Indirect MR arthrography of the shoulder. An alternative to direct MR arthrography?

INTRODUCTION: The purpose of this study was to evaluate the diagnostic power of indirect MR arthrography (I-MRA) particularly in rotator cuff tears. MATERIAL AND METHODS: Sonography, conventional MRI and I-MRA were compared with arthroscopy in 25 patients. Additionally literature about experience with the method in other shoulder disease was searched. RESULTS: Sensitivity and specificity in the detection of rotator cuff tears were 0.6 and 0.7 respectively using sonography, 0.66 and 1 with conventional MRI and 1 and 0.86 for I-MRA. I-MRA was especially useful in diagnosing partial tears. In other studies I-MRA showed good results in the evaluation of glenoid labral tears, with a sensitivity of 91% and a specificity of 92%. CONCLUSION: I-MRA can be successfully used to diagnose rotator cuff and labral tears.     

Using monoclonal antibodies to characterize a sequential epitope on the group I allergen of Bermuda grass pollen

We measured the incidence of cuff retear and injury to the suprascapular nerve after mobilization and repair of a massive rotator cuff tear. Of one hundred four rotator cuff repairs performed over a 5-year period, 10 patients (7 men and 3 women, age range 22 to 68 years) had primary repairs of massive rotator cuff tears requiring cuff mobilization and an acromioplasty as their only procedure. These patients were evaluated at a mean of 2.5 years (range 2.0 to 3.0 years) after surgery. At follow-up electromyographic examination confirmed that 1 of the 10 patients had an iatrogenic suprascapular nerve injury, whereas ultrasound evaluation revealed that 2 of 10 repairs failed. Pain relief was achieved in the eight patients with intact repairs and not in the two with recurrent tears. All patients had some limitation of active motion or strength, especially in external rotation. Thus 7 of 10 patients had neither evidence of nerve injury nor recurrent rotator cuff tears yet still showed limited active motion or weakness. It appears that operative injury to the suprascapular nerve during cuff mobilization can occur, but other factors such as inadequate cuff muscle function are more frequently responsible for the poor functional outcomes seen after successful repairs of massive rotator cuff tears.     

Partial-thickness tears of the rotator cuff: evaluation and management

The approach to management of a partial-thickness rotator cuff tear is best made with the understanding that this is not a singular condition. Rather, partial tears represent the common outcome of a variety of insults to the rotator cuff. Degenerative changes due to aging, anatomic impingement, and trauma may all be etiologic agents. Overhead athletes may develop tears due to repetitive microtrauma or internal impingement. Outlet radiographs and magnetic resonance imaging are recommended for routine preoperative evaluation. A nonoperative treatment program for rotator cuff strengthening and stretching is appropriate as initial treatment; modification of activities and anti-inflammatory medication are often used as well. Operative management may be considered when nonoperative treatment fails. Arthroscopic evaluation is required to determine the true extent of the cuff lesion. Arthroscopic subacromial decompression is recommended when outlet impingement is present. Rotator cuff debridement or formal cuff repair is dependent on the size of the cuff defect and the age and activity level of the patient. The importance of recognizing the different causes of partial-thickness rotator cuff tears is emphasized in this review of pathogenesis, clinical diagnosis, imaging, and treatment.     

MR imaging for traumatic tears of the rotator cuff: high prevalence of greater tuberosity fractures and subscapularis tendon tears

OBJECTIVE: The purpose of this study was to determine whether occult bony injuries or other characteristic MR abnormalities are frequent in patients suspected of having traumatic tears of the rotator cuff. SUBJECTS AND METHODS: MR arthrography of the shoulder was performed in 24 consecutive patients with suspected traumatic tears of the rotator cuff. MR findings were analyzed with regard to abnormalities of the supraspinatus, infraspinatus, and subscapularis tendons; and the humeral head. A comparison group of 24 consecutive patients with symptoms of nontraumatic tears of the rotator cuff was included in the investigation. RESULTS: Radiographically occult fractures of the greater tuberosity were found in nine (38%) of 24 patients with clinically suspected traumatic tears of the rotator cuff (seven of which occurred in patients <40 years old). Nine partial-thickness and five full-thickness supraspinatus tears were found in the trauma group. In the comparison group, the corresponding numbers were 13 and 10, respectively. Seven partial lesions of the cranial border of the subscapularis and six complete subscapularis tears (all six in patients >40 years old) were found in the trauma group (nine and one in the comparison group). CONCLUSION: Occult greater tuberosity fractures and complete subscapularis tears are commonly seen on MR images in patients suspected of having traumatic tears of the rotator cuff. Greater tuberosity fractures should be looked for specifically in patients younger than 40 years, and subscapularis tears should be looked for specifically in patients older than 40 years.     

Geometric and mechanical properties of the coracoacromial ligament and their relationship to rotator cuff disease

One of the most common causes of pain and disability in the upper limb is inflammation of the rotator cuff tendons. When no significant bony abnormality exists in the surrounding structures, the coracoacromial ligament has been implicated as a possible cause of impingement on the cuff tendons. Geometric and mechanical properties of 20 coracoacromial ligaments, 10 from shoulders with rotator cuff tears and 10 from normal shoulders, were accurately determined. In comparing rotator cuff tear and normal specimens, statistically significant changes in geometric properties were measured in the lateral band, but not in the medial band, of the ligament. The lateral band, which is the region most likely to impinge on the rotator cuff, was shorter and had a larger cross-sectional area in specimens with rotator cuff tears. Although there were no statistical differences in structural properties of the ligament between normal and rotator cuff tear groups, significant changes were evident in material properties. Previously reported histologic differences in the ligament in shoulders with rotator cuff tears are supported by the decreased material properties measured in the current study. Whether the differences in the coracoacromial ligament cause impingement or are due to impingement is still unknown at this time.     

Sonographic findings of rotator cuff tears: correlation with MR imaging

Sonography was performed in 41 patients with symptoms referable to the rotator cuff. Sonography was performed immediately after MR imaging, so that the information obtained by MR imaging could be applied to sonographic diagnosis. Twenty patients were diagnosed from T2-weighted images as having complete tears of the rotator cuff. Sonography showed full-thickness anechoic areas in 12 of the 20 patients, heterogeneous hyperechoic areas in seven, and no abnormal findings in the other one. Thirteen patients were diagnosed as having incomplete tears with MR imaging. Sonography showed heterogeneous hyperechoic areas in 12, but no abnormal findings in one of the 13. Hyperechoic areas in the rotator cuff were shown in four of eight patients who had been diagnosed from T2-weighted images as not having tears. We consider full-thickness anechoic areas to be specific findings of complete tears, although some patients with rotator cuff tears did not show this finding.     

Effects of acute administration of transdermal estrogen on postmenopausal women with systemic hypertension

Os acromiale, failure of fusion of the secondary centers of ossification of the acromion process, has been noted as a contributing factor in shoulder impingement syndrome and rotator cuff tears. Treatments for symptomatic os acromiale with or without rotator cuff tears have been reported in the literature and range from excision of small fragments to fusion of larger, fragments with internal fixation and bone grafting. Generally, rotator cuff repairs have been performed when possible. We report an acromion splitting approach through an existing os acromiale to gain exposure for the repair of a massive rotator cuff tear. Subsequent to this repair, the acromion was repaired with internal fixation. Good functional use of the patient's upper extremity was obtained and the patient expressed satisfaction with the surgical outcome. The acromion splitting approach is a viable approach in patients with an os acromiale and a coexistent rotator cuff tear.     

Prolonged survival in patients with advanced melanoma treated with neoadjuvant chemotherapy followed by resection

We conducted this cadaveric study to define a biomechanical rationale for rotator cuff function in several deficiency states. A dynamic shoulder testing apparatus was used to examine change in middle deltoid muscle force and humeral translation associated with simulated rotator cuff tendon paralyses and various sizes of rotator cuff tears. Supraspinatus paralysis resulted in a significant increase (101%) in the middle deltoid force required to initiate abduction. This increase diminished to only 12% for full glenohumeral abduction. The glenohumeral joint maintained ball-and-socket kinematics during glenohumeral abduction in the scapular plane with an intact rotator cuff. No significant alterations in humeral translation occurred with a simulated supraspinatus paralysis, nor with 1-, 3-, and 5-cm rotator cuff tears, provided the infraspinatus tendon was functional. Global tears resulted in an inability to elevate beyond 25 degrees of glenohumeral abduction despite a threefold increase in middle deltoid force. These results validated the importance of the supraspinatus tendon during the initiation of abduction. Glenohumeral joint motion was not affected when the "transverse force couple" (subscapularis, infraspinatus, and teres minor tendons) remained intact. Significant changes in glenohumeral joint motion occurred only if paralysis or anatomic deficiency violated this force couple. Finally, this model confirmed that rotator cuff disease treatment must address function in addition to anatomy.     

Magnetic resonance imaging assessment of the rotator cuff: is it really accurate?

Magnetic resonance imaging (MRI) is used increasingly for evaluating the rotator cuff. This study of 39 shoulders (38 patients) compared the accuracy of MRI interpretation of rotator cuff integrity by a group of community hospital radiologists (clinical community scenario, CCS) with that of a musculoskeletal radiologist (experienced specialist scenario, ESS), relative to arthroscopy. For the CCS subgroup, the sensitivity, specificity, positive predictive value (PV), negative PV, and accuracy for partial tears were: 0%, 68%, 0%, 82%, and 59%, respectively; for complete tears: 56%, 73%, 36%, 86%, and 69%, respectively; and for all tears combined: 85%, 52%, 50%, 87%, and 64%, respectively. For the ESS subgroup, the respective values for partial tears were: 20%, 88%, 20%, 88%, and 79%, respectively; for complete tears: 78%, 83%, 58%, 92%, and 82%, respectively; and for all tears: 71%, 71%, 59%, 81%, and 71%, respectively. We concluded that MRI assessment of the rotator cuff was not accurate relative to arthroscopy. MRI was most helpful if the result was negative, and MRI diagnosis of partial tear was of little value. Considering the high cost of shoulder MRI, this study has significant implications for the evaluation of patients with possible rotator cuff pathology.     

Ossification of the coracoacromial ligament: association with rotator cuff pathology of the shoulder

The objective of this study was to assess the association of ossification of the coracoacromial ligament (CAL) observed on conventional radiographs with the presence of rotator cuff pathology as demonstrated by magnetic resonance imaging (MRI), arthrography, and/or surgery. Conventional radiographs (internal and external rotation and outlet and axillary views) on eight patients showed ossification of the coracoacromial ligament. Rotator cuff integrity was assessed by physical examination in all 8 patients, by arthrography in 3 patients, and by MRI in 2 patients. Surgery was performed on four of the patients. Physical examination showed impingement findings and decreased rotator cuff strength suggestive of rotator cuff disease in all eight patients. The arthrograms and MRI examinations showed the presence of full-thickness rotator cuff tears. Four of these patients underwent surgery and the rotator cuff defects were confirmed and repaired. Identification of ossification of the CAL on conventional radiographs should be recognized as strongly suggestive of associated significant rotator cuff pathology.     

Comparison of fat-saturation fast spin echo versus conventional spin-echo MRI in the detection of rotator cuff pathology

The purpose of this study was to compare the diagnostic performance of fat-saturation fast-spin-echo (FSE) T2-weighted (T2W) sequences with conventional spin-echo (CSE) T2W sequences in the detection of rotator cuff pathology using surgery as the reference standard. Oblique coronal dual-echo CSE and FSE T2W images with fat saturation from 50 surgically confirmed MR shoulder examinations were acquired on a 1.5-T MR scanner. Blinded MR readers retrospectively analyzed each imaging sequence separately and ultimately correlated both sequences together with findings at surgery. FSE was 100% sensitive and 94% specific in detection of full-thickness tears (n = 19) and 73% sensitive and 97% specific in the detection of partial-thickness rotator cuff tears (n = 13). There was no statistically significant difference in the performance of FSE with fat saturation compared with CSE. The two discrepancies between imaging sequences related to the extent of partial-thickness tears. Our findings suggest that fat-saturation FSE imaging can effectively replace CSE imaging in the evaluation of rotator cuff pathology.     

Concomitant rotator cuff tear and brachial plexus injury in association with anterior shoulder dislocation: unhappy triad of the shoulder

High incidences of nerve lesions or rotator cuff tears in association with shoulder dislocations have been reported. However, the simultaneous occurrence of these three lesions has only been reported once previously. This case is an example of a not so uncommon injury, which emphasizes the importance of looking for associated brachial plexus and rotator cuff lesions when examining a patient with shoulder dislocation.     

Antitumor effect of DT-5461, a lipid A derivative, against human tumor xenografts is mediated by intratumoral production of tumor necrosis factor and affected by host immunosuppressive factors in nude mice

PURPOSE OF THE STUDY: The purpose of this report was to study the repercussions of rotator cuff condition on unconstrained shoulder arthroplasty results. METHODS: Between 1986 and 1993, 40 unconstrained shoulder prostheses were performed (24 total and 16 hemiarthroplasties). At the time of the operation, rotator cuff condition was reported to be normal in 15 shoulders, atrophic in 10, scarred in 3, torn in 12. Clinical and radiographical results were analyzed and supplemented with a rotator cuff echography. Postoperative follow-up averaged 42.25 months (12 to 97 months). RESULTS: When the rotator cuff was intact at the time of operation, clinical results were the best at the time of review. Constant score, overall mobility, forward elevation, external rotation with the elbow along the side were better for intact than for atrophic, scarred or torn rotator cuffs (p < 0.01). Ruptures repaired by local tissue transfer or trapezo deltoidal flap substitution (3 cases) gave satisfactory results, whereas two dacron cuff prostheses failed. In the non repaired ruptures (7 cases), arthroplasty resulted in 3/4 fair or poor results. At the time of review, the total incidence of postoperative rotator cuff tears was high (12 cases), functional repercussions were variable. Among the 15 rotator cuff tears observed at the time of the review, the long head of the biceps was present and in place in 9 cases and ruptured in 6 cases. In these latter cases, Constant score (p < 0.01), the forward elevation (p < 0.01), external rotation with elbow along side (p < 0.05) and overall mobility (p < 0.05) were worse; moreover, humeral head superior migration was greater (p < 0.01). DISCUSSION: Our study confirms the superiority of clinical results when the cuff was intact at the time of the operation. The repair of rotator cuff tears seems to be justified. When the rupture has not been repaired, clinical results were fair or poor in 5 cases out of 7, the initial rupture spread to the other tendons in 3 cases out of 7. Secondary ruptures were frequent (12 cases). No predictive factor was identified, but an overlapping of the greater tuberosity appears to be detrimental. Among rotator cuff tears present at the time of review, long head of the biceps rupture jeopardized clinical results and was associated with a proximal migration of the humeral head which was significantly more severe than with an intact non displaced long head of the biceps. CONCLUSION: During unconstrained shoulder prosthesis implantation, it is therefore recommend to systematically repair any associated rotator cuff rupture, in order to avoid any greater tuberosity overlap relative to the prosthetic head and to preserve the long head of the biceps tendon which limits upward migration of the humeral head and improves prosthetic kinetics.     

Suppression of alloreactivity with gamma delta T-cells: relevance to increased gamma delta T-cells following bone marrow transplantation

Morphologic changes in the long head of the biceps brachii (LHB) and bicipital groove associated with cuff tears were studied in 170 cadavers. In specimens with minimum or moderate cuff tears, the primary finding was relative stenosis at the bicipital groove induced by enlargement of the LHB. However, this stenosis was not apparent in specimens with massive cuff tears and in these specimens, the medial wall of the groove exhibited wear and tear, a potential cause of LHB instability. We suggest that the long head of the biceps brachii muscle can potentially compensate for inadequate rotator cuff function. This increasing activity could lead to enlargement of the tendon and cause deterioration of the bicipital gliding mechanism.     

Serious rotator cuff injuries

Usually, serious rotator cuff injuries can be operated upon and a high level of performance can be achieved afer surgery. This is not so for the substantial tears seen in baseball pitchers. However, a damaged rotator cuff can be rehabilitated and can recover from the threatened tear without surgery if detected early enough and given the proper treatment.     

Arthroscopic assessment of rotator cuff tear reparability

To evaluate the efficacy of arthroscopic techniques in determining the potential reparability of complete rotator cuff tears, a clinical investigation was performed. The parameters of tear size measurement, tendon quality, tendon mobility, and suture anchor placement were evaluated. These parameters were determined using both arthroscopic and open surgical technique. No statistically significant differences were noted when the arthroscopic findings were compared with the findings at open rotator cuff repair. Arthroscopic techniques can reliably assess rotator cuff tear size, tendon quality, tendon mobility, and suture anchor placement.     

Suprascapular nerve block for persistent rotator cuff lesions

The suprascapular nerve supplies sensory nerves to the posterosuperior aspect of the shoulder, including major portions of the rotator cuff. Suprascapular nerve block using steroid/bupivacaine is temporarily effective in reducing pain in rotator cuff tendinitis and tears, improving movement range in tendinitis and is possible in an outpatient setting with little or no complication risk.     

Dental caries and oral health behaviour situation of children, mothers and schoolteachers in Wuhan, People''s Republic of China

The rotator cuff tear is an extremely common disorder in the general as well in the orthopaedic praxis. The etiology is multifactorial with intrinsic and extrinsic factors. Clinical assessment of the patient is important for an exact diagnosis and an individual treatment plan. The treatment options of full thickness tears include conservative as well as operative procedures. Over the last years, modified techniques have improved the results of rotator cuff reconstruction.     

Evaluation of the toxicity of ISIS 2302, a phosphorothioate oligonucleotide, in a four-week study in cynomolgus monkeys

Partial-thickness rotator cuff tears are now acknowledged to be an important entity in the spectrum of the impingement syndrome. The pathogenesis of partial-thickness tears is often age- and activity-related. Surgical decision making is influenced by the extent of the tear and the associated bony and soft-tissue pathology.     

MR imaging of impingement and rotator cuff disorders. A surgical perspective

The role of MR imaging in the diagnosis of impingement and rotator cuff disorders is expanding greatly. This article discusses the clinically pertinent history, physical examination, and surgical treatment of rotator cuff problems. A rationale for consideration of open, "mini-open," and arthroscopic surgical intervention is proposed. The utilization of MR imaging by the orthopedic surgeon for nonoperative, preoperative, and postoperative decision-making are presented. A close working relationship between the radiologist and the orthopedist is emphasized.