The use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders

doi:10.1016/j.jse.2004.01.017

Journal of Shoulder and Elbow Surgery

Volume 13, Issue 3, May–June 2004, Pages 291-297

https://doi.org/10.1016/j.jse.2004.01.017 Get rights and content

Abstract

This study presents the use of in-office ultrasound, performed by an attending orthopaedic surgeon, as a means of evaluating the integrity of the rotator cuff. The results of 282 shoulder sonograms in patients ultimately treated surgically were included. Findings at surgery were recorded and compared with those documented during the ultrasound examination. Ultrasound findings included 118 full-thickness and 143 partial-thickness rotator cuff tears and 6 intact cuffs confirmed at surgery. One patient with a partial supraspinatus tear on ultrasound was intact at surgery, nine with complete supraspinatus tears had partial-thickness tears at surgery, one with an intact supraspinatus had a full-thickness tear at surgery, and four with partial-thickness supraspinatus tears had full-thickness tears at surgery. The sensitivity, specificity, positive predictive value, and negative predictive value were 94.1%, 96.1%, 96.6%, and 93.2%, respectively, for partial-thickness tears; 95.9%, 94.3%, 92.9%, and 96.8%, respectively, for full-thickness tears; and 99.6%, 85.7%, 99.6%, and 85.7%, respectively, when the rotator cuff was evaluated for damage (either partial- or full-thickness tears). This series documents the ability of an orthopaedic surgeon to image the rotator cuff effectively using portable ultrasound in the clinic setting, allowing for a more efficient implementation of the management plan.

Section snippets

Materials and methods

Four hundred fifty-one consecutive bilateral shoulder sonograms in four hundred six patients were obtained over a 3-year period. Of these, 282 shoulders were treated surgically in 262 patients. The findings of these 282 ultrasounds, for which the results were verified at surgery, were included in the study. There were 173 shoulders in men and 109 shoulders in women with a mean age of 50.4 years (range, 15-84 years).

A single orthopaedic surgeon in a busy clinic performed all of the ultrasound

Results

Ultrasound findings in the 282 surgical cases included 104 full-thickness supraspinatus tears, 148 partial-thickness supraspinatus tears, 14 full-thickness subscapularis tears, 9 full-thickness tears of the supraspinatus and subscapularis, and 7 intact rotator cuffs. At surgery, 95 full-thickness supraspinatus tendon tears were confirmed, as were 143 partial-thickness tears, all 14 subscapularis tears, all 9 combined supraspinatus and subscapularis tears, and 6 intact rotator cuffs. One patient

Discussion

In the early 20th century, Codman⁷ recognized the devastating effects that rotator cuff tears have on the individual patient and society in general. He believed that suboptimal results were due primarily to the fact that patients rarely presented at the early stages of disease. Today, early recognition as well as management of rotator cuff tears remains important. This includes documentation of the tear, which is often required by the patient, surgeon, and third-party payer before planning and

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Cited by (73)

Intraosseous migration of supraspinatus calcification: benefits of intraoperative ultrasound technique
2024, JSES Reviews, Reports, and Techniques
Intra osseous migration of rotator cuff calcification may have an unusual aspect on the imagery which may be confused with neoplasm or infection. This may result in unnecessary biopsies or interventions. The purpose of this case report is to present the benefit in diagnosis and treatment thanks to the use of intraoperative arthroscopic ultrasound-guided needling technique in a case of intra osseous migration of supraspinatus calcification for a patient with a suspicion of prostatic neoplasia.
Clinical applications of ultrasonography in the shoulder for the Orthopedic Surgeon: A systematic review
2020, Orthopaedics and Traumatology: Surgery and Research
Ultrasound imaging offers a non-invasive method to visualize the anatomy and function of the musculoskeletal system. Despite its benefits and widespread adoption in medicine, ultrasonography is still not well utilized by orthopaedic surgeons. The purpose of this systematic review was to provide a better understanding of the diagnostic accuracy and clinical utility of ultrasound of the shoulder for orthopaedic surgeons.
We searched Medline, Embase, Web of Science, and Scopus databases. Our search terms included orthopedic, orthopedic surgery, ultrasonography, and shoulder. Inclusion criteria consisted of studies that used bedside ultrasound for the diagnosis and therapy of patients with common clinical entities of the shoulder presenting to orthopedic clinics, to demonstrate the utility for orthopedic surgeons. We reported sensitivity, specificity, positive predictive value, negative predictive value. Studies were excluded if they used non-diagnostic ultrasound modalities (e.g. shock wave therapy, shear wave elastography, Doppler flowmetry, speckle tracking shear strain, vibro-acoustography).
Our search strategy yielded 771 of potentially relevant publications, 41 studies were retrieved for full text screening, and 24 were included in this systematic review. We found that ultrasound used in orthopedic clinics has good sensitivity and high specificity for the assessment of partial and full rotator cuff tears of the shoulder, including post-operative cuff repairs. There was some evidence that it may also be useful for the diagnosis of subacromial-subdeltoid bursitis, AC joint arthropathy, and labral tears; however further investigations are still required. Ultrasound improves that accuracy of injections into spaces of the shoulder (subacromial bursa, acromioclavicular joint, glenohumeral joints, and the long head of biceps tendon sheath) compared to landmark guided injections, that can be helpful for diagnostic purposes, but do not improve long term clinical outcomes.
We reviewed the literature for orthopaedic surgeons and show that ultrasound of the shoulder can be a useful diagnostic tool for orthopedic surgeons in outpatient clinics. We found no difference in sensitivity or specificity when ultrasound was performed at bedside by orthopedic surgeons or by radiologists for patients referred to orthopedic clinic.
Contribution of postoperative ultrasound to early detection of anchor pullout after rotator cuff tendon repair: Report of 3 cases
2020, Revue de Chirurgie Orthopedique et Traumatologique
La réparation des lésions de la coiffe des rotateurs par technique suture bridge est désormais répandue et largement pratiquée. Très peu d’études ont rapporté des cas de migration secondaire d’ancres radio-transparentes. L’objectif de ce travail prospectif est de montrer l’intérêt de l’échographie lors des consultations postopératoires pour dépister une migration et de décrire les modalités de réalisation de cet examen.
Cent deux patients ont bénéficié d’une réparation de la coiffe sous arthroscopie par technique suture bridge avec ancres de second rang impactées. Chaque patient a bénéficié lors des consultations de suivi postopératoire d’une imagerie échographique réalisée par l’opérateur.
À six semaines postopératoires, nous avons dépisté 3 patients avec une migration d’implant de second rang avec un recul moyen de 8,3 mm. Tous ont bénéficié d’une ré-intervention arthroscopique avec extraction de l’implant, systématiquement mobile dans son tunnel osseux. L’évolution clinique était favorable avec à trois mois de la reprise un score de Constant moyen à 72 et l’absence d’aggravation lésionnelle au contrôle échographique.
Au vu des données actuelles de la littérature, notre série paraît être la première à décrire : des migrations précoces à six semaines d’ancres radio-transparentes in vivo après réparation de la coiffe par technique de suture en pont ; un diagnostic échographique de migration d’ancre fait en consultation postopératoire par un chirurgien orthopédiste ; une description de la technique échographique pour dépister ce problème rare et spécifique.
Désormais, grâce à l’apport de l’échographie, nous avons la possibilité de surveiller le bon positionnement des ancres radio-transparentes après chirurgie de réparation de la coiffe des rotateurs et ce dès les premiers jours postopératoires, sans compromettre la cicatrisation tendineuse.
II.
Contribution of postoperative ultrasound to early detection of anchor pullout after rotator cuff tendon repair: Report of 3 cases
2020, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
It is essential for therapeutic decision-making in calcifying tendinopathy [7]. Postoperatively, ultrasound exploration refines clinical assessment and follow-up [28] and plays a reassuring educational role for the patient, while simplifying the care pathway [7,29,30]. There are a variety of assemblies for cuff repair (tension bands, single row, double row, etc.) and long head of the biceps tenodesis, in which the surgeon assesses anchor positioning.
Rotator cuff repair by suture bridge is now widely used. Few studies reported secondary pullout of radiotransparent anchors. The aim of the present prospective study was to demonstrate the contribution of in-office ultrasonography to detect pullout, and to describe the examination procedure.
A total of 102 patients underwent arthroscopic rotator cuff repair by suture bridge, with impacted second-row anchors. Ultrasonography was performed by the surgeon in postoperative consultations.
At 6 weeks’ follow-up, 3 patients showed mean 2nd-row implant pullout of 8.3 mm.
All underwent arthroscopic revision to extract the implant, which was mobile within its tunnel in all cases. Clinical progression was good, with mean Constant score 72 and no aggravation of the lesion on ultrasound at 3 months’ follow-up.
The present series would seem to be the first to report: early radiotransparent in-vivo pullout 6 weeks after suture bridge cuff repair; ultrasound detection of pullout in consultation by the orthopedic surgeon; a description of the ultrasound technique for screening this rare and specific problem.
Ultrasound now enables radiotransparent anchor positioning to be monitored following rotator cuff repair as of the first postoperative days, without compromising tendon healing.
II.
Do we really need to order magnetic resonance imaging? Shoulder surgeon ultrasound practice patterns and beliefs
2019, JSES Open Access
Despite significant benefits, many orthopedic surgeons are hesitant to incorporate diagnostic ultrasound into their practice. This may be because of a lack of comfort, knowledge, and/or training. The purpose of this study was to analyze practice patterns regarding the use of shoulder ultrasound by orthopedic surgeons to diagnose rotator cuff tears.
We conducted a survey of the members of the American Shoulder and Elbow Surgeons (ASES) regarding their use of ultrasound. A systematic review of the literature on the use of ultrasound in the shoulder by orthopedic surgeons was also performed.
Of the members of ASES responding to the survey, 55% are using ultrasound for diagnostic purposes in the shoulder. The leading reason for not using ultrasound as the sole imaging modality prior to performing rotator cuff repair was lack of confidence in the ability to determine the reparability of the tear (83%). Our systematic review showed that for an orthopedic surgeon diagnosing a full-thickness rotator cuff tear, the mean sensitivity was 92% and mean specificity was 89%.
Many ASES surgeons are not using ultrasound in the shoulder despite its many potential benefits over magnetic resonance imaging. This is because of a lack of confidence in the ability to quantify fatty infiltration, muscle atrophy, and the level of retraction medial to the acromion. Our systematic review showed that orthopedic surgeons can be accurate in the diagnosis of full-thickness rotator cuff tears. Future research should focus on defining parameters of shoulder ultrasound associated with rotator cuff tendon reparability. Educating surgeons on ultrasound technique, cost, and evidence may be a promising strategy to enhance the value in musculoskeletal care delivery.
Effect of surgeon-sonographer interaction on ultrasound diagnosis of rotator cuff tears: a five-year cohort study in 775 shoulders
2016, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
Regarding full-thickness tears only, our study showed a high sensitivity (88%), similar to what has been reported in the past (63% to 100%).1,2,4,6,8,13-21 Specificity (44%) was also similar to what was found in past research for full-thickness tears (44% to 100%).1,2,4,6,8,13-21 However, many of these previous studies had a low sample size (average, 66; range, 4-400) compared with our sample size of 775.10
Ultrasonography for the diagnosis of rotator cuff tears has been a topic of debate for years. The literature shows promising results for the diagnostic utility of ultrasonography for rotator cuff tears. This study assessed the effect of a surgeon-sonographer interaction on the ability of ultrasonography to predict the presence or absence of rotator cuff tears.
This study was a temporal cohort analysis of 775 patients to detect the diagnostic accuracy of ultrasonography at predicting a rotator cuff tear. The surgeon-sonographer interaction had three components: (1) presence of an ultrasound machine and ultrasonographer within a shoulder clinic, (2) the ultrasonographer attends shoulder operations, (3) and the ultrasonographer reviews patients preoperatively and postoperatively. Comparisons of 2 variables—presence and size of a tear—were made between the preoperative ultrasonographic findings with arthroscopic findings (gold standard).
The diagnostic utility for the detection of rotator cuff tears by ultrasonography at the start of the study was 93% sensitive and 68% specific, and at the end of the study was 99% sensitive and 93% specific. There was an improvement in the correlation of the ability to estimate the size of rotator cuff tears from ultrasonography to surgery in both full- and partial-thickness tears.
The surgeon-sonographer interaction improved the diagnostic utility of an office-based ultrasonographer over time, particularly with respect to the overall accuracy of ultrasonography for the detection of rotator cuff tears and for the ability to predict the size of full- and partial-thickness rotator cuff tears.

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Original articleThe use of in-office, orthopaedist-performed ultrasound of the shoulder to evaluate and manage rotator cuff disorders

Abstract

Section snippets

Materials and methods

Results

Discussion

Radiol Clin North Am

J Shoulder Elbow Surg

Eur J Radiol

Ultrasound and operative evaluation of arthritic shoulder joints

Ann Rheum Dis

Sonoanatomy of the shoulder

Acta Anat (Basel)

Rotator cuff sonographya reassessment

Radiology

Rotator cuff tearsprospective comparison of MR imaging with arthrography, sonography, and surgery

AJR Am J Roentgenol

Sources of error in sonographic diagnosis of the rotator cuff

Ultraschall Med

Sonographic signs of complete rotator cuff tears

Zhonghua Yi Xue Za Zhi (Taipei)

The shoulderrupture of the supraspinatus tendon and other lesions in or about the subacromial bursa