The use of magnetic resonance imaging in the diagnosis of rotator cuff tears

One hundred consecutive patients with symptoms of chronic subacromial impingement syndrome were evaluated by both arthrography and magnetic resonance imaging (MRI) techniques. By comparing intermediate and T2 weighted images, the ability to identify the normal and abnormal anatomy of the rotator cuff with the MRI was excellent. All 51 patients with arthrogram-proven rotator cuff tears had abnormal MRI scans (100% sensitivity). However, six of the 49 patients with normal arthrograms had abnormal MRI scans (88% specificity). At arthroscopy, four of these patients were found to have moderate to severe partial thickness rotator cuff tears. These findings indicate that in patients with longstanding subacromial impingement syndrome the MRI has an exceptionally high sensitivity for damage to the rotator cuff.     

Electromyographic evaluation after primary repair of massive rotator cuff tears

Anatomic dissections have suggested that mobilization of the supraspinatus and infraspinatus tendons greater than 1 cm may cause suprascapular nerve injury. This study evaluated rotator cuff function by use of electromyographic (EMG) analysis after primary repair of massive tears in 9 patients. All subjects had massive rotator cuff tears involving at least the entire supraspinatus and entire infraspinatus tendons. Rotator cuff advancement averaged 2.5 cm (range, 2.0-3.5 cm). No EMG evidence of suprascapular nerve injury was found postoperatively. The UCLA shoulder score improved from a preoperative mean of 11 to a postoperative mean of 28. There was 1 excellent, 6 good, 1 fair, and 1 poor result. The poor result was due to a documented failed repair. The EMG results suggest that mobilization and advancement of the rotator cuff up to 3.5 cm during primary repair may be performed safely without as much risk to the suprascapular nerve as anatomic studies would suggest.     

Acromial shapes and extension of rotator cuff tears: magnetic resonance imaging evaluation

Magnetic resonance imaging makes it possible to inspect the status of the rotator cuff and the shape of the acromion. To clarify the relationship between acromial shapes and rotator cuff tears, we evaluated magnetic resonance images obtained in 192 shoulders. We classified the acromial shapes into 3 types: type I (flat), type II (curved), and type III (hooked). Among a group of 91 shoulders with rotator cuff tears, 33 (36.3%) were type I, 22 (24.2%) type II, and 36 (39.6%) type III. The size of rotator cuff tears in type III acromions was significantly larger than in type I or II acromions. Comparison of the incidence of each acromial shape between groups of specimens with and without rotator cuff tears revealed no significant differences. We suggest that whereas acromial shapes have a bearing on the extent of rotator cuff tears, the correlation between rotator cuff tears and a type III acromion is not as strong as has been suggested in the literature.     

Arthroscopic treatment of massive rotator cuff tears

In the past 10 years, arthroscopic surgeons have gone from being unable to repair any rotator cuff tears arthroscopically to being able to repair virtually all rotator cuff tears, even complex massive tears, arthroscopically. The factors responsible for this rapid evolution have been: (1) recognition of the mechanical principles responsible for a secure repair (margin convergence, knot security, loop security); (2) recognition of major tear patterns that require different techniques of repair; and (3) development of instrumentation and arthroscopic portals that predictably accomplish secure repair of the rotator cuff and direct access to the pathologic areas. In the current study, the author analyzes each factor, anatomic and mechanical, that influences the quality of the repair, and explains how to optimize the overall repair by optimizing each step in the repair. In the author's series of arthroscopic repair of rotator cuff tears, the results have been gratifying, with massive tears achieving final results equivalent to those of smaller tears.     

巨大肩袖撕裂治疗现状

巨大肩袖撕裂是目前骨科疾病难点之一,对于其最佳治疗方式目前仍缺乏统一认识。治疗方式主要有药物治疗、物理治疗、康复治疗以及手术治疗等。对于可修复性巨大肩袖撕裂可尝试通过开放手术、关节镜辅助小切口治疗或全关节镜治疗,对于不可修复性撕裂可通过部分修复、肌腱移位、重建上方关节囊、补片增强、关节置换甚至关节融合等方式进行治疗。随着对肩袖撕裂的病因、损伤机制以及肩关节解剖力学等理解的逐步深入,同时得益于肩关节镜手术技术和关节镜器械的飞速发展,开发利用成体干细胞、富血小板血浆、新型修复补片材料等以降低手术失败率、术后再撕裂率以及关节僵硬等并发症,逐渐成为了目前研究的热点和重点。本文旨在对巨大肩袖撕裂治疗现状和最新研究进展进行综述,并探讨未来治疗研究趋势。     

A rat model of massive rotator cuff tears

Rotator cuff tears (RCTs) are the most common tendon injury seen in orthopedic patients. Massive RCT does not heal spontaneously and results in poor clinical outcomes. Muscle atrophy and fatty infiltration in rotator cuff muscles are major complications of chronic massive RCT and are thought to be the key factors responsible for the failure of attempted massive RCT repair. However, the pathophysiology of rotator cuff muscle atrophy and fat infiltration remains largely unknown, and no small animal model has been shown to reproduce the histologic and molecular changes seen in massive RCT. In this article, we report a novel rat massive RCT model, in which significant and consistent muscle atrophy and fat infiltration were observed in the rotator cuff muscles after rotator cuff tendon transection and denervation. The supraspinatus and infraspinatus muscle lost 25.4% and 28.9% of their wet weight 2 weeks after complete tendon transection, respectively. Six weeks after surgery, the average wet weight of supraspinatus and infraspinatus muscles decreased 13.2% and 28.3%, respectively. Significant fat infiltration was only observed in infraspinatus 6 weeks after tendon transection. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:588–595, 2011     

Accuracy of ultrasonography and magnetic resonance imaging for detection of full thickness rotator cuff tears

Background:

Rotator cuff problems are frequently seen by orthopedic surgeons and accurate diagnosis is essential for appropriate management. Value of the clinical assessment of a shoulder is often limited, therefore, imaging studies have important implications in the management of rotator cuff pathologies.

Aim:

The purpose of this retrospective study is to compare the accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for detection of full-thickness rotator cuff tears.

Materials and Methods:

We reviewed 91 consecutive cases of shoulder arthroscopy and open rotator cuff repair, who had undergone preoperative investigation in the form of either an ultrasound or MRI. Thirty-six patients had an ultrasound and 55 had an MRI for their affected shoulders. We compared the accuracy of US and MRI for detection of full-thickness rotator cuff tears, using the operative findings as the ‘gold standard’. Data regarding a supraspinatus tear was assessed for the purpose of this study.

Results:

Ultrasonography correctly diagnosed 15 out of 17 tears (sensitivity of 0.88). There were 17 true-negative and two false-positive ultrasounds (specificity of 0.89). MRI accurately identified 33 of the 36 tears (sensitivity of 0.91). There were 16 true-negative and three false-positive tears on MRI (specificity of 0.84). The positive predictive value (PPV) was 88% for US and 92% for MRI. The negative predictive value (NPV) was 89% for US and 84% for MRI. The overall accuracy of the ultrasound was 88.89% (95% confidence interval (CI) = 74.09 to 96.18) as compared to 89.09% (95% CI = 77.82% to 95.26%) for the MRI.

Conclusion:

Full-thickness rotator cuff tears can be identified using ultrasound and MRI with comparable accuracy. US being a dynamic study and better tolerated by the patient, can therefore be used as the first-line investigation for rotator cuff tear, where appropriate skills are available to reduce the waiting time and cost of investigation.     

Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears

We attempted to assess the accuracy of magnetic resonance imaging (MRI) in determining the size of recurrent cuff tears in correlation with size measured at surgery. Thirty-seven shoulders in 33 patients who had reoperation for a presumed failed rotator cuff repair were retrospectively evaluated. All patients had preoperative MRI, the results of which were read by a musculoskeletal radiologist to determine the presence of a tear and to estimate its size. All tears were measured intraoperatively in sagittal and coronal planes. Thirty-three shoulders had recurrent tears of the rotator cuff, and MRI correctly identified the presence of 30 of them. MRI correctly identified only 1 of the 4 patients without a recurrent tear of the cuff. The correlation coefficient for MRI accurately defining the size of cuff tears was 0.46. The sensitivity of MRI for the diagnosis of retear was 91%, and the specificity was 25%. MRI is accurate in diagnosing a recurrent full-thickness cuff tear in postsurgical shoulders. However, it is relatively inaccurate in correctly defining the size of the tear. MRI also has a tendency to overdiagnose cuff tears in postsurgical patients with continued pain and symptoms.     

Association of intramuscular cysts of the rotator cuff with tears of the rotator cuff: magnetic resonance imaging findings and clinical significance.

Cystic lesions that arise adjacent to the shoulder have been reported in association with labral tears or as an unusual manifestation of massive rotator cuff tears. The purpose of this study was to define the relationship between intramuscular cysts of the rotator cuff and tears of the rotator cuff. Thirteen cases of intramuscular cysts of the rotator cuff were identified on magnetic resonance imaging of the shoulder and analyzed retrospectively along with the clinical data. Surgical findings were retrospectively reviewed in 5 patients who underwent follow-up arthroscopy. This series shows that intramuscular cysts of the rotator cuff are associated with small, full-thickness tears or partial undersurface tears of the rotator cuff. These cysts are easily identified on T2-weighted sequences and, when present, should always prompt a thorough search for associated rotator cuff pathology.     

Management of massive and irreparable rotator cuff tears

Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including débridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.Level of EvidenceReview Article.     

不可修复性巨大肩袖损伤手术治疗策略

2009年5月28日,在上海交通大学附属第一人民医院主办的肩关节创伤及人工关节高级研讨班上,欧洲著名肩关节外科专家、法国Arnaud Godenèche医生就不可修复性巨大肩袖损伤的手术治疗策略作了精彩报告.     

Accuracy of the rotator cuff reparability score

BACKGROUNDThe reparability of large or massive rotator cuff tears is difficult to determine pre-operatively. We previously identified age ≥ 65 years, acromiohumeral interval ≤ 6 mm, and anteroposterior tear size ≥ 22 mm as risk factors for rotator cuff repair failure. We therefore developed a rotator cuff reparability score where each of the above risk factors is assigned a score of one point. AIMTo determine the accuracy of a rotator cuff reparability score.METHODSThis was a retrospective cohort study of recruited patients with large or massive rotator cuff tears treated at our institution between January 2013 and December 2019. Exclusion criteria were revision surgery and patients with contraindications for surgery. All patients underwent arthroscopic rotator cuff repair and were categorized into either complete or partial rotator cuff repair. Rotator cuff reparability scores were calculated for each patient. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were assessed. A receiver operating characteristic curve was plotted to determine the optimal cut-off rotator cuff reparability score. RESULTSEighty patients (mean age, 61 years; range, 25–84 years; 41 females and 39 males) were recruited. Intra- and inter-observer reliabilities were good to excellent. The number of patients with 0, 1, 2, and 3 risk factors for rotator cuff repair failure were 24, 33, 17, and 6, respectively. Complete repair was performed in all patients without risk factors. Two of the 33 patients with one risk factor and seven of the 17 patients with two risk factors underwent partial repair. One of the six patients with three risk factors underwent complete repair. The area under the curve was 0.894. The optimal cut-off score was two points with a sensitivity of 85.71% and a specificity of 83.33%. CONCLUSIONA rotator cuff reparability score of two was determined to be the optimal cut-off score for predicting the reparability of large or massive rotator cuff tears.     

巨大肩袖损伤关节镜手术治疗进展

巨大肩袖损伤的手术治疗是骨科医师面临的一个挑战,且肩袖撕裂后肌腱回缩、粘连及脂肪浸润会进一步加大手术修复难度,所以如何更好地修复巨大肩袖损伤成为了目前研究的热点与难点。近年来,随着关节镜技术不断发展,肩关节镜手术已成为治疗巨大肩袖损伤的金标准,但其不同术式的适应证、效果及联合应用仍存在争议。笔者认为对于功能要求较低的老年患者,可行肩关节清理联合肩峰成形术或肱骨大结节成形术,可短期缓解患者肩关节疼痛;对于伴有肱二头肌长头腱损伤的患者,肱二头肌长头腱切断或固定术效果显著;完全修补术依旧是巨大肩袖撕裂的一线治疗方法,而对于无法完全修补的巨大肩袖撕裂可行部分修补术;对于功能需求较高的年轻患者,补片增强技术可带来良好的效果;对于肩关节内外旋能力受限且功能要求较高的患者,建议选用肌腱转位术;对于无明显盂肱关节炎、三角肌力量较好、功能要求较高的患者,上关节囊重建术更具优势。此外,肩峰下假体植入术因其创伤小、费用低、相对安全等优点成为目前研究热点,其长期效果仍需进一步证实。