The current standard of the shoulder trauma series in Ireland - A national audit.

OBJECTIVES/AIMS: The primary aim of this study was to assess the current standard of shoulder radiographs in Ireland. The secondary aim of this study was to determine whether orthopaedic surgeons in Ireland are of the opinion that a national protocol is required, and what this protocol should consist of. METHODS: A national audit of shoulder trauma series x-rays performed in emergency departments was conducted. The number and type of views performed was recorded. The anteroposterior (AP) and axillary or Velpeau views were assessed to determine if they met pre-defined audit criteria. Consultant orthopaedic surgeons working in public trauma hospitals were invited to participate in an online survey by email. RESULTS: The number of shoulder trauma series included in this audit was 789. The majority of patients had two views performed (75.92%, n â€‹= â€‹599) and 21.17% (n â€‹= â€‹167) had an axillary or Velpeau view. The AP view met the audit criteria in 23.09% (n â€‹= â€‹181) of cases. The survey response rate was 70.8% (n â€‹= â€‹17). 88.2% (n â€‹= â€‹15) of surgeons agreed that three views should be performed for a shoulder trauma series and 94.12% (n â€‹= â€‹16) agreed that an axillary or Velpeau view should be included. The majority of surgeons surveyed (94%, n â€‹= â€‹16) are in favour of establishing a national protocol. CONCLUSION: The current standard shoulder trauma series in Irish hospitals consists of two views, most frequently a thoracic AP and a scapular Y view. We propose the introduction of a national protocol consisting of three views: Grashey AP, Scapular Y, and an axillary or Velpeau view.

3D C-arm navigated acromioclavicular joint stabilization.

INTRODUCTION: Surgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures. MATERIALS AND METHODS: The implantation of a TightRope® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed. RESULTS: All vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well. CONCLUSION: Intraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed.

Prevalence of associated injuries after anterior shoulder dislocation: a prospective study.

PURPOSE: Anterior shoulder dislocation can be associated with many lesions such as Bankart lesions, rotator cuff tears (RCT), Hill-Sachs lesions or greater tuberosity fractures. It has been documented that early management of the associated injury affords better recovery of shoulder function. The aim of this study was to highlight the incidence of associated injuries after anterior shoulder dislocation. METHODS: A total of 240 patients with traumatic anterior glenohumeral dislocations were subjected to complete history taking, neurovascular assessment and pre-reduction plain X-ray. An X-ray was taken immediately after reduction. Ultrasonography (US) and magnetic resonance imaging (MRI) were done within one week after reduction in all patients. Nerve conduction studies were ordered for any patient with suspected nerve injury. RESULTS: Associated lesions were reported in 144 (60%) patients. RCT was the most common injury (67 cases). It was isolated in 34 patients (14.15%), while it was combined with other lesions in 33 cases (13.75%). Axillary nerve injury was encountered in 38 patients, of them 8 (3.33%) were isolated and 30 (12.5%) were combined. Greater tuberosity fracture was found in 37 patients, of them 15 (6.25%) were combined with axillary nerve injury, and in the other 22 patients (9.17%) the fracture was isolated. All cases with Hill-Sachs and Bankart lesion were combined lesions with no isolated cases. There was a significant relation between the incidence of associated injuries and age, mechanism of injury and the affected side. CONCLUSIONS: Lesions associated with traumatic anterior glenohumeral dislocations are more frequent than expected. Thorough clinical examination and detailed imaging including US and MRI are mandatory to avoid a missed diagnosis.

Incidental findings are frequent in shoulder CT and MRI scans and increase with age.

Objectives: CT and MRI scans of the shoulder can lead to the identification of incidental findings (IF), which can have a major impact on the further treatment of the patient. The aim of this retrospective study was to record the prevalence of IF, incidentalomas (IT) and malignant IT for CT and MRI examinations of the shoulder and to investigate the effect of patient characteristics on the statistical occurrence of IF, IT and malignant IT. Materials and methods: A total of 903 shoulder examinations (415 CT, 488 MRI) were retrospectively analyzed for the presence of IF, subsequently categorized (harmless IF, IT requiring clarification, malignant IT) and analyzed regarding patient characteristics. The statistical analysis was carried out using independent t- and chi-square tests. A significance level of p < 0.05 was set. Results: Among the 903 patients evaluated (436 female, 467 male), 153 (16.9%) patients experienced IF (harmless IF: 101 (11.2%) patients, IT: 94 (10.4%), malignant IT: 4 (0.4%). The average age of the patients without IF and IT was significantly lower compared to the patients with IF and IT (p < 0.001). While IF occurred in 31.1% of the CT, IF was only detected in 4.9% of the MRI (p < 0.001). Conclusion: IF have a high prevalence (16.9%), especially in CT examinations of the shoulder, which increases with age. The exact detection and initiation of appropriate therapy is of great clinical importance, as early detection of life-threatening diseases enables more effective treatment and a potential gain in health and lifespan.

To what extent do typical components of shoulder clinical evaluation explain upper-extremity disability? A cross-sectional study.

BACKGROUND: Physical therapists use several evaluation measures to identify the most important factors related to disability. However, the degree to which these evaluation components explain shoulder disability is not well known and that may detract clinicians from the best clinical reasoning. OBJECTIVE: To determine how much evaluation components explain shoulder function. METHODS: Eighty-one individuals with unilateral shoulder pain for at least four weeks and meeting clinical exam criteria to exclude cervical referred pain, adhesive capsulitis, and shoulder instability, participated in this study. Several typical clinical evaluation components were assessed as potential independent variables in a regression model using the Disabilities of the Arm, Shoulder, and Hand (DASH) score as a proxy to shoulder function. Two multivariate models were built to include (1) evaluation components from physical exam plus clinical history and (2) a model considering all previous variables and magnetic resonance imaging (MRI) data. RESULTS: Pain catastrophizing was the best variable in the model explaining at least 10% of the DASH variance. Sex and lower trapezius muscle strength explained considerably less of shoulder function. The MRI data did not improve the model performance. CONCLUSION: The complexity of shoulder function is not independently explained by pathoanatomical abnormalities. Psychological aspects may explain more of shoulder function even when combined with physical components in some patients.

The use of clickers to evaluate radiographer's knowledge of shoulder images.

BACKGROUND: Conducting research can be daunting, although applicable methods can facilitate the process. A study was performed at an imaging department pertaining to the routine shoulder projections, namely the anteroposterior (AP) external rotation and lateral-Y (LAT-Y) projections. AIM: The aim of the study was to determine if radiographers (qualified, supplementary, community service) and student radiographers (second-year diploma, third-year diploma, second-year bachelor) use the radiographic evaluation criteria to evaluate the routine shoulder projections. SETTING: The study was conducted at an imaging department in the Free State province, South Africa. METHODS: Participants had to complete a survey by means of a questionnaire that was compiled in Microsoft Excel and converted to an audience response system known as clickers. The questions addressed aspects of shoulder imaging with regard to positioning, exposure factors and the evaluation of routine shoulder projections. The data were analysed separately using statistics software SAS Version 9.2. Fisher's exact test was used to determine statistically significant differences between students and radiographers. RESULTS: More than 80% of students selected the AP (external rotation) X-ray image demonstrating optimal milliamperage per second whereas 43% of radiographers selected the correct image. More than 50% of radiographers and students indicated that a breathing technique and a short exposure time reduce motion during shoulder imaging. CONCLUSION: Using clickers eased the process of testing the participants' knowledge, and the results were available immediately after completion of the test. Clickers can contribute to and expedite the process of data analysis.

Imaging of the Unstable Shoulder.

BACKGROUND: Unstable shoulder can occur in different clinical scenarios with a broad spectrum of symptoms and presentations: first-time (or recurrent) traumatic acute shoulder anterior dislocation or chronic anterior instability after repeated dislocations.Imaging in unstable shoulder is fundamental for choosing the right treatment preventing recurrence.The goal of imaging depends on clinical scenario and patient characteristics. METHOD: Careful selection and evaluation of the imaging procedures is therefore essential to identify, characterize and quantify the lesions. Proper imaging in unstable shoulder cases is critical to the choice of treatment to prevent recurrence, and to plan surgical intervention. RESULTS: In acute setting, radiographs have to roughly detect and characterize the bone defects present. At about 7 days, it is recommended to perform a MR to demonstrate lesions to labrum and/or ligaments and bone defects: in acute setting, the MRA is not necessary, because of effusion and hemarthrosis that behave as the contrast medium.In recurrence, it is fundamental not only to detect lesions but characterize them for planning the treatment. The first study to do is the MRI (with a magnetic field of at least 1.5 Tesla), and if possible MRA, above all in younger patients. Then, on the basis of the pathologic findings as bipolar lesion or severity of bone defects, CT can be performed. PICO method on 2D or 3D CT is helpful if you need to study a glenoid bone loss, with the "en face view" of glenoid, while a 3D CT reconstruction with the humeral head "en face view" is the gold standard to assess an Hill-Sachs lesion. CONCLUSION: The clinical diagnoses of anterior shoulder instability can be different and acknowledgement of imaging findings is essential to guide the treatment choice.Imaging features are quite different in chronic than in acute scenario. This requires appropriate indications of many different imaging techniques.

Classification of full-thickness rotator cuff lesions: a review.

Rotator cuff lesions (RCL) have considerable variability in location, tear pattern, functional impairment, and repairability.Historical classifications for differentiating these lesions have been based upon factors such as the size and shape of the tear, and the degree of atrophy and fatty infiltration. Additional recent descriptions include bipolar rotator cuff insufficiency, 'Fosbury flop tears', and musculotendinous lesions.Recommended treatment is based on the location of the lesion, patient factors and associated pathology, and often includes personal experience and data from case series. Development of a more comprehensive classification which integrates historical and newer descriptions of RCLs may help to guide treatment further. Cite this article: Lädermann A, Burkhart SS, Hoffmeyer P, et al. Classification of full thickness rotator cuff lesions: a review. EFORT Open Rev 2016;1:420-430. DOI: 10.1302/2058-5241.1.160005.

Intraoperative imaging of the shoulder: A comparison of two- and three-dimensional imaging techniques.

BACKGROUND: Isocentric three-dimensional C-arms allow for more effective intraoperative fracture reduction control compared to two-dimensional imaging techniques. However, this design is not appropriate for shoulder scanning. OBJECTIVE: To assess the feasibility of using a newer generation variable isocentric flat detector 3D C-arm for intraoperative glenohumeral and acromioclavicular joint assessment and to compare the accuracy of its intraoperative 3D imaging technology to a standard two-dimensional (2D) flat detector fluoroscope. METHODS: Five whole-body human cadavers were used (ten shoulders). Native shoulder scans were obtained. A glenohumeral arthrotomy was performed and several injuries and procedures were simulated. Five independent orthopaedic surgeons reviewed each scan and filled out a questionnaire assessing the quality of the images using a visual analog scale (VAS) and a points scoring system. RESULTS: The examiners rated the 3D images as very-good-to-excellent according to the established parameters: image quality; visualization of the corticalis and the spongiosa; delineation of the joint surface; presence of artifacts; and clinical assessment capability. This high quality of the images led to a higher interobserver reliability for 3D images compared to 2D images. CONCLUSIONS: Variable isocentric 3D C-arm technology is feasible for intraoperative assessment of shoulder procedures. Assessment of 3D images in shoulder procedures showed better interexaminer reliability in this experiment compared to 2D images. With the aid of intraoperative 3D shoulder imaging, intraoperative 3D C-arm navigation could help improve accuracy in the clinical setting.

Contribution of MRI and CT arthrography to the diagnosis of intra-articular tendinopathy of the long head of the biceps.

INTRODUCTION: Clinical diagnosis of biceps tendinopathy is difficult to make because of the poor sensitivity of existing clinical tests. The goal of this study was to determine whether MRI or CT arthrogram could contribute to the diagnosis of tendinopathy in the intra-articular portion of the long head of biceps (LHB), while using macroscopic findings during shoulder arthroscopy as a reference. MATERIAL AND METHODS: A prospective, single-centre study was performed over a 4-month period. The radiology part of the study was carried out by a radiologist experienced in shoulder imaging. The arthroscopy part of the study was conducted while the biceps was being evaluated for treatment purposes. The study included 87 patients having an average age of 45.7 years (range 17-78). Fifty-eight patients underwent CT arthrography and 38 underwent an MRI. Seven patients underwent both imaging exams. One patient was removed from the study because of a spontaneous LHB rupture. The demographics of the two study populations were equivalent. RESULTS: For the diagnosis of tendinopathy of the intra-articular portion of the long head of biceps, the CT arthrogram had a sensitivity of 71.43%, specificity of 100%, positive predictive value of 100% but a negative predictive value of 67.74%. For the diagnosis of tendinopathy of the intra-articular portion of the long head of biceps, the MRI had a sensitivity of 42.85%, specificity of 75%, positive predictive value of 50% but a negative predictive value of 69.23%. CONCLUSION: This study showed that radiological diagnosis of tendinopathy of the long head of biceps remains challenging. Nevertheless, CT arthrography is more sensitive and specific than MRI in identifying this disorder. LEVEL OF EVIDENCE: III (case-control study).