Efficacy of biceps-radial-slice magnetic resonance images for the diagnosis of biceps and pulley lesions.

BACKGROUND: Injuries to the biceps reflection pulley lead to instability of the long head of the biceps tendon (LHBT). However, conventional magnetic resonance (MR) imaging (MRI) has low diagnostic accuracy for LHBT and pulley lesions. Here, we investigated the usefulness of novel biceps-radial MRI for evaluating LHBT and pulley lesions. METHODS: Biceps-radial MR images of 84 patients (84 shoulders) were prospectively analyzed. The biceps-radial MRI protocol includes sequences acquired in radial planes perpendicular to the LHBT in the shoulder joint. All patients underwent shoulder arthroscopy, and the intraoperative LHBT and pulley lesion findings were compared to the preoperative evaluations. The diagnostic accuracies of the biceps-radial MR images and conventional MR images were determined. RESULTS: A normal LHBT was observed in 30 (31.6%) patients, partial tears in 43 (52.6%), and complete tears in 11 (15.8%). Normal LHBT stability was present in 54 (61.4%) patients, subluxation in 24 (31.6%), and dislocation in 6 (7.0%). The biceps-radial MR (kappa coefficient: 0.94) and conventional MR (kappa coefficient: 0.68) images accurately identified LHBT tears. The biceps-radial MR images excellently agreed with the arthroscopic findings (kappa coefficient: 0.91), whereas the conventional MR images poorly agreed (kappa coefficient: 0.17) regarding LHBT instability. A normal medial wall of the pulley was observed in 26 (31.0%) patients, partial tears in 30 (35.7%), and complete tears in 28 (33.3%). A normal lateral wall of the pulley was observed in 30 (35.7%) patients, partial tears in 21 (25.0%), and complete tears in 33 (39.3%). The biceps-radial MR images excellently agreed with the arthroscopic findings (kappa coefficient: 0.89), whereas the conventional MR images moderately agreed (kappa coefficient: 0.50) regarding medial pulley lesions. The biceps-radial MR images excellently agreed with the arthroscopic findings (kappa coefficient: 0.95) and the conventional MR images moderately agreed (kappa coefficient: 0.56) regarding lateral pulley lesions. CONCLUSION: Biceps-radial MRI allows for tracking of the LHBT and pulley from the supraglenoid tuberosity to the bicipital groove in the glenohumeral joint and accurate evaluations of LHBT and pulley lesions.

Can subcoracoid cyst formation be a sign of anterosuperior rotator cuff tears and biceps pulley lesions? A prospective radiologic and arthroscopic correlation study.

BACKGROUND: The aim of this study was to investigate the pathologies associated with subcoracoid cysts (ScCs) in patients with rotator cuff (RC) tears and the postoperative appearance of ScCs after arthroscopic repair. METHODS: A total of 114 patients who underwent arthroscopic RC repair were prospectively evaluated. The inclusion criteria were as follows: patients with or without ScCs, patients with Patte class 1 or 2 tears, and patients who were 40-65 years of age. Forty-four patients with ScCs (group 1) were evaluated during the 12-month study period. Fifty-two patients who had no ScCs (group 2) were evaluated as a control group. Preoperative and postoperative cyst volumes were measured on magnetic resonance imaging (MRI), and arthroscopic findings were noted. RESULTS: Thirty-one patients (70%) in group 1 had a subscapularis tear vs. 10 patients (19%) in group 2 (P < .001). Biceps lesions were encountered in 32 patients (72%) in group 1, whereas 12 patients (23%) had a biceps lesion in group 2 (P < .001). Cyst volume was significantly higher in the following situations: (1) patients who had a subscapularis tear compared with patients without a subscapularis tear, (2) patients who had biceps pulley lesions compared with patients without pulley lesions, and (3) patients who had both pathologies (P = .047, P = .01, and P = .002, respectively). Cyst volumes significantly decreased following RC repair in group 1 (P < .001). CONCLUSION: Among patients with small- to medium-sized, full-thickness supraspinatus tears, the prevalence of biceps pulley lesions and/or subscapularis tears is higher in patients with ScCs.

Biceps tenodesis versus tenotomy in isolated LHB lesions: a prospective randomized clinical trial.

INTRODUCTION: Currently there exists no clear evidence concerning the surgical treatment of LHB lesions with either tenotomy or tenodesis. The aim of the study is therefore to evaluate elbow flexion and forearm supination force as well as the biceps muscle distalization according to both techniques in isolated LHB lesions. METHODS: Consecutive patients aged 40-70 years with shoulder arthroscopies for isolated SLAP or biceps pulley lesions were prospectively randomized to arthroscopic suprapectoral intraosseous LHB tenodesis or tenotomy. Pre-, 6 and 12 months postoperatively, the SST, ASES, Constant-Murley and LHB scores were recorded. The elbow flexion force was measured in 10°/90° flexion, the supination force in neutral/pronation position. In addition, the maximum upper-arm circumference and its position relative to the radial epicondyle of the humerus were evaluated preoperatively and in follow-up. RESULTS: 20/22 patients (mean age 52.0 ± 8.5; range 36-63 years, 11 male) completed the follow-up. 9/20 were treated with LHB tenodesis (mean age 51.5 ± 9.5; range 37-63 years, 7 male) and 11/20 with tenotomy (mean age 52.8 ± 8.0; range 36-62 years, 4 male). The force measurements and scores showed no significant difference after 12 months. Tenodesis achieved a significant increase in force 6 months postoperatively compared to preoperatively. One tenodesis patient and three tenotomy patients showed a postoperative popeye-sign deformity. CONCLUSION: This prospective randomized study comparing LHB tenodesis and tenotomy in isolated LHB lesions has shown no significant difference in elbow flexion and forearm supination force and clinical scores after 12 months. After LHB tenotomy, there was a non-significant trend for a higher rate of popeye-sign deformities of the upper arm and biceps muscle cramps.

Concomitant intra-articular glenohumeral injuries in displaced fractures of the lateral clavicle.

PURPOSE: To detect concomitant intra-articular glenohumeral injuries, in acute displaced fractures of the lateral clavicle, initially missed due to unfeasible clinical evaluation of the acutely injured shoulder. METHODS: All patients suffering from an acute displaced lateral clavicle fracture with indication to surgical treatment underwent diagnostic shoulder arthroscopy prior to open reduction and internal fixation. In case of therapy-relevant intra-articular glenohumeral injuries, subsequent surgical treatment was performed. RESULTS: Intra-articular injuries were found in 13 of 28 patients (46.4 %) with initially suspected isolated lateral clavicle fracture. Additional surgical treatment was performed in 8 of 28 cases (28.6 %). Superior labral anterior-posterior (SLAP) lesions were observed in 4 of 28 patients (14.3 %; SLAP II a: 1; II b: 1; III: 1; and IV: 1). Lesions of the pulley system were found in 3 of 28 patients (10.7 %; Habermeyer III°). One partial articular supraspinatus tendon avulsion lesion (3.6 %) and one lesion of the subscapularis tendon (3.6 %; Fox and Romeo II°) were observed. CONCLUSIONS: Traumatic concomitant glenohumeral injuries in lateral clavicle fractures seem to be more frequent than expected in general. Subsequent surgical treatment of these formerly missed but therapy-relevant injuries may increase functional outcome and reduce complication rate. LEVEL OF EVIDENCE: IV.

The chondral print sign: what does it really mean?

BACKGROUND: The chondral print (CP) sign is a chondral change on the humeral head underneath the long head of the biceps (LHB) tendon. Several suggested causative links have been described, but the pathologic mechanism remains unclear. METHODS: We designed this prospective cohort association study of 102 consecutive shoulder arthroscopies to investigate proposed associations of CP with LHB, rotator cuff, labral pathology, and other chondral lesions. Data collection was by a specifically designed pro forma, and statistical analysis was performed. RESULTS: We identified 24 patients (23.5%) with the CP sign. Patients were a mean age of 58 years. Shoulders with positive CP sign had associated pathologies: 16 superior labral anteroposterior (SLAP) tears, 4 LHB instabilities, and 11 other LHB lesions. We also recorded other chondral lesions, 10 humeral head and 12 on the glenoid surface. The overall arthroscopic appearance of CP signs could be classified into 3 different types. Statistical analysis revealed that the CP sign is not statistically associated with LHB instability, any other LHB pathologies, rotator cuff tears, or instability. The CP sign was statistically positively associated with SLAP lesions (but only if type 1 were included). There was a weak association of CP sign with age and a positive association of SLAP lesions with other (non-CP) humeral chondral lesions. CONCLUSIONS: Our prospective association study cannot determine the cause of the CP sign. It does not seem to be a reliable sign of LHB instability or of other LHB pathology. There is an association with age and degenerative SLAP lesions.

Pulley lesions in rotator cuff tears: prevalence, etiology, and concomitant pathologies.

PURPOSE: This study aimed to demonstrate the prevalence of lesions in the biceps pulley complex in a representative, consecutive series of rotator cuff tears and rotator cuff interval treatments. We also analyzed associated tear pattern of rotator cuff injuries and superior labrum anterior-posterior (SLAP) lesions. We evaluated the relationships of these lesions to traumatic genesis and the prevalence of pulley lesions in revision cases. METHODS: This retrospective study analyzed all pre- and intra-operative documentation on arthroscopic rotator cuff reconstructions and isolated pulley lesion treatments performed by a single surgeon over 2 consecutive years. According to Habermeyer et al., we classified cases into four groups, based on the presence of additional or related complete or partial rotator cuff tears, SLAP lesions, trauma, and primary or revision surgery. RESULTS: Among 382 patients with rotator cuff tears, 345 (90.3%) had an injured pulley system; 151 (43.8%) had partial tears of the rotator cuff; out of these, 106 (30.6%) were articular-sided. All of these articular-sided partial tears showed extension into the pulley complex. In 154 cases (44.6%), history of shoulder trauma was associated with the beginning of symptoms. In addition, concomitant SLAP lesions occurred in 25-62% of pulley lesions, correlating with the severity of pulley lesions. Among the 345 cases, there have been 32 (9.3%) revision cases where a pulley lesion was intra-operatively identified and addressed. CONCLUSIONS: Pulley complex lesions are present in 90.3% of surgically treated rotator cuff lesions, particularly in articular-sided injuries. In addition, we found a significant relationship between the incidence of SLAP lesions and the severity of pulley lesions. It seems reasonable to assume an important role of pulley system injuries in the pathogenesis of rotator cuff lesions.

Evaluation of Conventional MR Imaging of the Shoulder in the Diagnosis of Lesions of the Biceps Pulley.

RATIONALE AND OBJECTIVES: To determine the diagnostic accuracy and reproducibility of conventional MR imaging (MRI) of the shoulder in evaluating biceps pulley lesions using arthroscopy as the standard of reference. METHODS: In a retrospective study, MR examinations of 68 patients with arthroscopically proven torn or intact biceps pulley were assessed for the presence of pulley lesions by three radiologists. The following criteria were evaluated: displacement of the long head of the biceps tendon (LHBT) relative to the subscapularis tendon (displacement sign), subluxation/dislocation of the LHBT, the integrity of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), lesions of the supraspinatus (SSP) and subscapularis (SSC) tendons adjacent to the rotator interval, presence of biceps tendinopathy and subacromial bursitis. RESULTS: There were 42 patients with pulley lesions in the study group. Conventional MR imaging showed an overall sensitivity of 95.2%, 88.1% and 92.9%, a specificity of 61.5%, 73.1%, and 80.8% and an accuracy of 82.4%, 82.4% and 88.2% in the diagnosis of pulley lesions. Interobserver agreement was substantial (multirater k = 0.75). Biceps tendinopathy (97.6%, 95.2%, 97.6%), defects of the SGHL (86.3%, 81.0%, 88.1%) and the displacement sign (88.1%, 81.0%, 85.7%) were the most sensitive diagnostic criteria. Subluxation/dislocation of the LHBT was insensitive (78.6%, 42.9%, 33.3%), but specific (69.2%, 100,0%, 96.2%). CONCLUSION: In the diagnosis of pulley lesions, conventional MR imaging is reproducible and shows high sensitivity and accuracy but moderate specificity.

Arthroscopic diagnosis of long head of biceps tendon instability in refractory anterior shoulder pain: A comparison study between pulley tear and non-tear lesions.

BACKGROUND: Long head of the biceps tendon (LHBT) instability and biceps reflection pulley (BRP) lesions are common cause of refractory anterior shoulder pain. We described a technique using dynamic arthroscopy to determine associated intraarticular pathologies. METHODS: Patients with refractory anterior shoulder pain and arthroscopically-diagnosed LHBT instability were enrolled. LHBT instability and the integrity of BRP and concomitant intra-articular lesions were investigated by ramp test. Demographics and arthroscopic findings were compared between patients with and without BRP tear. RESULTS: Forty patients were enrolled. BRP tear was noted in 25 patients (group A) and superior glenohumeral ligament (SGHL) insufficiency through ramp test in 15 patients (group B). Concomitant intraarticular pathologies were noted in 27 patients, including 19 in group A (76%) and eight in group B (53%), without significant group-wise difference (p = 0.138). The incidence of articular-side subscapularis tear was significantly higher in group A (p = 0.021), and those of the other intraarticular pathologies were similar between groups A and B. Fraying at the articular side of the subscapularis and supraspinatus tendons was frequent in group B, without difference of incidence as compared to group A (p = 0.5 and p = 0.084, respectively). CONCLUSIONS: LHBT instability was a common disorder in patients with refractory shoulder pain. In those patients, dynamic assessment of BRP lesions and SGHL insufficiency and meticulous survey of associated intra-articular pathologies, including subscapularis tear are necessary for making accurate diagnosis and treatment decision.

Assessment of Acute Lesions of the Biceps Pulley in Patients with Traumatic Shoulder Dislocation Using MR Imaging.

BACKGROUND: Shoulder dislocations represent common injuries and are often combined with rotator cuff tears and potentially damage to the biceps pulley. PURPOSE: To assess the occurrence and type of biceps pulley lesions in patients after traumatic anterior shoulder dislocation using 3T MRI. METHODS: Thirty-three consecutive patients were enrolled between June 2021 and March 2022 (14 women, mean age 48.0 ± 19 years). All patients underwent MR imaging at 3 T within one week. Images were analyzed for the presence and type of pulley tears, subluxation/dislocation of the LHBT, rotator cuff lesions, joint effusion, labral lesions, and osseous defects. RESULTS: Seventeen patients (52%) with traumatic anterior shoulder dislocation demonstrated biceps pulley lesions. Of those, eleven patients (33%) showed a combined tear of the sGHL and CHL. All seventeen patients with lesions of the biceps pulley showed associated partial tearing of the rotator cuff, whereas three patients showed an additional subluxation of the LHBT. Patients with pulley lesions after dislocations were significantly older than those without (mean age 52 ± 12 years vs. 44 ± 14 years, p = 0.023). CONCLUSION: Our results suggest an increased awareness for lesions of the biceps pulley in acute traumatic shoulder dislocation, particularly in patients over 45 years.

Lesions of the biceps pulley: a prospective study and classification update.

HYPOTHESIS: The purpose of the study was to investigate which anatomic structures are affected in a series of patients with pulley lesions and whether all lesions can be classified according to the Habermeyer classification. METHODS: One hundred consecutive patients with pulley lesions were prospectively studied. During arthroscopy, lesions of the superior glenohumeral ligament (SGHL), medial coracohumeral ligament (MCHL) and/or lateral coracohumeral ligament (LCHL), adjacent rotator cuff, and biceps (long head of the biceps) were recorded. All lesions were then classified according to the Habermeyer classification. The χ2 test was used for statistical analysis. RESULTS: There were 3 lesions in group 1, 20 in group 2, 6 in group 3, and 35 in group 4 according to the Habermeyer classification. Thirty-six lesions were not classifiable because of an intact SGHL. A lateral pulley sling (LCHL) lesion was found in 95% of the patients, and a medial pulley sling (MCHL-SGHL) lesion was noted 64%. An isolated lesion of the MCHL and/or SGHL was present in 5%, and an isolated lesion of the LCHL was found in 36%. Combined medial-lateral sling lesions were correlated with complete subscapularis tears and biceps fraying. CONCLUSION: The lateral pulley sling is more often affected than the medial sling. The SGHL is not always affected, and isolated lesions of the medial sling are rare. Lesions of both slings correlated with complete subscapularis tears and fraying of the long head of the biceps. An updated classification of direct pulley lesions is proposed: type 1, lesion of the medial pulley (MCHL and/or SGHL); type 2, lesion of the lateral pulley (LCHL); and type 3, lesion of the medial and lateral pulley slings. Concomitant lesions of the indirect pulley stabilizers can be mentioned additionally according to the well-known classifications.