Resistance of a defect of the supraspinatus tendon to intraarticular hydrodynamic pressure: an experimental study on rabbits.

The healing of a standardized defect of the supraspinatus tendon in a time-related series on rabbits was monitored with arthrography and simultaneous determination of the intra-articular hydrodynamic pressure of the glenohumeral joint. All normal glenohumeral joints produced a biphasic pressure versus volume curve. Rupture of a normal glenohumeral joint occurred at a pressure level of 140-170 mm Hg and was located in the area around the biceps tendon sheath. In joints with a defect of the supraspinatus tendon, leakage of the contrast medium was evident up to the sixth week, at an intra-articular pressure varying from 40 to 100 mm Hg. After week 6, no leakage of the cuff was seen during the determination of the intraarticular pressure. This was in accordance with the histological findings: the defect was covered with solid scar tissue from the ninth week onward. Resistance to hydrodynamic intraarticular pressure proved a reliable method of determining the strength of the healing of the supraspinal defects.

Ultrasonography and arthrography in the diagnosis of tears of the rotator cuff.

The accuracy of ultrasonography and arthrography in the prediction of lesions of the rotator cuff was evaluated and compared with the operative findings in a retrospective study of forty-nine patients (forty-nine shoulders). In the detection of full-thickness (stage-III) tears of the rotator cuff, ultrasonography had an over-all sensitivity of 74 per cent, a specificity of 95 per cent, an accuracy of 84 per cent, a predictive value of a positive test of 95 per cent, and a predictive value of a negative test of 75 per cent. In contrast, arthrography demonstrated a sensitivity of 93 per cent, a specificity of 95 per cent, an accuracy of 94 per cent, a predictive value of a positive test of 96 per cent, and a predictive value of a negative test of 91 per cent. Ultrasonography could not reliably differentiate between partial (stage-II) and full-thickness (stage-III) tears. Lesions of the long head of the biceps brachii tendon were recorded by ultrasonography for twenty-two patients (45 per cent) and by arthrography for eleven patients (22 per cent). The ultrasonographic finding of fluid in the sheath of this tendon is not a reliable sign of a lesion in the tendon.

Diagnostic performance of low field MRI in acute knee injuries.

The diagnostic performance of low field (0.1 T) magnetic resonance imaging (MRI) was studied prospectively and double-blindly among 33 patients with acute knee injuries. The subsequent arthroscopy was the golden standard. For lesions of the medial meniscus low field MR had a sensitivity of 88% and a specificity of 80%; for lesions of the lateral meniscus the sensitivity was 25% and the specificity 97%. For anterior cruciate ligament tears, low field MRI had a sensitivity of 83% and a specificity of 85%. The specificity for posterior cruciate ligament tears was 97%. The performance of low field MRI equalled that reported earlier for high field MRI, the only exception being the sensitivity for lateral meniscus lesions.

Single and double contrast arthrography in lesions of the glenohumeral joint.

One hundred and forty-five arthrograms from single and double contrast arthrography were compared with respect to their accuracy in revealing lesions of the glenohumeral joint. Total and partial rotator cuff tears were accurately delineated by both single and double contrast arthrography. The size of the tear did not correlate with surgical findings with either technique. The volume of the injected contrast medium was larger in full-thickness rotator cuff tears than in normal arthrograms (p less than 0.001; t test). As expected, this volume was not correlated with the size of the tear. Dislocation of the biceps tendon was well imaged if the biceps sheath was filled with contrast medium. The sheath became filled less frequently in total rotator cuff tears than in cases with an intact cuff (p less than 0.001; X2 test). No difference in filling frequency of the sheath could be observed between single and double contrast arthrography. This study did not reveal any major advantages of double contrast arthrography over single contrast examinations in lesions of the rotator cuff and those of the tendon of the long head of the biceps brachii.

Radiographic anatomy of the intertubercular groove of the humerus.

Disturbances of the gliding mechanism of the tendon of the long head of the biceps brachii in the intertubercular groove have been suggested as a cause of shoulder pain. The purpose of this paper was to find a standard radiographic view for measurements of the intertubercular groove of the human humeral head. The effect of the direction of the X-ray beam on the image of the groove was studied in cadaver specimens. A standardized optimal X-ray beam direction was subsequently used in a clinical study on 30 patients. In all the patients the groove could be delineated and the depth, width and slope of the medial wall measured. The width and depth of the groove was neither significantly correlated to the size of the humeral head nor the sex. The slope of the medial wall varied from 18 to 71 degrees (mean 48.1 +/- SD 10.7 degrees).

Ultrasonography of the tendons of the shoulder.

The purpose of the present study was to compare ultrasonographic signs with macroscopic and histological findings in lesions of the rotator cuff and the biceps tendon. Twenty-six shoulder joints from 10 male and 3 female cadavers, ranging in age from 40 to 89 years (mean 65.9), were examined with a linear array real-time ultrasonographic scanner provided with a 7.5 MHz transducer. Arthrotomy and histological preparations were made after ultrasonography. Thinning and discontinuity of echogenic homogenicity of the tendons of the rotator cuff were the most reliable ultrasonographic signs of a total tear of the tendon, but focal hyper- and hypo-echogenic changes of the tendons of the rotator cuff were unreliable criteria. Partial tears of the rotator cuff were difficult to determine with static ultrasonograms. Ultrasonography readily revealed discontinuity of echogenic homogenicity of the biceps tendon as a sign of a rupture of the tendon, which was commonly associated with rotator cuff tears.

Double contrast barium meal and acetylcysteine.

In a prospective double blind study, acetylcysteine, a local and systemic respiratory tract mucolytic agent, or a placebo, were given to 100 patients prior to a double contrast barium meal to decrease the gastric mucus viscosity and to make the mucus layer thinner, in order to permit barium to outline the furrows surrounding the areae gastricae instead of the overlying thick mucus. However, acetylcysteine failed to improve either visualization of the areae gastricae or the general quality of the double contrast barium meal.

Arthrography of the biceps tendon.

The purpose of this study was to analyse the factors having an influence on the arthrographic imaging of the biceps tendon. The study comprised 174 patients suffering from chronic shoulder pain. They underwent conventional shoulder arthrography with sodium meglumine metrizoate or metrizamide as a contrast medium. In the patients with a full-thickness tear of the rotator cuff, the biceps tendon sheath failed to fill with contrast medium more often than in those with an intact tendinous cuff. Metrizamide filled the biceps tendon sheath more readily than sodium meglumine metrizoate in patients with a full-thickness tear of the rotator cuff. The volume of the contrast medium injected had no influence on the imaging of the biceps tendon.

Electroencephalography and magnetic resonance imaging after diving and decompression incidents: a controlled study.

Electroencephalography and magnetic resonance imaging after diving and decompression incidents: a controlled study. Undersea Hyper Med 1999.; 26(2):61-65.--Diving incidents with symptoms of decompression sickness (DCS) and/or arterial gas emboli (AGE) might increase the degree of pathologic change in the electroencephalogram (EEG) or magnetic resonance imaging (MRI) of the supraspinal central nervous system (CNS). Diving itself, even without known symptoms of DCS and/or AGE, has been proposed to increase the number of CNS lesions using either EEG or MRI. In the first part of a two-part study we examined the effects of recompression treatment on EEG in decompression incidents in a group of sport and professional divers compared with a control group of healthy naval divers. In the second part we recorded brain MRI from three groups of volunteers: 1) divers who were treated for DCS in pressure chamber, 2) divers who had never had symptoms of DCS (and/or AGE), and 3) healthy normal controls who were not divers. Our results indicate that DCS increases the incidence of pathologic EEG recordings, whereas recompression treatment decreases them. The results of MRI do not verify evidence of increased numbers of CNS lesions in normal divers as compared to non-diving, healthy control subjects, whereas some of the divers treated for DCS in a pressure chamber had hyperintense lesions in brain white matter. None of them had any abnormalities in EEG, neurologic performance, or psychologic behavior. Both EEG and MRI are sensitive and non-specific methods for judging suspected evidence of brain lesions from diving or diving accidents.

Donor site morbidity of radial forearm flaps. A clinical and ultrasonographic evaluation.

Harvesting of a forearm flap based on the radial artery has been thought to cause functional or circulatory problems in the donor hand. Eighteen patients were examined three to 24 months after a radial forearm flap had been raised. The function of both hands was studied for grip strength, mobility of the wrist and elbow joints, and sensitivity of the area served by the superficial radial nerve. The patients were interviewed and the cosmetic result was evaluated. Duplex ultrasonography and colour Doppler ultrasonography of both ulnar arteries were done, and the brachial arteries were measured as controls. Angle-corrected peak flow velocity (cm/s) in the ulnar artery of the donor forearm was significantly increased at the level of the wrist compared with the control forearm (100.9 compared with 73.1 cm/s, p = 0.017), as was the ulnar: brachial peak flow velocity ratio (1.18 compared with 0.76, p = 0.001). The grip strength of the donor hand was weaker by 11.9% (86.5 compared with 72.2 Kp), 10 (56%) had areas of sensory loss over the radial nerve distribution, and seven of the 18 patients complained of cold intolerance. Four patients considered the donor site result so bad that they would not have chosen the operation had they known what the result would look like. The radial forearm flap donor site is not without problems, and the patients must be carefully selected and properly informed preoperatively.

Arthrotomography of the unstable shoulder.

Thirty-seven patients suffering from clinically verified subluxation of the shoulder joint underwent double-contrast arthrotomography. Sixteen of these patients were operated on, 4 of whom after arthroscopy, and 1 patient had only arthroscopy. Arthrotomography readily revealed lesions of the glenoid labrum, most of them small, and also redundancy of the anterior joint capsule. The method can be recommended in the examination of the glenoid labrum in patients suffering from anterior subluxation of the shoulder.

Diagnostic value of stress radiography in lesions of the lateral ligaments of the ankle.

The diagnostic accuracy of inversion and anterior stress radiography in rupture of the lateral ligaments of the ankle joint was assessed in 56 patients undergoing surgery. In inversion stress radiography, 58 per cent of the patients with confirmed rupture of the lateral ligaments of the ankle had a talar tilt of 10 degrees or more, allowing a predictive value of a positive test of 94 per cent. In anterior stress radiography, 53 per cent of the patients had a posterior tibiotalar distance of 9 mm or more, allowing a predictive value of a positive test of 81 per cent. In measurements of talar tilt and anterior displacement of the talus values higher than normal in the injured ankle may be a sign of a rupture of the lateral ligament.

The diagnostic value of arthrography and plain radiography in rotator cuff tears.

In 26 patients with surgically verified rotator cuff tears, the findings at radiography and arthrography were analysed. Plain anteroposterior radiograms were of no value in diagnosis. In plain groove-films, the slope of the medial wall and the depth of the intertubercular groove correlated with dislocations of the biceps tendon. In arthrography, leakage of the contrast medium into the subacromial or subdeltoid bursa was a reliable sign of a full-thickness tear. There was no correlation between the size of the tear measured at arthrography and at surgery. In cases where the biceps tendon sheath was visualised, the appearance was in agreement with the surgical findings.

Diagnostic value of sonography in lesions of the biceps tendon.

Lesions of the biceps tendon have been studied with plain radiographs and arthrograms of the intertubercular groove. Sometimes, however, especially when the rotator cuff has a full-thickness tear anteriorly, the sheath of the biceps tendon fails to fill with contrast medium, thus preventing diagnosis of dislocation of the tendon. To solve this problem the authors have tried sonography of the biceps tendon. The suitability of sonography for examining the intertubercular groove and the biceps tendon was assessed in ten volunteers. Thirty patients with chronic shoulder pain were subsequently studied by radiography, arthrography, and sonography. The observations made with these examinations were compared, and in 21 of the patients who were treated by operation with the surgical observations as well. Sonography seemed to provide accurate information about the configuration of the intertubercular groove and the position of the biceps tendon. The technique could be used to show dislocation of the tendon in cases in which the tendon sheath is not visualized in arthrography. Tenderness and the site of this in relation to the anterior upper end of the humerus could also be verified with sonography.

Radiographic diagnosis of biceps tendinitis.

The radiographic findings and arthrographic image of the intertubercular groove and the biceps tendon were analysed in 143 patients with chronic shoulder pain. Forty-eight patients had been operated on, and of these 33 had tendinitis, caused by attrition in a narrow intertubercular groove in 17 cases, by medial dislocation of the biceps tendon in 11 cases, and by impingement associated with rupture of the rotator cuff in five cases. Plain radiographs revealed degenerative changes in the walls of the groove in half of the patients with biceps tendinitis. A shallow groove was seen in cases of medial dislocation of the biceps tendon, but also in many with a normal tendon. The arthrogram, however, showed whether a shallow groove was associated with dislocation of the tendon. In patients with attrition tendinitis the groove had a depth of 4.8 mm or more or an inclination of the medial wall of 58 degrees or more. Radiographic measurements of the dimensions of the intertubercular groove may provide valuable information on the state of the biceps tendon.

Shoulder arthrography with sodium meglumine metrizoate and iopamidol.

The purpose of this study was to analyze arthrographic imaging of the structures of the shoulder joint when using either sodium meglumine metrizoate or iopamidol as a contrast medium. Two hundred and ten patients underwent single-contrast shoulder arthrography. In patients with a full-thickness tear of the rotator cuff, both contrast agents reliably revealed this lesion. However, in patients with a full-thickness rotator cuff tear, the biceps tendon could be demonstrated more readily with iopamidol, which is a non-ionic contrast medium.

Surgical repair of the rotator cuff and surrounding tissues. Factors influencing the results.

The surgical pathology and clinical results of 78 reconstructions of chronic rotator cuff tears were reviewed retrospectively. The predominant complaint preoperatively was chronic pain with impaired shoulder function, resistant to repeated conservative treatment. Results according to a functional assessment were excellent or satisfactory in 71% of the patients, unsatisfactory in 12%, and failed in 17%. Relief of pain including night pain and pain with activity was obtained. Surgery should include a thorough exploration of the rotator cuff and the adjacent tissues. Accompanying problems, including biceps tendon disorders or impingement factors, must be recognized and treated at the time of the reconstruction procedure. Repair of the torn rotator cuff and treatment of concomitant lesions are effective operative procedures when symptoms are persistent and fail to respond to conservative treatment.