Preoperative Radiographic Risk Factors for Incomplete Arthroscopic Supraspinatus Tendon Repair in Massive Rotator Cuff Tears.

PURPOSE: To determine if preoperative imaging findings of massive rotator cuff (RC) tears were associated with (1) incomplete arthroscopic repair and (2) the use of advanced mobilization techniques (interval slides) and/or the use of a load-sharing rip stop repair construct. METHODS: Eighty-six consecutive patients who underwent arthroscopic repair for massive RC tears performed by a single surgeon between July 2013 and July 2015 were retrospectively evaluated. Previously proposed radiographic risk factors for irreparability (acromiohumeral distances, tangent sign, and the Goutallier stage of fatty infiltration for the supraspinatus) were analyzed. Associations between preoperative imaging characteristics and intraoperative results of RC surgery were determined using binary logistic regressions and Fisher's exact tests. The interobserver reliability of imaging characteristics was determined using intraclass correlation coefficients (ICCs). RESULTS: Seventy-six massive RC tears were fully reparable (88%). In the case of 10 RC tears (12%), a complete repair was not obtained. Inability to obtain a complete repair of the supraspinatus was associated with a positive tangent sign (30% irreparable) versus a negative tangent sign (6.3% irreparable, odds ratio [OR] = 6.3, P = .0102) and with Goutallier grade 3-4 fatty infiltration of the supraspinatus (42.9% irreparable) versus grade 0-2 fatty infiltration (5.7% irreparable, OR = 11.8, P = .001). Advanced arthroscopic techniques (interval slides or load-sharing rip stop) for dealing with poor-quality or retracted tendon were used in 62% of cases; however, no associations were found between preoperative imaging characteristics and these techniques. Interobserver reliability was moderate (ICC = 0.75-0.90) for the tangent sign (ICC = 0.78) and high-grade (Goutallier 3-4) fatty infiltration of the supraspinatus (ICC = 0.74). CONCLUSIONS: A positive tangent sign and/or high-grade fatty infiltration (Goutallier 3-4) of the supraspinatus were risk factors for incomplete RC repair. However, these were not completely predictive of reparability because the majority of massive RC tears with these imaging characteristics were still fully reparable. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis.

BACKGROUND: Pseudoparalysis is defined as active forward flexion less than 90° with full passive motion. There is controversy about the ideal surgical management of a massive rotator cuff tear with pseudoparalysis. PURPOSE/HYPOTHESIS: The purpose of this study was to prospectively analyze the ability to reverse pseudoparalysis with an arthroscopic rotator cuff repair (ARCR). The hypothesis was that in the absence of substantial glenohumeral arthritis, preoperative fatty infiltration of grade 3 or higher and an acromiohumeral interval (AHI) of less than 7 mm would not prevent reversal of pseudoparalysis with an ARCR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A prospective multicenter study of ARCR performed for preoperative pseudoparalysis was conducted. The minimum follow-up was 1 year. The mean patient age was 63 years, and pseudoparalysis was present for a mean of 4.2 months preoperatively. Preoperative radiographic evaluation included plain film evaluation of the AHI and Hamada classification and MRI evaluation of fatty degeneration and rotator cuff retraction. Functional outcome was determined by the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, visual analog scale (VAS), and subjective shoulder value (SSV). RESULTS: Of the 58 patients enrolled, 56 had at least 1 year of follow-up. Mean active forward flexion improved from 47° preoperatively to 159° postoperatively (P < .001). Statistically significant improvements were seen in the SST (from 2.8 preoperatively to 10.1 postoperatively), SSV (from 28 to 83), ASES Shoulder Score (from 37 to 88), and VAS (from 5.7 to 1.1) (P < .001). Pseudoparalysis was reversed in 53 of 56 patients (95%). There was no difference in the rate of reversal of pseudoparalysis between those patients with an AHI of less than 7 mm (88.2%) and those with an AHI of 7 mm or more (96.9%) (P =.289). Pseudoparalysis was reversed in all 8 of the patients with fatty degeneration of grade 3 or higher in 1 or more of the rotator cuff muscles. CONCLUSION: ARCR can lead to reversal of preoperative pseudoparalysis in patients with minimal preoperative glenohumeral arthritis. ARCR is a viable first line of treatment for patients with pseudoparalysis in the absence of advanced glenohumeral arthritis.

Magnetic resonance imaging of the glenoid labrum.

The glenoid labrum is a redundant fold of the joint capsule made of fibrous and fibrocartilagenous tissue that attaches to the rim of the glenoid of the scapula. The location and severity of tears of the labrum generally dictate clinical management, which may range from medical management to arthroscopic debridement and labral repair. In the more severe cases, a shoulder stabilization procedure may be needed. This article discusses the anatomy, various lesions and cysts, and magnetic resonance imaging of the glenoid labrum.

Acetabular labral tears and cartilage lesions of the hip: indirect MR arthrographic correlation with arthroscopy--a preliminary study.

OBJECTIVE: The purpose of this study was to assess the diagnostic correlation between indirect MR arthrography, conventional MRI, and arthroscopy in acetabular labral and cartilage lesions of the hip. MATERIALS AND METHODS: Fourteen patients who underwent conventional and indirect MR arthrography with arthroscopic correlation were studied over the course of 18 months. MR studies were performed on a 1.5-T magnet. Sequences consisted of unilateral sagittal turbo spin-echo proton density fat-suppressed, axial turbo spin-echo T2 fat-saturated, and coronal turbo spin-echo proton density fat-saturated images. Whole-pelvis coronal T1 and STIR sequences were also performed. Patients received IV gadolinium contrast material and exercised for 15 minutes. Gadolinium-enhanced fat-saturated T1 sequences were obtained in three planes. Arthroscopy was performed by two orthopedic surgeons who specialize in treating hip disorders. Cases were then retrospectively reviewed by two experienced musculoskeletal radiologists who were blinded to the arthroscopic findings. Cases were examined for acetabular labral tears and chondral lesions. Extraarticular findings of femoral acetabular impingement were recorded. Unenhanced and gadolinium-enhanced images of the labrum were compared for differences and changes in diagnosis. Comparison was made between the arthroscopic and MR findings for analysis of the results. RESULTS: Of the 13 labral tears found at arthroscopy, 85% were detected by conventional MRI, whereas 100% were identified via indirect MR arthrography. Seventy percent of the labral tears identified on conventional MRI were better delineated by indirect MR arthrography. Identification of chondral abnormalities was not improved via indirect MR arthrography over conventional MRI. CONCLUSION: IV contrast-enhanced indirect MR arthrography appears to be an effective means of hip evaluation for labral tears. It does not appear to improve detection of cartilage abnormalities when compared with conventional MRI.

Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.

PURPOSE: The purpose of this study was to assess the functional results of arthroscopic repair of massive rotator cuff tears in patients who had stage 3 and 4 fatty degeneration of the rotator cuff musculature, according to the Goutallier scale. METHODS: From January 1997 to December 2001, 22 patients with massive rotator cuff tears and Goutallier stage 3 or 4 fatty degeneration of the infraspinatus, with a mean age of 66.5 +/- 9.26 years, underwent arthroscopic rotator cuff repair and were available for follow-up. The average tear size was 4.8 +/- 0.85 cm in medial-to-lateral width and 6.2 +/- 1.53 cm in anterior-to-posterior length, with an approximate tear size area of 30.0 +/- 10.0 sq cm, and involved 2 tendons (supraspinatus and infraspinatus) or 3 tendons (supraspinatus, infraspinatus, and subscapularis) in each case. The mean time from surgery to follow-up was 39.3 months (range, 24-60 months). In addition to comparison of preoperative and postoperative range of motion, strength and University of California, Los Angeles (UCLA) score, outcomes were also assessed with the Constant score. RESULTS: The increase of mean active forward elevation was 53.7 degrees (preoperative: 103.2 degrees and postoperatively: 156.9 degrees ). The gain of mean active external rotation was 19.1 degrees (preoperative: 35.7 degrees and postoperative: 54.8 degrees). The gain of mean external rotation power was 1.9 (preoperative: 2.3 and postoperative: 4.2). The improvement in the UCLA score was 17.2 points (preoperative: 12.3 and postoperative: 29.5). The mean postoperative Constant score was 74.8/100, and the weighted postoperative Constant score was 88.5/100. In 5 patients with fatty degeneration greater than 75% (advanced stage 4), results were less dramatically improved than in 17 patients with fatty degeneration of 50% to 75%, all of whom exhibited clinical improvement. However, clinical improvement was achieved even in 2 of 5 patients with advanced stage 4 involvement. CONCLUSIONS: Arthroscopic rotator cuff repair in patients with grade 3 or 4 fatty degeneration (> or =50%) can provide significant functional improvement. Those with 50% to 75% fatty degeneration showed a much greater degree of improvement (with all 17 cases exhibiting beneficial postoperative increases in their UCLA scores ranging from 12 to 26 points) than those with >75% fatty degeneration (with only 2 of 5 cases showing an increase of 10 or more points in their UCLA scores). However, clinical improvement was observed in 86.4% of cases that would have been classified as likely to fail by the Goutallier criteria. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Chondrolysis of the glenohumeral joint after arthroscopy: findings on radiography and low-field-strength MRI.

OBJECTIVE: The purpose of this report is to describe the clinical and imaging findings of chondrolysis of the glenohumeral joint. CONCLUSION: In the appropriate clinical setting, both radiographs and MR images of the shoulder can be used to establish the diagnosis of chondrolysis of the glenohumeral joint.

Magnetic resonance imaging accuracy for the diagnosis of superior labrum anterior-posterior lesions in the community setting: eighty-three arthroscopically confirmed cases.

Magnetic resonance imaging (MRI) has been shown in the literature to have high accuracy for the diagnosis of superior labrum anterior-to-posterior (SLAP) lesions. However, these studies have been performed at specialized institutions and have not been evaluated for community settings. Our hypothesis was that MRI diagnosis of SLAP lesions in the community setting is not as accurate as suggested by previous literature. The MRI reports for 83 consecutive surgically confirmed type II SLAP lesions were evaluated. The findings regarding the presence of SLAP lesions were documented from the community radiologists' MRI readings. Two blinded, fellowship-trained musculoskeletal radiologists evaluated these same 83 MRIs, as well as 17 MRIs with surgically confirmed normal superior labra. The musculoskeletal radiologists also used a visual analog scale to subjectively grade the quality of each MRI. MRIs were performed at 14 different centers and were read by 28 different community radiologists. There were 37 noncontrast MRIs and 46 MRI arthrograms. The community radiologists accurately identified 51% of the SLAP lesions. The sensitivities for the community radiologists were significantly better for the MRI arthrograms than for the noncontrast MRIs (P = .0002). For the two musculoskeletal radiologists, the sensitivities were 60% and 67.5%, and the specificities were 71% and 76.5%. The accuracies for the musculoskeletal radiologists were 62% and 69%. One of the musculoskeletal radiologists had significant correlation between the visual analog score and MRI diagnostic accuracy (P = .0006). The sensitivity for one of the musculoskeletal radiologists was significantly greater than the sensitivity for the community radiologists (P = .0063). The accuracies between the other musculoskeletal radiologist and the community radiologists were not significantly different (P = .0577). In this community setting, MRI was not accurate for the diagnosis of SLAP lesions. Musculoskeletal radiologists were more accurate than the community radiologists; however, the musculoskeletal radiologists were not as accurate as previous literature might predict.

MRI of the postoperative shoulder.

Performing and interpreting MRI of the shoulder in patients after surgery is a difficult task. The normal anatomic features are distorted by the surgical alterations as well as the artifacts that result from metal and other materials used in the surgical procedures. This article reviews the common surgical procedures undertaken in patients with rotator cuff disease and shoulder instability, and how they affect the appearance of the relevant anatomic structures on MRI examination. It also reviews the more common causes for residual and recurrent abnormalities seen in such patients and how MRI can be used to diagnose such lesions, thus aiding the orthopedic surgeon in treating these difficult clinical problems.