Tangent Sign Research Articles

Another Assessment of Fat Degeneration of Retracted Supraspinatus Muscle.

BackgroundThe purpose of this study was to assess the relevance of preoperative magnetic resonance imaging (MRI) evaluation by occupation ratio (OR) at maximum diameter of supraspinatus muscle.MethodsPatients from the Inje University Sanggye Paik Hospital who received rotator cuff repair and underwent pre- and postoperative MRI were selected as subjects of this study. On T1-weighted MRIs, OR of fat and muscle at Y-shaped view, OR at a location on supraspinatus muscle where its diameter was maximum on coronal view, and pre- and postoperative Goutallier Classification and changes in the tangent sign were measured. Statistical significance of postoperative OR was assessed regarding time from symptom onset to surgery, size of rotator cuff tear, preoperative OR, and the difference between ORs measured at maximum diameter of supraspinatus muscle and Y-shaped view.ResultsPreoperative OR at Y-shaped view was 52.28 ± 8.57 (32.5–65.3). Preoperative OR difference between maximum diameter and Y-shaped view was 13.76 ± 10.51 (2.38–42.04), and Pearson correlation coefficient was 0.604 (p=0.001). Postoperative OR at Y-shaped view was 63.77 ± 9.35 (37.3–76.1). Pearson correlation coefficient of pre- and postoperative Goutallier Classification was -0.579 (p=0.002) and Pearson correlation coefficient of the postoperative difference between ORs measured at maximum diameter of supraspinatus muscle and Y-shaped view was -0.386 (p=0.047).ConclusionsFatty degeneration of supraspinatus muscle in rotator cuff tear patients should be evaluated not only in the conventional Y-shaped view, but also at location of maximum diameter of supraspinatus muscle to establish patients’ therapeutic plan.

Evaluation of risk factors for irreparable rotator cuff tear in patients older than age 70 including evaluation of radiologic factors of the shoulder

Rotator cuff tears (RCTs) are generally considered to occur at the age of 40 to 50, but some becomes massive tears at the age of 60 to 70 if neglected. This study evaluated preoperative factors affecting tear size and reparability of rotator cuffs based on magnetic resonance imaging findings among patients older than age 70. We identified 270 patients with full-thickness RCTs (175 reparable tears, group A; 95 irreparable tears, group B) that were confirmed with magnetic resonance imaging findings from January 2009 to March 2016. Irreparable tear was identified if all of the following criteria were met: (1) a large to massive RCT based on the DeOrio and Cofield classification, (2) sum of preoperative global fatty degeneration index of the supraspinatus and infraspinatus ≥6, and (3) positive tangent sign. Preoperative variables included demographic data, medical history, and radiologic data. Acromial index, critical shoulder angle, and acromiohumeral interval (AHI) were evaluated to investigate the relationship between anatomic factors and reparability of RCT. Stepwise multivariated regression analysis revealed older age, longer symptom duration, longer duration of overhead sports activity, lower preoperative forward elevation of the shoulder joint, and shorter AHI as risk factors for irreparable RCTs. This study suggests that older age at surgery, longer duration of symptoms, longer duration of overhead sports activity, lower preoperative forward elevation of the shoulder joint, and shorter AHI are independent risk factors for irreparable RCT.

Arthroscopic single-row repair of massive potentially irreparable postero-superior cuff tear.

We retrospectively evaluated the results of complete repair of massive potentially irreparable postero-superior tears in a consecutive cohort of patients. With the increasing and widespread use of superior capsular reconstruction, a complete repair of the superior cuff, also if not functional, may be a valuable option for irreparable cuff lesions. A consecutive case series of massive potentially irreparable postero-superior cuff tears that underwent complete repair was included in the study. Irreparability of cuff tear was defined when on preoperative MRI images, a positive tangent sign, a Goutallier 3-4 stage of fatty infiltration, and an absent acromion-humeral distance were present. A single-row complete repair was performed using triple-loaded titanium suture anchors. Operative time was recorded, as well as intra- and postoperative complications. Patients were followed for 12months post-op; they were clinically evaluated with the use of constant score (CS) and subjective shoulder value (SSV) at 3, 6, and 12months; a 12-month postoperative ultrasound evaluation was obtained. Thirty-two patients satisfying the inclusion criteria were enrolled. The mean age was 52years (range 41-58). The repair was completed with a mean use of 2.4 triple-loaded suture anchors (range 2-4); the mean operative time was 70min (range 45-90). The mean preoperative CS was 55 (range 45-75, SD 17), while the SSV was 40 (range 30-70, SD 22). At the final follow-up, the mean CS and SSV were 72 (range 62-85, SD 8) and 80 (range 60-90, SD 10) (p < 0.001 with respect to the preoperative scores), respectively. At the final follow-up, sonography showed a complete healing of the cuff in 20 cases (62.5%). No intra-operative complications occurred; at the final follow-up, five patients (15, 6%) were not satisfied of the results and asked for revision surgery. The complete repair of massive potentially irreparable rotator cuff tear in patients younger than 60years old yielded good results at a short-term follow-up, with a sonographic re-tear rate of about 20%. Even if it is logical to consider a tendon with severe fatty degeneration as non-functional, the superior soft tissue reconstruction we achieved may have at least the same results of a superior capsular reconstruction, with obvious lower costs. Level 4, case series with no comparison group.

Prediction of the Irreparability of Rotator Cuff Tears

To determine the influence of preoperative factors on reparability of rotator cuff tears (RCTs) and yield a predictive model for predicting irreparability preoperatively. Among patients with full-thickness RCTs, the reparable group underwent arthroscopic rotator cuff repairs for reparable RCTs whereas the irreparable group underwent alternative surgical procedures for irreparable RCTs. We analyzed age, sex, chronic pseudoparalysis (CPP), mediolateral and anteroposterior tear sizes, acromiohumeral distance (AHD), tangent sign, fatty infiltration (FI) (group 1, Goutallier stage 0 or 1; and group 2, Goutallier stage 2, 3, or 4), and tendon involvement (TI) (type 1, supraspinatus; type 2, supraspinatus and subscapularis; type 3, supraspinatus and infraspinatus; and type 4, all 3 tendons). The irreparability rate was 12.5%. Between the reparable (663 patients) and irreparable (95 patients) groups, significant differences were found in age (58.8 ± 8.3years vs 65.6 ± 8.0years, P < .001); female sex (46.9% vs 63.2%, P= .014); CPP (6.5% vs 36.8%, P < .001); mediolateral tear size (23.7 ± 12.1mm vs 47.4 ± 9.1mm, P < .001); anteroposterior tear size (17.9 ± 11.5mm vs 43.4 ± 16.2mm, P < .001); AHD (9.0 ± 1.7mm vs 5.8 ± 1.6mm, P < .001); tangent sign (2.9% vs 61.1%, P < .001); group 2 FI of the subscapularis (6.9% vs 20.0%, P < .001), supraspinatus (12.1% vs 58.9%, P<.001), infraspinatus (26.8% vs 69.5%, P < .001), and teres minor (4.2% vs 10.5%, P= .008); and type 1, 2, 3, and 4 TI (88.1%, 6.2%, 5.4%, and 0.3%, respectively, vs 29.5%, 21.1%, 28.4%, and 21.1%, respectively; P < .001). Multiple logistic regression analysis showed CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI were significant independent predictors of irreparability, with odds ratios of 3.539 (P= .007), 1.087 (P < .001), 0.624 (P<.001), 6.141 (P < .001), 2.233 (P= .034), and 12.350 (P= .016), respectively. These factors yielded a predictive model for irreparability as follows: Logit P= 1.264× CPP+ 0.084× Mediolateral tear size - 0.472× AHD+ 0.804× Group 2 FI of supraspinatus+ 1.815× Tangent sign+ 2.514× Type 4 TI - 3.460. The irreparability of RCTs is strongly associated with CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4TI and can be preoperatively calculated using the predictive equation. Level III, retrospective comparative study.

A review of lumbosacral transitional vertebrae and associated vertebral numeration.

To review the current literature on methods of accurate numeration of vertebral segments in patients with Lumbosacral transitional vertebrae (LSTVs). LSTVs are a common congenital anomaly of the L5-S1 junction. While their clinical significance has been debated, unquestionable is the need for their identification prior to spinal surgery. We hypothesize that there are no reliable landmarks by which we can accurately number transitional vertebrae, and thus a full spinal radiograph is required. A Pubmed and EMBASE search using various combinations of specific key words including "LSTV", "lumbosacral transitional vertebrae", "count", "vertebral numbering", and "number" was performed. The gold standard for spinal segment numeration in patients with LSTV remains whole spine imaging and counting caudally, starting from C2. If whole spine imaging is not available, the use of the iliac crest tangent sign on coronal magnetic resonance imaging (MRI) has fairly reliable sensitivity and specificity (81 and 64-88%, respectively) for accurate numeration of LSTV. The role of paraspinal anatomic markers such as the right renal artery, superior mesenteric artery, aortic bifurcation, and conus medullaris, for identification of vertebral levels is unreliable and should not be used. A sagittal whole spine view should be added as a scout view when patients obtain lumbar MRI to standardize the vertebral numbering technique. To date, there has been no other method for accurate numeration of a transitional vertebral segment, other than counting caudally from C2. These slides can be retrieved under Electronic Supplementary Material.

Preoperative Korean Shoulder Scoring System Correlates with Preoperative Factors of Rotator Cuff Tears.

BackgroundThe Korean Shoulder Scoring System (KSS) is a reliable and valid procedure for discriminative assessment of the clinical status of patients with rotator cuff tears. This study evaluates the correlation between the preoperative KSS and factors in patients with rotator cuff tears.MethodsFrom November 2009 to June 2016, 970 patients who underwent arthroscopic rotator cuff repair were retrospectively evaluated. A total of 490 patients met the study criteria. Preoperative factors included age, sex, symptom duration, mediolateral (ML) and anteroposterior (AP) tear size, acromiohumeral distance (AHD), tangent sign, tendon involvement (type I, supraspinatus; type II, supraspinatus and subscapularis; type III, supraspinatus and infraspinatus; type IV, all 3 tendons), fatty infiltration of rotator cuff muscles (group I, Goutallier stages 0 and 1; group II, Goutallier stages 2, 3, and 4), and KSS.ResultsOld age, ML tear size, and AP tear size negatively correlated with the preoperative KSS (p<0.001). AHD showed a positive correlation with the preoperative KSS (p<0.001). A significantly inferior preoperative KSS was found in females and type III tendon involvement (p<0.001). For supraspinatus and infraspinatus, the preoperative KSS of group II fatty infiltration showed a significantly lower score than group I fatty infiltration (p<0.05).ConclusionsA relatively lower preoperative KSS was associated with old age, large tear size, narrow AHD, female, type III tendon involvement, and group II fatty infiltration of the supraspinatus and infraspinatus. Our study indicates that preoperative KSS can be a good measurement for the preoperative status of patients with rotator cuff tears.

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

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

Fatty Degeneration of the Rotator Cuff Reflects Shoulder Strength Deficits in Patients With Rotator Cuff Tears.

Fatty degeneration is an important clinical factor in patients with rotator cuff tears. Goutallier grade, occupation ratio, and tangent sign help identify fatty degeneration; however, little is known about how closely these measurement techniques correlate with actual muscle strength deficits. The authors evaluated each method's ability to determine the correlation between fatty degeneration and muscle strength deficits. The authors included 203 patients who underwent full-thickness rotator cuff repair (mean age, 61.29±7.92 years). All patients were evaluated with preoperative magnetic resonance imaging to identify fatty degeneration and with an isokinetic test to determine actual shoulder strength. Fatty degeneration was evaluated using Goutallier grade, occupation ratio, and tangent sign. The actual shoulder strength deficit was evaluated by abduction, whereas external and internal rotation were tested using the isokinetic test. More severe fatty degeneration was correlated with lower degrees of abduction, external rotation, and internal rotation. The occupation ratio was more closely correlated with actual muscle strength deficits. However, in patients with massive tears, the correlation between fatty degeneration and muscle strength was less pronounced. Tangent sign (+) findings had a significantly lower strength of external rotation and abduction. The fatty degeneration of the rotator cuff muscle measured by each method was correlated with actual shoulder strength deficits in patients with rotator cuff tears. However, the correlations were less clear in patients with massive rotator cuff tears. Therefore, in cases of massive rotator cuff tears, fatty degeneration was correlated with muscle strength deficits but was not directly proportional to their extent. [Orthopedics. 2018; 41(1):e15-e21.].

Preoperative radiographic risk factors for incomplete arthroscopic supraspinatus tendon repair in massive rotator cuff tears

Purpose The purposes of this study were to: determine if preoperative imaging findings thought to be characteristic of massive RC tears were associated with the need for advanced mobilization techniques (interval slides), and/or the use of a load sharing rip stop (LSRS) repair construct, and to determine the extent to which these imaging findings predicted the likelihood of an incomplete arthroscopic repair. Methods Eighty-six consecutive patients that underwent arthroscopic repair for massive RC tears performed by a single surgeon were retrospectively evaluated. Previously proposed radiographic risk factors for irreparability (acromiohumeral distances, tangent sign and the Goutallier stage of fatty infiltration for the supraspinatus) were analyzed. Associations between preoperative imaging characteristics and intraoperative results of RC surgery were determined using binary logistic regressions and Fisher's exact tests. The inter-observer reliability of imaging characteristics was determined using intraclass correlation coefficients (ICC). Results Seventy-six massive RC tears were fully reparable (88%). In the case of 10 RC tears (12%), a complete repair was not obtained. Inability to obtain a complete repair of the supraspinatus was associated with a positive tangent sign (30% irreparable) versus a negative tangent sign (6.3% irreparable, OR = 6.3, P = 0.0102) and with Goutallier grade 3–4 fatty infiltration of the supraspinatus (42.9% irreparable) versus grade 0–2 fatty infiltration (5.7% irreparable, OR = 11.8, P = 0.001). No associations were found between preoperative imaging characteristics and use of interval slides or LSRS. Inter-observer reliability was moderate (ICC 0.75–0.90) for the tangent sign (ICC = 0.78) and high-grade (Goutallier 3–4) fatty infiltration of the supraspinatus (ICC = 0.74). Conclusions A positive tangent sign and/or high-grade fatty infiltration (Goutallier 3–4) were risk factors for incomplete RC tear repair. However, these were not completely predictive of reparability, as the majority of massive RC tears with these imaging characteristics were still fully reparable.

The incidence and effect of fatty atrophy, positive tangent sign, and rotator cuff tears on outcomes after total shoulder arthroplasty

Treatment choices for total shoulder arthroplasty (TSA) in the absence of full-thickness rotator cuff tears (RCTs) are not clearly defined in current literature. This study investigated the prevalence and effect of preoperative partial-thickness RCTs and muscular degenerative changes on postoperative outcomes after TSA. Medical records and magnetic resonance imaging studies were reviewed for patients who underwent TSA for primary glenohumeral osteoarthritis with minimum 2-year follow-up to determine preoperative tear classification, Goutallier grade, and supraspinatus tangent sign. Postoperative pain on the visual analog scale, range of motion, and patient outcomes scores were obtained to correlate preoperative RCT status, Goutallier grading, tangent sign, and postoperative outcomes. Patients with full-thickness RCT on preoperative magnetic resonance imaging were excluded. Forty-five patients met all inclusion criteria (average age, 65 ± 10 years; average follow-up, 43 months). Of the patients undergoing TSA, 40% had a significant (>50% thickness) partial RCT. Grade 3 to 4 Goutallier changes were noted in 22% of all patients, and 13% demonstrated grade 3 to 4 changes in the context of no tear. Positive tangent sign was present in 7% of all patients. The preoperative Goutallier grade of the infraspinatus was significantly negatively correlated with postoperative forward elevation (P = .02) and external rotation (P = .05), but rotator cuff pathology, including tear status, Goutallier grade, and the presence of a tangent sign, did not correlate with postoperative functional outcome scores. Even in the absence of a full-thickness RCT, rotator cuff atrophy, fatty infiltration, and partial thickness tearing are common findings. Although postoperative range of motion is correlated to Goutallier changes of the infraspinatus, rotator cuff pathology is not correlated to outcomes after TSA; therefore, one may proceed with TSA without concern of their effect on postoperative outcomes.

Rotator cuff muscle degeneration and tear severity related to myogenic, adipogenic, and atrophy genes in human muscle.

Large rotator cuff tear size and advanced muscle degeneration can affect reparability of tears and compromise tendon healing. Clinicians often rely on direct measures of rotator cuff tear size and muscle degeneration from magnetic resonance imaging (MRI) to determine whether the rotator cuff tear is repairable. The objective of this study was to identify the relationship between gene expression changes in rotator cuff muscle degeneration to standard data available to clinicians. Radiographic assessment of preoperative rotator cuff tear severity was completed for 25 patients with varying magnitudes of rotator cuff tears. Tear width and retraction were measured using MRI, and Goutallier grade, tangent (tan) sign, and Thomazeau grade were determined. Expression of myogenic-, adipogenic-, atrophy-, and metabolism-related genes in biopsied muscles were correlated with tear width, tear retraction, Goutallier grade, tan sign, and Thomazeau grade. Tear width positively correlated with Goutallier grade in both the supraspinatus (r = 0.73) and infraspinatus (r = 0.77), along with tan sign (r = 0.71) and Thomazeau grade (r = 0.68). Decreased myogenesis (Myf5), increased adipogenesis (CEBPα, Lep, Wnt10b), and decreased metabolism (PPARα) correlated with radiographic assessments. Gene expression changes suggest that rotator cuff tears lead to a dramatic molecular response in an attempt to maintain normal muscle tissue, increase adipogenesis, and decrease metabolism. Fat accumulation and muscle atrophy appear to stem from endogenous changes rather than from changes mediated by infiltrating cells. Results suggest that chronic unloading of muscle, induced by rotator cuff tear, disrupts muscle homeostasis. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2808-2814, 2017.

Can Preoperative Magnetic Resonance Imaging Predict the Reparability of Massive Rotator Cuff Tears?

Background: Numerous studies have shown preoperative fatty infiltration of rotator cuff muscles to be strongly negatively correlated with the successful repair of massive rotator cuff tears (RCTs). Purpose: To assess the association between factors identified on preoperative magnetic resonance imaging (MRI), especially infraspinatus fatty infiltration, and the reparability of massive RCTs. Study Design: Case-control study; Level of evidence, 3. Methods: We analyzed a total of 105 patients with massive RCTs for whom MRI was performed ≤6 months before arthroscopic procedures. The mean age of the patients was 62.7 years (range, 46-83 years), and 46 were men. Among them, complete repair was possible in 50 patients (48%) and not possible in 55 patients (52%). The tangent sign, fatty infiltration of the rotator cuff, and Patte classification were evaluated as predictors of reparability. Using the receiver operating characteristic curve and the area under the curve (AUC), the prediction accuracy of each variable and combinations of variables were measured. Results: Reparability was associated with fatty infiltration of the supraspinatus (P = .0045) and infraspinatus (P < .001) muscles, the tangent sign (P = .0033), and the Patte classification (P < .001) but not with fatty infiltration of the subscapularis and teres minor (P = .425 and .132, respectively). The cut-off values for supraspinatus and infraspinatus fatty infiltration were grade >3 and grade >2, respectively. The examination of single variables revealed that infraspinatus fatty infiltration showed the highest AUC value (0.812; sensitivity: 0.86; specificity: 0.76), while the tangent sign showed the lowest AUC value (0.626; sensitivity: 0.38; specificity: 0.87). Among 2-variable combinations, the combination of infraspinatus fatty infiltration and the Patte classification showed the highest AUC value (0.874; sensitivity: 0.54; specificity: 0.96). The combination of 4 variables, that is, infraspinatus and supraspinatus fatty infiltration, the tangent sign, and the Patte classification, had an AUC of 0.866 (sensitivity: 0.28; specificity: 0.98), which was lower than the highest AUC value (0.874; sensitivity: 0.54; specificity: 0.96) among the 2-variable combinations. Conclusion: The tangent sign or Patte classification alone was not a predictive indicator of the reparability of massive RCTs. Among single variables, infraspinatus fatty infiltration was the most effective in predicting reparability, while the combination of Goutallier classification <3 of the infraspinatus and Patte classification ≤2 of the rotator cuff muscles was the most predictive among the combinations of variables. This information may help predict the reparability of massive RCTs.

Changes of Muscle Atrophy According to the Immediate Postoperative Time Point in Magnetic Resonance Imaging After Arthroscopic Rotator Cuff Repair

The purpose of this study was to investigate changes of rotator cuff muscles after arthroscopic rotator cuff repair by measuring the muscle atrophy (MA) of rotator cuff muscles at the preoperative, immediate postoperative, and 1-year postoperative time points. Inclusion criteria were (1) arthroscopic rotator cuff repair of a full-thickness rotator cuff tear and (2) the presence of the preoperative (approximately 1 month before surgery), immediate postoperative (approximately 3 days after surgery), and 1-year postoperative magnetic resonance imaging (MRI) undertaken at our institution. Exclusion criteria were (1) the absence of any of the 3 MRIs, (2) isolated subscapularis repair, and (3) rotator cuff repair with margin convergence only. The MA was assessed with the modified tangent sign (TS), the occupation ratio (OR), and the cross-sectional areas (CSAs) of the supraspinatus and infraspinatus. Structural integrity was evaluated using Sugaya's classification. Measurements 1year after surgery were compared with those of the preoperative and the immediate postoperative time points according to the integrity. Seventy-seven patients were included in the study. The TS improved in 23.4% of patients and worsened in 6.5% with the preoperative baseline, while it improved in 5.2% of patients and worsened in 23.4% (P < .001). The OR improved in 24.5% of patients but worsened in 3.9% with the preoperative baseline, while it improved in 13.0% and worsened in 11.7% patients (P < .001). The CSAs of the supraspinatus and infraspinatus changed by 8.7% ± 24.5% and-0.3% ± 16.1% with the preoperative baseline and by-12.8% ± 20.3% and-10.5% ± 14.9% with the immediate postoperative baseline (all P < .001). The results of the study showed that changes of the MA after arthroscopic rotator cuff repair were different with respect to the baselines and the integrity. Generally, the MA measured with the immediate postoperative baseline worsened, whereas that measured with the preoperative baseline improved. Level III, retrospective comparative study.

Tendon retraction with rotator cuff tear causes a decrease in cross-sectional area of the supraspinatus muscle on magnetic resonance imaging

Muscle atrophy and fatty degeneration of the rotator cuff muscles have been reported as negative prognostic indicators after rotator cuff repair. Although the Y-shaped view is widely used for measuring the cross-sectional area of the supraspinatus muscle, the contribution of retraction of the torn tendon as well as muscle atrophy must be considered. The purpose of this study was to clarify the relationship between cross-sectional area and tendon retraction or size of the tear. This study included 76 shoulders that were evaluated arthroscopically for the presence and size of tears. Cross-sectional areas of rotator cuff muscles were measured from the Y-shaped view to 3 more medial slices. The occupation ratio and tangent sign were evaluated on the Y-shaped view. The retraction of torn tendon was also measured on the oblique coronal images. On the Y-shaped view, the cross-sectional area of the supraspinatus and the occupation ratio decreased in conjunction with the increase in tear size. A significant decrease in cross-sectional area was noted only in large and massive tears on more medial slices from the Y-shaped view. Significant decreases in the cross-sectional area of the infraspinatus were observed in large and massive tears on all images. A negative correlation was found between tendon retraction and cross-sectional area, which was strongest on the Y-shaped view. To avoid the influence of retraction of the supraspinatus tendon, sufficient medial slices from the musculotendinous junction should be used for evaluation of muscle atrophy.

Recovery of Muscle Strength After Intact Arthroscopic Rotator Cuff Repair According to Preoperative Rotator Cuff Tear Size

Background: The recovery of muscle strength after arthroscopic rotator cuff repair based on the preoperative tear size has not yet been well described. Purpose/Hypothesis: The purpose of this study was to evaluate the recovery period of muscle strength by a serial assessment of isometric strength after arthroscopic rotator cuff repair based on the preoperative tear size. The hypothesis was that muscle strength in patients with small and medium tears would recover faster than that in those with large-to-massive tears. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 164 patients who underwent arthroscopic rotator cuff repair were included. Isometric strength in forward flexion (FF), internal rotation (IR), and external rotation (ER) was evaluated preoperatively and at 6, 12, 18, and 24 months after surgery. Preoperative magnetic resonance imaging scans were assessed to evaluate the quality of the rotator cuff muscle, including fatty infiltration, occupation ratio, and tangent sign. Patient satisfaction as well as visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES), and Constant scores were assessed at every follow-up. Results: Muscle strength demonstrated the slowest recovery in pain relief and the restoration of shoulder function. To reach the strength of the uninjured contralateral shoulder in all 3 planes of motion, recovery took 6 months in patients with small tears and 18 months in patients with medium tears. Patients with large-to-massive tears showed continuous improvement in strength up to 18 months; however, they did not reach the strength of the contralateral shoulder at final follow-up. At final follow-up, mean strength in FF, IR, and ER was 113.0%, 118.0%, and 112.6% of the contralateral shoulder in patients with small tears, respectively; 105.0%, 112.1%, and 102.6% in patients with medium tears, respectively; and 87.6%, 89.5%, and 85.2% in patients with large-to-massive tears, respectively. Muscle strength in any direction did not significantly correlate with postoperative patient satisfaction (P = .374, .515, and .692 for FF, IR, and ER, respectively), whereas it highly correlated with preoperative quality of the muscle. Conclusion: The recovery of muscle strength after arthroscopic repair was poorly correlated with patient satisfaction. This study recommends that regardless of pain relief and improved shoulder function, patients with larger than medium tears should be encouraged to continue with rehabilitation for the maximal restoration of muscle strength beyond 1 year postoperatively.

Arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears.

While a conventional single- or double-row repair technique could be applied for repair of C-shaped tears, a different surgical strategy should be considered for repair of U- or L-shaped tears because they typically have complex patterns with anterior, posterior, or both mobile leaves. This study was performed to examine the outcomes of the modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears. Thirty-two patients who underwent an arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears between January 2012 and December 2013 were included in this study. Margin convergence was first performed to reduce the tear gap and tension, and then, an arthroscopic Mason-Allen technique was performed to restore the rotator cuff footprint in a side-to-end repair fashion. All patients were evaluated preoperatively and for a minimum of 2years of follow-up with a visual analog scale (VAS) for pain, Constant score, and ultrasonography. There was significant improvement in all VAS and Constant scores compared with the preoperative values (P<0.001). Functional results by Constant scores included 9 cases that were classified as excellent, 11 cases as good, 8 cases as fair, and 2 cases as poor. Binary logistic regression analysis revealed that heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes. Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair/poor clinical outcomes. Complications occurred in 5 of the 32 patients (15.6%), and the reoperation rate due to complications was 6.3% (2 of 32 patients). An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears. Case Series, Therapeutic Level IV.

Quantitative Shear-Wave US Elastography of the Supraspinatus Muscle: Reliability of the Method and Relation to Tendon Integrity and Muscle Quality.

To evaluate the reliability of ultrasonographic (US) elastography of the supraspinatus (SSP) muscle, define normal shear-wave velocity (SWV) values, and correlate findings with tendon integrity and muscle quality. The study was approved by the local ethics committee, and written informed consent was obtained from all patients. SSP SWV (in meters per second) was prospectively assessed twice in 22 asymptomatic volunteers (mean age ± standard deviation, 53.8 years ± 15.3; 11 women and 11 men) by two independent examiners by using shear-wave elastography. Forty-four patients (mean age, 51.9 years ± 15.0; 22 women and 22 men) were prospectively included. SWV findings were compared with tendon integrity, tendon retraction (Patte classification), fatty muscle infiltration (Goutallier stages 0-IV), and muscle volume atrophy (tangent sign) on magnetic resonance (MR) images. Descriptive statistics, Spearman correlation, analysis of variance, two-sample t test, and intraclass correlation coefficient (ICC) were used. Test-retest reliability for mean total SWV (MTSWV) was good for examiner 1 (ICC = 0.70; 95% confidence interval [CI]: 0.30, 0.87; P = .003) and excellent for examiner 2 (ICC = 0.80; 95% CI: 0.53, 0.92; P < .001). Interexaminer reliability was excellent (ICC = 0.89; 95% CI: 0.64, 0.96; P < .001). MTSWV in volunteers (3.0 m/sec ± 0.5) was significantly higher than that in patients (2.5 m/sec ± 0.5; P = .001). For tendon integrity, no significant difference in MTSWV was found. For tendon retraction, MTSWV varies significantly between patients with different degrees of retraction (P = .047). No significant differences were found for Goutallier subgroups. MTSWV was significantly lower with a positive tangent sign (P = .015; n = 10). Shear-wave elastography is reproducible for assessment of the SSP muscle. Mean normal SSP SWV is 3.0 m/sec ± 0.5. SWV decreases with increasing fat content (Goutallier stage 0-III) and increases in the final stage of fatty infiltration (Goutallier stage IV).

Atrophy, inducible satellite cell activation, and possible denervation of supraspinatus muscle in injured human rotator-cuff muscle.

The high frequency of poor outcome and chronic pain after surgical repair of shoulder rotator-cuff injury (RCI) prompted this study to explore the potential to amplify muscle regeneration using nitric oxide (NO)-based treatment. After preoperative magnetic resonance imaging (MRI), biopsies of supraspinatus and ipsilateral deltoid (as a control) were collected during reparative surgery for RCI. Muscle fiber diameter, the pattern of neuromuscular junctions observed with alpha-bungarotoxin staining, and the γ:ε subunit ratio of acetylcholine receptors in Western blots were examined in tandem with experiments to determine the in vitro responsiveness of muscle satellite cells to activation (indicated by uptake of bromodeoxyuridine, BrdU) by the NO-donor drug, isosorbide dinitrate (ISDN). Consistent with MRI findings of supraspinatus atrophy (reduced occupation ratio and tangent sign), fiber diameter was lower in supraspinatus than in deltoid. ISDN induced a significant increase over baseline (up to 1.8-fold), in the proportion of BrdU+ (activated) Pax7+ satellite cells in supraspinatus, but not in deltoid, after 40 h in culture. The novel application of denervation indices revealed a trend for supraspinatus muscle to have a higher γ:ε subunit ratio than deltoid (P = 0.13); this ratio inversely with both occupancy ratio (P < 0.05) and the proportion of clusters at neuromuscular junctions (P = 0.05). Results implicate possible supraspinatus denervation in RCI and suggest NO-donor treatment has potential to promote growth in atrophic supraspinatus muscle after RCI and improve functional outcome.

A positive tangent sign predicts the repairability of rotator cuff tears

We hypothesize that patients with a positive tangent sign will have rotator cuff tears that are not able to be repaired primarily. We performed a retrospective review of the charts of patients who had undergone surgery for repair of a rotator cuff tear. The operative note was reviewed to determine whether the cuff tear was primarily repaired. The magnetic resonance imaging study of each patient was reviewed to assess for a positive or negative tangent sign. The reviewer was blinded to the result of each measurement. Eighty-one patients met the inclusion criteria. Of the 79 included in our analyses, 17 had a positive tangent sign and 62 had a negative tangent sign. There was only 1 patient with a negative tangent sign who had an irreparable rotator cuff tear. There were 3 patients with a positive tangent sign who had a repairable rotator cuff. With a pretest prevalence of irreparable tears of 18.9%, a positive finding suggested a post-test probability of 82.3% with a positive tangent sign and a post-test probability of only 1.6% when the tangent sign was negative. Our results showed decision-making value in both a negative tangent sign and a positive tangent sign. The tangent sign is an easily performed and reproducible tool with good intraobserver and interobserver reliability that is a powerful predictor of whether a rotator cuff tear will be repairable.

Rotator cuff tear imaging in patients over 70 years: Specific MRI findings?

During the symposium held by the French Arthroscopy Society on rotator cuff tears in patients over 70 years of age, the absence of studies into potential specific pathological features in this age group was pointed out. Here, our main objective was to describe magnetic resonance imaging (MRI) findings in this patient population. Tendons and muscles are smaller, lamellar dissection more prominent, and dystrophic changes more marked in patients over 70 years of age. We retrospectively studied 50 patients with isolated supraspinatus tears, including 25 younger than 50 and 25 older than 70 years of age. Tear size and retraction were evaluated according to Patte; tendon thickness, lamellar dissection, and fatty infiltration according to Goutallier; muscle size according to Thomazeau; and the tangent sign according to Zanetti. In contradiction to our study hypothesis, lateral tendon thickness was similar in the two age groups. Medial thickness of the tendon-muscle junction, however, was greater in the younger group. Lamellar dissection was more marked and fatty infiltration more severe in the older group. As expected, marked muscle wasting and a positive tangent sign were noted in over two-thirds of patients in the older group. This preliminary study in a small number of patients identified specific MRI features of supraspinatus tears in patients older than 70 years compared to younger patients. A larger study would be useful to confirm these findings.