factor and rotator cuff disease. We assessed study quality with the Newcastle-Ottawa Scale (NOS) and performed a qualitative assessment of risk of bias.ResultsAfter a full-text review of 212 articles, 12 articles assessing diabetes, 5 assessing hypertension and 8 assessing hyperlipidemia were eligible. The odds of having rotator cuff disease was increased with diabetes (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.43–1.55), hypertension (OR 1.40, 95% CI 1.19–1.65) and hyperlipidemia/dyslipidemia (OR 1.48, 95% CI 1.42–1.55). Diabetes was also specifically associated with rotator cuff tears (OR 1.28, 95% CI 1.07–1.52). Synthesizing assessment for risk of bias suggested that current epidemiologic evidence for an association was plausible for diabetes and hyperlipidemia but not hypertension.ConclusionsDiabetes, hypertension, and hyperlipidemia were associated with rotator cuff disease in our meta-analysis. However, the possibility of bias exists for all 3 co-morbidities evaluated and is likely highest for hypertension. High-quality studies with the ability to incorporate time since first diagnosis of co-morbidity are scarce and much needed.     

Transoss?re Nahttechnik bei kompletten Rotatorenmanschettenrupturen

In recent years arthroscopic techniques for rotator cuff repair have been successfully developed with technically advanced implants and biomechanically matured suture configurations. Suture anchors have been established as the standard treatment. We describe a special technique for arthroscopic transosseous rotator cuff repair using a hollow needle with simultaneous perforation of tendon and bone. Isolated articular-sided partial or full-thickness tears of the supraspinatus tendon without advanced tendon retraction represent ideal indications. In a prospective cohort study 41 patients with arthroscopic transosseous repair of full-thickness supraspinatus tendon tears were followed up clinically and radiologically using indirect MR arthrography after an average of 45 months. The Constant score improved from 53 to 84 points. In 5 cases a re-rupture was present at follow-up with only 1 patient complaining of poor shoulder function. The arthroscopic transosseous rotator cuff repair represents a reliable alternative to the established techniques using suture anchors or knotless implants with comparable clinical and radiological results. The biological and economical advantages exceed the flat learning curve.     

超声引导经肩袖间隙注射治疗冻结肩的临床研究

目的探讨超声引导经肩袖间隙肩关节腔和三角肌下滑囊注药治疗冻结肩的可行性与临床疗效。 方法选取2020年3月至2021年3月于解放军总医院第一医学中心确诊的65例冻结肩患者进行超声引导经肩袖间隙肩关节腔和三角肌下滑囊注药治疗。治疗前超声检查测量肩袖间隙处肱二头肌长头肌腱至皮肤的最短距离和喙肱韧带的厚度，分别于治疗前和治疗后1周、1个月及3个月行视觉模拟量表（VAS）疼痛评分以及Constant量表和美国加利福尼亚大学（UCLA）量表肩关节功能评分。 结果治疗前测量肱二头肌长头肌腱至皮肤最短距离为（11.81±2.52）mm，喙肱韧带厚度平均为（2.69±0.42）mm。所有患者均成功进行超声引导经肩袖间隙肩关节腔和三角肌下滑囊注药治疗。与治疗前评分比较，治疗后1周、1个月和3个月的VAS疼痛评分随时间延长而降低，两两比较差异均有统计学意义（P均＜0.008）。与治疗前比较，治疗后1个月、3个月Constant量表和UCLA量表的肩关节功能评分得到改善，评分比较差异均有统计学意义（P均＜0.016）；与治疗后1个月比较，治疗后3个月Constant量表和UCLA量表的肩关节功能评分改善不明显，评分比较差异无统计学意义（P＞0.016）。与治疗前相比，治疗后1个月、3个月Constant量表中的疼痛程度、日常生活能力、肩关节活动程度和肌力均得到改善，评分比较差异均有统计学意义（P均＜0.016）；与治疗后1个月相比，治疗后3个月的疼痛程度、日常生活能力、肩关节活动度和肌力均未见进一步改善，评分差异均无统计学意义（P均＞0.016）。 结论超声引导经肩袖间隙注射可一次进针实现肩关节腔和三角肌下滑囊2个部位的注射，临床短期疗效满意，可作为冻结肩超声引导微创治疗的方案之一。     

Ultrasound of the shoulder.

Ultrasound of the shoulder is a powerful and accurate method for the examination of the rotator cuff, biceps mechanism and the synovium. This article describes the anatomy, standard examination technique, indications, pitfalls and potential errors. It lists suggested imaging algorithms for a range of shoulder pathology.     

The rotator cable: magnetic resonance evaluation and clinical correlation

The rotator cable is an extension of the coracohumeral ligament coursing along the undersurface of the supraspinatus and infraspinatus tendons. The rotator cable is thought to play a role in the biomechanical function of the intact and torn rotator cuff. It can be seen on all the imaging planes used for the conventional magnetic resonance imaging of the shoulder. Clinically, the integrity of the rotator cable can play a role in the treatment selection for patients with a rotator cuff tear.     

Shoulder MRI refinements: Differentiation of rotator cuff tear from artifacts and tendonosis, and reassessment of normal findings

One of the difficulties with rotator cuff imaging lies in the normal variability of the tendon's signal. There may be intermediate signal present within the tendon because of magic-angle phenomenon, muscle and tendon fiber interdigitation, or tendinopathy related to degenerative changes or overuse injury. Partial and complete rotator cuff tears should be distinguishable from these causes of intermediate signal if water signal is reliably identified. This article reviews the important issue of distinguishing between rotator cuff tear and other causes of high signal in the rotator cuff, including artifacts and tendonosis. We include a review of the literature and a brief report of a study we conducted on 20 shoulders of 14 asymptomatic, young volunteers. In this study, the rotator cuff tendons were evaluated for abnormal signal at different TE values to determine at what TE the interpreters were able to confidently distinguish the high-signal intensity of a tear (water) from the intermediate signal intensity associated with artifact and tendinopathy. Readers were able to distinguish water and tendon signal in 70% to 100% of fast-spin echo (FSE) fat-saturated images with TE of 66, but there was interobserver variability at this TE, suggesting that it is less reliable than 88 ms in the identification of rotator cuff tears. By using FSE fat-saturated sequences with TE of 88 and fast spin echo inversion recovery (FSEIR) sequences, readers at all levels of experience were able to differentiate water signal intensity from tendon signal intensity in 100% of cases. Therefore, we suggest that either FSEIR images or FSE fat-saturated images with TE greater than 66 be used to facilitate the differentiation of fluid signal from intermediate increased signal intensity in rotator cuff imaging. Additionally, this article reviews the normal findings of shoulder magnetic resonance imaging (MRI) as revealed by the asymptomatic subjects included in our study, and assesses these findings in respect to previous publications. The normal features reviewed include the subacromion-subdeltoid (SA/SD) bursa, the biceps tendon sheath, the acromioclavicular (AC) joint, and the greater tuberosity of the humerus. A small amount of fluid was commonly seen in the SA/SD bursa, as well as the biceps tendon sheath. Subjective down-sloping of the acromion in the coronal plane, mild degenerative change of the AC joint, and undersurface spurring of the AC joint were uncommon in our normal subjects. Cystic change limited to the posterior aspect of the greater tuberosity was identified in 15% to 45% of shoulders.     

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。     

The postoperative shoulder

Because disability and pain may persist or recur after shoulder surgery, visualization of the postoperative shoulder before further treatment is of great interest. Postoperative status is reevaluated most frequently after rotator cuff repair, capsulorrhaphy in patients with chronic instability, and acromioplasty, where postoperative symptoms are clinically difficult to distinguish from rerupture or inadequate surgical results. Postoperative evaluation or follow-up after surgical treatment of tumors or surgical repair of shoulder injuries are other potential indications. Whereas surgical procedures for osseous components primarily will be evaluated by plain film radiographs, magnetic resonance imaging is a valuable tool for other sites of surgical treatment, such as soft-tissue components, with further potential indication for magnetic resonance arthrography. This article focuses on normal and abnormal postoperative findings in the shoulder, with emphasis of magnetic resonance imaging, and discusses specific findings based on magnetic resonance arthrography.     

Lack of adverse effect of transportation on room temperature stored platelet concentrates

The ability of platelet concentrates stored at room temperature to withstand transportation after removal from the rotator and ideal temperature environment was studied by reinfusing autologous 51Cr- labeled platelets obtained from normal volunteers. Periods of up to 6 hours off the rotator and not under temperature control did not result in a significant change in platelet viability. Platelets transported up to 12 hours after 24 hours of storage and then placed on a rotator for the remainder of the 72-hour storage interval also showed expected recovery and survival. Thus, room temperature stored platelets may be used even when transportation for up to 6 hours is required before the concentrates are transfused.     

Rotator cuff pathology and subacromial impingement

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.     

Shoulder arthroscopy: principles and practice

Shoulder arthroscopy has an expanding role in the diagnostic and therapeutic management of shoulder disorders. This article describes the principles of shoulder arthroscopy, including basic technique,indications, and complications. The clinical applications to several shoulder pathologies, such as rotator cuff disorders, glenohumeral instability, and biceps anchor superior lesions, ar reviewed.     

Platelet-rich plasma and the shoulder: clinical indications and outcomes

Purpose of Review

The orthopedic community has seen a rapid rise in the clinical use of platelet-rich plasma (PRP) in the management of shoulder pathologies over the past decade. The purpose of this paper is to review the current literature regarding the indications and outcomes of PRP for the surgical and non-surgical management of common shoulder pathologies, including rotator cuff tears.

Recent Findings

Multiple studies have been published recently regarding the use of PRP for the operative and non-operative treatment of rotator cuff tears. There has been less research published on the use of PRP in the management of other conditions of the shoulder. Despite attempts to standardize and classify PRP formulations, there remains great variation in the inter- and intra-subjection composition, preparation, and administration techniques of PRP, limiting the conclusions that can be drawn regarding the utility and effectiveness of this biologic treatment as reported by Mazzocca et al. (J Bone Joint Surg Am. 94(4):308–16, 2012).

Summary

Recent literature has shown equivocal to minor benefit of PRP use for shoulder pain, function, and healing. While few complications have been reported and PRP administration appears to carry little risk to the patient, the body of literature is currently inconclusive regarding the clinical benefit and cost-effectiveness of PRP in the treatment of shoulder pathology. As for PRP use specifically as an adjunct to surgical rotator cuff repairs, there is no clear consensus on its effectiveness in either clinical or structural outcomes. To further delineate the efficacy of PRP for shoulder pathology, it is essential that more double-blinded, randomized controlled investigations with large sample sizes and standardized PRP preparations be performed.

     

Mechanisms of rotator cuff tendinopathy: Intrinsic,extrinsic, or both?

The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes.     

妇科再次腹腔镜术的探讨——附36例临床分析

目的：探讨妇科再次腹腔镜术的指征。手术时机、处理方法及价值。方法：回顾性分析因妇科疾病行再次腹腔镜术的３６例病人的临床资料。结果：再次腹腔术与首次腹腔镜术间隔时间３个月至６０个月，中位间隔时间为２５个月。１８例（５０％）的再次腹腔镜术指征与首次相同，其中不孕症１４例（原发不孕９例，继发不孕５例），盆腔包块３例，继发性痛经１例。手术指征不一致的１８例中，不孕症３例，盆腔包块４例，绝育１便，异位妊娠６     

Ultrasound‐Guided Biceps Peritendinous Injections in the Absence of a Distended Tendon Sheath

This retrospective study evaluated the technical success rate of a novel injection into the long head of the biceps tendon sheath by a rotator interval approach in 26 patients. A 25‐gauge, 1.5‐in needle was positioned into the rotator interval from a lateral approach, where a therapeutic injection was performed. Postinjection sonograms images were reviewed to assess for fluid within the sheath to calculate the technical success rate. Fluid distention of the biceps tendon sheath was shown in all 26 cases, corresponding to a 100% technical success rate. In addition, postinjection ultrasound imaging of the anterior shoulder provided additional diagnostic findings in 6 of 26 patients (23%).     

Effects of high- and low-energy radial shock waves therapy combined with physiotherapy in the treatment of rotator cuff tendinopathy: a retrospective study

Purpose: The aim of this study was to investigate the efficacy of high- and low-energy radial shock waves combined with physiotherapy for rotator cuff tendinopathy patients.

Methods: Data from rotator cuff tendinopathy patients received high- or low-energy radial shock waves combined with physiotherapy or physiotherapy alone were collected. The Constant and Murley score and visual analog scale score were collected to assess the effectiveness of treatment in three groups at 4, 8, 12, and 24?weeks.

Results: In total, 94 patients were involved for our retrospective study. All groups showed remarkable improvement in the visual analog scale and Constant and Murley score compared to baseline at 24?weeks. The high-energy radial shock waves group had more marked improvement in the Constant and Murley score compared to the physiotherapy group at 4 and 8?weeks and at 4?weeks when compared with low-energy group. Furthermore, high-energy radial shock waves group had superior results on the visual analog scale at 4, 8, and 12?weeks compared to low-energy and physiotherapy groups.

Conclusions: This retrospective study supported the usage of high-energy radial shock waves as a supplementary therapy over physiotherapy alone for rotator cuff tendinopathy by relieving the symptoms rapidly and maintaining symptoms at a satisfactory level for 24?weeks.

• Implications for Rehabilitation

• High-energy radial shock waves can be a supplemental therapy to physiotherapy for rotator cuff tendinopathy.

• We recommend the usage of high-energy radial shock waves during the first 5 weeks, at an interval of 7 days, of physiotherapy treatment.

• High-energy radial shock waves treatment combined with physiotherapy can benefit rotator cuff tendinopathy by relieving symptoms rapidly and maintain these improvements at a satisfactory level for quite a long time.