Role of shear wave elastography in the evaluation of the treatment and prognosis of supraspinatus tendinitis

BACKGROUND Supraspinatus tendinitis recurs easily after treatment.One of the main reasons is the lack of objective tools for the efficacy evaluation.Shear wave elastography(SWE)can quantitatively analyze the tissue elasticity of region of interest by measuring the Young’s modulus(YM)value.AIM To explore the role of SWE in the efficacy and prognostic evaluation of supraspinatus tendinitis.METHODS Eighty-seven patients with supraspinatus tendinitis treated in Jiading District Central Hospital Affiliated Shanghai University of Medicine and Health Sciences were recruited.Another 30 healthy volunteers were enrolled as the control group.The visual analogue scale(VAS)and Constant-Murley Score(CMS)were recorded before treatment.All participants were scanned by SWE scan,and the YM value of the region of interest were recorded.Spearman correlation analysis was performed on YM values with VAS and CMS.Univariate repeated measures analysis of variance was used to calculate the changing trend of VAS,CMS and SWE under different treatment courses.After treatment,the patients were further grouped based on who achieved significantly effective and curative treatment.The patients in the continued treatment group continued to receive treatment according to the YM value,and the remaining patients who stopped receiving treatment were included in the stopped treatment group.All patients were followed up for 1 year,and the difference in recurrence rates between the continued treatment group and the stopped treatment group were compared.RESULTS The SWE images of supraspinatus muscle in healthy volunteers were mainly blue,while those of patients with supraspinatus tendinitis showed regional red and green areas.The average YM value of the supraspinatus muscle in healthy volunteers was 26.12±4.03 kPa.The average YM value of patients with supraspinatus muscle was greater than that of healthy volunteers(average YM=60.61±11.53 kPa,t=26.344,P<0.001).The YM value was positively correlated with VAS(r=0.564,P<0.001)and negatively correlated with CMS(r=-0.411,P<0.001).The changes of VAS and CMS were the most obvious in course 1 and then decreased gradually.The degree of change in YM values was similar in different courses.After a 1-year follow-up,the cumulative relapse-free rate in the continued treatment group was 91.43%,which was significantly higher than that in the stopped treatment group(64.71%,X2=7.379,P=0.007).CONCLUSION SWE can objectively indicate the severity of supraspinatus tendinitis.Using the YM value as a criterion for curative effect may reduce the recurrence rate.

Imaging analysis on the collagen distribution pattern in hypovascular zone of normal supraspinatus tendon

Objective:To investigate the collagen distribution pattern in the normal supraspinatus tendon with use of com- puter imaging analysis system, and through this way, to probe into the underlying relationship between the collagen distribu- tion pattern and supraspinatus tendon tears. Methods: The slice specimens of normal supraspinatus tendon, with histological and immunohistochemical staining, were divided into 2 groups according to their respective distance of selected cross-sec- tions from the insertion of supraspinatus tendon, namely, one was at a distance of 1 cm near the insertion of supraspinatus tendon (Group A); the other was 2 cm close to the insertion (Group B). Computer imaging analysis system was employed for detecting the collagen area percentage on the cross-section of tendon. The Obtained data were processed by Spss8 .0. Results: ①The collagen cross-section area percentage in Group A was smaller than that in Group B. ②Type Ⅰ and Ⅲ colla- gen area percentage in Group A were smaller than those in Group B respectively. ③ In the same group of A or B, type Ⅰ collagen area percentage was conspicuously larger than that type Ⅲ held. Conclusion: There exists a significant difference of coffagen distribution near the insertion of normal supraspinatus tendon; the disparity pattern of collagen distribution is directly pertinent to the pre-existing hypovascularity zone in this region, which could play a certain part in the pathogenesis of supraspinatus tendon tears, and could be an intrinsic factor contributing to the etiology of supraspinatus tendon tears.

Double Band Double-Pulley Repair for Articular Surface Partial Tears of the Supraspinatus in Throwing Athletes: Improving the Transtendon Technique

Disabled shoulders of throwing athletes typically present with extended undersurface partial tears of the rotator cuff, which include the posterior supraspinatus and the anterior infraspinatus tendon to a variable extent. We propose a modified transtendon repair technique to adequately treat this subset of patients. The repair includes two double-loaded anchors, at the anterior and the posterior end of the tear, respectively. With the help of an angulated penetrator we create a medial and a lateral band of sutures on top of the cuff, producing a broad contact in the tendon-to-bone interface. All the 9 so far operated patients were young men, 7 of them base-ball pitchers, and 5 active in competitive sports. The Constant Score rose from 72 points preoperatively to 99 points at 12 months follow-up. Three of the still active pitchers were able to return to their previous level in sports after one year. The improved footprint contact of our novel repair construct should allow for better healing and, therefore, a higher chance of return to competition.

Arthroscopic repair of partial articular supraspinatus tendon avulsion lesions by conversion to full-thickness tears through a small incision

Purpose To assess the clinical efficacy of converting partial articular supraspinatus tendon avulsion(PASTA)lesions to full-thickness tears through a small local incision of the bursal-side supraspinatus tendon followed by repair.Methods We retrospectively analyzed 41 patients with Ellman grade 3 PASTA lesions and an average age of(54.7±11.4)years from March 2013 to July 2017.Patients without regular conservative treatment and concomitant with other shoulder pathologies or previous shoulder surgery were excluded from the study.The tears were confirmed via arthroscopy,and a polydioxanone suture was placed to indicate the position of each tear.A small incision of approximately 6 mm was made using a plasma scalpel on the bursal-side supraspinatus tendon around the positioned suture to convert the partial tear into a full-thickness tear.The torn rotator cuff was sutured through the full thickness using a suture passer after inserting a 4.5-mm double-loaded suture anchor.Data were analyzed using a paired Student’s t-test with statistical significance defined as p<0.05.Results At the final follow-up of 2 years,the pain-free shoulder joint range of motion and visual analog scale score were significantly improved compared to those before surgery(p<0.001).The postoperative American Shoulder and Elbow Surgeons shoulder score was(90.6±6.2),which was significantly higher than the preoperative score of(47.9±8.3)(p<0.001).The University of California at Los Angeles shoulder rating scale score increased from(14.7±4.1)prior to surgery to(32.6±3.4)points after surgery(p<0.001).No patient had joint stiffness.Conclusion This modified tear completion repair,by conversion to full-thickness tears through a small incision,has less damage to the supraspinatus tendon on the side of the bursa compared to traditional tear completion repair in the treatment of PASTA lesions.This surgical method is a simple and effective treatment that can effectively alleviate pain and improve shoulder joint function.

The Hug-up Test： A New, Sensitive Diagnostic Test for Supraspinatus Tears

Background： The supraspinatus tendon is the most commonly affected tendon in rotator cuff tears. Early detection ofa supraspinatus tear using an accurate physical examination is, therefore, important. However, the currently used physical tests for detecting supraspinatus tears are poor diagnostic indicators and involve a wide range of sensitivity and specificity values. Therefore, the aim of this study was to establish a new physical test for the diagnosis of supraspinatus tears and evaluate its accuracy in comparison with conventional tests. Methods： Between November 2012 and January 2014, 200 consecutive patients undergoing shoulder arthroscopy were prospectively evaluated preoperatively. The hug-up test, empty can （EC） test, full can （FC） test, Neer impingement sign, and Hawkins-Kennedy impingement sign were used and compared statistically tbr their accuracy in terms of supraspinatus tears, with arthroscopic findings as the gold standard. Muscle strength was precisely quantified using an electronic digital tensiometer. Results： The prevalence of supraspinatus tears was 76.5%. The hug-up test demonstrated the highest sensitivity （94.1%）, with a low negative likelihood ratio （NLR, 0.08） and comparable specificity （76.6%） compared with the other four tests. The area under the receiver operating characteristic curve for the hug-up test was 0.854, with no statistical difference compared with the EC test （z = 1.438, P = 0.075） or the FC test （z = 1.498, P = 0.067）. The hug-up test showed no statistical difference in terms of detecting different tear patterns according to the position （X2 = 0.578, P = 0.898） and size （Fisher＇s exact test, P 〉 0.999） compared with the arthroscopic examination. The interobserver reproducibility of the hug-up test was high, with a kappa coefficient of 0.823. Conclusions： The hug-up test can accurately detect supraspinatus tears with a high sensitivity, comparable specificity, and low NLR compared with the conventional clinical tests and could, therefore, improve the diagnosis of supraspinatus tears in clinical settings.

Ultrasound in Assessment of Supraspinatus Tendon Injury： Correlation with Arthroscopy

INTRODUCTIONRotator cuffinjuries are common in all athletic. Of all rotator cuff injuries, the supraspinatus tendon involves mostly. Severe supraspinatus tendon injury may affect the patient＇s quality of life. However, supraspinatus tendon injury can be relatively asymptomatic in some cases and may require sonographic examination for diagnosis, With continued improvement in shoulder arthroscopy, surgical treatment for supraspinatus tendon injury has become more effective and less invasive.

Focused extracorporeal shock wave therapy combined with supervised eccentric training for supraspinatus calcific tendinopathy

BACKGROUND AND OBJECTIVE Extracorporeal shockwave therapy (ESWT) is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Eccentric exercise has been introduced as an effective treatment choice for Achilles tendinopathy, but poor evidence exists about its role in the treatment of rotator cuff tendinopathy. METHODS The study-group was assigned to receive focal ESWT (f-ESWT) plus a supervised eccentric training (SET) of the shoulder abductor muscles. The matched control-group received f-ESWT only. The post-treatment assessment at follow-up (T1) was performed nine weeks after the enrollment (T0). We assessed shoulder pain and function by the means of a numeric rating scale (p-NRS) and a DASH scale. As secondary outcome, we measured the isometric strength of the abductor muscles of the affected shoulder using a handheld dynamometer. RESULTS At T1, we recorded a significant decrease in pain (P<0.001) and an improvement in upper limb function (P<0.001) in both groups. However, we observed no statistical differences in favor of the study-group, in terms of p-NRS and DASH total score. A mild increase (+13% from baseline) of the maximum isometric abduction strength was noticed in the study group at T1. CONCLUSION Our findings did not support the hypothesis that adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome (pain and function) of shock wave therapy.

Eccentric training as a new approach for rotator cuff tendinopathy: Review and perspectives

Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy. Although tendon problems are very common, they are not always easy to treat. Eccentric training has been proposed as an effective conservative treatment for the Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the rotator cuff tendinopathy. The mechanotransduction process associated with an adequate dose of mechanical load might explain the beneficial results of applying the eccentric training to the tendons. An adequate load increases healing and an inadequate(over or underuse) load can deteriorate the tendon structure. Different eccentric training protocols have been used in the few studies conducted for people with rotator cuff tendinopathy. Further, the effects of the eccentric training for rotator cuff tendinopathy were only evaluated on pain, function and strength. Future studies should assess the effects of the eccentric training also on shoulder kinematics and muscle activity. Individualization of the exercise prescription, comprehension and motivation of the patients, and the establishment of specific goals, practice and efforts should allbe considered when prescribing the eccentric training. In conclusion, eccentric training should be used aiming improvement of the tendon degeneration, but more evidence is necessary to establish the adequate doseresponse and to determine long-term follow-up effects.

Reporting rotator cuff tears on magnetic resonance arthrography using the Snyder's arthroscopic classification

AIM To determine diagnostic performance of magnetic resonance arthrography(MRA) in evaluating rotator cuff tears(RCTs) using Snyder's classification for reporting.METHODS One hundred and twenty-six patients(64 males, 62 females; median age 55 years) underwent shoulder MRA and arthroscopy, which represented our reference standard. Surgical arthroscopic reports were reviewed and the reported Snyder's classification was recorded. MRA examinations were evaluated by two independent radiologists(14 and 5 years' experience) using Snyder's classification system, blinded to arthroscopy. Agreement between arthroscopy and MRA on partial-and fullthickness tears was calculated, first regardless of their extent. Then, analysis took into account also the extent of the tear. Interobserver agreement was also calculated the quadratically-weighted Cohen kappa statistics.RESULTS On arthroscopy, 71/126 patients(56%) had a fullthickness RCT. The remaining 55/126 patients(44%) had a partial-thickness RCT. Regardless of tear extent, out of 71 patients with arthroscopically-confirmed fullthickness RCTs, 66(93%) were correctly scored by both readers. All 55 patients with arthroscopic diagnosis of partial-thickness RCT were correctly assigned as having a partial-thickness RCT at MRA by both readers. Interobserver reproducibility analysis showed total agreement between the two readers in distinguishing partial-thickness from full-thickness RCTs, regardless of tear extent(k = 1.000). With regard to tear extent, in patients in whom a complete tear was correctly diagnosed, correct tear extent was detected in 61/66 cases(92%); in the remaining 5/66 cases(8%), tear extent was underestimated. Agreement was k = 0.955. Interobserver agreement was total(k = 1.000).CONCLUSION MRA shows high diagnostic accuracy and reproducibility in evaluating RCTs using the Snyder's classification for reporting. Snyder's classification may be adopted for routine reporting of MRA.

Assessing the accuracy of arthroscopic and open measurements of the size of rotator cuff tears: A simulation-based study

BACKGROUND Arthroscopic procedures are commonly performed for rotator cuff pathology.Repair of rotator cuff tears is a commonly performed procedure.The intraoperative evaluation of the tear size and pattern contributes to the choice and completion of the technique and the prognosis of the repair.AIM To compare the arthroscopic and open measurements with the real dimensions of three different patterns of simulated rotator cuff tears of known size using a plastic shoulder model.METHODS We created three sizes and patterns of simulated supraspinatus tears on a plastic shoulder model(small and large U-shaped,oval-shaped).Six orthopaedic surgeons with three levels of experience measured the dimensions of the tears arthroscopically,using a 5 mm probe,repeating the procedure three times,and then using a ruler(open technique).Arthroscopic,open and computerized measurements were compared.RESULTS A constant underestimation of specific dimensions of the tears was found when measured with an arthroscope,compared to both the open and computerized measurements(mean differences up to-7.5±5.8 mm,P<0.001).No differences were observed between the open and computerized measurements(mean difference-0.4±1.6 mm).The accuracy of arthroscopic and open measurements was 90.5%and 98.5%,respectively.When comparing between levels of experience,senior residents reported smaller tear dimensions when compared both to staff surgeons and fellows.CONCLUSION This study suggests that arthroscopic measurements of full-thickness rotator cuff tears constantly underestimate the dimensions of the tears.Development of more precise arthroscopic techniques or tools for the evaluation of the size and type of rotator cuff tears are necessary.

Anatomy and clinical application of suprascapular nerve to accessory nerve transfer

BACKGROUND Loss of motor function in the trapezius muscle is one complication of radical neck dissection after cutting the accessory nerve(AN) during surgery.Nerve repair is an effective method to restore trapezius muscle function,and includes neurolysis,direct suture,and nerve grafting.The suprascapular nerve(SCN) and AN are next to each other in position.The function of the AN and SCN in shoulder elevation and abduction movement is synergistic.SCN might be considered by surgeons for AN reanimation.AIM To obtain anatomical and clinical data for partial suprascapular nerve-to-AN transfer.METHODS Ten sides of cadavers perfused with formalin were obtained from the Department of Human Anatomy,Histology and Embryology,Peking University Health Science Center.The SCN(n = 10) and AN(n = 10) were carefully dissected in the posterior triangle of the neck,and the trapezius muscle was dissected to fully display the accessory nerve.The length of the SCN from the origin of the brachial plexus(a point) to the scapular notch(b point) and the distance of the SCN from the origin point(a point) to the point(c point) where the AN entered the border of the trapezius muscle were measured.The length and branches of the AN in the trapezius muscle were measured.A female patient aged 55 years underwent surgery for partial SCN to AN transfer at Department of Oral and Maxillofacial Surgery,Peking University School and Hospital of Stomatology.The patient suffered from recurrent upper gingival cancer.Radical neck dissection was performed on the right side,and the right AN was removed at the intersection between the nerve and the posterior border of the SCM muscle.One-third of the diameter of the SCN was cut off,and combined epineurial and perineurial sutures were applied between the distal end of the cut-off fascicles of the SCN and the proximal end of the AN without tension.Both subjective and objective evaluations were performed before,three months after,and nine months after surgery.For the subjective evaluation,the questionnaire included the Neck Dissection Impairment Index(NDII) and the Constant Shoulder Scale.Electromyography was used for the objective examination.Data were analyzed using t tests with SPSS 19.0 software to determine the relationship between the length of the SCN and the linear distance.A P value of < 0.05 was considered as statistically significant.RESULTS The whole length of the AN in the trapezius muscle was 16.89 cm.The average numbers of branches distributed in the descending,horizontal and ascending portions were 3.8,2.6 and 2.2,respectively.The diameter of the AN was 1.94 mm at the anterior border of the trapezius.The length of the suprascapular nerve from the origin of the brachial plexus to the scapular notch was longer than the distance of the suprascapular nerve from the origin point to the point where the accessory nerve entered the upper edge of the trapezius muscle.The amplitude of trapezius muscle electromyography indicated that both the horizontal and ascending portions of the trapezius muscle on the right side had better function than the left side nine months after surgery.The results showed that the right-sided supraspinatus and infraspinatus muscles did not lose more function than the left side.CONCLUSION Based on anatomical data and clinical application,partial suprascapular nerve-to-AN transfer could be achieved and may improve innervation of the affected trapezius muscle after radical neck dissection.