Supraspinatus Tears Research Articles

Ultrasound Findings in Adult Patients with Chronic Shoulder Pain Having No History of Trauma

OBJECTIVE: To evaluate the frequency of non-traumatic chronic shoulder pain sonographically in the local population. METHODOLOGY: This cross-sectional study was conducted at the Department of Radiology, Combined Military Hospital Malir, from March to October 2020. A history of shoulder pain of more than one month duration was included. Patients with a History of shoulder dislocation, neurological, renal, hepatic and cardiac diseases were excluded. The sample size was 196. A non-probability consecutive sampling technique was employed. SPSS version 23 was used for statistical analysis. RESULTS: 196 patients (69.9% males and 30.1% females) with non-traumatic shoulder pain (56.4 % right side and 43.4% left) were scanned. The mean age was 42.80±11.20 years. Out of 196, 118(60.2%) were having complaints in dominant limbs (right 51.0% and left 9.2%); 78(39.8%) were having pain in non-dominant limbs (right 6.6% and left 33.2%). Significant findings were supraspinatus partial tear (46.9%), sub-acromial sub-deltoid bursitis(8.2%), and biceps tenosynovitis(6.1%), adhesive capsulitis, a complete tear of supraspinatus tendon, impingement syndrome, joint effusion, subscapularis tendon tear and tenosynovitis. 44(22.4%) patients had two pathologies, and 31 (15.8%) patients had three pathologies, respectively. Significant co-existent findings were biceps tenosynovitis (13.8%), Impingement syndrome (9.2%), bursitis (8.2%) and joint effusion (7.1%). Age and number of pathological were moderately positively correlated, r (194) = 0.46, p < 0.01 and keeping CI = 95%. CONCLUSION: Partial tears of the supraspinatus tendon were the most common pathology in non-traumatic shoulder myalgia, diagnosed on ultrasound, followed by sub-acromial sub-deltoid bursitis and biceps tenosynovitis, having moderate linear relation with age. KEYWORDS: Shoulder pain, Impingement syndrome, Rotator Cuff Tears, Tenosynovitis, Ultrasound Shoulder

Interventional Pain Management Using Dextrose Prolotherapy in Treating a Partial Supraspinatus Tear: A Case Report

Shoulder pain is a medical condition that may affect the well-being and compromise the quality of life of an individual, especially in the elderly. A supraspinatus tear is the most common cause of shoulder pain. Several treatments are available for this problem, such as surgical and conservative treatment. The surgical approach is found to be more efficacious but has a high rate of recurrence. Prolotherapy is one of the novel pain treatment modalities that could provide significant pain relief in musculoskeletal diseases. In this case report, we report a 53-year-old woman, who came to the outpatient clinic complaining of pain in her right shoulder for three months. The pain had been getting worse in the previous seven days, felt continuously throughout the day, and exacerbated when she raised her arm. The physical examination revealed a limited range of motion of active abduction and flexion with a positive drop arm test of the right shoulder. An ultrasound revealed a tear-drop appearance. The patient was treated with interventional pain management using dextrose prolotherapy. After undergoing prolotherapy treatment for three sessions over two months, the patient was declared completely healed from the supraspinatus tear. In conclusion, prolotherapy coupled with an ultrasound-guided procedure appears to be beneficial in alleviating pain and completely healing supraspinatus tears.

Analysis of Abduction Moment Arms after Rotator Cuff Tear and Acellular Dermal Matrix Allograft Reconstruction.

Biomechanical testing of abduction moment arms presents a useful method to assess the contribution of individual rotator cuff muscles to glenohumeral function. This study aimed to investigate the changes in abduction moment arms after a supraspinatus tear treated with Superior Capsule Reconstruction (SCR), Bursal Acromial Reconstruction (BAR), and a combined SCR-plus procedure, all with human dermal allograft. 7 fresh-frozen cadaveric specimens were tested in 6 conditions: (1) intact, (2) 50% supraspinatus tear (partial tear), (3) 100% supraspinatus tear, (4) SCR, (5) SCR+BAR, (6) BAR. In each condition, moment arms for the individual muscles of teres minor, subscapularis, and infraspinatus were calculated throughout 90º of abduction using Optotrak motion capture. ANOVA and post-hoc Tukey testing were performed to determine significance. In teres minor, the moment arms of the SCR (11.92mm), BAR (10.05mm), and SCR+BAR (11.87mm) conditions were greater than those in the intact (8.51mm, p=0.001, p=0.001, p=0.001, respectively), partial tear (9.09mm, p=0.001, p=0.128, p=0.001, respectively), and complete tear (8.75mm, p=0.001, p=0.011, p=0.001, respectively) conditions. Similarly in subscapularis, moment arms in the SCR (13.36mm), BAR (13.84mm), and SCR+BAR (13.53mm) conditions were greater than those in the intact condition (10.59mm, p=0.006, p=0.001, p=0.003, respectively) and partial tear condition (10.43mm, p=0.006, p=0.001, p=0.003, respectively). In teres minor, SCR (11.92mm) and SCR+BAR (11.87mm) were also found to have significantly increased moment arms compared to BAR (10.05mm, p=0.001, p=0.001, respectively). In Infraspinatus, BAR (13.77mm) was found to have a significantly decreased moment arm compared to the partial tear condition (15.78mm, p=0.026), with no other significant findings between conditions. These results suggest that the moment arm contributions from individual muscles comprising the rotator cuff can change after reconstruction to compensate for tears. SCR and SCR+BAR increase moment arms in teres minor and subscapularis, potentially allowing for increased abduction ability.

Un-resolving frozen shoulder: Are we really treating it?

To perform ultrasound examination in un-resolving frozen shoulder disorder, in Pakistani cohort visiting rheumatology clinic. This cross sectional study was carried out at Department of Rheumatology, Indus Medical College Tando Mohhamad Khan, from 16th March 2022 to 30th October 2022. Patients diagnosed as unilateral frozen shoulder on clinical grounds and received intra-articular injection (s) in last six months, never been investigated, still persisting with pain and restricted range of shoulder motion were enrolled. After the demographic details and shoulder examination, ultrasound examination of both shoulder joints was performed by senior musculoskeletal radiologist, to know the exact diagnosis. In 138 cases on ultrasound examination following injuries were noted: rotator cuff tendinopathy (RCT) (61%), adhesive capsulitis (21%), mixed lesion (rotator cuff tendinopathy and adhesive capsulitis) (14%).In age group < 50 years rotator cuff tendinopathy was the major lesion, while in cases >50 years age group: adhesive capsulitis (AC) was predominant lesion (p-0.05).Rotator cuff tendinopathy had significant association with supraspinatus tears (p<0.5). In Un-resolving frozen shoulder pain, ultrasound examination of involved joint helps in reaching the exact cause which may differ from the existing diagnosis and guides to further management.

The effect of medial shift of supraspinatus tendon on the glenohumeral joint motion-a cadaveric study.

Full-thickness retracted massive supraspinatus tears are a challenge for arthroscopic surgeons where multiple options for treatment exist, but medializing the attachment is a relatively easy procedure for which a decision can be taken intraoperatively. We investigate the viability of MATERIAL AND METHODS: Ten freshly thawed cadavers were taken and dissected. The supraspinatus tendon was resected, and then its attachment was progressively medialized. The range of motion (abduction, internal and external rotation) was recorded and compared. As a result, we noted a statistically significant decrease inabduction, internal and external rotationwith progressive medialization of the supraspinatus insertion. Medialized repair of the supraspinatus can be performed only to an extent beyond which it compromises glenohumeral motion. We noted a statistically significant decrease in ROM with even a 3 mm medialization of the tendon, but the acceptable medialization has to be determined on a case-to-case basis.

Arthroscopic Repair of Large Subscapularis Tear Over the First Facet

Background: Long-term studies on arthroscopic repair of large subscapularis (SSC) tears over the first facet with or without supraspinatus (SSP) tear are limited. Purpose: To assess the structural and clinical outcomes of arthroscopic repair of large SSC tears using magnetic resonance imaging (MRI) and identify the factors related to SSC retear and poor outcomes. Study Design: Case series; Level of evidence, 4. Methods: This study involved 109 patients (84.0 ± 36.2 months of follow-up) who underwent arthroscopic repair of large SSC tears (Yoo and Rhee classification type III [n = 81] or IV [n = 28]) between 2011 and 2019. All patients underwent MRI at 6.1 ± 0.4 months after surgery, and 79 of 109 patients (72.5%) were followed up over 7 years. Clinical outcomes (active range of motion, functional scores, and belly press strength) and final poor clinical outcomes (reoperation, osteoarthritic change, and poor clinical outcome) were recorded. SSP tear size, rotator cuff atrophy and fatty infiltration (Goutallier classification), SSC tendon integrity (intact, intermediate, definite tear), and SSP tendon integrity (Sugaya classification) were evaluated by MRI. Results: The overall SSC retear rate was 8.3% (9/109) (type III, 2/81 [2.5%]; type IV, 7/28 [25.0%]; P < .001). SSC Goutallier grade 4 showed a higher retear rate than grade 3 (7/33 [21.2%] vs 2/33 [6.1%]; P = .149). A large SSP tear (in millimeters) (odds ratio [OR], 1.5; P = .003), SSC Goutallier grade 4 (OR, 10.8; P = .047), and SSP Goutallier grade 3 or 4 (OR, 0.02; P = .013) were independent factors for SSC retear. Clinical outcomes, except for external rotation, were poorer in patients with SSC retear than in those without retear. Final poor clinical outcomes were observed in 27 of 79 patients (34.2%); female sex (OR, 7.7; P = .007), SSC retear (OR, 8.2; P = .025), and SSP retear (OR, 4.7; P = .031) were independent factors. Conclusion: Arthroscopic repair of large SSC tears has shown promising structural outcomes for type III tears but not type IV tears. SSC retear was affected by SSC atrophy, as well as SSP tear size and atrophy. Approximately one-third of the final poor clinical outcomes could be predicted, and SSC retear, SSP retear, and female sex were associated with long-term poor clinical outcomes, underscoring the importance of carefully selecting patients for arthroscopic repair of large SSC tears.

Investigating the multifactorial etiology of supraspinatus tendon tears.

The purpose of this study was to develop a multivariable model to determine the extent to which a combination of etiological factors is associated with supraspinatus tendon tears. Fifty-four asymptomatic individuals (55 ± 4 years) underwent testing of their dominant shoulder. Diagnostic ultrasound was used to assess for a supraspinatus tendon tear. The etiological factors investigated includeddemographics (age and sex), tendon impingement during shoulder motion (via biplane videoradiography), glenohumeral morphology (via computed tomography imaging), family history of a tear (via self-report), occupational shoulder exposure (via shoulder job exposure matrix), and athletic exposure (via self-report). Univariate relationships between etiological predictors and supraspinatus tears were assessed using logistic regression and odds ratios (ORs), while multivariable relationships were assessed using classification and regression tree analysis. Thirteen participants (24.1%) had evidence of a supraspinatus tear. Individuals with a tear had a higher critical shoulder angle (OR 1.2, p = 0.028) and acromial index (OR 1.2, p = 0.016) than individuals without a tear. The multivariable model suggested that a tear in this cohort can be explained with acceptable accuracy (AUROC = 0.731) by the interaction between acromial index and shoulder occupational exposure: a tear is more likely in individuals with a high acromial index (p < 0.001), and in individuals with a low acromial index and high occupational exposure (p < 0.001). The combination of an individual's glenohumeral morphology (acromial index) and occupational shoulder exposure may be important in the development of supraspinatus tears.

Abduction causes increased strain gradient compared to forward flexion: Evidence from a cadaver model of simultaneous strain study of the rotator cuff tendons

BackgroundVarious strain studies of the supraspinatus have been done in isolation. Given that rotator cuff muscles function as a group, it may be physiologically representative to measure strain behaviour with the glenohumeral joint intact. Here, we explored a novel method in measuring simultaneous strain behaviour of the rotator cuff tendons and investigated the effect of full-thickness anterior tear of the supraspinatus on the infraspinatus and subscapularis tendons. MethodsNine cadaveric shoulders were evaluated on a customized rig. Using linear differential variable transducers to measure strain, each shoulder was subjected to up to 60° of elevation in the coronal, scapular, and sagittal planes. We also assessed 30° of external rotation and up to 60° of internal rotation of the humerus. Full-thickness anterior tear of the supraspinatus was then made before re-assessing strain patterns in the scapular plane.Findings:Strain measurements of the intact tendons revealed a significant strain gradient between the articular and bursal sides of the supraspinatus during increasing degrees of elevation in the coronal and scapular planes. Full thickness anterior tear of the supraspinatus is localised to the tendon and does not affect the surrounding cuff musculature, with a potential shielding effect of the infraspinatus during early glenohumeral abduction. InterpretationSignificant strain gradient exists between the articular and bursal sides of the supraspinatus during abduction but not during forward flexion in an intact glenohumeral joint. Rehabilitation exercises for anterior supraspinatus tears can be appropriately targeted on the remaining intact rotator cuff musculature.

Microfragmented adipose tissue in the treatment of a full-thickness supraspinatus tear: a case report.

A 70-year-old female presented with an 8-month history of right anterior shoulder pain and weakness, unresolved with conservative management. Among other shoulder pathology, the patient was diagnosed with a full-thickness supraspinatus tear and elected to proceed with the microfragmented adipose tissue procedure to treat the injured tendon and nearby relevant structures. Improvements in pain and function were documented along with progressive healing of the supraspinatus on ultrasound and MRI following the procedure. This case demonstrates the efficacy of microfragmented adipose tissue as a relatively novel approach to treating non-retracted, full-thickness rotator cuff tears.

Diagnostic Performance of Belly-Press Angle in Predicting the Severity of Subscapularis Tear

Background: Neglected partial subscapularis tears often cause functional impairment even after repair of the supraspinatus and infraspinatus tear is done. Numerous physical examinations for detecting partial subscapularis tears have been described in previous studies. Purpose: To analyze the relationship between the preoperative clinical features and the severity of a partial subscapularis tear and to provide diagnostic clues for patients requiring subscapularis repair. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: This retrospective study included 286 patients who underwent arthroscopic shoulder surgery between 2020 and 2022. Preoperative clinical features, including range of motion, functional scores, muscle strength ratio, modified belly-press test (measuring belly-press angle), and bear-hug test, were collected. Magnetic resonance imaging (MRI) evaluation was done according to the Yoo and Rhee classification. Types of subscapularis tear, supraspinatus lesion, and biceps lesion were recorded during arthroscopic surgery. A comparison of preoperative clinical features between the no-repair group (type 2A or less) and surgical repair group (type 2B or more) was done. The optimal cutoff value of the belly-press angle was determined and the diagnostic performance of the belly-press angle, bear-hug test, and MRI were evaluated using the receiver operating characteristic curve. Results: Among 286 patients, 189 (66.1%) had subscapularis tears with type 2A or more. There was a significant difference in muscle strength ratio of the belly-press (P < .001), belly-press angle (P < .001), and bear-hug test (P < .001) between the no-repair group (type 2A or less) and the surgical repair group (type 2B or more). With a belly-press angle of 15° as a new cutoff value, the modified belly-press test showed 67.6% sensitivity, 73.9% specificity, and 69.6% accuracy in detecting type 2B or higher subscapularis tear. Conclusion: Patients with type 2A and 2B subscapularis tears (according to the Yoo and Rhee classification) showed differences in belly-press strength ratio, belly-press angle, and bear-hug test. The cutoff value of the 15° belly-press angle showed an accuracy of 69.6% in detecting subscapularis tears with type 2B or higher.

The Long Head of the Biceps Has a Stabilizing Effect on the Glenohumeral Joint in Simulated Infraspinatus or Subscapularis but Not Supraspinatus Rotator Cuff Deficiency—A Biomechanical Study

To investigate the stabilizing role of the long head of the biceps (LHB) for different simulated rotator cuff (RC) tears. Human cadaveric specimens (n= 8) were fixed in a robotic-based experimental setup with a static loading of the RC, deltoid, and the LHB. RC tears were simulated by unloading of the corresponding muscles. A throwing motion and an anterior load-and-shift test were simulated under different RC conditions by unloading the supraspinatus (SS), subscapularis (SSc), infraspinatus (IS), and combinations (SS+ SSc, SS+ IS, SS+ SSc+ IS). The LHB was tested in 3conditions: unloaded, loaded, and tenotomy. Translation of the humeral head and anterior forces depending on loading of the RC and the LHB was captured. Loading of LHB produced no significant changes in anterior force or glenohumeral translation for the intact RC or a simulated SS tear. However, if SSc or IS were unloaded, LHB loading resulted in a significant increase of anterior force ranging from 3.9 N (P= .013, SSc unloaded) to 5.2 N (P= .001, simulated massive tear) and glenohumeral translation ranging from 2.4 mm (P= .0078, SSc unloaded) to 7.4 mm (P=.0078, simulated massive tear) compared to the unloaded LHB. Tenotomy of the LHB led to a significant increase in glenohumeral translation compared to the unloaded LHB in case of combined SS+ SSc (2.6 mm, P= .0391) and simulated massive tears of all SS+ SSc+ IS (4.6 mm, P= .0078). Highest translation was observed in simulated massive tears between loaded LHB and tenotomy (8.1 mm, P= .0078). Once SSc or IS is simulated to be torn, the LHB has a stabilizing effect for the glenohumeral joint and counteracts humeral translation. With a fully loaded RC, LHB loading has no influence. With an intact RC, the condition of the LHB showed no biomechanical effect on the joint stability. Therefore, from a biomechanical point of view, the LHB could be removed from the joint when the RC is intact or reconstructable. However, since there was a positive effect even of the unloaded LHB in this study when SSc or IS is deficient, techniques with preservation of the supraglenoid LHB origin may be of benefit in such cases.

Diagnostic performance of a 3D double-echo steady-state sequence at 3 T using radial reformats for detecting and grading rotator cuff tears: a pilot diagnostic accuracy study with magnetic resonance imaging and arthroscopic correlation.

In diagnosing rotator cuff tears (RCTs), magnetic resonance imaging (MRI) is the imaging modality of choice, and its accuracy is improving constantly. To evaluate the diagnostic performance of a high-resolution 3D double-echo steady-state (DESS) sequence with radial and paracoronal 3-T MRI regarding the grading of RCTs in correlation with conventional 2D MRI and arthroscopic findings. We retrospectively compared arthroscopic findings of RCTs with preoperative MRI, including conventional 2D sequences and radial and paracoronal DESS images in 20 patients. Two observers evaluated supraspinatus (SSP), infraspinatus (ISP), and subscapularis (SSC) tendon tears using a grading system. For statistical analysis, arthroscopy was used as the reference standard. Inter-observer agreement for detecting and grading SSP, ISP, and SSC tendon tears on radial and paracoronal sliced 3D DESS MRI was excellent (intraclass-correlation [ICC] = 0.92-0.98; all P < 0.001). Regarding the detection of SSP lesions, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 93.8%, 50%, 88.2%, and 66.7% for both radial and paracoronal DESS imaging. A sensitivity of 100%, specificity of 61.1%, PPV of 22.2%, and NPV of 100% were noted for detecting ISP tendon tears using radially reformatted DESS images. Regarding detecting SSC tendon tears using radially reformatted DESS images, sensitivity, specificity, PPV, and NPV were 100%, 81.3%, 50%, and 100%, respectively. The results with standard 2D MRI were similar. The DESS technique with radially reformatted images provided excellent sensitivity and high inter-observer agreement in detecting RCTs. It showed a moderate to high correlation between MRI and arthroscopy for diagnosing SSP and SSC tendon tears.

Modified arthroscopic intra-articular transtendinous looped biceps tenodesis leads to satisfactory functional outcomes and less frequent Popeye deformity compared to biceps tenotomy

PurposeThe present study aimed to propose a modified intra-articular transtendinous looped biceps tenodesis (mTLBT) using a suture anchor and to compare the functional outcomes and incidence of Popeye deformities between biceps tenotomy and mTLBT.MethodsMedical records of patients who underwent either tenotomy or mTLBT for the long head of the biceps tendon (LHBT) lesion between January 2016 and April 2021 were retrospectively reviewed. The inclusion criteria were patients aged 40–70 years with LHBT pathologies, such as superior labrum anterior to posterior (SLAP) lesions > type II, LHBT pulley system rupture with bicipital instability, and intra-articular LHBT tear. The exclusion criteria were full-thickness supraspinatus tears, frozen shoulder, shoulder fracture, and postoperative traumatic events that affected the operated shoulder. All patients were followed up for at least 1 year. Popeye deformity, bicipital cramping pain, visual analog scale (VAS) pain score, and functional outcome scores (University of California at Los Angeles [UCLA] and American Shoulder and Elbow Surgeons [ASES] scores) were recorded. Fisher’s exact test and Chi-square test were used for categorical variables, whereas the Mann–Whitney U test was used for nonparametric variables.ResultsThe mTLBT and tenotomy groups included 15 and 40 patients, respectively. The incidence of Popeye deformity and biceps cramping pain in the tenotomy group (52.5% and 50%, respectively) was significantly higher than that in the mTLBT group (13.3% and 20%, respectively) (p = 0.009 and p = 0.045, respectively). The postoperative VAS, UCLA, and ASES scores were not significantly different between the two groups. One patient in the tenodesis group experienced metallic-anchor pullout.ConclusionmTLBT is an arthroscopic intra-articular top of the groove tenodesis that can be performed completely in the intra-articular space and is especially suitable for patients with an intact or partially torn rotator cuff. This technique is reliable for treating biceps pathologies as it results in similar functional outcome scores, lesser biceps cramping pain, and less frequent Popeye deformity compared to biceps tenotomy.Level of EvidenceIII.

Relative contributions of the supraspinatus cord and strap tendons to shoulder abduction and translation

The supraspinatus (SS) is formed by a larger anterior bipennate muscle with a cord like tendon and a posterior unipennate muscle with a strap like tendon. There is a tendinous connection between the two SS subunits. Yet, the relative mechanical contribution of the SS cord and SS strap muscular tendinous units to load transmission and subsequent shoulder abduction force is unknown. We hypothesized that a simulated SS cord versus a SS strap tear will generate less shoulder abduction force; and further, an intact SS cord will offset the expected abduction loss from a SS strap tear, but the inverse will not be true. Twenty fresh-frozen cadaveric specimens were tested in a shoulder simulator with physiological load vectors applied to the upper and lower subscapularis, SS cord, SS strap, infraspinatus, and teres minor. The roles of the SS cord and SS strap muscles were delineated by varying their loads, while keeping constant loads on other muscles. The randomized testing trials included a Native condition and four test Cases which simulated tears by dropping the load and force transfer via the SS cord-to-SS strap connection by adding the load. Testing was completed at both 0° and 30° of abduction. During each test shoulder abduction force, rotator cuff strains and humeral translation were measured. Simulated isolated SS cord and SS strap tears lead to a significantly lower shoulder abduction force (p<0.001). A simulated cord tear at 0° and 30° reduced the abduction force by 53% and 38%, respectively. A simulated strap tear at 0° and 30° dropped the abduction force by 27% and 23%, respectively. The decline in abduction force was larger for the SS cord tear versus SS strap tear (p≤0.001). A SS cord tear with full load transfer to the strap was able to recover to native values at both 0° and 30° (p≥0.288). Likewise, a SS strap tear with full load transfer to the SS cord showed a similar recovery to native values at both 0° and 30° (p≥0.155). During full load transfer, the tendon strain followed the loading pattern. A SS cord tear or SS strap tear did not cause a change in humeral translation (p≥0.303). A mechanical findings support the efficacy of nonoperative treatment of small (<10mm) SS tears,11 because an intact SS strap tendon can effectively offset the abduction loss of a torn SS cord tear, and vice versa.

Midterm Clinical Outcomes After Arthroscopic Rotator Cuff Repair in Olympic Volleyball Players: Return to Sports and Return to Performance.

The decision-making process and predicting the time to return to sport (RTS) and return to performance (RTP) after arthroscopic rotator cuff repair (ARCR) in elite volleyball players are difficult issues to address, even among experienced shoulder surgeons. The purpose of the study was to evaluate the results in Olympic-level volleyball players treated with arthroscopic supraspinatus repair and to report the RTS and the RTP. It was hypothesized that these athletes had higher RTS and faster RTP. Case series; Level of evidence, 4. This study included 17 elite volleyball athletes (11 male, 6 female; mean age, 26.2 years) who underwent ARCR for partial- and full-thickness supraspinatus tears that did not improve despite nonoperative treatment. The clinical results were evaluated at 12 months postoperatively. The authors compared the athletes' preoperative, 6-month, and 12-month Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and the visual analog scale (VAS) for pain after competition and conducted 6- and 12-month isometric strength analyses. The athletes' RTS and RTP times were recorded. All tears were on the dominant side (15 right, 2 left), and 82% were partial tears (14 partial thickness, 3 full thickness). The mean time from the onset of symptoms to surgery was 11.3 ± 6.7 months. While the mean Kerlan-Jobe Orthopaedic Clinic score was 31 preoperatively, it was 89 after 6 months (P < .001 vs preoperative) and 96 after 12 months (P = .003 vs 6 months). The mean VAS for pain was 7.9 preoperatively, 0.4 at 6 months (P < .001 vs preoperative), and 0.1 at 12 months (P = .02 vs 6 months). All athletes were able to reach their preinjury level, with RTS at a mean of 6.9 months and RTP at a mean of 12.4 months. ARCR appears to be an effective option for Olympic-level volleyball players who do not benefit from nonoperative treatment. All athletes returned to their preinjury level of sports. The surgeon and athlete can plan surgical decision-making and timing based on the mean RTS time of 6.9 months and mean RTP time of 12.4 months.

Arthroscopic Superior Capsular Reconstruction With the Long Head of the Biceps Tendon to Reinforce the Repair of a Supraspinatus Tear and Increase Healing

Rotator cuff tears continue to be a challenge for the shoulder surgeon since there is still a high rate of retears. To increase the rate of repair and decrease the number of retears, we present a technique, in which we reinforce a tension-free double-row repair of the supraspinatus with reconstruction of the superior capsule with the long head of the biceps (LHB). With this reinforcement of the cuff suture using the LHB, we increase both the biomechanics and biology of the repair and decrease the rate of reruptures.

Midterm outcome of superior capsular reconstruction using doubled acellular human dermal allograft for irreparable rotator cuff tear

Thicker (folded) facia lata autografts have been shown to be superior to thinner grafts and single-layered acellular human dermal (HD) allografts for superior capsular reconstruction (SCR) in biomechanical studies. The aim of this study was to evaluate the mid-term clinical outcomes following SCR for irreparable supraspinatus tears using doubled (folded) HD allograft. Thirty-two patients who had undergone SCR using doubled HD allograft between February 2012 through January 2020 were recruited in a continuous manner in this retrospective study. The inclusion criteria were SCR performed for irreparable supraspinatus tear and a minimum of two years follow-up. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) score. The secondary outcome measures were complications and revision surgery. A subgroup analysis was performed between patients who received a "Standard" graft of mean 3mm thickness or a "Thick" graft of mean 4.4mm thickness. One patient was lost to follow-up. A total of 31 patients (31 shoulder joints) were analyzed with mean follow-up duration of 48 months (range, 25-96 months). Following surgery, there was significant improvement in ASES score from 18.1 ± 14.3 (preoperative) to 76.3 ± 25.1 (postoperative) (P < 0.001) with a satisfactory clinical outcome obtained in 83.8% of the patients. In a subset of eight patients completing five-years follow-up, clinical improvements were sustained. The percentage of patients with a clinically successful outcome was higher with thick grafts compared to patients with standard grafts, although this failed to reach statistical significance (94.4% vs 69.2%, RR=1.36, 95%CI 0.93-1.99, P = 0.13). One patient within the standard group underwent revision surgery. SCR for irreparable rotator cuff tears with doubled HD allograft results in improved clinical outcomes and low reoperation at mid-term follow-up duration.

Paper 47: Deep Learning Accurately Predicts Supraspinatus Pathology on Shoulder Magnetic Resonance Imaging

Objectives: Rotator cuff tears (RCT) are common injuries that increase in frequency with age. Deep learning is a subfield of artificial intelligence that uses artificial neural networks to perform a variety of tasks, including image analysis. Several previous studies have investigated the utility of deep learning for identifying fatty infiltration, muscle atrophy, and tear size of the supraspinatus muscle on shoulder magnetic resonance imaging (MRI). However, limited data exists on the use of deep learning for image analysis to determine the presence of supraspinatus pathology versus normal anatomy on shoulder MRI. RadImageNet, a recently published database consisting of 1.35 million annotated computed tomography (CT), MRI, and ultrasound (US) images from greater than 130,000 patients, contains thousands of shoulder MRI images. No research to date has investigated whether deep learning algorithms can accurately detect supraspinatus pathology on MRIs in the RadImageNet database. The objective of the present study was to determine if deep learning algorithms can accurately differentiate shoulder MRI images as those with supraspinatus pathology versus normal anatomy in the RadImageNet database. Methods: The RadImageNet database was queried for all MRI images containing supraspinatus pathology. Both supraspinatus tears (partial and full thickness) and tendinosis images are categorized under the same “supraspinatus pathology” label in the database. In the comparison cohort with normal anatomy, coronal and sagittal images capturing the supraspinatus muscle were included. Although the supraspinatus was still visualized, all sagittal images medial to the glenoid were excluded to better represent the supraspinatus pathology images. The training/validation/test datasets were created using a random 80/10/10 split of the entire cohort. Data were pre-processed using standard data augmentation, including random cropping, rotation, and translation of images. ConvNeXt, a pre-trained deep learning model for the purposes of image analysis, was chosen as the base architecture for transfer learning to optimize both accuracy and computing speed. The ConvNeXt model was trained using training (N=4,937 images) and validation (N=619 images) sets for 15 epochs. Algorithm performance was assessed on an independent test cohort (N=619 images) not used during model training. Performance metrics included classification accuracy, sensitivity, specificity, and positive and negative predictive values. Model training was performed in PyTorch on an 8-gigabyte NIVIDIA Quadro M4000 Cloud Graphics Processing Unit. Results: A total of 5,241 shoulder MRIs with supraspinatus pathology and 932 without any pathology were obtained for comparison. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of the classifier on the independent test set was 98.9% (95% confidence interval: 97.7% – 99.5%), 98.7%, 100.0%, 100.0%, and 93.1%, respectively. A confusion matrix for model predictions on the test set is displayed in Figure 1. Interpretation plots displaying six examples of incorrect model predictions are shown in Figure 2. Class 1 and 2 designate images without pathology and those with supraspinatus pathology, respectively. All six images were cases where the model predicted “normal” when the ground truth label of the image was supraspinatus pathology. Figure 3 demonstrates an example of class activation mapping, which visually indicates the areas on an image that influenced the model prediction the most. Bright yellow coloration indicates highly influential regions whereas purple coloration corresponds to regions that were less influential. In Figure 3, which is an example image of supraspinatus pathology, one of the most influential regions appears to localize to the supraspinatus tendon. Conclusions: Deep learning is a viable method for differentiating supraspinatus pathology from normal anatomy on shoulder MRIs. The ConvNeXt model demonstrated excellent performance in predicting images with supraspinatus pathology on shoulder MRIs in the RadImageNet database. Future research using deep learning techniques to classify different rotator cuff tear types and sizes is warranted.

Evaluation of the acromion variants in MRI and their association with rotator cuff injuries in non-traumatic patients

PurposeUnderstanding demographic and MRI parameters with determinant role in rotator cuff tearing (RCT) is required to predict outcomes and select more appropriate treatment in patients with non-traumatic shoulder pain. This study aimed to survey the association of rotator cuff tears with these factors. MethodsWe performed this cross-sectional study on patients referred to Kashani Hospital with non-traumatic shoulder pain suspected of rotator cuff injuries from April 2020 to February 2021. We obtained their demographic data and MRI from electronic hospital records. After that, two radiologists reviewed MRI and recorded data. We employed the SPSS 23 software to organize the obtained results and statistical evaluations. Results371 subjects, with the age of 48.61 ± 14.89 years, were included in our study, and 50% of them were male. The flat and down-sloping acromion and partial tearing of the supra and infraspinatus tendons were more frequent than the others. Gender could not consider as a determinant factor for the severity of tendon injuries, acromion types and variants. The relation of age to acromion morphology and the tendinopathy severity was significant. Remarkably, down-sloping acromion was higher at all the acromion shapes; however, it makes no difference in the level of supra and infraspinatus involvement. Moreover, we found that partial tearing was higher in all acromion types, except concave. This distribution was significant only for supraspinatus tears. ConclusionThe clinical decision is the most important step in patients with RCT and MRI prognostic factors, which are helpful to improve the management of the cases. RCT in older patients and down-slope acromion was more severe than the others. According to the previous studies, acromion morphology (as an important determinant factor) in RCT could be influenced by age, as well.

Development and clinical validation of deep learning for auto-diagnosis of supraspinatus tears

BackgroundAccurately diagnosing supraspinatus tears based on magnetic resonance imaging (MRI) is challenging and time-combusting due to the experience level variability of the musculoskeletal radiologists and orthopedic surgeons. We developed a deep learning-based model for automatically diagnosing supraspinatus tears (STs) using shoulder MRI and validated its feasibility in clinical practice.Materials and methodsA total of 701 shoulder MRI data (2804 images) were retrospectively collected for model training and internal test. An additional 69 shoulder MRIs (276 images) were collected from patients who underwent shoulder arthroplasty and constituted the surgery test set for clinical validation. Two advanced convolutional neural networks (CNN) based on Xception were trained and optimized to detect STs. The diagnostic performance of the CNN was evaluated according to its sensitivity, specificity, precision, accuracy, and F1 score. Subgroup analyses were performed to verify its robustness, and we also compared the CNN’s performance with that of 4 radiologists and 4 orthopedic surgeons on the surgery and internal test sets.ResultsOptimal diagnostic performance was achieved on the 2D model, from which F1-scores of 0.824 and 0.75, and areas under the ROC curves of 0.921 (95% confidence interval, 0.841–1.000) and 0.882 (0.817–0.947) were observed on the surgery and internal test sets. For the subgroup analysis, the 2D CNN model demonstrated a sensitivity of 0.33–1.000 and 0.625–1.000 for different degrees of tears on the surgery and internal test sets, and there was no significant performance difference between 1.5 and 3.0 T data. Compared with eight clinicians, the 2D CNN model exhibited better diagnostic performance than the junior clinicians and was equivalent to senior clinicians.ConclusionsThe proposed 2D CNN model realized the adequate and efficient automatic diagnoses of STs, which achieved a comparable performance of junior musculoskeletal radiologists and orthopedic surgeons. It might be conducive to assisting poor-experienced radiologists, especially in community scenarios lacking consulting experts.