Dual-Energy CT Arthrography: Advanced Muscolo-Skelatal Applications in Clinical Practice.

This paper provides a comprehensive overview of the potential applications of dual-energy CT (DECT) in improving image quality and the diagnostic capabilities of CT arthrography (CTA) in clinical practice. The paper covers the use of virtual non-contrast (VNC) images, in which the injected contrast medium is subtracted from the articular cavity in order to better analyze 2D and 3D images of the bone. Moreover, virtual monoenergetic imaging (VMI) applications and their potential use for the reduction of metal artifacts and improving image contrast are reviewed. The role of virtual non-calcium (VNCa) in detecting bone marrow edema surrounding the imaged joint will be discussed. Furthermore, the role of iodine maps in enhancing the contrast between soft tissues, optimizing the visualization of contrast material, and distinguishing contrast material from calcifications is described. Finally, a case series including different joints is provided to underline the additional advantages of high-spatial-resolution dual-energy CT reconstructed images.

Arthroscopic Superior Capsular Reconstruction (ASCR): All Soft Anchors Technique.

Rotator cuff tears are among the most common orthopaedic injuries. If not treated, they can result in a massive irreparable tear because of tendon retraction and muscle atrophy. Mihata et al. in 2012 described the technique of superior capsular reconstruction (SCR) using fascia lata autograft. This has been considered an acceptable and effective method for treating irreparable massive rotator cuff tears. We describe an arthroscopically assisted superior capsular reconstruction (ASCR) technique using all soft anchors to preserve the bone stock and reduce possible hardware complications. Moreover, knotless anchors for the lateral fixation make the technique easier to reproduce.

Evaluation of glenoid labral tears: comparison between dual-energy CT arthrography and MR arthrography of the shoulder.

OBJECTIVE: To compare the diagnostic accuracy of dual-energy computed tomography arthrography (DE-CTA) and magnetic resonance arthrography (MRA) of the shoulder in depicting glenoid labral tears. METHODS: This prospective institutional review board-approved study included 47 consecutive patients (28 males, 19 females; mean age of 34.2 years) studied between January 2017 and October 2018. All patients underwent DE-CTA and MRA the same day. Two radiologists (25 and 11 years of experience, respectively), blinded to clinical data, evaluated the presence labral tears on virtual-blended 120 kV standard CTA and on DE-CTA images. A third radiologist (18 years of experience) evaluated the MRA images. Diagnostic accuracy values were calculated by using surgery as standard of reference. Inter-observer and intra-observer agreements were calculated with k statistics. A value of p < 0.05 was considered statistically significant. RESULTS: Surgery revealed the presence of labral tears in 38/47 patients (80.9%). Sensitivity and specificity values in diagnosing labral tears were 84.2% and 77.8% for MRA (Reader 3), 84.2% and 77.8% for CTA (Reader 1), 84.2% and 88.9% for CTA (Reader 2), 89.5% and 88.9% for DE-CTA (Reader 1), and 92.1% and 88.9% for DE-CTA (Reader 2). A nonsignificant increase in AUC values with respect to MRA was obtained by reading the CTA (p = 0.470) and DE-CTA dataset (p = 0.217), respectively. Inter-observer agreements were near perfect for CTA (k = 0.84) and substantial for DE-CTA reading (k = 0.76). Intra-observer agreements were near perfect both for CTA (k = 0.88) and for DE-CTA reading (k = 0.82). CONCLUSION: DE-CTA and MRA were not different in terms of diagnostic performance.

Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes.

BACKGROUND: To evaluate the anatomic integrity of rotator cuff repair performed by medialized single row and augmented by a porcine dermal patch, in comparison with a nonaugmented group. METHODS: We conducted a single-center, prospective, double-blinded, randomized controlled trial. The sample size was predefined, and patients were divided into a study group and a control group, assessed preoperatively and at 1, 3, 6, 12, and 24 months. The EuroQol-visual analog scale; Constant-Murley questionnaire; Disabilities of the Arm, Shoulder and Hand Score; and Simple Shoulder Test were administered. The humeral-acromial distance was calculated on radiographs. Tendon thickness, tear extension, and tendon signal intensity were all measured on magnetic resonance images (MRIs) along with an evaluation of footprint extension and a classification into one of 4 healing grades-healed, thinned, partially healed, not healed. RESULTS: The study population consisted of 92 patients who were equally randomized into 2 homogenous groups. Sixty-nine patients completed the 24-month follow-up. The study group showed a healing rate of 97.6% compared with 59.5% for the standard repair group. The study group showed better results in terms of repaired tendon thickness and footprint coverage, with a P value < .05, although the tendon density was comparable. The study group showed better strength recovery and functionality with the outcome scores submitted. During the entire study, only 2 patients reported complications, calling for a biopsy during revision surgery. CONCLUSIONS: Rotator cuff repairs augmented with a porcine dermal patch resulted in excellent clinical outcomes with a higher healing rate and close-to-normal MRI findings. The technique is safe and effective; in addition, it is reproducible and allows for better outcomes compared with those of standard medialized single-row repairs.

Isolated Subscapularis Tendon Tear in a Skeletally Immature Soccer Player.

Subscapularis injury in adolescents, usually associated to an avulsion fracture of the lesser humeral tuberosity, accounts for less than 2% of all fractures of the proximal humerus. Isolated tears of the subscapularis tendon without a history of dislocation and associated avulsion fractures are an even rarer occurrence, and treatment is controversial. This article describes a rare case of a 12-year-old suffering from an isolated subscapularis tear and discusses its management. The patient was evaluated at presentation, and at 1 to 2.5 months after he underwent a cuff tear arthroscopic repair with a single "all suture" anchor loaded with two wires, active/passive range of motion (A/PROM), Constant-Murley score, and American Shoulder and Elbow Surgeons (ASES) score were noted. Patient reported an excellent outcome, recovered the whole ROM, was pain free, and returned to the previous level of activity. Isolated avulsion of the subscapularis tendon requires a high index of suspicion for a proper diagnosis as early treatment is required for a good recovery. Arthroscopy reserves more advantages in proper hands, restoring the previous levels of function and activity. An increase in attention for this condition is mandatory in a society where many adolescents are getting more and more active in high levels of sport activities.

MR arthrography of the shoulder: evaluation of isotropic 3D intermediate-weighted FSE and hybrid GRE T1-weighted sequences.

PURPOSE: To compare the diagnostic accuracy of three-dimensional (3D) fast spin echo (FSE) intermediate-weighed (IW-3D) and 3D hybrid double-echo steady-state T1-weighted sequences (Hy-3D) and two-dimensional (FSE) images (2D) at shoulder MR arthrography (MRA). MATERIALS AND METHODS: Institutional review board approval was obtained and informed consent was waived for this retrospective study. From September 2011 to October 2014, 102 patients who had undergone 1.5 Tesla MRA of the shoulder, including conventional 2D-FSE and IW-3D and Hy-3D images were included in our study. The mean interval between MRA and surgery was 21 days (range 2-70 days). MR images were retrospectively and independently reviewed by two experienced radiologists blinded to the clinical and surgical data. Supraspinatus tendon (SST), infraspinatus tendon (IST) and subscapularis tendon (SCT) tears, as well as antero-inferior, superior and posterior labral lesions were assessed, using surgery as the reference standard. Each reader's performance in assessing rotator cuff and labrum abnormalities was evaluated using the area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CIs). The difference was evaluated using a univariate z test. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy (Acc) for all types of rotator cuff tears and labral lesions were calculated. A value of p < 0.05 was considered statistically significant. Inter-observer agreement was calculated using kappa statistics. RESULTS: The difference of diagnostic accuracy achieved was not significant (p > 0.05). In particular, differences in AUC values ranged from 0.002 (p = 0.98) to 0.014 (p = 0.82) as regards the comparison between 2D and IW-3D images, from 0.002 (p = 0.98) to 0.034 (p = 0.08) concerning the comparison between 2D and Hy-3D images and from 0.010 (p = 0.82) to 0.032 (p = 0.09) when comparing Hy-3D to IW-3D images. Accuracy values in evaluating RC lesions and labral lesions were 95.1, 92.1, 91.2, 93.1, 93.1 and 94.1% by reading 2D, Hy-3D and IW-3D images, respectively. The difference of diagnostic accuracy achieved using the datasets analyzed was not significant (p > 0.05). Inter-observer agreement was very good for each of the datasets that were evaluated, with near-perfect agreement for 2D dataset (k = 0.86), Hy-3D (k = 0.81) and IW-3D (k = 0.83). CONCLUSIONS: The accuracy of IW-3D and Hy-3D images was not significantly higher than the 2D sequences in evaluating RC and labral lesions.

Reliability of forced internal rotation and active internal rotation to assess lateral instability of the biceps pulley.

PURPOSE: the aim of this study was to investigate the relationship between positive painful forced internal rotation (FIR) and lateral pulley instability in the presence of a pre-diagnosed posterosuperior cuff tear. The same investigation was conducted for painful active internal rotation (AIR). METHODS: a multicenter prospective study was conducted in a series of patients scheduled to undergo arthroscopic posterosuperior cuff repair. Pain was assessed using a visual analog scale (VAS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) was administered. The VAS score at rest, DASH score, and presence/absence of pain on FIR and AIR were recorded and their relationships with lesions of the lateral pulley, cuff tear patterns and shape of lesions were analyzed. RESULTS: the study population consisted of 115 patients (mean age: 55.1 years) recruited from 12 centers. The dominant arm was affected in 72 cases (62.6%). The average anteroposterior extension of the lesion was 1.61 cm. The mean preoperative VAS and DASH scores were 6.1 and 41.8, respectively. FIR and AIR were positive in 94 (81.7%) and 85 (73.9%) cases, respectively. The lateral pulley was compromised in 50 cases (43.4%). Cuff tears were partial articular in 35 patients (30.4%), complete in 61 (53%), and partial bursal in 19 (16.5%). No statistical correlation between positive FIR or AIR and lateral pulley lesions was detected. Positive FIR and AIR were statistically associated with complete lesions. Negative FIR was associated with the presence of partial articular tears. CONCLUSIONS: painful FIR in the presence of a postero-superior cuff tear does not indicate lateral pulley instability. When a cuff tear is suspected, positive FIR and AIR are suggestive of full-thickness tear patterns while a negative FIR suggests a partial articular lesion. LEVEL OF EVIDENCE: level I, validating cohort study with good reference standards.