实时超声检查与磁共振成像诊断冈上肌腱撕裂的对比研究

目的评价实时超声检查与磁共振成像(MRI)对冈上肌腱撕裂病变的诊断价值。方法回顾性分析2003年1月至2008年1月间经手术证实冈上肌腱撕裂且临床资料完整的70例患者的实时超声检查及MRI检查资料,以开放手术或肩关节镜术中结果作为金标准,比较两种检查方法的有效性。结果 70例冈上肌腱撕裂,术前实时超声检查诊断65例,MRI诊断67例。实时超声检查诊断冈上肌腱撕裂的敏感性、特异性、阳性预测值、阴性预测值及准确性分别为92.8%、82.1%、92.8%、82.1%及89.8%。MRI诊断冈上肌腱撕裂的敏感性、特异性、阳性预测值、阴性预测值及准确性分别为95.7%、85.7%、94.4%、88.9%及92.9%。经χ2检验,冈上肌腱撕裂实时超声检查的有效性与MRI检查的有效性无统计学差异(χ2=0.09,P0.05)。结论实时超声检查与MRI同样能够准确地诊断冈上肌腱撕裂,可作为冈上肌腱检查的首选影像学方法 。     

Magnetic resonance imaging of shoulder impingement

MRI is an accurate technique for diagnostic evaluation of a broad spectrum of shoulder pathology. In particular, rotator cuff injuries are a frequent cause of pain and disability. The mechanism of injury to the supraspinatus tendon usually begins with microscopic tears of fibers of the triple helix collagen molecule. This leads to increased motion of the bound water within the collagen molecule that lengthens the effective T2 of the tendon, allowing short TE imaging sequences to detect signal in abnormal tendons. Clinically significant disease probably does not occur without frank collagen rupture, and the associated collection of free water within the severely diseased tendon presents as high signal on long TE images. Thus, the clinical significance of tendon disease is best evaluated on long TR, long TE image acquisitions. Any process that accelerates microscopic tear formation or delays repair can increase a patient's risk of supraspinatus tendon tears. Impingement is the most important process accelerating microscopic tear formation. MRI's multiplanar, tomographic imaging ability markedly improves the ability to sensitively and specifically detect bony impingement. Hopefully, this will allow earlier arthroscopic decompression and improved patient prognosis with impingement.     

超声引导下注射在肩部伤病治疗中的应用实例分析

目的:介绍超声引导下注射治疗肩部伤病的方法。方法:分别列举了一些典型的病例,包括肱二头肌长头腱鞘内囊肿、肩袖撕裂、冈上肌腱钙化和冻结肩等,详细介绍了超声引导下这些病例的注射技术。结果:所介绍的病例在超声引导下注射后均取得良好的临床效果。结论:二头肌长头腱鞘内囊肿、肩袖撕裂、冈上肌腱钙化和冻结肩都可以用超声明确诊断,同时可以在超声下引导治疗。     

The application of sonography in shoulder pain evaluation and injection treatment after stroke: a systematic review

[Purpose] This review article is designed to expose the application of sonography in shoulder pain after stroke. [Methods] A range of databases was searched to identify articles that address sonography examination, with or without ultrasound guided corticosteroid injection for hemiplegic shoulder pain (HSP). The electronic databases of PubMed, CENTRAL, CINAHL, Cochrane Library, Medline were searched. [Results] According to the articles identified in our databases research, sonographic technique has potential to provide objective measurements in patients with HSP. The main sonography finding of HSP included subacromial subdeltoid (SASD) bursal effusion, tendinosis of the supraspinatus and subscapularis tendon, long head of biceps tendon sheath effusion, and shoulder subluxation. Our analysis also revealed significantly decreased pain score (VAS) and increased passive external rotation degree in the steroid injection group than control group. [Conclusion] The sonography examination is useful for HSP assessment and ultrasound guided technique is recommended for HSP injection treatment.Key words: Stroke, Shoulder pain, Ultrasound     

Axillary mononeuropathy after herpes zoster infection mimicking subacromial impingement syndrome

Subacromial impingement syndrome is a frequent cause of shoulder pain and it is readily confused with other shoulder problems. We present a patient with herpes zoster infection associated with axillary mononeuropathy that was initially misdiagnosed as subacromial impingement syndrome. A 75-yr-old female patient was admitted to the internal medicine clinic because of pain and weakness in her right shoulder. As she did not respond to medical treatment and local injection therapy, magnetic resonance imaging of the right shoulder was ordered. As the magnetic resonance imaging revealed subacromial impingement of the supraspinatus tendon, the patient was referred to the physical medicine and rehabilitation department for rehabilitation. In our initial physical examination, her shoulder abductor muscle strength was 2/5 and her shoulder external rotator muscle strength was 3/5. A subacromial injection test with 10 ml of 1% lidocain was negative and the magnetic resonance imaging did not show a complete rotator tendon rupture that could explain such a muscle strength loss. So, an electrodiagnostic evaluation was performed and the patient was diagnosed to have a right axillary neuropathy. A more detailed questioning of the patient disclosed a history of herpes zoster approximately 3 mos ago. Herpes zoster-associated axillary neuropathy can mimic subacromial impingement syndrome, and magnetic resonance imaging examination alone may lead to a misdiagnosis. Therefore, we imply that clinical and electrophysiological evaluations would be of great importance in relevant patients with shoulder problems.     

Biodegradable spacer reduces the subacromial pressure: A biomechanical cadaver study

BackgroundFailure after rotator cuff repair remains a major clinical problem and could be related to excessive pressures from the acromion. Previous studies with irreparable tears showed good clinical results of tendon healing with arthroscopic insertion of a protective biodegradable spacer balloon between the repaired tendon and the acromion. One hypothesis is that compression pressures on the repaired tendon will be reduced by the spacer. This cadaver study aimed to investigate the effects of this subacromial spacer on compression pressures over a repaired supraspinatus tendon in passive motion.MethodsRotator cuff tear and repair were performed in six fresh-frozen cadaveric shoulders, followed by insertion of a biodegradable subacromial spacer. Specimens were tested using a passive shoulder simulator for abduction-adduction, flexion-extension and internal-external rotations. A sensor positioned below the acromion was used to measure compression pressure changes through passive range of motion before and after placement of a subacromial spacer. Peak pressures were measured in adduction-abduction motion, near 90° abduction.FindingsBoth the mean and peak pressures in abduction-adduction were significantly reduced after insertion of the subacromial spacer (from mean 121.7 (SD 9.5) MPa to 51.5 (SD 1.2) MPa and from peak 1749.6 (SD 80.7) MPa to 535.1 (SD 27.6) MPa) (P < 0.0001).InterpretationThe reduced peak pressures and wider load distributions over the sensor during both passive abduction-adduction and flexion-extension motions suggest that the use of the spacer will lead to reduced wear of the repair in patients, and potentially prevent rotator cuff re-tear after surgical repair.     

Interobserver variation in sonography of the painful shoulder

PURPOSE: This study was conducted as a prospective assessment of interobserver variability in the sonographic evaluation of the rotator cuff. METHODS: Three musculoskeletal radiologists who had different levels of scanning experience each performed shoulder sonography on 24 consecutive patients during 1 patient visit. The diagnostic criteria full-thickness rotator cuff tear, tendon calcification, tendinosis of the supraspinatus, subacromial fluid, subacromial synovial/bursal thickening, dynamic signs of impingement, and abnormality in the long head of biceps tendon were scored, with independent observers recording the data. Statistical analysis was performed using Cohen's kappa test, with significance assessed at p values of less than 0.05. RESULTS: There was good agreement (kappa >0.60, p <0.01) between the experienced operators for full-thickness rotator cuff tear, tendon calcification, dynamic signs of impingement, and abnormality of the long head of biceps tendon. There was no significant agreement between the experienced operators and the less experienced operator in several categories, including (and importantly) full-thickness rotator cuff tears (kappa=0.18-0.21). CONCLUSIONS: In experienced hands sonography of the rotator cuff is a reproducible diagnostic test, but agreement is poor when there is marked disparity between the operators' experience levels. Our findings suggest a need for a more clearly defined training curriculum for sonography of the shoulder in radiology training programs.     

The bursal and articular sides of the supraspinatus tendon have a different compressive stiffness

OBJECTIVE: To measure the compressive stiffness of the supraspinatus tendon and to determine whether regional difference exists in the bursal and articular side of the tendon. DESIGN: Indentation testing was performed on both the bursal and articular sides of the supraspinatus tendon, focused on the 'critical area', where rotator cuff tears often occur. BACKGROUND: When the supraspinatus tendon wraps around the humeral head or is under impingement condition, compressive force on the tendon surface is expected. Therefore, compressive stress has been recently considered to be one of the important factors associated with the cuff tear. The mechanical properties would be essential for analytic modeling of stress distribution. METHODS: Indentation tests were performed at 15 locations on the bursal and articular surfaces of the supraspinatus tendon. A mathematical model with exponential relationship was used to describe the measured force-deformation relationship and to calculate the compressive stiffness of the supraspinatus tendon. RESULTS: The over-all initial stiffness on the bursal and articular sides of the tendon was significantly different. On the bursal side, the anterior third had a significantly higher initial stiffness than the other thirds on average. On the articular side, initial stiffness at location 10 mm proximal to the greater tuberosity was significantly higher than the rest on average. CONCLUSIONS: The compressive stiffness of the supraspinatus tendon was found to be non-homogenous throughout the structure.RelevanceNon-homogenous compressive stiffness of the supraspinatus tendon would affect the load transmission within the tendon, which might be associated with the potential mechanism of tear. Such characteristics needs to be considered when performing finite element modeling of stress fields in the tendon.     

Klinische Resultate und Rerupturrate der Arthroscopic-Bone-Needle-Technik

Background

Reconstruction of a rotator cuff tendon tear using transosseous sutures was the gold standard when surgery was still done open or mini-open and has the advantage of no implants and cost-effectiveness. Arthroscopic rotator cuff repair is less invasive but suture anchors are expensive. This abstract will introduce a novel technique for treatment of arthroscopic rotator cuff repair combining the advantages of an arthroscopic procedure and transosseous sutures. The purpose of the study was to evaluate the clinical results, patient satisfaction, short-term re-rupture rates with magnetic resonance imaging (MRI) and hardware costs of this procedure.

Material and Methods

From August 2008 to November 2009 a total of 66 patients with a tear of the supraspinatus tendon were treated using an arthroscopic bone needle. Patients were evaluated with the constant score (CS), patient satisfaction and complications. The hardware costs of a supraspinatus reconstruction using the arthroscopic bone needle were documented and compared in each case to the hardware costs using the estimated number of suture anchors that would have been necessary. A separate study was performed to evaluate the rerupture rate after supraspinatus reconstruction whereby 20 consecutive patientstreated from July 2010 to January 2011 had an MRI 3 months postoperatively and were evaluated by independent radiologists using the criteria of Sugaya. The arthroscopic bone needle technique is based on the Giant Needle? method but changes in the design, material and in the surgical technique were made to allow multiple usage of the needle and (in contrast to the Giant Needle? method) the sutures were first made in the bone and not in the tendon, which allows the surgeon to decide how and where the sutures penetrate the tendon and what configuration of sutures and knots should be made.

Results

The 60 patients (including 25 women, mean age 61 years) were examined approximately 1 year postoperatively at follow?Cup and 6 patients had an additional infraspinatus rupture and 16 a subscapularis rupture. The acromioclavicular (AC) joint was resected in 41 and the long head of the biceps was treated in 45 patients. The average CS was 73 (SD 12) which equals a CS normalized for age and gender of 92% (SD 15) and 56 patients (93%) were satisfied or very satisfied with the surgery. No axillary nerve injuries or fractures of the greater tuberosity occurred. The hardware costs of a supraspinatus reconstruction were reduced by 80% using the arthroscopic bone needle technique compared to suture anchors (121?EUR versus 600?EUR) and 2 patients (10%) suffered a rerupture of the reconstructed tendon in the MRI.

Conclusion

The arthroscopic bone needle technique proved to be a new, safe and cost-effective method with good clinical results and low rerupture rate for the repair of rotator cuff ruptures.     

高频超声诊断冈上肌腱撕裂

目的观察冈上肌腱撕裂超声声像图特征,评估高频超声诊断冈上肌腱撕裂的效能。方法纳入65例(65肩)超声诊断为冈上肌腱撕裂患者,以同期10名健康志愿者(20肩)为对照,对比超声与关节镜术中诊断结果,采用Cohen's Kappa系数分析二者诊断的一致性,评价超声诊断效能。结果冈上肌腱撕裂超声多表现为无回声、肌腱滑囊面凹陷及连续性不佳,据以诊断撕裂的敏感度分别为85.42%、89.58%及93.75%,特异度分别为76.47%、100.00%及76.47%;超声根据肌腱滑囊面凹陷诊断冈上肌腱撕裂与关节镜术中诊断的一致性最佳(Kappa=0.818),其次为肌腱连续性不佳(Kappa=0.716)及无回声区(Kappa=0.586)。超声根据上述特征诊断与关节镜术中诊断差异均无统计学意义(P均>0.05)。结论高频超声可较准确地诊断冈上肌腱撕裂;根据滑囊面凹陷诊断与关节镜诊断冈上肌腱撕裂的一致性最佳;回声特点结合动态观察肌腱连续性有助于减少漏、误诊。     

肩袖损伤合并肩峰下撞击综合征的MRI表现

目的探讨肩袖损伤合并肩峰下撞击综合征的MRI影像表现。材料与方法对33例X线片无骨折但临床怀疑肩袖损伤或肩峰下撞击综合征的患者,用1.5 T MRI机检查,观察肩袖损伤及肩峰下撞击综合征在MR上的影像特征,分析两者的相关性,并与手术结果对比,计算准确率。结果 33例中肩袖损伤20例(合并肩峰下撞击综合征10例),肩峰下撞击综合征15例(合并肩袖损伤10例)。肩袖损伤和肩峰下撞击综合征术前MR诊断准确率分别约为95.0%、71.3%。结论肩关节MRI扫描对肩袖损伤及肩峰下撞击综合征的诊断有较高的临床应用价值,肩袖损伤者中至少半数合并肩峰下撞击综合征,临床和影像应予重视。     

Effectiveness of tendon transfers for massive rotator cuff tears: a simulation study

OBJECTIVE To determine what the most effective tendon transfer is in the case of a dysfunctional rotator cuff. DESIGN: A tendon transfer procedure of latissimus dorsi, teres major or a combination of these two to the insertions of either teres minor, infraspinatus, supraspinatus, or subscapularis is simulated using a biomechanical musculoskeletal model of the upper extremity. BACKGROUND: Massive rotator cuff tears are not easily repaired. To compensate for this loss of rotator cuff function other techniques like muscle transfers are developed. METHODS: Three range of motion tasks and six activities of daily living of 24 subjects were measured. Kinematics from these tasks were used as input to the Delft Shoulder and Elbow Model. The muscle parameters of the Delft Shoulder and Elbow Model were modified to simulate a rotator cuff tear and the ability to perform the measured tasks with and without simulated transfer procedures was checked. RESULTS: The highest improvements (28-30%, P = 0.00 ) in the ability to perform tasks were observed after a simulated tendon transfer of either both muscles or teres major alone attached to the supraspinatus or infraspinatus insertion. Although all transfer procedures produce significant improvements (P = 0.00 ), there is a significant difference between the procedures (Chi square=58.8, P = 0.00 ) dependent on attachment site. CONCLUSIONS: According to the simulation procedure used in the current study, a tendon transfer of teres major and latissimus dorsi or teres major alone to the supraspinatus insertion appears to be the most effective procedure in the case of a dysfunctional rotator cuff. Practical factors, like subacromial space, volume of the muscles and tendons, tensile properties and the ability to split the muscles, will finally determine which is the preferred transfer option.     

Measurement of strain and tensile force of the supraspinatus tendon under conditions that simulates low angle isometric elevation of the gleno-humeral joint: Influence of adduction torque and joint positioning

BackgroundRecently, supraspinatus muscle exercise has been reported to treat rotator cuff disease and to recover shoulder function. However, there have been no report on the direct measurement of strain on the supraspinatus tendon during simulated isometric gleno-humeral joint elevation.MethodsTen fresh-frozen shoulder specimens with the rotator cuff complex left intact were used as experimental models. Isometric gleno-humeral joint elevation in a sitting position was reproduced with low angle of step-by-step elevation in the scapular plane and strain was measured on the surface layer of the supraspinatus tendon.FindingsIn isometric conditions, applied tensile force of the supraspinatus tendon increased significantly with increases in adduction torque on the gleno-humeral joint. Significant increases in the strain on the layer were observed by increase in adduction torque, which were recorded in isometric elevation at − 10° and 0°, but little increase in the strain was observed at 10° or greater gleno-humeral elevation.InterpretationIncreased strain on the surface layer of the supraspinatus tendon was observed during isometric gleno-humeral elevation from − 10 to 0°. These findings demonstrate a potential risk of inducing overstretching of the supraspinatus tendon during supraspinatus muscle exercise.     

Shoulder pain. Guidelines to diagnosis and management

The cause of shoulder pain can usually be diagnosed after a pertinent history has been obtained and a relevant physical examination performed. To carry out such an evaluation, the examiner must understand the salient anatomic relationships of the shoulder. Causes of shoulder pain include supraspinatus tendinitis (the most common), bicipital tendinitis, impingement syndromes, supraspinatus rupture, subacromial bursitis, arthritis, frozen shoulder, and various conditions that refer pain to the shoulder. Treatment in most cases consists of rest and administration of a nonsteroidal antiinflammatory drug or injection of a corticosteroid preparation, or both.     

Percutaneous ultrasound-guided injections in the musculoskeletal system

Ultrasound guidance is an accurate method for the delivery of therapeutic injections in the musculoskeletal system. The visualization of the needle in real time allows for reliable placement of the needle tip in the tendon sheath, bursa, or joint of interest. Both superficial and deep articulations and tendon sheaths can be targeted for diagnostic or therapeutic interventions. In addition, intratendinous calcifications, the plantar fascia, and interdigital (Morton's) neuromas can also be visualized and injected directly under real-time guidance. Performing percutaneous interventions with ultrasound ensures accurate needle tip placement and helps direct the needle away from other regional soft-tissue structures such as nearby neurovascular bundles.     

The effect of a rotator cuff tear and its size on three-dimensional shoulder motion

BackgroundRotator cuff-disease is associated with changes in kinematics, but the effect of a rotator cuff-tear and its size on shoulder kinematics is still unknown in-vivo.MethodsIn this cross-sectional study, glenohumeral and scapulothoracic kinematics of the affected shoulder were evaluated using electromagnetic motion analysis in 109 patients with 1) subacromial pain syndrome (n = 34), 2) an isolated supraspinatus tear (n = 21), and 3) a massive rotator cuff tear involving the supraspinatus and infraspinatus (n = 54). Mixed models were applied for the comparisons of shoulder kinematics between the three groups during abduction and forward flexion.FindingsIn the massive rotator cuff-tear group, we found reduced glenohumeral elevation compared to the subacromial pain syndrome (16°, 95% CI [10.5, 21.2], p < 0.001) and the isolated supraspinatus tear group (10°, 95% CI [4.0, 16.7], p = 0.002) at 110° abduction. Reduced glenohumeral elevation in massive rotator cuff tears coincides with an increase in scapulothoracic lateral rotation compared to subacromial pain syndrome (11°, 95% CI [6.5, 15.2], p < 0.001) and supraspinatus tears (7°, 95% CI [1.8, 12.1], p = 0.012). Comparable differences were observed for forward flexion. No differences in glenohumeral elevation were found between the subacromial pain syndrome and isolated supraspinatus tear group during arm elevation.InterpretationThe massive posterosuperior rotator cuff-tear group had substantially less glenohumeral elevation and more scapulothoracic lateral rotation compared to the other groups. These observations suggest that the infraspinatus is essential to preserve glenohumeral elevation in the presence of a supraspinatus tear. Shoulder kinematics are associated with rotator cuff-tear size and may have diagnostic potential.     

低场MRI在跟腱损伤中的应用价值

目的 探讨低场MRI在跟腱损伤诊断及术后随访中的应用价值.方法 15例跟腱损伤患者经低场四肢专用磁共振多序列检查,其中7例行缝补术后随访,分析其低场MRI表现,并与5例正常跟腱比较.结果 5例正常跟腱矢状面各序列显示呈条带状均匀低信号.1例利器切割伤显示跟腱下段大部分中断,断面整齐.5例部分撕裂显示跟腱增粗,内部信号不均匀,部分纤维束连续.9例完全性撕裂均显示跟腱连续性完全中断,2例表现为肌腱普遍增粗、形态不规则,T1WI 、T2WI上信号弥漫增高,7例表现为肌腱局部增粗、断裂,断端回缩呈＂杵＂状改变或扭曲,T1WI 、T2WI上中断处呈高信号.7例术后随访显示高信号强度逐渐下降.结论 低场磁共振能够明确地显示跟腱损伤的部位、程度及形态、信号改变,在跟腱损伤的诊断和术后随访方面能提供重要价值.     

Biomechanical analysis of tendon transfers for massive rotator cuff tears

OBJECTIVE: To determine why certain tendon transfers are mechanically more effective than other tendon transfers for the treatment of a massive rotator cuff tear. DESIGN: A tendon transfer procedure of latissimus dorsi, teres major or a combination of these two to the insertions of either teres minor, infraspinatus, supraspinatus, or subscapularis is simulated using a biomechanical musculoskeletal model of the upper extremity. BACKGROUND: Massive rotator cuff tears are not easily repaired. To compensate for the loss of rotator cuff function, techniques such as muscle transfers are developed. METHODS: Three range of motion tasks were used as input to the Delft shoulder and elbow model. The muscle parameters of the Delft shoulder and elbow model were modified to simulate a rotator cuff tear. A biomechanical analysis of the transferred muscles was performed, taking outcome variables such as moment arms, muscle length and muscle force into account. RESULTS: Due to the massive rotator cuff tear, an elevation and external rotation moment is lost. When the tendon was transferred to the insertions of infraspinatus or supraspinatus, the humerus was capable of elevating and externally rotating. CONCLUSIONS: On the basis of mechanical parameters such as moment arms, muscle length and force it can be concluded that a tendon transfer of the teres major to the supraspinatus insertion will produce the best functional outcome in the treatment of massive rotator cuff tears. RELEVANCE: To find biomechanical evidence for an optimal tendon transfer that will lead to improved treatment of patients with a massive rotator cuff tear.     

肩峰下撞击综合征的经皮超声引导下肩峰下滑囊造影表现

目的 探讨肩峰下撞击综合征（SIS）的经皮超声引导下肩峰下滑囊造影（PUSB）表现。方法 对150例经临床诊断为SIS患者行PUSB检查,动态观察造影剂在滑囊内的弥散情况及是否进入肩袖、关节腔。结果 53例造影剂在滑囊内呈线状均匀分布,诊断为单纯性肩峰下滑囊炎。97例造影剂在滑囊内分布不均匀,诊断为粘连性肩峰下滑囊炎。40例可见造影剂由滑囊进入肩袖肌腱,但未达肱骨头表面;32例可见造影剂由滑囊进入肩袖肌腱,到达肱骨头表面;78例造影剂未进入肩袖肌腱。结论 PUSB可实时动态评估肩峰下滑囊炎、滑囊粘连、肩袖损伤等情况,对SIS的诊断具有较高的应用价值。     

Acromio-clavicular joint cyst associated with a complete rotator cuff tear – A case report

This case report describes a patient with an acromio-clavicular joint (ACJ) cyst, associated with a complete tear of the supraspinatus tendon, and the related arthropathy. Ultrasound was a suitable imaging modality to make the diagnosis, and rule out other pathologies. Full assessment of the rotator cuff must be carried out in the presence of ACJ cysts due to their common co-existence with large cuff tears. Cyst aspiration is not a suitable treatment, due to the high likelihood of recurrence. Optimal treatment requires management of the underlying rotator cuff tear.