Does Immobilization Post Injection Reduce Contrast Extravasation in MR Arthrography of the Shoulder?

BACKGROUND: Contrast leakage after arthrography is common. We sought to investigate if immobilization could prevent it. PURPOSE: The purpose of this study was to determine the effects on contrast extravasation and image quality produced by strict immobilization of the shoulder between arthrography puncture and subsequent MR imaging. MATERIAL AND METHODS: Fifty patients underwent shoulder MR arthrography using a standard shoulder puncture in the anteroinferior quadrant. Ten milliliters of contrast mixture of saline, iodinated contrast, and gadolinium contrast was injected by a senior musculoskeletal (MSK) radiologist using a 21G needle. Half of the patients were immediately immobilized using a shoulder sling, and the other half were allowed to move their shoulder and arm freely during the time before MR imaging. MR arthrography was performed with a 3 T system using standard T1 and PD weighted sequences. The MR images were reviewed independently by 2 MSK radiologists and graded for extravasation using a five-point scale (1: none, 2: less than 2 cm, 3: 2-5 cm, 4: 5-10 cm, 5: more than 10 cm) and for image quality using a 5 point scale (1: poor, 5: good). The Pearson correlation was calculated to assess the correlation between leakage and image quality. RESULTS: There was no significant difference in amount of leakage between both groups, and global image quality was found equal in both groups. A negative correlation was found between leakage and quality assessment. CONCLUSION: This study shows that it cannot be avoided by strict shoulder immobilization and that it negatively affects image quality and interpretation.

Limited value of current shoulder arthroplasty registries in evidence-based shoulder surgery: a review of 7 national registries.

National shoulder arthroplasty registries are currently used to assess incidence, indication, type of prosthesis and revision, but they seem to lack sufficient information to lead to evidence based decision-making in shoulder surgery. There appears to be a large difference in registered parameters and outcome measurement per country. First we investigated whether existing registries have sufficient common datasets to enable pooling of data. Second, we determined whether known risk factors for prosthetic failure are being recorded. Through a non-systematic literature review studies on registries were analyzed for included parameters. Seven national registries were scrutinized for the data collected and these were classified according to categories of risk factors for failure: patient-, implant and surgeon related, and other parameters. This shows a large heterogeneity of registered parameters between countries. The majority of parameters shown to be relevant to outcome and failure of shoulder prostheses are not included in the studied registries. International agreement on parameters and outcome measurement for registries is paramount to enable pooling and comparison of data. If we intend to use the registries to provide us with evidence to improve prosthetic shoulder surgery, we need adjustment of the different parameters to be included.

Determining On-/Off-track Lesions in Glenohumeral Dislocation Using Multiplanar Reconstruction Computed Tomography Is Easier and More Reproducible Than Using 3-dimensional Computed Tomography.

BACKGROUND: The glenoid track is a useful tool to predict engagement and therefore the risk of recurrence of dislocation in the presence of Hill-Sachs and/or bony Bankart lesions. To assess the glenoid track preoperatively, only methods using 3-dimensional reconstruction (3DR) have been described, but these lack a standardized, reliable, and easy description. PURPOSE/HYPOTHESIS: The purpose was to evaluate a new method for determining the glenoid track using computed tomography (CT) scan with multiplanar reconstruction (MPR) in comparison with using 3DR images. Our hypothesis was that the MPR method would be easier to standardize and more reproducible. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 52 patients whose arthro-CT scan revealed a Hill-Sachs lesion, whether in combination with a bony Bankart lesion or not, were included. Digital Imaging and Communications in Medicine data from the 52 CT scans were all analyzed using open source image analysis software. Glenoid width, with or without associated bony defect, and the Hill-Sachs interval (HSI) were measured on MPR as well as on 3DR images. All measurements obtained using both methods were directly compared and evaluated for intra- and interobserver reliability. RESULTS: In absolute values, only small differences were seen between the MPR and 3DR methods, amounting to a maximal difference of 0.07 cm for the HSI and 0.04 cm for the glenoid width. For glenoid measurements, both methods were similar. For humeral measurements, the MPR method demonstrated higher inter- and intraobserver reliability than did the 3DR method. CONCLUSION: The newly described MPR method for the assessment of the glenoid track and HSI is at least as accurate as the published 3DR method, with better intra- and interobserver reliability. Because MPRs are also easier to obtain, this method could be recommended in daily practice.

How reliable are imaging protocols in the diagnosis of subscapularis tears?

The purpose of the study is to evaluate the accuracy of detecting subscapularis tendon tears on different imaging modalities in comparison with surgical findings. In addition, the accuracy of long head of biceps tendon pathology in assisting the diagnosis of a subscapularis tear was evaluated. Retrospectively, 336 patients who underwent surgery in the UZ Brussel for rotator cuff pathology and had pre-operative imaging at the hospital were included. Pathology of the subscapularis tendon and the long head of biceps tendon on imaging modalities was compared to arthroscopic and/or open surgery findings. 111 of the 336 patients (33.0%) had a subscapularis tear diagnosed during surgery. None of the imaging modalities reaches the cut-off weighted kappa value (k) for substantial agreement of 0.61. Magnetic re- sonance imaging and magnetic resonance arthro- graphy have the highest k of 0.288, indicating minimal agreement with arthroscopy. Computed tomography arthrography (k = 0.167) and ultrasound (k = 0.173) shows both no agreement. Biceps instability was significantly correlated with a subscapularis tear, but the negative predictive value was always higher than the positive predictive value on ultrasound, magnetic resonance arthrography and computed tomography arthrography. The negative predictive value for detection of full thickness tears is as high as 96.2% on magnetic resonance arthrography. Accurate imaging diagnosis in daily practice of subscapularis tendon tears remains a challenge with the best results for magnetic resonance arthrography. The value of biceps instability lies in its negative predictive value rather than its positive predictive value.

Health care utilization after hospitalization following a road traffic accident.

Purpose: In recent years, there has been an increasing interest in measuring and modeling health care utilization. However, only limited research has been performed in the field of health care utilization following road traffic accidents. This article aims to measure the incremental health care utilization after hospital discharge after a road traffic accident and explore the association between socio-demographic and injury-related variables and health care utilization.Material and methods: Generalized linear models with negative binomial distribution and log-link were executed per type of health care provider (general practitioner, medical specialists, rehabilitation services and outpatient nursing care) and per type of discharge location (discharged to home, discharged to in-hospital rehabilitation). Health care utilization of the 6 months after discharge was compared with the 6 months before the accident (baseline care).Results: Health care utilization six months after discharge is significantly higher than baseline care, except for outpatient nursing care and general practitioners in in-hospital rehabilitation. The increase in visits to medical specialists ranged on average between 1 and 2.2 visits. For general practitioner, there was an increase of 0.4 visits and 0.8 in outpatient nursing care for those who returned home after acute hospitalization. The average increase in rehabilitation services ranged between 3.6 and 20. Associated influential factors differ per health care provider and discharge destination.Conclusion: Evidence of this study suggests higher health care utilization during the first 6 months following hospitalization due to a road traffic injury, compared with baseline care. Associated variables differ per type of health care provider and discharge-destination. More in-depth research on subgroups is needed.Implications for rehabilitationHealth care utilization varies across different patient characteristics and type of injuries which should be considered in the communication with patients on their care trajectory post-discharge.General descriptions of health care utilization in traffic victims at the population level are lacking. Output similar to our study could serve as a reference for post-discharge care planning.The research output can be a starting point for future research on quality indicators of the expected quantity of care.Efforts must be made to estimate suchlike reference tables on post-discharge services in other patient groups and secondary data are a suitable data-source for those analyses.

Do patients with minor shoulder instability have a different outcome from those with recurrent anteroinferior instability?

PURPOSE: Minor or anterosuperior shoulder instability (MSI) is a relatively new concept with other characteristics than recurrent anteroinferior instability (TUBS). MSI includes patients without history of dislocation, with non-specific clinical symptoms and signs but with indications of laxity of (SGHL)/MGHL with isolated injury of (SGHL)/MGHL seen during arthroscopy. TUBS patients typically present with recurrent anteroinferior instability with at least labral injury of the anterior band of the IGHL. In this study, we focus on the postoperative (rehabilitation) course. Our hypothesis is that its duration is prolonged in patients with MSI when compared to those with TUBS. METHODS: Thirty-five patients with isolated anterosuperior capsuloligamentous lesions identified during arthroscopic surgery (group I-MSI) and 65 with at least an anteroinferior capsuloligamentous lesion (group II-TUBS) completed a survey that included a questionnaire enquiring into relief of pain and return to activity, the Oxford Shoulder Instability Score (OSIS) and the Western Ontario Shoulder Instability index (WOSI). Final follow-up occurred at a mean of 76 months postoperatively. RESULTS: Pain at night, at rest and during overhead activities disappeared later in group I than in group II (respectively, p = 0.03; 0.01; 0.01). Patients with MSI returned later to professional activities (p = 0.02) and to the same sport (p = 0.01). In addition, they had worse outcome as measured by OSIS (p = 0.01) and WOSI (p = 0.07). CONCLUSION: Patients with MSI have poorer prospects regarding time to relief of pain, return to work and sports and outcome scores compared to patients with TUBS.

Treatment of severe glenoid deficiencies in reverse shoulder arthroplasty: the Glenius Glenoid Reconstruction System experience.

BACKGROUND: The treatment of glenoid bone deficiencies in primary or revision total shoulder arthroplasty is challenging. This retrospective study evaluated the short-term clinical and radiologic results of a new custom-made patient-specific glenoid implant. METHODS: We treated 10 patients with severe glenoid deficiencies with the Glenius Glenoid Reconstruction System (Materialise NV, Leuven, Belgium). Outcome data included a patient-derived Constant-Murley score, a visual analog score (VAS), a satisfaction score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. We compared the postoperative position of the implant with the preoperative planned position on computed tomography scans. RESULTS: At an average follow-up period of 30.5 months, the mean patient-derived Constant-Murley score was 41.3 ± 17.5 points (range, 18-76 points) with a visual analog scale of 3.3 ± 2.5 points (range, 0-7 points). The mean 11-item version of the Disabilities of the Arm, Shoulder and Hand score was 35.8 ± 18.4 (range, 2-71), and the mean Simple Shoulder Test was 47.5% ± 25.3% (range, 8%-92%). Eight patients reported the result as better (n = 3) or much better (n = 5). One patient had an elongation of the brachial plexus, and 1 patient had a period of instability. The average preoperative glenoid defect size was 9 ± 4 cm3 (range, 1-14 cm3). The mean deviation between the preoperative planned and the postoperative version and inclination was 6° ± 4° (range 1°-16°) and 4° ± 4° (range 0°-11°), respectively. CONCLUSION: Early results of the Glenius Glenoid Reconstruction System are encouraging. Adequate pain relief, a reasonable functionality, and good patient satisfaction can be obtained in these difficult cases. Further follow-up will determine the bony ingrowth and subsequent longevity of this patient-specific glenoid component.

Outcome at 3 to 5 years of a treatment algorithm for rotator cuff tears in an elderly population.

The purpose of this study is to evaluate the results of a conservative approach of rotator cuff tears in an elderly population at 3 to 5 years of follow-up. Prospective comparative study. All patients started with a program of exercises of at least 1 to 3 months. When no satisfying results for pain relief and ADL were achieved, surgery for cuff tear repair was offered. Patients were contacted after 3 to 5 years for evaluation by questionnaire, an ultrasound and a strength measurement exam. 97 patients (104 shoulders) with a mean age of 68,5 years were included. 47.1% of shoulders were treated conservatively whereas 52.9% switched to surgical treatment. Evaluation after 3 to 5 years showed no significant difference between type of treatment and post treatment test scores (Constant score, SF12v2, OSS and WORC). Delaying surgery for 3 months does not seem to influence outcome negatively.

Imaging of the coracoglenoid ligament: a third ligament in the rotator interval of the shoulder.

OBJECTIVE: The coracoglenoid ligament (CGL) forms part of the anterosuperior capsuloligamentous complex of the shoulder. Although it has received attention in the anatomical literature, it has not been investigated on imaging. The purpose of this study is to determine the percentage value and the interobserver agreement of identification and classification of the CGL on MR and MR arthrography (MRA) imaging. MATERIALS AND METHODS: Retrospectively, 280 MR and 150 MRA examinations were evaluated for detection of the CGL by two musculoskeletal radiologists. On the MRA examinations the CGL configuration in relation to the superior glenohumeral (SGHL) and coracohumeral ligament (CHL) was classified into five types. Additionally, the percentage of intra-articular appearance of the CGL and its mean thickness value were calculated. Finally, a possible correlation between pathological condition and anatomical type was evaluated on MRA. RESULTS: The CGL could be identified in 56%/54% of MRI and in 76%/77% of MRA examinations. On MRA, the CGL was detected as distinct structures in 37%/35% of cases and it appeared fused (partially or totally) with the SGHL and/or CHL in 39%/42%; it was absent in 12%/12% and it appears undistinguishable in the remaining cases. The interobserver agreement was excellent (κ = 0.98 for detection on MRI; p = 0.927 for classification of anterosuperior anatomy on MRA; κ = 0.873 and 0.978 for identification on sagittal and axial external rotation MRA respectively; κ = 0.943 for classification as intra- or extra-articular on MRA). CONCLUSIONS: The CGL can be reliably identified on MRI and MRA.

What can the Radiologist do to Help the Surgeon Manage Shoulder Instability?

Imaging of the shoulder forms an important adjunct in clinical decision making in patients with shoulder instability. The typical lesions related with classic anterior and anteroinferior shoulder dislocation are an anteroinferior labral avulsion with or without bony fragment of bone loss - a (bony) Bankart lesion - and a posterolateral humeral head impaction fracture - the Hill-Sachs lesions. These are relatively straightforward to identify on imaging, although normal variants of the inferior labrum and variants of labral damage may cause confusion. Other capsuloligamentous lesions, often associated with less typical types of instability, are much more difficult to identify correctly on imaging, as they occur in the anterosuperior part of the glenohumeral joint with its many normal variants or because they result in more subtle, and therefore easily overlooked, changes in morphology or signal intensity. This paper aims at describing the appearance of the normal and pathologic glenohumeral joint related to shoulder instability. Ample reference will be given as to why identification of abnormalities, whether normal or pathologic, is important to the surgeon facing a treatment decision.

Glenohumeral translation in ABER position during muscle activity in patients treated with Latarjet procedure: an in vivo MRI study.

PURPOSE: The Latarjet procedure is frequently performed when treating traumatic anteroinferior shoulder instability. This procedure is supposed to have a triple effect: osseous, muscular and ligamentous. The main stabilizing mechanism in cadaver studies on fresh-frozen shoulders seems to be the sling effect produced by the subscapularis and the conjoint tendon. It has been hypothesized that muscle contraction in ABER position (abduction-external rotation) is able to translate the humeral head posteriorly and superiorly due to the sling effect. The aim of this study was to analyse the humeral head translation relative to the glenoid with the arm in ABER position with and without muscle contraction. METHODS: Twenty-one subjects divided into two groups (Group A: after Latarjet; Group B: healthy subjects) were examined with an open MRI system with the shoulder in abduction-external rotation (ABER) position to analyse humeral head translation during muscle activity. RESULTS: In normal shoulders, there was no significant difference in anteroposterior or superoinferior translation between the rest position and the muscle-activated state. In subjects after the Latarjet procedure, the difference was significant and was also significant between both groups of subjects for posterior translation, but not for superior translation. CONCLUSION: In patients treated with Latarjet procedure, there are significant changes in glenohumeral translation during muscular activity when in ABER position, with the humeral head going more posteriorly, in comparison with normal shoulders. This study confirms the stabilizing sling effect of the transposed conjoint tendon in the ABER position. LEVEL OF EVIDENCE: Retrospective case-control study, Level III.

Advanced imaging of the glenohumeral ligaments.

The glenohumeral ligaments (GHLs) are the most important passive stabilizers of the shoulder joint. Recognition of acute and chronic glenohumeral ligamentous lesions is very important in the preoperative work-up of shoulder instability and trauma. This article describes and depicts the normal anatomy of the GHLs and their appearance during arthroscopy and on MR and computed tomography arthrography (CTA). Pathologic findings of the superior, middle, and inferior GHLs are described and illustrated with MR and CTA and their corresponding intraoperative arthroscopic images. MR arthrography (MRA) is useful for direct visualization of all GHLs including most lesions of their intra-articular portion and associated capsulolabral pathologies. Sprains, midsubstance tears, avulsion, or fibrous infiltration of the GHL can be identified on MRA images using fast spin-echo sequences with and without fat saturation in the three planes. Although CTA is reputed to better depict associated bony and cartilage lesions, CTA allows only indirect evaluation of the GHLs by outlining their contour or showing contrast penetration. Normal variants may create pitfalls that one should be aware of. Signs of GHL pathology on imaging include: discontinuity, nonvisualization, changes in signal intensity (on MRA), contrast extravasation, contour irregularity, thickening, or waviness.

Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss.

BACKGROUND: Coracoid bone graft osteolysis and fibrous union are the principal causes of failure in patients treated with the Latarjet procedure. This study aims to investigate the hypothesis that coracoid bone graft osteolysis is more pronounced in cases without glenoid bone loss, which may be due to a diminished mechanotransduction effect at the bone healing site. METHODS: We prospectively followed up 34 patients, treated with a mini-plate Latarjet procedure, divided into 2 groups (group A patients had glenoid bone loss >15% and group B patients had no glenoid bone loss). A computed tomography scan evaluation with 3-dimensional reconstruction was then performed on all patients to evaluate coracoid bone graft osteolysis according to our coracoid bone graft osteolysis classification. RESULTS: The computed tomography scan analysis showed a different distribution of osteolysis between group A and group B. The statistical analysis showed a significant difference (P < .01, Bonferroni test) between groups A and B for the following sections: proximal/lateral/superficial, proximal/medial/deep, distal/lateral/superficial, and distal/lateral/deep. On average, the coracoid grafts in group A patients showed less osteolysis than the coracoid grafts in group B patients (39.6% vs 65.1%). DISCUSSION: The coracoid bone graft underwent much less osteolysis in patients with significant glenoid bone loss (>15%) than in those without it. Because factors of blood supply, compression, and surgical technique were the same for both groups, we believe that the mechanotransduction effect from the humeral head on the graft influences its remodeling. CONCLUSION: The results of this study suggest that the bone graft part of the Latarjet procedure plays a role in patients with significant coracoid bone loss but much less so when there is no bone loss.

Arthroscopy of the sternoclavicular joint: an anatomic evaluation of structures at risk.

INTRODUCTION: Recently, arthroscopy of the sternoclavicular joint (SCJ) has been described in clinical setting. The aim of this study is to examine the accessibility and safety of the SCJ by arthroscopy in a cadaveric model. MATERIALS AND METHODS: An inferolateral and superomedial portal to the SCJ was created in 20 cadaveric specimens. After debridement, the specimens were dissected with a needle positioned in the portal tracts. The distance between the needles and bony landmarks, tendons and ligaments were measured. The integrity of the posterior capsule was evaluated macroscopically. In eight specimens, after anterior dissection, the needles were replaced by K-wires that perforated the posterior capsule to evaluate the distance to the neurovascular structures behind the SCJ. RESULTS: Both portals were found to be safe while allowing good access to the joint. The superomedial portal went through the tendon of the sternocleidomastoideus muscle and the inferolateral portal through the pectoralis major muscle. The portals entered the capsule medial and lateral to the anterior sternoclavicular ligament. The posterior capsule was never perforated during debridement. The perforating K-wires, however, usually perforated either a major vein or artery, but were at a safe distance from the vagal nerve. CONCLUSIONS: In this cadaver study, arthroscopy of the sternoclavicular joint could be used as a minimally invasive procedure allowing debridement of the joint without damaging the posterior capsule of the joint. If the capsule is inadvertently be breached, a major risk of neurovascular damage exists. We advise to have a backup of a cardiothoracic surgeon when performing this procedure.

Determination of a reference system for the three-dimensional study of the glenohumeral relationship.

OBJECTIVE: Knowledge of the normal and pathological three-dimensional glenohumeral relationship is imperative when planning and performing a total shoulder arthroplasty. There is, however, no consensus on which references should be used when studying this relationship. The purpose of the present study was to define the most suitable glenoid plane with normally distributed parameters, narrowest variability, and best reproducibility. MATERIALS AND METHODS: Three-dimensional reconstruction CT scans were performed on 152 healthy shoulders. Four glenoid planes, each determined by three surgically accessible bony reference points, were determined. Two planes were triangular, with the same base defined by the most anterior and posterior point of the glenoid. The most inferior and the most superior point of the glenoid, respectively, define the top of Saller's inferior plane and the Saller's superior plane. The two other planes are formed by best-fitting circles. The circular max plane is defined by the superior tubercle, and two points at the distal third of the glenoid. The circular inferior plane is defined by three points at the rim of the inferior quadrants of the glenoid. RESULTS: The parameters of all four planes behave normally. The humeral center of rotation is identically positioned for both the circular max and circular inferior plane (X = 91.71°/X = 91.66° p = 0.907 and Y = 90.83°/Y = 91.7° p = 0.054, respectively) and different for the Saller's inferior and Saller's superior plane (p ≤ 0.001). The circular inferior plane has the lowest variability to the coronal scapular plane (p < 0.001). CONCLUSIONS: This study provides arguments to use the circular inferior glenoid plane as preferred reference plane of the glenoid.

Assessment of the long head of the biceps tendon of the shoulder with 3T magnetic resonance arthrography and CT arthrography.

We studied the assessment of proximal biceps tendon lesions including degeneration, tendon luxation, and partial and complete tendon tears with 3T MR arthrography and CT arthrography. Thirty-six patients who underwent both studies, as well as arthroscopy were included in the study. The images were randomized and blinded and independently reviewed by two musculoskeletal radiologists. The pooled sensitivity for lesion detection for CT arthrography was 31% and the specificity 95%. The pooled sensitivity for MR arthrography was 27% and the specificity 94%. There were no statistically significant differences between CT and MR. The interobserver agreement calculated with the kappa statistic was poor for CT and for MR. Both CT arthrography and MR arthrography perform poorly in the detection of biceps tendon pathology of the shoulder.

Magnetic resonance arthrography of glenohumeral lesions: anatomy and arthroscopically confirmed pathology.

Interpretation of magnetic resonance (MR) arthrography images of the glenohumeral ligaments is made difficult by anatomical variations and by the lack of descriptions of signs of pathology of the ligaments. In this review, we describe the normal and pathologic appearance of the glenohumeral ligaments of the shoulder. These ligaments play an important role in stabilization of the shoulder. Both 1.5 and 3 T MR units were used to acquire the MR images. The principal investigator reviewed the imaging reports and arthroscopic reports. All cases were correlated with arthroscopy. Lesions of the superior glenohumeral, middle glenohumeral, and inferior glenohumeral, including humeral avulsion of the glenoid ligament are discussed. Diagnosis of lesions of the glenohumeral ligaments remains a challenge.