The Correlation between Various Shoulder Anatomical Indices on X-Ray and Subacromial Impingement and Morphology of Rotator Cuff Tears

Objectives

Rotator cuff injury caused by subacromial impingement presents different morphologies. This study aims to investigate the correlation between various shoulder anatomical indexes on X-ray with subacromial impingement and morphology of rotator cuff tears to facilitate surgical management.

Method

This retrospective study was carried out between January 2020 and May 2022. Patients who were diagnosed as sub-acromial impingement associated with rotator cuff tears (without tendon retraction) and received arthroscopic surgery were enrolled in this study. The radiographic indexes of acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), acromial Index (AI), and sub-acromial distance (SAD) were measured on preoperative true AP view and outlet view. The location of rotator cuff tear (anterior, middle, posterior, medial, and lateral) and morphology of tear (horizontal, longitudinal, L-shaped, and irregular shaped) were evaluated by arthroscopy. Groups were set up due to different tear location and tear morphologies, by comparing the various radiographic indices between each group (one-way analysis of variance and t-test), the correlation between radiographic indices and tear characteristics was investigated.

Results

We analyzed 92 shoulders from 92 patients with a mean age of 57.23 ± 8.45 years. The AS in anterior tear group (29.32 ± 6.91°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.000) and posterior tear group (24.01 ± 7.69°) (p = 0.041). The AS in posterior tear group (24.01 ± 7.69°) was significantly larger than that in middle tear group (18.41 ± 6.13°) (p = 0.029). The LAA in middle tear group (67.41 ± 6.54°) was significantly smaller than that in posterior group (72.74 ± 8.78°) (p = 0.046). The AS in longitudinal tear group (26.86 ± 8.41°) was significantly larger than that in horizontal tear group (22.05 ± 9.47°) (p = 0.035) and L-shaped group (21.56 ± 6.62°) (p = 0.032). The LAA in horizontal group (70.60 ± 6.50°) was significantly larger than that in L-shaped group (66.39 ± 7.31°) (p = 0.033). The AI in L-shaped tear group (0.832 ± 0.074) was significantly larger than that in horizontal tear group (0.780 ± 0.084) (p = 0.019) and irregular tear group (0.781 ± 0.068) (p = 0.047).

Conclusion

Acromion with a larger AS and a smaller LAA tend to cause anterior or posterior rotator cuff tears rather than middle tears in sub-acromial impingement. Meanwhile acromion with a larger AS tends to cause a longitudinal tear, a larger LAA tends to cause horizontal tears and a larger AI tends to cause L-shaped tears.     

侧卧位和沙滩椅位在关节镜治疗巨大肩袖撕裂中的应用效果比较

目的 比较侧卧位和沙滩椅位对关节镜下巨大肩袖撕裂修补术临床疗效的影响。方法 回顾性分析2019年1月至2021年1月我院收治的关节镜治疗巨大肩袖撕裂病人95例,根据手术体位分为侧卧位组（49例）和沙滩椅位组（46例）。比较两组病人的手术时间、术中出血量、术中平均收缩压,术前及术后3、12个月的加州大学洛杉矶分校（UCLA）肩关节评分、美国肩肘外科协会（ASES）评分、疼痛视觉模拟量表（VAS）评分、肩关节活动度,以及术后12个月的并发症发生情况,并通过MRI评估肩袖再撕裂情况。结果 与沙滩椅位组相比,侧卧位组手术时间短［（74.5±4.1） min vs. （97.0±5.7） min］、术中出血量少［（55.6±3.4） mL vs. （79.9±5.7） mL］、术中平均收缩压低［（99.7±6.7） mmHg vs. （122.5±6.3） mmHg］,差异均有统计学意义（P＜0.05）。术后两组UCLA评分、ASES评分、VAS评分比较,差异无统计学意义（P＞0.05）;术后3、12个月的肩关节前屈、外旋及外展活动度比较,差异无统计学意义（P＞0.05）。术后随访12个月,两组均无血管、神经损伤,切口感染等术后并发症发生,术后复查MRI,两组均未见修复肩袖再撕裂。结论 侧卧位及沙滩椅位关节镜下修补巨大肩袖撕裂均能达到良好临床疗效,其术后功能评分、肩关节活动度、并发症及再撕裂率相似,但侧卧位术中控制性降压可降至更低水平,手术时间更短,术中出血量更少。     

An assessment of the effectiveness of magnetic resonance imaging of the shoulder: literature review

Objective. To analyse and compare all papers published to date (August 2000) that quantify the effectiveness, defined as the impact of clinician’s diagnosis or management plans, or patient outcome, of MRI of the shoulder. Design. A computerised search of Index Medicus with a broad search strategy relating to shoulder MRI was performed. Manual assessment of all papers listed was undertaken with classification of each paper depending on whether it addressed questions of (1) technical performance, (2) diagnostic performance or (3) outcome. Results. Four of 265 qualifying papers addressed aspects of effectiveness and these were reviewed. The impact on the clinician’s diagnosis varied widely between papers: the primary diagnosis was altered in 23% to 68% of cases, and the management plans were subsequently changed in 15% to 61% of cases. Only one paper addressed the impact on patient health. Conclusions. The effectiveness of MRI of the shoulder depends on the clinical skills of the referring clinician and prevalence of disease in the study population. This will have implications when the effectiveness of an imaging technique between different institutions is compared, and this in turn will influence any comparisons of cost-effectiveness. Received: 22 October 1999 Revision requested: 31 January 2000 Revision received: 21 August 2000 Accepted: 24 August 2000     

Correlation between Rotator Cuff Tears and Repeated Subacromial Steroid Injections: A Case-Controlled Study

INTRODUCTION

Concern exists regarding potential damage to the rotator cuff from repeated corticosteroid injections into the subacromial space.

PATIENTS AND METHODS

In this retrospective, case-controlled study, 230 consecutive patients presenting to three orthopaedic units with subacromial impingement and investigated as an end-point with magnetic resonance imaging (MRI) of the shoulder were divided into groups having received less than three or three or more subacromial injections of corticosteroids.

RESULTS

With no significant difference in age and sex distribution, analysis by MRI showed no significant difference between the two groups in the incidence of rotator cuff tear (P < 1.0).

CONCLUSIONS

This suggests that corticosteroid use in patients with subacromial impingement should not be considered a causative factor in rotator cuff tears.     

Current Perspectives on Rotator Cuff Anatomy

Understanding the anatomy of the rotator cuff and the surrounding structures that influence its function is essential to treating rotator cuff disease. During the past decade, advances in basic science and surgical technology have improved our knowledge of this anatomy. This review article presents the current concepts on rotator cuff anatomy and how they should be used in the surgical management of rotator cuff tears.     

MRI对肩袖撕裂的诊断价值

目的 评价肩关节MRI对肩袖撕裂的诊断价值,并分析其影像特征及损伤机制.方法 回顾性分析76例肩袖撕裂的MRI表现及临床症状.结果 肩袖全层撕裂共25例.其中冈上肌腱撕裂23例,同时向冈下肌腱延伸5例,6例合并肩胛下肌腱部分撕裂,1例合并肱二头肌长头腱断裂,2例合并关节盂前上盂唇撕脱.肩袖部分撕裂共51例,全部发生在冈上肌腱.其中上表面侧11例,下表面侧32例,肌腱内部分撕裂8例.其中8例同时在上表面及下表面发生部分撕裂,3例同时合并下表面及肌腱内部分撕裂.结论 肩关节MRI是评价肩袖撕裂比较有效的检查方法,为临床制定正确的治疗方案提供可靠的依据.     

Impingement of the rotator cuff in athletes caused by instability of the shoulder joint

An impingement of the rotator cuff can be caused by chronic anterior instability of the shoulder joint. This particular disease is often found in athletes engaged in overhead motion in abduction/external rotation of the arm, such as in ball sports like volleyball or European handball, racket sports like tennis or badminton, or swimming. For those patients that cannot be cured by conservative treatment such as muscular stabilization, surgical treatment is indicated: anterior reconstruction of the capsule and/or the glenoid labrum, and in addition — if necessary — subacromial decompression and revision of the rotator cuff. Between October 1988 and April 1992, we operated on 66 shoulders in 64 top athletes suffering from chronic anterior or multidirectional instability of the shoulder joint that had caused an impingement syndrome of the rotator cuff. In all cases, the athlete was unaware of the instability. Conservative treatment had been unsuccessful. Surgical treatment was successful in close to 90% of the athletes.     

Transosseous arthroscopic repair of partial articular-surface supraspinatus tendon tears

Partial articular-surface tendon avulsion (PASTA) lesions of the supraspinatus muscle represent a common cause for shoulder impairment and a preceding pathology for full-thickness tendon tears. Arthroscopic tendon repair is a possible surgical method of treatment. The purposes of cuff repair are anatomical tendon healing, prevention of tear size progression to completion and reduction of shoulder pain. In this report, we describe a transtendon arthroscopic technique of transosseous refixation of articular-side partial tears leaving the bursal layer of the supraspinatus tendon intact. A curved hollow needle is used to perform an all arthroscopic transosseous mattress suture. Thus, anatomical tendon-to-bone contact of the rotator cuff to the footprint is restored. Preliminary clinical results of 16 patients are convincing with significant pain relief and functional improvement.     

MR findings of meniscal extrusion correlated with arthroscopy

PURPOSE: To correlate MR exams showing meniscal extrusions >3 mm beyond the tibial margin with arthroscopic findings. Meniscal extrusion (> 3 mm extension beyond the tibial margin) has been described on previous studies as having a high index of association with meniscal root tears. These previous studies were limited by a lack of exact arthroscopic correlation. We also assessed the prevalence of meniscal root tears on MR examinations without meniscal extrusions. MATERIALS AND METHODS: A retrospective review was performed of 300 consecutive knee MR exams of patients who went on to arthroscopy. All patients had a complete MR exam performed on a 3T GE MR scanner. MR exams were reviewed for medial meniscal extrusion > 3 mm from the tibial margin. The exams with medial meniscal extrusion were reviewed for meniscal tears on MR exam. The exams without meniscal extrusion were reviewed for meniscal root tears. Results were subsequently correlated with arthroscopy. RESULTS: Of the 300 MR exams, 42 demonstrated medial meniscal extrusion >3 mm from the tibial margin. Of these 42 patients, 34 had meniscal degeneration, complex tear, or a large radial tear near to or involving the meniscal root on MR examination. A total of 33 of these tears described on MR exam were seen at arthroscopy. A total of 24 of these tears were root tears, seven were complex tears, and two had severe meniscal degeneration. There was one root tear described on MR exam that was not seen on arthroscopy. Eight of the 42 patients had no meniscal tear demonstrated on MR examination or arthroscopy. All eight of these patients were > or = 50 years old. There were two meniscal root tears on both MR exam and at arthroscopy in the 258 patients without meniscal extrusion on MR exam. CONCLUSION: There is a high prevalence of meniscal root tears in patients with meniscal extrusion on MR exam. Meniscal root tears are uncommon in patients without meniscal extrusion on MR exam. There may be a subset of patients in which the meniscal root is stretched rather than torn. Medial meniscal extrusion in patients > 50 years old may be associated with a meniscal "stretch" injury due to degeneration of the meniscus without a meniscal tear detectable on arthroscopy. These menisci may have increased laxity due to compromised meniscal collagen fibers. This may predispose the patient to premature osteoarthritis.     

Clinical and structural results of partial supraspinatus tears treated by subacromial decompression without repair

Patients with primary impingement and articular sided partial tears of the supraspinatus are often treated by subacromial decompression without repair, if the extent of the tear is estimated to be below 50% of tendon thickness. It has been questioned whether repair of these cuff lesions is necessary, because these tears could progress to full thickness tears with deteriorating clinical results. Our hypothesis was that subacromial decompression without repair of the supraspinatus tendon leads to significant clinical improvement for patients with grade I and II articular sided tears without progression to a full thickness tear on a regular basis. 46 consecutive patients (av. Age 59.2 years, range 33–76.6 years) were retrospectively reviewed after an average follow up of 50.3 months (36–86 months). 26 patients (43.5%) had a grade I tear according to Ellman, which was left alone, 20 patients suffered from a grade II tear, which was debrided. Clinical outcome was assessed with the ASES Score and ultrasound evaluation was performed on all patients to detect possible progression to a full thickness tear. The average ASES Score significantly improved from 37.4 to 86.6 points (p < 0.0001). The mean postoperative Constant Score was 87.6 points. Only three patients (6.5%) progressed to a full thickness tear detectable on ultrasound examination. Only one of these patients had a poor result with an ASES Score of 35 points, the other two were very satisfied and had an ASES score above 90 points. 8 patients showed no more signs of partial tearing on ultrasound and these patients had an average ASES Score of 93.1 points. Overall clinical outcome was rated excellent in 35 cases (76.1%), good in 5 (10.9%), average in 2 (4.3%) and poor in 4 (8.7%). Our results indicate that good and excellent results can be achieved mid- to long term by acromioplasty without repair of the rotator cuff in articular sided partial tears grade I and II. These results reach almost 95% of the value of a healthy shoulder. A better result on ultrasound examination was associated with a superior clinical outcome, while progression to a full thickness tear was rare.