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。     

切开修补关节囊盂唇治疗肩关节前方不稳定

目的评价切开修补关节囊盂唇复合体治疗肩关节前方不稳定的疗效。方法从2001年3月～2005年6月,34例(36肩)肩关节前方不稳定患者,27肩CT造影显示Bankart损伤,9肩有关节囊韧带肩胛颈撕脱损伤(ALPSA损伤)。按肩关节不稳定方向分型,25肩均为前方单向不稳定,11肩合并有下方不稳定。其中27例有明显的外伤史,12例合并有肱骨头后缘缺损(Hill-Sachs征)。采用带线的铆钉进行切开修补关节囊盂唇复合体的方法治疗肩关节前方不稳定,观察评价患肩的功能。结果术后随访6个月～4年,平均2．2年。肩关节功能按Walch-Duplay评分：优19肩,良12肩,中3肩,差2肩,优良率为86．1%。1例术后发生再脱位,由再次创伤造成,该患者行关节镜检查,发现修补处撕脱并盂缘缺损,再次行喙突移位固定术。结论采用切开修补关节囊盂唇复合体治疗创伤性肩关节前方不稳定,疗效肯定,肩关节功能恢复良好,并发症少,再脱位发生率低。     

肩关节不稳：前方软组织损伤

肩关节不稳定临床常见,肩关节前方软组织损伤如Bankart损伤、HAGL损伤、肩袖损伤、GAGL损伤等是引起肩关节不稳的常见原因。Bankart损伤是创伤性肩关节前向不稳定的常见损伤,其损伤机制为肩关节过度外展时关节盂受到轴向压力而无外旋,包括纤维Bankart损伤和骨性Bankart损伤。影响其修复效果的因素包括肩关节盂缺损的大小、有无Hill-Sachs损伤、有无肩关节囊松弛、盂肱下韧带有无牵拉以及术中修复损伤时使用锚钉的数量。ALPSA损伤是指肩关节盂唇关节囊骨膜袖状撕脱损伤,临床诊断较为困难,需注意与Bankart损伤进行鉴别。HAGL损伤指肩关节囊从肱骨侧撕裂,其损伤机制为肩关节过度外展、外旋。盂肱下韧带是肩关节外展90°外旋时的主要前方稳定结构,其前部起点为2点到4点,后部起点为7点到9点。该结构在肱骨侧的止点可分为两种类型：一种是围领型,其止点均至于关节面边缘;一种是V型,其前后束止于关节面边缘。有研究表明,盂肱下韧带可能撕裂的3个位置分别是肩胛盂起点（40%）、体部（35%）、肱骨侧止点（25%）。Wolf前瞻性观察了64例肩关节前方不稳定患者,发现Bankart损伤47例（73.5%）、关节囊松弛11例（17.2%）、HAGL损伤6例（9.3%）。导致创伤性肩关节不稳软组织损伤的类型多样,根据其损伤类型不同,其治疗方法也有所区别,不同类型的损伤术后复发率也不同。     

MRI在肩关节脱位中关节唇损伤诊断中的应用价值

目的探讨MRI诊断肩关节脱位中关节唇损伤的准确性及临床价值。方法收集2017年1月至2019年1月本院收治的肩关节脱位中关节唇损伤患者130例的MRI影像学资料,同时选择同期无肩部损伤的肩部良性病变患者50例为对照组,对两组MRI的影像学资料进行分析。结果关节镜结果显示,130例肩关节脱位中关节唇损伤患者盂唇撕裂76例,异常盂唇15例,复杂盂唇损伤39例。术前MRI诊断结果显示,盂唇撕裂52例,异常盂唇12例,复杂盂唇损伤37例,正常盂唇29例。50例对照组未见盂唇异常改变。两组MRI。MRI诊断肩关节脱位中关节唇损特异度较高为100%,灵敏度为77.69%,准确性为83.89%。结论 MRI诊断肩关节脱位中关节唇损失具有较高的特异度和准确性,为临床治疗提供了一定的依据,值得在临床推广应用。     

肩关节盂唇损伤的关节镜诊断和治疗

目的 探讨肩关节镜诊断和治疗盂唇损伤的应用意义和临床疗效。方法 对明确诊断盂唇损伤的36例病例,进行X线检查、单纯造影、MR加造影和关节镜技术的比较总结回顾。28例单纯盂唇损伤,采用肩关节镜下损伤盂唇的部分切除术;5例合并肱二头肌长头腱复合体（SLAP）病损,采用肩关节镜下盂唇损伤处清创术,术后患肩零度位牵引;3例合并Bankart病损,行肩关节镜下盂唇损伤处清创术后,通过有限切口进行改良的Bristow手术。结果 术后随访10个月～3年,平均2年。参照美国Michasel Reese医疗中心的评分标准,疼痛评分总分75分:术前平均35分,术后平均65分。关节功能评分总分25分:术前平均10分,术后平均20分。全部病例术后临床症状均有明显改善,恢复日常生活与工作,8例合并SLAP或Bankart病损者,术后未出现肩关节不稳定症状。结论 盂唇是肩关节内损伤的好发部位之一。肩关节镜是明确诊断和治疗盂唇损伤的有效的先进技术。肩关节镜下手术有一定难度,需特备的手术器械,因此要求术者熟练掌握肩关节镜技术。     

CT造影与MRI造影诊断肩关节SLAP损伤的比较

目的探讨肩关节腔CT造影与MRI造影在临床诊断肩关节上盂唇由前向后损伤(Superior labral anteroposterior,SLAP)中的应用价值。方法纳入自2017-01—2020-06疑似肩关节SLAP损伤68例,患者分别进行肩关节CT和MRI造影,以关节镜检查结果为标准,比较CT造影和MRI造影诊断肩关节SLAP损伤的灵敏度、特异度、准确度。结果关节镜检查确诊48例肩关节SLAP损伤,其中Ⅰ型5例,Ⅱ型29例,Ⅲ型10例,Ⅳ型4例;确诊骨缺损17例,肩袖损伤14例。CT造影确诊34例肩关节SLAP损伤,17例骨缺损,9例肩袖损伤。MRI造影确诊36例肩关节SLAP损伤,11例骨缺损,14例肩袖损伤。CT造影与MRI造影诊断肩关节SLAP损伤的准确度差异无统计学意义(P0.05)。CT造影诊断骨缺损的敏感度明显高于MRI造影,而MRI造影诊断肩袖损伤的敏感度明显高于CT造影,差异均有统计学意义(P0.05)。结论 CT造影与MRI造影均可作为肩关节SLAP损伤的主要影像学诊断方法,CT造影对SLAP损伤合并的骨缺损有较高的检出率,MRI造影对SLAP损伤合并的韧带、肩袖损伤有较高的检出率。     

关节镜下GⅡ锚钉固定治疗肩关节Bankart损伤

目的探讨关节镜下GⅡ锚钉固定治疗肩关节Bankart损伤的疗效。方法对3例肩关节不同类型Bankart损伤的患者行关节镜下GⅡ锚钉固定、缝合关节囊重建撕裂的盂唇。术后按常规康复治疗。结果 3例均获随访,时间分别为9、11、8个月,无复发脱位。UCLA评分由术前23.4、21.8、24.7分提高至术后32.8、32.5、40.2分,差异有统计学意义（P〈0.01）。结论关节镜下GⅡ锚钉固定治疗肩关节Bankart损伤切口小,愈合快,疗效好。     

骨性Bankart损伤的修复

<正>骨性Bankart损伤为肩关节盂唇前方的骨折或伴有肩关节复发性前脱位的盂唇缺损~[1-2],常见于创伤性肩关节前脱位或前下脱位,占盂肱关节创伤性不稳中的5.4%~70%~[3-5]。一、骨性Bankart损伤分类Porcellini等~[4]将骨性Bankart损伤分为急性与慢性损伤,病程3个月者为急性损伤,3个月者为慢性损伤。多数学者认为,损伤在3个月内的急性盂肱关节脱位合并前方     

肩关节镜下缝线锚钉修复合并关节盂唇前后延伸撕裂的严重SLAP损伤

目的探讨肩关节镜下缝线锚钉修复合并关节盂唇上部从前到后的损伤（SLAP）的疗效。方法 2007年至2009年,结合体格检查、MRI和关节镜诊断为关节盂唇前后沿伸撕裂的SLAP损伤患者12例,关节镜下采用缝线锚钉治疗。其中SLAP-Ⅴ型损伤（Bankart损伤＋SLAPⅡ型损伤）7例,SLAP-Ⅷ型损伤（SLAPⅡ型损伤合并后下方盂唇撕裂）3例以及一种新的SLAP损伤类型2例,即SLAPⅢ型损伤＋前后盂唇撕裂并脱位。术前及术后随访采用ASES评分及Constant-Murley功能评估。结果所有患者平均随访27个月。术前及终末随访ASES评分为（77.4±3.7）分vs（94.3±2.6）分,两者比较差异有统计学意义（t=28.1,P〈0.05）;Constant-Murley评分为（78.1±4.6）对（93.9±3.7）分（t=28.9,P〈0.05）。术后无一例患者发现再脱位,且均重返伤前工作岗位。结论随着肩关节镜技术的不断进步,肩关节盂唇严重损伤的修复更加有效、微创及简便。     

外展外旋位肩关节MR造影对Perthes病变的价值

目的比较肩关节MR造影处于外展外旋位（ABER位）与中立位对Perthes病变的诊断价值。方法由两名影像诊断医师独立回顾分析206例肩关节MR造影图像,每例患者均行中立位与ABER位检查,分析结果与肩关节镜手术相比较。计算肩关节MR造影中立位与ABER位评价Perthes病变的诊断敏感性和特异性,并采用McNemar检验进行统计分析。采用Kappa统计计算两名影像诊断医师评价的一致性。结果 206例患者中,35例证实为Perthes病变,60例前下盂肱韧带复合体正常。对于这95例,肩关节MR造影中立位评估Perthes病变的敏感性和特异性分别为65.71%～68.57%和95%～96.67%,ABER位则为88.57%～91.43%和91.67%～93.33%。肩关节MR造影ABER位的敏感性显著高于中立位检查（P〈0.05）。2名影像诊断医师的评价一致性极好（Kappa〉0.75）。结论肩关节MR造影ABER位可以明显提高Perthes病变的诊断敏感性。     

Accuracy of internet images of glenoid labral injuries

IntroductionThe internet is a convenient source of health information used widely by patients and doctors. Previous studies have found that the written information provided was often inaccurate. There is no literature regarding the accuracy of medical images on the internet. The aim of this study was to assess the accuracy of internet images of injuries to the glenoid labrum following shoulder dislocation.MethodsThe Google and Bing search engines were used to find images of Bankart, Perthes and anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. Three independent reviewers assessed the accuracy of image labelling.ResultsOf images labelled ‘Bankart lesion’, 30% (9/30) were incorrect while ‘Perthes lesion’ images were incorrect in 15% of cases (9/60) and 4% of ‘ALPSA lesion’ images were incorrect (2/46). There was good interobserver reliability (kappa = 0.81). Labelling accuracy was better on educational sites than on commercial sites (6% vs 25% inaccurate, p=0.0013).ConclusionsCaution is recommended when interpreting non-peer reviewed images on the internet.     

Computerized assessment of Bankart lesions under tension with magnetic resonance arthrography

Accurate anatomic depiction of Bankart lesions based on magnetic resonance imaging (MRI) is crucial for the treatment of posttraumatic recurrent dislocation of the glenohumeral joint. MR arthrography, the intraarticular injection of dilute gadolinium before MR imaging, improves sensitivity in the detection of shoulder pathology. Abduction and external rotation (ABER) of the shoulder places dynamic stress on the inferior capsular pouch and anterior labroligamentous complex, important structures for anterior shoulder stability. This study sought to determine whether MR arthrography, by use of computerized image analysis, can visualize Bankart lesions better with the shoulder in the neutral position or in ABER. We evaluated 12 shoulders after traumatic anterior dislocation. The MR images were analyzed with image-analyzing software. We compared 3 parameters at 5 levels of the glenoid in the neutral position and in ABER: detachment (the length of detachment between the anterior glenoid rim and the anterior periosteal attachment), displacement (the distance between the anterior glenoid rim and the tip of the displaced labrum), and Bankart area (the area bounded by the detachment line, the displacement line, and the anterior aspect of the Bankart lesion). MR images revealed that Bankart lesions were under tension in ABER and lax and redundant with the shoulder in the neutral position. All 3 parameters were greater in ABER than in the neutral position in all cases (P = .012, P = .0006, and P = .012). Computerized image assessment of MR arthrography with the shoulder in ABER provides excellent visualization and evaluation of Bankart lesions.     

Stem torsion in total hip replacement

Background and purpose Immobilization in external rotation (ER) for shoulder dislocation has been reported to improve the coaptation of Bankart lesions to the glenoid. We compared the position of the labrum in patients treated with immobilization in ER or internal rotation (IR). A secondary aim was to evaluate the rate of Bankart lesions.

Patients and methods 55 patients with primary anterior shoulder dislocation, aged between 16 and 40 years, were randomized to immobilization in ER or IR. Computer tomography (CT) and magnetic resonance imaging (MRI) were performed shortly after the injury. After the immobilization, MRI arthrography was performed. We evaluated the rate of Bankart lesions and measured the separation and displacement of the labrum as well as the length of the detached part of the capsule on the glenoid neck.

Results Immobilization in ER reduced the number of Bankart lesions (OR = 3.8, 95% CI: 1.1 –13; p = 0.04). Separation decreased to a larger extent in the ER group than in the IR group (mean difference 0.6 mm, 95% CI: 0.1 – 1.1, p = 0.03). Displacement of the labrum and the detached part of the capsule showed no significant differences between the groups.

Interpretation Immobilization in ER results in improved coaptation of the labrum after primary traumatic shoulder dislocation.     

Oxyphenbutazone (Tanderil®) in Surgery for Herniated Discs: A Double Blind Trial

Background and purpose In detection of glenoid labrum pathology, MR arthrography (MRA) has shown sensitivities of 88-100% and specificities of 89-93%. However, our practice suggested that there may be a higher frequency of falsely negative reports. We assessed the accuracy of this costly modality in practice.

Patients and methods We retrospectively reviewed MRA reports of 90 consecutive patients with clinical shoulder instability who had undergone shoulder arthroscopy. All had a history of traumatic anterior shoulder dislocation and had positive anterior apprehension tests. All underwent arthroscopy and stabilization during the same procedure. We compared the findings, using arthroscopic findings as the gold standard in the identification of glenoid labrum pathology.

Results 83 of the 90 patients had glenoid labrum tears at arthroscopy. Only 54 were correctly identified at MRA. All normal glenoid labra were identified at MRA. This gave a sensitivity of 65% and a specificity of 100% in identification of all types of glenoid labrum tear. 74 patients had anterior glenoid labral tears that were detected at an even lower rate of sensitivity (58%).

Interpretation The sensitivity of MRA in this series was substantially lower than previously published, suggesting that MRA may not be as reliable a diagnostic imaging modality in glenohumeral instability as previously thought. Our findings highlight the importance of an accurate history and clinical examination in the management of glenohumeral instability. The need for MRA may not be as high as is currently believed.     

TFCC-lesion. MR arthrography vs. arthroscopy of the wrist

In a blinded study from January to July 2000, 125 patients suffering from specific complaints of the wrist were examined with direct MR arthrography prospectively. Within 24 hours an arthroscopy of the wrist was performed. With the MR arthrography in 70 patients or 56% of all patients injury of the TFCC was diagnosed. In 65 patients this could be verified arthroscopically. In the remaining 55 patients no TFCC lesion was diagnosed with the MR arthrography. However lesions were found via arthroscopy in three cases,were MRI findings expected an intact TFCC. In the remaining 52 cases the MRT could exclude a lesion of the TFCC correctly. An agreement of the MRT and arthroscopic results could be determined in 93.6% of the cases (correlation). The diagnosis of a TFCC lesion by means of MRI was correct in 94% of the cases (sensitivity), the exclusion of such lesion in 89% (specificity). Positive or negative predictive values of 91% or 93% were achieved. Since neither a specificity nor a sensitivity of 100% can be reached at the moment, the MR arthrography cannot replace the arthroscopy. However it could be a potent additional tool for wrist diagnosis if intraarticular contrast is used. It can facilitate the diagnostics and the indication for surgery at the ulnocarpal wrist and help to reduce arthroscopic interventions that are only for diagnostic purposes and without any therapeutic consequences. With improvement of the technique of magnet resonance tomography we can expect further increase of accuracy and the clinical use of the MR arthrography in the diagnostic workup at the ulnocarpal wrist.     

Clinical tests and indirect MR-arthrography in the evaluation of tears of the glenoid labrum

Purpose: Clinical and radiological evaluation of labral tears remains challenging. It has been shown that intravenous administration of contrast agents produces an MR arthrographic effect without the need for intraarticular injection. This is the first study evaluating this new technique of indirect MR arthrography in diagnosis of glenoid labrum tears. Methods: 28 patients with clinically suspected labral injuries were prospectively investigated (1.5 Tesla, flexible surface coil). A native MR exam of the shoulder (transverse and oblique-coronar orientation, T1-weighted spin-, proton density- and T2^*-weighted gradient echo sequences) and indirect MR arthrography (transverse and oblique-coronar orientation, fat-suppressed T1-weighted spin-echo sequences, intravenous injection of gadopentetate dimeglumine [0.1 mmol/kg], followed by 10–15 min of joint movement) were performed. Results were confirmed by arthroscopy and/or open surgery. Additionally sensitivity evaluation of clinical tests for investigation of labral tears were performed. Results: Indirect MR-Arthrography improved delineation of the glenoid labrum and hyaline cartilage significantly (p < 0.05). Sensitivity and specificity of indirect MR arthrography in diagnosis of labral injuries were 90 % and 89 % respectively, compared to 79 % and 67 % of the native MR exam. The reliability of the checked clinical tests is not sufficient enough to determine labral lesions (predictive value between 50 and 70 %). Conclusion: Indirect MR-arthrography is a promising non-invasive technique in the evaluation of the glenoid labrum.      

Intraarticular lesions in traumatic anterior shoulder instability: A study based on the results of diagnostic imaging

Background?Diagnostics of intraarticular lesions is important in the treatment of traumatic anterior shoulder instability.

Patients and methods?We studied 30 patients: 26 men and 4 women. For all patients preoperative examinations involved arthrography, CT arthrography, MR arthrography, and 3D-CT.

Results?The articular capsule adhered to the margin of the glenoid in only 3 cases. In the remaining 27 patients, the joint capsule was detached, showing medial translation. Hill-Sachs lesions were present in 24 cases. Bankart lesions were detected in all cases, and they extended over 2–5 h. Osseous Bankart lesions were detected in 13 cases. MR arthrography revealed the articular labrum in all cases, but AIGHL in only 16 cases. Bankart lesions were found in all cases. When the patients were divided according to the frequency of dislocation, there was a correlation between both distance of the detached joint capsule and visualization of AIGHL and the frequency of dislocation.

Interpretation?From this study, the frequency of dislocation was higher in the patients with severe detachment of the joint capsule, in whom AIGHL could not be visualized by MR arthrography.

?     

Diagnostic value of MR Arthrogram in SLAP lesions of the shoulder

BackgroundSuperior labrum anterior to posterior (SLAP) lesions are important cause of shoulder pain and instability. MR Arthrogram is key investigation for assessment of these lesions. We aimed this study to evaluate the diagnostic performance of MR Arthrogram in SLAP tears.Materials and methodsThis was a retrospective study of 124 clinically diagnosed SLAP cases who had MR Arthrogram performed. Clinical, radiological and operative records were reviewed. MR Arthrogram findings were compared with arthroscopy. Those patients who did not undergo arthroscopy were not included in the final sensitivity analysis.ResultsOut of 124 cases, 54(43.54%) had normal MR Arthrogram, 32 (25.8%) had impingement or cuff related problems, 2 (1.61%) had Bankart lesions, and in 36 (29%) cases SLAP lesions were identified. Out of 54 patients with normal MR Arthrogram, 44 were discharged to physiotherapy and 10 underwent arthroscopy, showing SLAP lesion in one patient. Out of 32 patients with impingement or cuff problems, 19 were discharged to rehabilitation and 13 underwent surgery. Out of 36 patients with SLAP lesions, 5 recovered spontaneously, 5 were awaiting outpatient review and 26 underwent arthroscopy showing SLAP lesions in 22 cases. Overall, only 51 patients underwent arthroscopy. The MR Arthrogram was falsely positive in 4 cases (15.38%) and falsely negative in one case (3.84%). The sensitivity of MR Arthrogram was 95.6% (22/23), specificity 85.7% (24/28), positive predictive value 84.6% (22/26) and the negative predictive value was 96% (24/25).ConclusionMR Arthrogram is a useful technique for the diagnosis and preoperative planning of suspected SLAP lesions. It may also save patients from unnecessary diagnostic arthroscopy.     

Double bucket handle tear of the superior labrum in a young patient presented with shoulder instability treated with arthroscopic debridement: A case report

Introduction and importanceThe two major etiologies of shoulder superior labral tears anterior to posterior (SLAP) are traumatic and degenerative processes. Bucket handle tears of the superior labrum represent one-third of labral lesions. However, in this article, we present a double bucket handle tear which has been reported once in the literature.Presentation of caseA 25-year-old male presented with complaint of chronic pain in his right shoulder with a remote history of traumatic dislocation. Physical examination revealed a positive apprehension test. Shoulder magnetic resonance imaging (MRI) showed a superior labral tear with a Hill-Sach lesion. Arthroscopy showed a double bucket handle tear of superior labrum and mild biceps tendonitis along with Bankart lesion. The tear was resected and the Bankart lesion was repaired followed by supervised physical therapy. Good clinical outcomes in form of resolution of pain and shoulder instability at six months were obtained.DiscussionSLAP tears are common shoulder lesion that is reported differently in the literature. Arthroscopic studies had reported the incidence between 3.9%-11.8. The diagnosis of such lesion relies on the clinical presentation and imaging. Knesek et al. classified SLAP lesions based on the integrity of the biceps anchor and the type of labral tear (Knesek et al., 2013). The standard treatment of symptomatic SLAP lesions is Arthroscopic debridement. However, non-operative management was described in the literature.ConclusionDouble bucket handle injuries of the superior labrum are reported in literature once. These lesions can be treated with arthroscopic debridement and Bankart repair and followed by supervised physical therapy.