X线、CT和MR关节造影在外伤性肩袖撕裂中的诊断价值

目的　分析X线、CT和MR单对比关节造影在外伤性肩袖撕裂中的诊断价值。方法经关节镜证实的外伤性肩袖撕裂 2 0例。在透视下穿刺肩关节腔 ,注入 15～ 2 0ml的混合性对比剂 (由10ml欧乃派克和 2 0ml3mmol/L的马根维显稀释液组成 ) ,在 45min内完成X线摄片、CT和MR扫描。结果　关节镜证实肩袖的完全撕裂、部分撕裂分别为 9例和 11例。完全撕裂的X线、CT和MR关节造影均正确诊断 9例 (9/ 9)。肩袖部分撕裂的X线关节造影正确诊断 3例 (3/ 11) ;CT关节造影正确诊断 2例 (2 / 11) ;MR关节造影正确诊断 7例 (7/ 11)。结论　单对比的MR关节造影在外伤性肩袖撕裂中的诊断价值高于X线及CT造影     

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.     

肩袖损伤的MR诊断进展

肩袖损伤是引起肩部疼痛和功能障碍的常见原因,可表现为全层撕裂或部分撕裂。MRI具有较高的软组织分辨力,可直接显示肩袖损伤部位及相关病理改变。本文复习肩袖的解剖结构,总结肩袖撕裂的MR诊断标准和主要表现及与X线平片、CT、B超相比的优越性、敏感性。研究表明,高场强MRI能更好地显示肌腱未受损部分与撕裂的对比,为临床制定正确的治疗方案提供帮助。     

Ultrasonography of symptomatic rotator cuff tears compared with MR imaging and surgery

Purpose

To compare the accuracy of ultrasonography and magnetic resonance imaging in the detection of rotator cuff tears.

Materials and methods

Ninety-six patients with clinically suspected rotator cuff pathology underwent ultrasonography and magnetic resonance imaging of the shoulder. The findings in 88 patients were compared with arthroscopy or open surgery.

Results

Full-thickness tear was confirmed in 57 cases, partial-thickness tear in 30 cases and degenerative changes without tear in 1. In all 57 cases of full-thickness tear and in 28 out of 30 cases of partial-thickness tear the supraspinatus tendon was involved. The accuracy in the detection of full-thickness tears was 98 and 100% for ultrasonography and magnetic resonance imaging, respectively. The accuracy in the detection of bursal or articular partial-thickness tears was 87 and 90% for ultrasonography and magnetic resonance imaging, respectively.

Conclusions

In experienced hands ultrasonography should be considered as an accurate modality for the initial investigation of rotator cuff, especially supraspinatus, tears.     

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.     

MRI和MR关节腔造影诊断肩袖撕裂的实验研究

目的 :探讨常规MRI和MR肩关节腔造影诊断肩袖撕裂的价值。方法 :采用 2 0个人离体肩关节标本 ,将常规MRI和追加MR肩关节腔造影检查结果与大体解剖、组织病理学结果进行比较。结果 :常规MRI检出肩袖部分撕裂的敏感度约为 61.9% ,追加MR肩关节腔造影后敏感度提高到 90 .5 %。常规MRI和MR关节腔造影检出肩袖完全撕裂的敏感度和特异度均为 10 0 %和 97.1%。结论 :在常规MRI检查的基础上追加MRI关节腔造影能提高检出肩袖部分撕裂的敏感度。     

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. Received: 7 August 2000 Revision requested: 13 October 2000 Revision received: 27 November 2000 Accepted: 12 December 2000     

磁共振肩关节造影在肩袖完全撕裂诊断的临床应用

目的:探讨磁共振肩关节造影检查对肩袖完全撕裂的诊断价值.方法:回顾性分析54例肩袖完全撕裂MR关节造影及MRI表现,与肩关节镜手术结果对照.结果:54例肩袖完全撕裂病例,MRI诊断的敏感度、特异度及准确度分别是87.03％、50.00％和79.41％;MR关节造影诊断Ⅰ型9例、Ⅱ型21例,其敏感度分别为88.89％、95.24％;特异度分别为97.87％、97.14％;准确度分别为96.43％、96.43％;明显高于常规MRI诊断,差异均有统计学意义(P＜0.05);与关节镜结果对比,其一致性极佳(Kappa=0.841);而对于Ⅲ型肩袖完全撕裂,MR关节造影均不能显示.结论:MR关节造影能较准确判断Ⅰ型、Ⅱ型肩袖完全撕裂范围及程度,是MRI诊断肩袖损伤的有效补充,为临床诊断和治疗能提供更准确的依据,而对于Ⅲ型肩袖完全撕裂,MR关节造影不能显示其损伤部位及程度,无法对其进行诊断.     

MR imaging diagnosis of rotator cuff tears

Thirty-one symptomatic patients were studied with MR imaging to evaluate the sensitivity and specificity of shoulder MR in the diagnosis of rotator cuff tears. Correlative studies included arthroscopy in 19 patients and arthrography in 12 patients. Images were obtained on either a 0.5- or 1.5-T Philips superconducting magnet using spin-echo pulse sequences (650-850/30 [TR, TE], 2000/30, 100) with 5-mm slices oriented in an oblique coronal plane perpendicular to the glenohumeral joint. The MR studies were initially interpreted without knowledge of the results of other diagnostic procedures. The MR diagnosis of cuff tear was made when irregularity, discontinuity, and increased signal were identified in the rotator cuff. MR images showed tears in 10 patients (32%) and were negative for tear in 21 patients (68%). MR correlated with arthroscopy and arthrography in 17 of 18 normal patients, in eight of 10 patients with complete tears, and in one of three patients with partial tears. For complete rotator cuff tears, the sensitivity, specificity, and accuracy were 80%, 94%, and 89%, respectively. For all tears (partial and complete), the sensitivity, specificity, and accuracy were 69%, 94%, and 84%, respectively. These data suggest that MR imaging is an accurate procedure for the diagnosis of complete rotator cuff tears. The number of partial tears (three) in this series is too small to evaluate the value of MR imaging in the diagnosis of partial tears.     

The active abduction view: A new maneuvre in the diagnosis of rotator cuff tears

The plain film views of the shoulder in the case of a fresh rotator cuff tear are usually normal. Reduction of the space between the under surface of the acromion process of the scapula and the humeral head occurs only in late, neglected cases. A new projection is described, the active abduction view of the shoulder, where in many patients with a complete rotator cuff tear the humeral head is closely apposed to the acromion, obliterating the subacromial space. In such a situation, the medial portion of the torn rotator cuff retracts during active abduction, allowing approximation of the two bones.     

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.An erratum to this article can be found at     

Indirect MR arthrography of the shoulder in detection of rotator cuff ruptures

The aim of this study was to compare the efficacy of indirect MR arthrography images obtained following intravenous contrast injection and conventional MR imaging in the diagnosis of rotator cuff tears. Twenty-four patients with clinically suspected rotator cuff disease were examined. Conventional MR images and post-contrast indirect MR arthrography images were obtained. All images were evaluated in a blinded fashion by two musculoskeletal radiologist. Results were than analyzed depending on surgical output. The correlation coefficient (Spearman rank correlation test) and the kappa values for agreement between surgery and imaging techniques were calculated. The correlation coefficients between indirect MR arthrography and surgery for reader 1 and reader 2 were 0.9137 and 0.9773, respectively. Whereas the agreement between conventional MR imaging and surgery was moderate (ϰ = 0.383–0.571), the agreement between indirect MR arthrography and surgery was excellent (ϰ = 0.873–0.936). We suggest the use of indirect MR arthrography technique when conventional MR images are equivocal in diagnosis of rotator cuff disease. Received: 12 April 2000/Revised: 22 May 2000/Accepted: 23 May 2000     

肩袖撕裂的肩关节MR造影评价

目的 评价肩关节MR造影对肩袖撕裂的诊断价值。方法 分析32例病人的肩关节MR造影图像,评价内容包括肩袖肌腱、盂唇、肱二头肌长头腱,结果与肩关节镜及肩部开放手术比较。结果 以肩关节镜和手术结果为标准,32例病人包括14例全层撕裂,6例下表面部分撕裂,12例无撕裂。肩关节MR造影判定有无肩袖撕裂的敏感性、特异性和准确性都为100％;诊断全层撕裂的敏感性、特异性和准确性分别为100％、94％和97％。同时,肩关节MR造影还正确诊断了所有的多肌腱撕裂、合并的盂唇异常及肱二头肌长头腱异常。结论 肩关节MR造影可以准确、全面地评价肩袖撕裂。     

MRI、MR肩关节造影及高频超声诊断肩袖损伤的差异性分析

目的探讨MRI、MR肩关节造影(MRAr)及高频超声诊断肩袖损伤的差异性。方法收集2015年2月—2016年9月间于天津市第五中心医院就诊的疑似肩袖损伤病人84例,其中男52例,女32例,年龄22~64岁,平均(48.2±12.1)岁。回顾分析病人的MRI、MRAr及高频超声影像资料,采用χ~2检验比较MRI和高频超声2种方法诊断效能的差异。采用Kappa检验分析MRI、高频超声,以及MRI、高频超声和MRAr 3种方法联合分别与肩关节镜检查结果的一致性。结果对于Ⅰ型肩袖撕裂,MRI、MRAr和高频超声3种检查方法的准确度均为100%。MRAr对于Ⅰ型、Ⅱ型、Ⅳ型肩袖损伤有较高的检出率,总准确度为97.8%(45/46),而对于Ⅲ型、Ⅴ型、Ⅵ型肩袖撕裂则无法检出。MRI和高频超声诊断肩袖损伤的敏感度、特异度及准确度分别为88.8%、75.0%、88.1%和87.5%、75.0%、86.9%,2种方法对肩袖损伤诊断效能的差异无统计学意义(χ~2=0.856,P=0.1)。MRI、高频超声和MRAr 3种方法联合诊断肩袖损伤的敏感度、特异度及准确度分别为93.7%、100%、94.0%。3种方法分别与肩关节镜检查结果比较,均具有较高的一致性(κ=0.81,P=0.001;κ=0.79,P0.001;κ=0.94,P0.001)。结论高频超声可以作为肩袖损伤的初筛检查方法,MRI可作为有效补充,MRAr对于Ⅰ型、Ⅱ型、Ⅳ型肩袖损伤有较高的检出率,3种方法相互补充,明显提高诊断准确性。     

巨大肩袖损伤的手术修复结果

Objective To evaluate the clinical results of arthroscopic repair of massive rotator cuff tear. Methods The study involved 16 patients with massive rotator cuff tears treated arthroscopically from September 2007 to June 2009. There were 6 males and 11 females at average age 61.5 years (45-75 years). The rotator cuff tears was repaired with arthroscopic double-row reconstruction. The range of motion, pain, strength of flexed elevation and function evaluation score were all recorded before operation and at final follow-up. The results were evaluated by t test and compared according to age and course of disease. Results All patients were healed without complications and the outcome was improved significantly ( P < 0.01 ). The mean VAS score was improved from preoperative 5.6 to postoperative 1.7,the average forward flexion from 69. 1°to 151.2°, the average external rotation from 14.7° to 32.2°, and internal rotation from L1 level to T10, the mean Constant-Murle from 39 to 85, the mean UCLA from 10.4 to 28, the mean SST from 2.8 to 8.8 and the strength of flexed elevation from 10.7% of normal side to 65.0%. Compared with preoperation, there was statistical difference in aspects of pain, range of motion, muscle strength and function in postoperation (P < 0.01 ). Conclusion Arthroscopic doublerow fixation can attain satisfactory results in repair of massive rotator cuff tear.     

Diagnosis of partial and complete rotator cuff tears using combined gradient echo and spin echo imaging

Most magnetic resonance (MR) studies evaluating the rotator cuff for tears have used T2-weighted imaging in the coronal oblique and sagittal oblique planes, T2^*-weighted gradient echo imaging, however, has advantages over spin echo imaging, including contiguous slices without cross-talk, high contrast around the cuff, and intrinsically shorter imaging times which can be used to increase the number of signals averaged and thus improve the signal-to-noise ratio. We reviewed the shoulder MR scans of 87 consecutive patients who underwent both a MR scan and a shoulder arthroscopy during which the size of tears, if present, was graded. The reviewers were blinded as to the history and arthroscopic results. The MR scans included oblique coronal T2^*-weighted gradient echo and oblique sagittal T2-weighted spin echo images. MR cuff grades were correlated with arthroscopic findings. For complete tears, the sensitivity of MR was 0.91 and the specificity 0.95. For partial tears, the sensitivity was 0.74 and the specificity 0.87. This accuracy is similar to two-plane T2-weighted imaging as previously reported in the literature. There was a statistically significant correlation (p < 0.0005) between the cuff grade as determined by MR and the arthroscopic findings.     

巨大肩袖损伤的手术修复结果

目的 探讨关节镜治疗巨大肩袖损伤的临床效果及影响因素.方法自2007年9月至2009年6月接受手术治疗的巨大肩袖损伤患者16例,男6例,女10例;平均年龄61.5岁.采取关节镜下双排重建对损伤肩袖进行修复.记录术前及最终随访时的疼痛、活动范围、前屈上举的肌肉力量以及功能评分,进行配对t检验;并按不同年龄、病程进行分组,进行统计学分析.结果 所有患者均顺利愈合,术前疼痛视觉模拟评分(visual analogue score,VAS)为5.6,前屈上举为69.1°,外旋为14.7°,内旋达L1水平,Constant-Murley评分为39,加州大学洛杉矾分校评分(UCLA)为10.4,肩关节简单评分(SST)为2.8,前屈上举的肌力相当于健侧的10.7%.术后VAS为1.7,前屈上举为151.2°,外旋为32.2°,内旋达T10水平,Constant-Murley评分为85.6,UCLA为28,SST为8.8,前屈上举的肌力为健侧的65.0%.术后与术前在疼痛、活动范围、肌力及功能方面差异均有统计学意义(P<0.01).不同性别和不同病程在手术前后的差异均无统计学意义.结论通过关节镜手术对损伤的肩袖进行双排重建可获得较为满意的临床治疗结果.

Abstract：

Objective To evaluate the clinical results of arthroscopic repair of massive rotator cuff tear. Methods The study involved 16 patients with massive rotator cuff tears treated arthroscopically from September 2007 to June 2009. There were 6 males and 11 females at average age 61.5 years (45-75 years). The rotator cuff tears was repaired with arthroscopic double-row reconstruction. The range of motion, pain, strength of flexed elevation and function evaluation score were all recorded before operation and at final follow-up. The results were evaluated by t test and compared according to age and course of disease. Results All patients were healed without complications and the outcome was improved significantly ( P < 0.01 ). The mean VAS score was improved from preoperative 5.6 to postoperative 1.7,the average forward flexion from 69. 1°to 151.2°, the average external rotation from 14.7° to 32.2°, and internal rotation from L1 level to T10, the mean Constant-Murle from 39 to 85, the mean UCLA from 10.4 to 28, the mean SST from 2.8 to 8.8 and the strength of flexed elevation from 10.7% of normal side to 65.0%. Compared with preoperation, there was statistical difference in aspects of pain, range of motion, muscle strength and function in postoperation (P < 0.01 ). Conclusion Arthroscopic doublerow fixation can attain satisfactory results in repair of massive rotator cuff tear.     

肩关节镜下肱二头肌长头肌腱转位重建肩关节上关节囊修复巨大肩袖撕裂

目的探讨肩关节镜下利用肱二头肌长头肌腱(LHBT)转位重建肩关节上关节囊修复巨大肩袖撕裂的临床效果。方法采用回顾性病例系列研究分析2017年12月至2019年1月同济大学附属上海市第十人民医院收治的64例巨大肩袖撕裂患者临床资料,其中男26例,女38例;年龄50~75岁[(62.5±4.8)岁]。在关节镜下利用LHBT转位行肩关节上关节囊重建。记录和评估术前及末次随访时肩关节活动度(前屈、外展、外旋)、肩-肱距、视觉模拟评分(VAS)、Constant-Murley评分、美国肩肘外科协会(ASES)评分。借助MRI评估末次随访时重建结构的完整性以及肩袖再撕裂发生率。观察术后并发症情况。结果患者均获随访13~25个月[(18.2±4.3)个月]。末次随访时,肩关节前屈为(149.5±7.8)°,外展为(162.0±6.6)°,外旋为(60.6±11.8)°,肩-肱距为(7.4±0.6)cm,VAS为1.0(0.0,1.0)分,Constant-Murley评分为(90.5±2.6)分,ASES评分为(90.8±4.2)分,均较术前明显改善[前屈:(73.8±5.3)°,外展:(85.8±5.5)°、外旋:(34.3±5.8)°,肩-肱距:(5.9±0.8)cm,VAS:6.5(6.0,7.0)分,Constant-Murley:(41.8±5.4)分,ASES评分:(41.4±6.1)分](P<0.01)。56例患者末次随访时重建结构完好,7例患者重建结构小撕裂予以翻修,1例患者重建失败予以翻修,肩袖修补术后再撕裂率13%(8/64)。患者术后无明显手术并发症出现,切口无感染。结论利用LHBT转位重建肩关节上关节囊修复巨大肩袖撕裂,安全可靠,可有效改善关节活动度,并减轻患肩关节疼痛,恢复肩关节功能。