Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases

BACKGROUND: There has been limited acceptance of shoulder ultrasonography by orthopaedic surgeons in the United States. The purpose of this retrospective study was to determine the diagnostic performance of high-resolution ultrasonography compared with arthroscopic examination for the detection and characterization of rotator cuff tears. METHODS: One hundred consecutive shoulders in ninety-eight patients with shoulder pain who had undergone preoperative ultrasonography and subsequent arthroscopy were identified. The arthroscopic diagnosis was a full-thickness rotator cuff tear in sixty-five shoulders, a partial-thickness tear in fifteen, rotator cuff tendinitis in twelve, frozen shoulder in four, arthrosis of the acromioclavicular joint in two, and a superior labral tear and calcific bursitis in one shoulder each. All ultrasonographic reports were reviewed for the presence or absence of a rotator cuff tear and a biceps tendon rupture or dislocation. All arthroscopic examinations were performed according to a standardized operative procedure. The size and extent of the tear and the status of the biceps tendon were recorded for all shoulders. The findings on ultrasonography and arthroscopy then were compared for each parameter. RESULTS: Ultrasonography correctly identified all sixty-five full-thickness rotator cuff tears (a sensitivity of 100 percent). There were seventeen true-negative and three false-positive ultrasonograms (a specificity of 85 percent). The overall accuracy was 96 percent. The size of the tear on transverse measurement was correctly predicted in 86 percent of the shoulders with a full-thickness tear. Ultrasonography detected a tear in ten of fifteen shoulders with a partial-thickness tear that was diagnosed on arthroscopy. Five of six dislocations and seven of eleven ruptures of the biceps tendon were identified correctly. CONCLUSIONS: Ultrasonography was highly accurate for detecting full-thickness rotator cuff tears, characterizing their extent, and visualizing dislocations of the biceps tendon. It was less sensitive for detecting partial-thickness rotator cuff tears and ruptures of the biceps tendon.     

肩关节前方盂唇损伤的MRI和MR关节造影诊断

目的:探讨MRI和MR关节造影在肩关节前方盂唇损伤中的诊断价值,评估MR关节造影在鉴别肩关节前方盂唇不同类型损伤中的作用。方法:自2007年1月至2010年12月,对经肩关节MRI、MR关节造影诊断后进行关节镜手术治疗的153例肩部损伤患者的临床资料进行了回顾性分析。由1位骨骼肌肉系统影像学医生和1位运动医学医生共同阅片,得出一致的MRI和MR关节造影诊断,并与关节镜下结果进行比较。计算MRI和MR关节造影诊断肩关节前方盂唇损伤的敏感性、特异性和准确性。在MR关节造影下存在前方盂唇损伤的患者中,对其不同类型损伤进行分型,与关节镜下分型进行对比研究。结果:153例中,肩关节前方盂唇损伤78例,肩袖损伤67例,上盂唇从前到后(superior labrum anterior to posterior,SLAP)损伤8例,MRI和MR关节造影诊断肩关节前方盂唇损伤的灵敏度分别为80.8%和92.3%,特异度分别为89.3%和97.3%,准确度分别为85.0%和94.8%。78例关节镜下存在肩关节前方盂唇损伤的患者中,Bankart损伤39例,前方盂唇骨膜袖套样撕脱(ALPSA)损伤32例,Perthes损伤7例,MR关节造影正确诊断Bankart、ALPSA和Perthes损伤的灵敏度分别为84.6%、84.4%和57.1%。结论:MR关节造影较MRI诊断肩关节前方盂唇损伤的灵敏度、特异度和准确度更高,MR关节造影能在术前进一步明确盂唇损伤的类型,为确定术前计划提供依据。     

Shoulder arthroscopy: setting, portals and normal exploration

Arthroscopy has been established as a valuable technique in diagnosis and treatment of the injured and deseased shoulder. Arthroscopy is not a new diagnostic tool but offers new approaches to the surgical treatment of shoulder pathology. Shoulder arthroscopy is usally performed under general anesthesia or/with scalene block. The patient is positioned in opposite lateral decubitus position or in beach chair position. Diagnostic arthroscopic is initiated with insertion of the arthroscope from the posterior portal into the gleno humeral joint. Inspection should be organized systematic visualization of the entire joint (articular surfaces of the glenoid and humeral head, glenoid labrum, long head of the biceps tendon, sub scapularis tendon, axillary pouch, capsular ligaments, synovial membrane). Then endoscopic visualization of the subacromail space is a valuable and essential adjunct to the gleno humeral arthroscopy (impingement syndrome, rotator cuff tears, calcific tendinitis, acromiocalvicular joint disorders).     

Biceps tendon and superior labral injuries

Twenty-two patients sustained injury to the biceps tendon, rotator cuff interval, or superior labrum. Seven patients with "interval lesions" underwent biceps tenodesis, one biceps repair, and three subscapularis repairs. All were satisfied, although one tenodesis failed with distal biceps retraction. Key arthroscopic findings included biceps or subscapularis fraying. Thirteen patients with "S.L.A.P. (superior labrum anterior to posterior) lesions" underwent labral debridement. All but one obtained pain relief. Eight cadaveric shoulders exhibited extreme anatomic variability of the bicipital origin/superior labral attachment. Biomechanical study showed anterior-superior and posterior-superior labral strain with simulated biceps contraction to be greatest in shoulder abduction (p < 0.01). Biceps tendon strain was greatest in shoulder adduction (p < 0.05). A continuum of injuries to the biceps tendon exist, from the rotator cuff interval to the labral attachment. Key arthroscopic findings may assist in the difficult diagnosis of interval lesions. Individual anatomy and mechanism of injury may determine the site of the lesion.     

Lesions of the superior labrum anterior-posterior and biceps tendon

Biomechanical studies have shown that the biceps tendon and the superior labrum have significant contributions to the glenohumeral stability. Since superior labrum anterior-posterior (SLAP) lesions pose diagnostic difficulties, they should be kept in mind when evaluating a painful shoulder. Although magnetic resonance arthrography is of great use in diagnostic studies, diagnostic arthroscopy is still the best method for these lesions. Treatment may vary depending on the type of the lesion. As our knowledge about the glenohumeral anatomy enhances, success rates of the arthroscopic treatment of SLAP lesions will increase.     

Value of diagnostic measures in soft tissue diseases and soft tissue lesions of the shoulder joint

Calcifying tendinitis, acute tendinitis, frozen shoulder, rotator cuff rupture, subluxation of the gleno-humeral joint and injury of the biceps tendon are commonly classed under the blanket term "peri-arthropathy of the shoulder". It is now possible to make a precise diagnosis of these shoulder disorders by means of a clinical examination supported by X-ray examination, ultrasonography, arthrography, computed tomography (CT), magnetic resonance imaging (MRI) and arthroscopy. Calcifying tendinitis is diagnosed by consideration of the patient's history, followed by clinical examination and X-ray examination. Acute tendinitis is a clinical diagnosis, as is frozen shoulder. Ruptures of the rotator cuff can be detected by ultrasonography, which is a screening method; such ruptures can also be detected by arthrography. The localization and extent of the defect are best estimated by arthroscopy. Shoulder instability is another clinical diagnosis. Bony defects of the humeral head (Hill-Sachs lesion) or the glenoid rim are revealed by computed tomography (CT). CT arthrography reveals the presence of any Broca-Hartman lesion in the anterior inferior part of the anterior capsular mechanism. Rupture, subluxation or luxation of the biceps tendon are diagnosed either by clinical examination or by arthroscopy. Knowledge of the sensitivity, specificity and accuracy of the diagnostic procedures makes it possible to carry them out in a standardized, logical sequence. Arthroscopy allows a decidedly more accurate diagnosis than any of the other methods, but as it is an invasive procedure it should be kept until last when diagnosis of disorders of the gleno-humeral joint is required.     

Intracapsular origin of the long head of the biceps tendon with glenoid avulsion of the glenohumeral ligaments

An 18-year-old woman presented with a history of recurrent glenohumeral dislocations involving her right dominant shoulder. Physical examination suggested physiologic hyperlaxity and anterior instability. Magnetic resonance arthrography demonstrated an anomalous intracapsular origin of the long head of the biceps tendon (LHBT), with normal-appearing LHBT in the intertubercular groove. Diagnostic arthroscopy confirmed the absence of the LHBT attachment on the superior labrum. Instead, the LHBT originated from the capsule of the shoulder joint. Diagnostic arthroscopy also revealed glenoid avulsion of the glenohumeral ligaments (GAGL) lesion as a tear in the anterior-inferior capsule near its insertion on the glenoid and labrum. An arthroscopic anterior capsulolabral repair was performed with rotator interval closure by imbrication of superior and middle glenohumeral ligaments. A retrospective review of the magnetic resonance arthrogram identified irregularity and interposition of contrast between the capsule and the anterior-inferior labrum that was reproduced in the abduction-external rotation view corresponding with the GAGL lesion seen at arthroscopy. At 12 months postoperatively, the patient demonstrated full range of motion and no signs of instability. This case report helps to raise awareness about 2 rare shoulder lesions: the anomalous origin of LHBT and the GAGL lesion. Diagnosing such lesions on preoperative magnetic resonance imaging may aid in operative planning and avoid unexpected intraoperative findings.     

Arthroscopic shoulder surgery

Arthroscopy has proven to be a very important orthopaedic tool for treatment of the knee and other joints. Since 1972, we have used the arthroscope to examine the interior of shoulder joints. We prefer to perform arthroscopy while the patient is under general anaesthesia, as local anaesthetic may result in unnecessary patient discomfort and there can be difficulty in distracting and rotating the humerus. Arthroscopic operative procedures include the inspection of a torn glenoid labrum and certain lesions of the biceps tendon, viewing a torn rotator cuff, locating loose bodies in the shoulder, surgery for recurrent dislocations, and division of the coracoacromial ligament.     

肩关节相关结构正常与异常的MRI影像学特征

目的 探讨正常肩关节和肩峰撞击证、肩袖撕裂、复发性肩关节前方不稳的ＭＲＩ影像学特征。方法 对２８５例肩关节疾病患者５ ２０例无症状对照人群的肩关节ＭＲＩ影像学特征进行分析。结果 在冠状斜位显像Ｔ１相中正常冈上肌为中等强度信号显影,肌腱－肌腹连接自肱骨头的上方并移行止于肱骨大结节处为低强度信号显影。当肩商在肩峰处反复撞击而发生病理改变时则表现为肌腱信号强度增加,并可出现肌腱外形欠光滑、肌腱－肌腹连接     

Direct biceps tendon and supraspinatus contact as an indicator of rotator cuff tear during shoulder arthroscopy in the lateral decubitus position

The purpose of this study was to evaluate consecutive shoulder arthroscopies for the presence or absence of a space between the biceps tendon and the supraspinatus as an indicator of a full-thickness rotator cuff tear. We performed 588 consecutive shoulder arthroscopies in the lateral decubitus position, and the presence or absence of a space between the rotator cuff (supraspinatus) and the biceps tendon was recorded immediately upon entering and insufflating the joint. Of the 588 patients, 174 (30%) were found to have full-thickness rotator cuff tears. Of these 174 patients, 171 had absence of the space between the biceps and the supraspinatus, for a sensitivity of 98%. Of the 414 patients in whom no full-thickness tear was present, 4 had absence of the space, for a specificity of 99%. The 4 patients with a false-negative result had adhesive capsulitis. During shoulder arthroscopy, a normal interval exists between the supraspinatus and biceps tendons as a result of joint insufflation. Loss of this interval is both highly sensitive (98%) and specific (99%) for a full-thickness rotator cuff tear. The space between the rotator cuff and the biceps tendon can be a reliable adjunct for verification of a full-thickness rotator cuff tear immediately upon entering the shoulder joint but should not be used in place of a full arthroscopic evaluation of the cuff.     

磁共振肩关节造影技术诊断肩关节损伤的临床应用

目的探讨磁共振(MR)肩关节造影诊断肩关节损伤的临床价值。方法回顾性分析20例肩关节损伤患者常规MRI和MR肩关节造影的影像表现,并与肩关节镜手术结果对照。结果关节镜诊断结果:肩袖部分撕裂17例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤5例。MRI诊断结果:肩袖部分撕裂16例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤1例。MR肩关节造影诊断结果:肩袖部分撕裂17例,肩袖全层撕裂3例,肩袖撕裂并发盂唇损伤5例。MR肩关节造影诊断结果与关节镜结果一致。结论MR肩关节造影较常规MRI检查能够提高肩关节损伤的诊断准确性。     

Tecniche chirurgiche artroscopiche per la riparazione delle lesioni del sottoscapolare

Arthroscopic repair of the subscapularis tendon has been introduced later than arthroscopic repair of the rotator cuff because of technical difficulties and lack of anatomical knowledge of this tendon, the so-called “forgotten tendon”. The anatomic repair of this tendon is functional to maintain proper biomechanics of the shoulder. A careful evaluation of the patient, both with clinical tests and instrumental examinations, is mandatory prior to approaching arthroscopic evaluation. During arthroscopy possible and frequent biceps pathologies should be addressed and both releasing of the adhesions and coracoplasty should be considered. Arthroscopic repair is performed with suture anchor reinserting of the tendon at the footprint, with possible medialization of the insertion, with all the variable approaches described for rotator cuff repair; results can be comparable to the ones obtainable with open technique repair, however arthroscopic approach cannot adress the extrarticular retracted lesions.     

Ultrasonographic evaluation of the rotator cuff and biceps tendon

Ultrasonography of the rotator cuff and biceps tendon was investigated in 106 patients who had been referred for arthrography of the shoulder. Both the sensitivity and the specificity of ultrasound in detecting a tear of the rotator cuff were 91 per cent. The predictive value of a negative sonogram was 95 per cent and the predictive value of a positive sonogram was 84 per cent. Ultrasonography proved to be superior to arthrography in the examination of the normal and abnormal biceps tendon. Sonographically detectable effusions from the tendon sheath of the biceps were present in 19 per cent of this population of patients. This finding was statistically highly associated (90 per cent) with rotator cuff tears and other soft-tissue abnormalities of the shoulder. Based on these results, it appears that ultrasonography can be used as the initial imaging test for many patients with suspected abnormalities of the rotator cuff or biceps tendon.     

Biceps tenodesis associated with arthroscopic repair of rotator cuff tears

Associated lesions of the biceps tendon are commonly found during arthroscopic repair of rotator cuff tears. These lesions are treated with tenodesis, classically performed through an open approach. However, it seems reasonable to seek a single approach to correct both lesions; therefore, we have proposed a new arthroscopic technique that allows an exclusive arthroscopic tenodesis by including the biceps tendon in the rotator cuff suture, a surgical technique with a single suture of the rotator cuff that includes the biceps tendon. We treated 97 shoulders in 96 patients arthroscopically for complete rotator cuff tears. Of these shoulders, 15 required tenodesis for treatment of biceps tendon lesions. Through an arthroscopic approach, a subacromial decompression followed by a rotator cuff repair was carried out in association with a biceps tenodesis. In this technique, one limb of the suture was passed through the biceps tendon, and the other was passed through the rotator cuff tear, bringing both tissues together in the final suture. Of the patients, 9 were men and 5 were women. Their mean age was 71 years (range, 41-80 years). The dominant arm was affected in all patients. Postoperative evaluation, by use of the UCLA score, after a mean follow-up period of 32.4 months showed satisfactory results in 93.4% of patients: 11 had excellent results, 3 had good results, and only 1 had an unsatisfactory result. In this case a postoperative magnetic resonance imaging scan showed an intact rotator cuff and biceps tenodesis. The suture involving the rotator cuff and the biceps tendon proved effective to correct both lesions, with the main advantage being that an additional approach was not required.     

Double-contrast computed tomography of the shoulder

As a modality for the study of abnormalities of the shoulder, double-contrast computed tomography (CT) is accurate, is relatively easy to perform, and requires only a low dose of radiation. The results can be extremely helpful in preoperative planning. In this study, CT images were obtained for 247 patients who had undergone routine double-contrast shoulder arthrography. Abnormalities shown on CT images included glenoid labrum attenuation and tears, glenoid fractures, loose joint bodies, intracapsular staples, intra-articular screws, adhesive capsulitis, rotator cuff tears, peritendinitis calcarea, biceps tendon tears, and capsular abnormalities. In the 41 cases in which surgical correlation was available, all of the confirmed abnormalities had been identified on double-contrast CT images. Of the patients with rotator cuff tears, 80% had other abnormalities of the shoulder, and 48% had glenoid labrum tears. Of the patients with peritendinitis calcarea, 40% had glenoid labrum tears, and 33% had rotator cuff tears. Double-contrast CT studies of the shoulder are recommended when patients experience a decrease in range of motion, persistent shoulder pain, or signs of instability. Frequently, patients with rotator cuff tears and peritendinitis calcarea have coexisting abnormalities.     

Arthroscopy and MRT of the shoulder--a comparative retrospective analysis]

MR Imaging is proving to an effective means for evaluating the shoulder. The use of a surface coil and high resolution scanning techniques have allowed detailed analysis of normal anatomy and suspected pathology of the shoulder. On the other way arthroscopic inspection provides a more extensive visualization of the joint in different positions. 31 patients, well documented, were studied with MR Imaging and correlated with findings in arthroscopy and open revision in some cases. The MR studies were retrospective interpreted without the knowledge of the results of other diagnostic procedures. For the evaluation of rotator cuff tears MRI proved to have a sensitivity of 83.3% and an accuracy of 90.3%. When Arthroscopy was correlated with open revision the sensitivity was 61.8% and the accuracy 78%. Labral pathology and Hill-Sachs lesions will be better evaluated in arthroscopy as in MRI (sensitivity of arthroscopy 100% and of MRI 69%, accuracy of arthroscopy 100% and of MRI 87.1%). With the high resolution scanning technique and a surface coil MRI has been shown to be useful in the evaluation of rotator cuff tears and impingement syndrome but not in diagnosis of labral pathology and Hill-Sachs lesions.     

Arthroscopy of the shoulder

The procedure for diagnostic shoulder arthroscopy and proper positioning of operative portals are discussed. The superior medial portal approach to the shoulder is described. Conditions visualized by arthroscopy include the following: glenoid labrum tears, synovitis, loose bodies, instabilities, adhesive capsulitis, rotator cuff lesions, and extra-articular decompressions.     

Schulterarthroskopie

Diagnostic and surgical arthroscopy of the shoulder joint has gained in importance in recent years in trauma surgery, replacing open surgery in many cases of soft tissue lesions. Compared with other diagnostic methods, arthroscopy offers the broadest and most reliable information on shoulder lesions. Dislocation of the glenoid labrum after traumatic shoulder luxation, lesions of the biceps tendon, rotator-cuff tear or subacromial impingement syndrome all represent indications for arthroscopy. Due to the further development of instruments and special anchoring materials, surgical techniques are becoming faster and increasingly effective, while at the same time the complication rate decreases.     

Arthroscopic shoulder surgery

Summary Arthroscopy has proven to be a very important orthopaedic tool for treatment of the knee and other joints. Since 1972, we have used the arthroscope to examine the interior of shoulder joints. We prefer to perform arthroscopy while the patient is under general anaesthesia, as local anaesthetic may result in unnecessary patient discomfort and there can be difficulty in distracting and rotating the humerus. Arthroscopic operative procedures include the inspection of a torn glenoid labrum and certain lesions of the biceps tendon, viewing a torn rotator cuff, locating loose bodies in the shoulder, surgery for recurrent dislocations, and division of the coracoacromial ligament.