A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair.

PURPOSE: The purpose of this study was to propose a modified Patte classification system for tendon retraction, including the cut-off points for predicting reparability and rotator cuff healing after arthroscopic rotator cuff repair (ARCR) and assess its prediction accuracy and measurement reliability. METHODS: This retrospective study included 463 consecutive patients scheduled to undergo ARCR for full-thickness supraspinatus tears. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off points for predicting reparability and tendon healing. The modified Patte classification system, in which these cut-off points were combined with the original Patte classification, classified the tendon retraction as stages I-V. The prediction accuracy of reparability and tendon healing was assessed using the area under the curve (AUC). Measurement reliability was determined using Cohen's κ statistics. RESULTS: Of the 402 included patients, 32 rotator cuff tears were irreparable and 71 of the remaining 370 were diagnosed with healing failure. ROC analysis determined the cut-off point of reparability at the medial one-fifth and that of tendon healing at the medial one-third of the humeral head. The AUC of the modified Patte classification for predicting reparability and tendon healing was 0.897 (excellent) and 0.768 (acceptable), respectively. Intra-rater reliability was almost perfect (mean κ value: 0.875), and inter-rater reliability was substantial (0.797). CONCLUSION: Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. The modified Patte classification system can be easily implemented in clinical practice for planning surgical procedures and counselling patients in the day-by-day clinical work. LEVEL OF EVIDENCE: Level III.

Correlation between Severity of Synovitis and Clinical Features in Rotator Cuff Tears.

BACKGROUND: Rotator cuff tears can be asymptomatic in some cases; however, even when the tear size is small, clinical symptoms can be very severe. This suggests that symptoms of rotator cuff tears are related to factors other than the size. Although synovitis has been cited as one of the factors, there is no grading system for synovitis in rotator cuff tears. Moreover, there are few studies that evaluated the relationship between synovitis and clinical features in patients with rotator cuff tears. METHODS: Patients with medium-sized rotator cuff tears, who were scheduled for arthroscopic repair, were recruited for this study. The glenohumeral joint was divided into 4 quarters. Then, vascularity and hypertrophy of the joint were graded in each quarter using a modified scoring system. Clinical assessment was performed preoperatively and at 3 months and 6 months after surgery. Finally, correlation between the severity of synovitis and clinical features was analyzed. RESULTS: The intraobserver correlation coefficient was 0.815 to 0.918 and the interobserver correlation coefficient was 0.779 to 0.992 for the single measurement. Vascularity was significantly correlated with the range of motion, strength, and constant score within 6 months after surgery. Hypertrophy was correlated with the range of motion within 6 months after surgery. CONCLUSIONS: Synovitis in the shoulder with rotator cuff tears can be graded by using our modified scoring system. The severity of synovitis was closely related to the clinical features after surgery. Therefore, when treating patients with rotator cuff tears, treatment of synovitis should also be considered.

A classification for partial subscapularis tendon tears.

PURPOSE: The aim of the study was to analyze partial subscapularis tendon (SSC) tears and provide a descriptive classification. METHODS: The retrospective study included 50 patients with arthroscopically confirmed partial SSC tears. Internal rotation (IR) force measurements and IR ROM have been made and compared to the healthy contralateral side. Then the footprint of the SSC was routinely investigated by arthroscopy with standardized measurement of the bony footprint lesion. The partial tears were classified according to the mediolateral and craniocaudal extension of the rupture in the transverse and coronal plane, respectively. RESULTS: Partial SSC tears could be classified into split lesions (type 1, n = 11) and 3 further groups depending on the mediolateral peeled-off length of the bony footprint (type 2: < 10 mm, n = 20; type 3: 10-15 mm, n = 10; type 4: > 15 mm, n = 9). Type 2-4 could be further divided depending on the craniocaudal peeled-off length of the bony footprint (group A: < 10 mm, group B: 10-15 mm, group C: > 15 mm). Significantly decreased IR strength was shown for types 2-4 (p < 0.05) but not for split lesions as compared to healthy side. Types 1-4 showed significant decreased active IR ROM and all except type 3 (n.s.) which showed decreased passive IR ROM compared to the healthy side (p < 0.05). CONCLUSION: We present a novel classification for partial SSC tears for a more detailed and reproducible description. This can help to improve the current knowledge about the appropriate treatment. It could be shown that partial tears of the subscapularis can have an impact on IR strength and motion. LEVEL OF EVIDENCE: III.

Definition of the terms "acute" and "traumatic" in rotator cuff injuries: a systematic review and call for standardization in nomenclature.

BACKGROUND: Although of high relevance for clinical decision making, there exists no consensus throughout the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears. With differing definitions, the comparability of outcome studies may be limited. The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings. METHODS: Four different internet databases were searched in February 2020 using the terms ("acute" OR "traumatic" OR "trauma" OR "athlete" OR "young") AND ("rotator cuff tears" OR "rotator cuff tear" OR "rotator cuff" OR "rotator cuff rupture" OR "supraspinatus" OR "infraspinatus" OR "subscapularis" OR "teres minor"). Prospective, retrospective, cohort and case-control studies as well as case series were included. Systematic reviews, cadaveric or laboratory studies and studies on non-traumatic or non-acute rotator cuff tears were excluded. RESULTS: The literature search conducted 10,349 articles of which 10,151 were excluded based on the title, 119 based on the abstract and 33 based on the manuscript. A total of 46 studies were finally included for review and subsequently analyzed. Overall, there exists no consensus neither on the term "acute" nor on "traumatic" in the context of rotator cuff tears in the literature. The time span for acute injuries ranged between 2 weeks and 6 months. For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging. CONCLUSION: The term "acute" should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon and joint effusion, which typically requires adequate imaging within 2 weeks from trauma. Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities. The term "traumatic" should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.

Automated rotator cuff tear classification using 3D convolutional neural network.

Rotator cuff tear (RCT) is one of the most common shoulder injuries. When diagnosing RCT, skilled orthopedists visually interpret magnetic resonance imaging (MRI) scan data. For automated and accurate diagnosis of RCT, we propose a full 3D convolutional neural network (CNN) based method using deep learning. This 3D CNN automatically diagnoses the presence or absence of an RCT, classifies the tear size, and provides 3D visualization of the tear location. To train the 3D CNN, the Voxception-ResNet (VRN) structure was used. This architecture uses 3D convolution filters, so it is advantageous in extracting information from 3D data compared with 2D-based CNNs or traditional diagnosis methods. MRI data from 2,124 patients were used to train and test the VRN-based 3D CNN. The network is trained to classify RCT into five classes (None, Partial, Small, Medium, Large-to-Massive). A 3D class activation map (CAM) was visualized by volume rendering to show the localization and size information of RCT in 3D. A comparative experiment was performed for the proposed method and clinical experts by using randomly selected 200 test set data, which had been separated from training set. The VRN-based 3D CNN outperformed orthopedists specialized in shoulder and general orthopedists in binary accuracy (92.5% vs. 76.4% and 68.2%), top-1 accuracy (69.0% vs. 45.8% and 30.5%), top-1±1 accuracy (87.5% vs. 79.8% and 71.0%), sensitivity (0.94 vs. 0.86 and 0.90), and specificity (0.90 vs. 0.58 and 0.29). The generated 3D CAM provided effective information regarding the 3D location and size of the tear. Given these results, the proposed method demonstrates the feasibility of artificial intelligence that can assist in clinical RCT diagnosis.

Coracoid morphology is not associated with subscapularis tears.

BACKGROUND: The observation of the roller-wringer effect fueled the idea that coracoid morphology is related to subscapularis pathology. We aimed to examine this relationship, specifically focusing on how the coracohumeral distance (CHD) and 2 new metrics of coracoid morphology relate to subscapularis tears. METHODS: In this retrospective study, we identified consecutive patients 45 years or older who underwent shoulder arthroscopy for any indication. We blindly reviewed preoperative magnetic resonance imaging studies of each patient, measuring the CHD, lateral extent (LE), and caudal extent (CE) of the coracoid process. Patients' subscapularis condition was assessed via operative reports; stratified according to Lafosse grade criteria; and compared for differences in the CHD, LE, and CE by 1-way analysis of variance and 2-tailed t tests. RESULTS: The study included 201 patients. Of these, 112 had no evidence of subscapularis injury, whereas Lafosse grade I injuries were identified in 52 patients; grade II, in 19; and grades III-V, in 18. The CHD, LE, and CE were not correlated with subscapularis injury (CHD, P = .36; LE, P = .36; and CE, P = .13). CONCLUSIONS: We found no correlation between subscapularis injury and the CHD, LE, and CE. These findings support the idea that coracoid morphology may not be a cause of subscapularis pathology and suggest that coracoplasty may not be necessary prophylactically or as part of subscapularis repair.

Is there a difference in the acromiohumeral distances measured on radiographic and magnetic resonance images of the same shoulder with a massive rotator cuff tear?

BACKGROUND: The purpose of our study was to compare the acromiohumeral distance (AHD) between radiographic and magnetic resonance images (MRIs) of the same shoulder with massive rotator cuff tears (MRCTs). METHODS: Thirty-four shoulders with MRCTs that had an MRI and radiograph of the same shoulder within an average of 40.3 days (range: 8-109 days) were identified. AHD was measured digitally on radiograph and MRI by 3 examiners. Shoulders were grouped into Hamada grades <3 (group 1) and Hamada grades ≥3 (group 2). RESULTS: The mean age was 66.4 years (range: 51-89). There were 19 men (59%). The Kappa for inter-rater reliability was 0.982 (95% confidence interval [CI] 0.975, 0.988) for radiographs and 0.88 (95% CI 0.75, 0.94) for MRI. There was a significant difference in the mean AHD of group 1 on radiograph vs. MRI (7.9 mm vs. 2.5 mm, respectively; P < .0001), but no difference in group 2 (1.8 mm vs. 2.2 mm, respectively; P = .45). There was no difference in AHD in group 1 between shoulders with Goutallier stage <3 (8.1 ± 1.9 mm) and those with Goutallier stage ≥3 (7.3 ± 2.1 mm) (P = .3479). There was no difference in AHD in group 2 between shoulders with Goutallier stage <3 (3.0 ± 0.1 mm) and those with Goutallier stage ≥3 (1.5 ± 1.0 mm) (P = .079). CONCLUSION: There is a significant difference in AHD measurements between radiograph and MRI of the same shoulder with MRCT in early Hamada grades. AHDs measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures.

Shoulder Terrible Triad: Classification, Functional Results, and Prognostic Factors.

INTRODUCTION: The shoulder terrible triad (STT) is a traumatic anterior shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the functional results and prognostic factors of surgery in patients with STT. METHODS: Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity fracture. Variables registered on the day of surgery were preoperative Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator. RESULTS: Twenty-seven patients underwent a complete follow-up. The dominant arm was affected in 50% of cases. The mean follow-up was 27 (12 to 43) months. The mean WORC and Constant scores improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), respectively. The ASES and subjective shoulder value scores at the end of the follow-up were 60 and 56 points, respectively. RC tears and nerve injuries that did not involve the axillary or suprascapular nerves were associated to better results than greater tuberosity fractures and injuries to the axillary or suprascapular nerves, respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES scores (P = 0.035). Preoperative WORC and Constant scores were independent prognostic factors. CONCLUSIONS: The most frequent patterns include complete RC tears, anterior capsular injuries, and an axillary nerve injury. Patients had improved functional scores at the end of follow-up after surgery. Better functional results were correlated to RC tears, injuries to nerves with innervation distal to the shoulder, and higher preoperative Constant and WORC scores.

Reliability and validity of the Greek shoulder pain and disability index in patients with shoulder pain.

Background: The Shoulder Pain and Disability Index is one of the most common questionnaire to evaluate the impact of shoulder disorders on function. There is no valid and reliable Greek version of the Shoulder Pain and Disability Index available at present for all shoulder disorders. Therefore, the aim of the current study was to test the reliability and validity of the Shoulder Pain and Disability Index in patients with shoulder pain for at least four weeks.Methods: The validation study was conducted in clinical settings by questionnaires comprising the Greek Shoulder Pain and Disability Index and Disability of the Arm, Shoulder, and Hand questionnaire. 130 (68 women and 62 men) Greek reading patients over 18 years old with shoulder pain for at least four weeks were recruited from physical therapy clinics. Internal consistency of the translated instrument was measured using Cronbach's α. to establish test-retest reliability, the patients without any change in their condition after 2-3 days from their initial visit were asked to complete the Shoulder Pain and Disability Index for a second time. An intraclass correlation coefficient was used to assess the test-retest reliability of the Shoulder Pain and Disability Index. The Greek version of the Shoulder Pain and Disability Index and Disability of the Arm, Shoulder, and Hand questionnaire was also administered in both visits. Concurrent validity was measured by correlating the Shoulder Pain and Disability Index with the Greek Shoulder Pain and Disability Index and Disability of the Arm, Shoulder and Hand scale using Pearson's correlation coefficient.Results: The results showed that the Greek Shoulder Pain and Disability Index has good internal consistency (Cronbach α = 0.947), test-retest reliability (ICC =0.926) and concurrent validity (r > 0.7). The standard error of measurement (SEM) and the smallest detectable change (SDC) of the Greek SPADI total score were 4.77 and 13.18.Conclusions: The Greek version of the Shoulder Pain and Disability Index is a reliable and valid measure when administered to patients aged over 18 years old with shoulder pain for at least four weeks.Implications for RehabilitationThe Greek version of the Shoulder Pain and Disability Index has been found to be reliable and valid when used in patients with shoulder pain for at least four weeks.The results of the psychometric characteristics were compatible with those of the original English version.The Shoulder Pain and Disability Index could be applied to a Greek-speaking population to assess functional limitations and symptoms in patients over 18 years old with shoulder pain for at least four weeks.

The arthroscopic triple-row modified suture bridge technique for rotator cuff repair: functional outcome and repair integrity.

BACKGROUND: The optimal technique for arthroscopic rotator cuff repair is still controversial. Large tears with a high grade of retraction have an especially high risk of retearing. This study reports the clinical and radiologic results of a triple-row modified suture bridge technique for the treatment of full-thickness rotator cuff tears with medium and high grades of retraction. METHODS: A total of 101 shoulders in 100 patients underwent a triple-row modified suture bridge reconstruction for full-thickness rotator cuff tears with retraction grade II and grade III according to Patte; 81 patients were reached for follow-up 36.2 months after surgery. At follow-up, clinical outcome was assessed by the American Shoulder and Elbow Surgeons score, subjective shoulder value, visual analog scale score, University of California-Los Angeles shoulder score, and Constant score (CS). At follow-up, an ultrasound examination was performed to determine tendon integrity or retears in all patients. RESULTS: The overall retear rate was 4.9% (4/81). The clinical outcome was good to excellent (American Shoulder and Elbow Surgeons score, 94 ± 11; subjective shoulder value, 92 ± 12; University of California-Los Angeles shoulder score, 33 ± 5; Constant score, 90 ± 9). In the radiologic follow-up, no retear was found in any of the follow-up patients after an average of 36.2 months. There was no significant difference in clinical outcome parameters between rotator cuff tears Patte II and Patte III (P > .05). CONCLUSION: For tears with a high grade of retraction, surgical treatment using a triple-row modified suture bridge technique represents a good treatment option with a low rate of retearing and good to excellent clinical results.

Advanced Rotator Cuff Tear Score (ARoCuS): a multi-scaled tool for the classification and description of rotator cuff tears.

BACKGROUND: To introduce a (semi-)quantitative surgical score for the classification of rotator cuff tears. MATERIAL AND METHODS: A total of 146 consecutive patients underwent rotator cuff repair and were assessed using the previously defined Advanced Rotator Cuff Tear Score (ARoCuS) criteria: muscle tendon, size, tissue quality, pattern as well as mobilization of the tear. The data set was split into a training (125 patients) and a testing set (21 patients). The training data set fitted a nonlinear predictive model of the tear score based on the ARoCuS criteria, while the testing data served as control. Based on the scoring results, rotator cuff tears were assigned to one of four categories (ΔV I-IV) and received a stage-adapted treatment. For statistical analysis, mean values ± standard deviation, interclass correlation coefficients (ICC) and kappa values were calculated. RESULTS: Overall, 32 patients were classified as ΔV I, 68 as ΔV II and 37 as ΔV III. Nine patients showed ΔV IV tears. Patients of all ΔV groups improved significantly their Constant scores (p < 0.001) and profited from significant pain reduction after surgery (p < 0.001). To date, ten patients have undergone revision surgery with five of them primarily classified as ΔV IV. Kappa values for the interobserver reliability ranged between 0.69 and 0.95. ICC scores for the ΔV category were 0.95 for interobserver reliability. CONCLUSIONS: The ARoCuS facilitates intra-operative decision-making and enables surgeons and researches to document rotator cuff tears in a standardized and reproducible manner.

Patterns of tendon retraction in full-thickness rotator cuff tear: comparison of delaminated and nondelaminated tendons.

OBJECTIVE: To analyze full-thickness rotator cuff tears, compare retraction patterns in delaminated and nondelaminated tendons, and correlate retraction distances with anteroposterior tear lengths. MATERIALS AND METHODS: In 483 MR examinations reported as showing full-thickness cuff tear, two musculoskeletal radiologists independently characterized tendons as delaminated or nondelaminated. Tendon delamination was defined as either horizontal intra-substance splitting of bursal and articular layers by an intervening plane of fluid, or differential retraction of bursal and articular layers. In a subset of 144 shoulders with surgically proven full-thickness cuff tears (45 delaminated, 99 nondelaminated tendons), matched cohorts (n = 45) were further analyzed to compare tendon retraction distance, anteroposterior tear length and retraction ratios (retraction distance/anteroposterior length). RESULTS: Delamination was present in 13% of 483 total tears, and 31% of 144 operated tears (p = 0.001). In nondelamination and delamination cohorts, mean anteroposterior tear length measured 30.0 and 31.5 mm respectively (p = 0.6). Although nondelaminated tendons showed mean retraction 31.5 mm, articular and bursal layers of delaminated tendons showed mean retractions 36.3 mm and 21 mm respectively (p < 0.0001). Anteroposterior tear length and retraction distance were significantly associated in all cuff tears (p < 0.0001). Retraction ratio for nondelaminated tendons (1.05) was significantly different from retraction ratios for articular (1.21) and bursal (0.70) layers of delaminated tendons (p < 0.0001). CONCLUSION: In full-thickness rotator cuff tear, delaminated and nondelaminated tendons show significant differences in retraction distances, despite similarities in anteroposterior dimensions. Delaminated tendons are important to identify and report because they are more likely to fail conservative treatments and undergo operative repairs.

Estimating the Minimal Important Difference for the Western Ontario Rotator Cuff Index (WORC) in adults with shoulder pain associated with partial-thickness rotator cuff tears.

BACKGROUND: Knowledge about Minimal Important Differences (MIDs) is essential for the interpretation of continuous outcomes, especially patient-reported outcome measures (PROMS). OBJECTIVE: The aim of this study was to estimate the MID for the Western Ontario Rotator Cuff Index (WORC: score 0 (best) to 2100 (worst disability)) in adults with shoulder pain associated with partial-thickness rotator cuff tears, 'symptomatic PTTs', undergoing conservative treatment with physiotherapy. DESIGN: A prospectively-designed anchor-based MID analysis using data from a prospective prognostic study with a three-month follow-up conducted within an outpatient care setting in Germany. METHODS: The MID was estimated using data from 64 adults with atraumatic symptomatic PTTs who underwent three months of conservative treatment with physiotherapy. The anchor was a seven-point Global Perceived Change (GPC) scale. RESULTS: Based on a definition of the MID being the threshold of "being (at least slightly) improved" with a probability nearest to 0.90 (i.e. 9 of 10 patients achieving the MID), the MID for the WORC was estimated as -300 for 'improved' shoulder-related disability in 9 out of 10 patients (95% CI 8 out of 10 patients to everyone) undergoing three months of exercise-based physiotherapy for symptomatic PTTs. CONCLUSIONS: This is the first published MID estimate for the WORC in adults with symptomatic PTTs of the rotator cuff undergoing typical treatment comprising conservative treatment with physiotherapy. The conceptual framework for interpretation facilitates its use in similar clinical contexts.

Establishing minimally important differences for the American Shoulder and Elbow Surgeons score and the Western Ontario Rotator Cuff Index in patients with full-thickness rotator cuff tears.

BACKGROUND: The American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff Index (WORC) are frequently used measures in clinical research for patients with rotator cuff tears (RCTs). The minimally important differences (MIDs) for these measures have not been established in patients with RCTs. The purpose of this study was to establish the MIDs for patients with known RCTs treated both surgically or nonsurgically. METHODS: We included 222 subjects with full-thickness RCTs. The WORC and ASES were collected at baseline and at 4, 8, 16, 32, 48, and 64 weeks, as was an end of study form with questions about change in the condition after treatment. We calculated anchor-based and distribution-based MIDs. We used regression modeling to determine change in MIDs as predicted by several variables. RESULTS: For the anchor-based method, we found an MID of 21.9 for the ASES and -282.6 for the WORC. When using the distribution-based method of ½ and ⅓ the standard deviation, we arrived at an MID of 26.9 and 17.9 points for the ASES and -588.7 and -392.5 points for the WORC. No variables predicted MID changes. CONCLUSION: This is the first study to report MIDs for the ASES and WORC in a population of patients with only full-thickness RCTs. This information will directly improve our ability to determine when patients with RCTs are changing in a meaningful manner and accurately power clinical studies using these outcome measures.

Post-operative rotator cuff integrity, based on Sugaya's classification, can reflect abduction muscle strength of the shoulder.

PURPOSE: Magnetic resonance (MR) imaging is common in structural and qualitative assessment of the rotator cuff post-operatively. Rotator cuff integrity has been thought to be associated with clinical outcome. The purpose of this study was to evaluate the inter-observer reliability of cuff integrity (Sugaya's classification) and assess the correlation between Sugaya's classification and the clinical outcome. It was hypothesized that Sugaya's classification would show good reliability and good correlation with the clinical outcome. METHODS: Post-operative MR images were taken two years post-operatively, following arthroscopic rotator cuff repair. For assessment of inter-rater reliability, all radiographic evaluations for the supraspinatus muscle were done by two orthopaedic surgeons and one radiologist. Rotator cuff integrity was classified into five categories, according to Sugaya's classification. Fatty infiltration was graded into four categories, based on the Fuchs' classification grading system. Muscle hypotrophy was graded as four grades, according to the scale proposed by Warner. The clinical outcome was assessed according to the constant scoring system pre-operatively and 2 years post-operatively. RESULTS: Of the sixty-two consecutive patients with full-thickness rotator cuff tears, fifty-two patients were reviewed in this study. These subjects included twenty-three men and twenty-nine women, with an average age of fifty-seven years. In terms of the inter-rater reliability between orthopaedic surgeons, Sugaya's classification showed the highest agreement [ICC (2.1) = 0.82] for rotator cuff integrity. The grade of fatty infiltration and muscle atrophy demonstrated good agreement, respectively (0.722 and 0.758). With regard to the inter-rater reliability between orthopaedic surgeon and radiologist, Sugaya's classification showed good reliability [ICC (2.1) = 0.70]. On the other hand, fatty infiltration and muscle hypotrophy classifications demonstrated fair and moderate agreement [ICC (2.1) = 0.39 and 0.49]. Although no significant correlation was found between overall post-operative constant score and Sugaya's classification, Sugaya's classification indicated significant correlation with the muscle strength score. CONCLUSIONS: Sugaya's classification showed repeatability and good agreement between the orthopaedist and radiologist, who are involved in the patient care for the rotator cuff tear. Common classification of rotator cuff integrity with good reliability will give appropriate information for clinicians to improve the patient care of the rotator cuff tear. This classification also would be helpful to predict the strength of arm abduction in the scapular plane. LEVEL OF EVIDENCE: IV.

Bursal-Sided Rotator Cuff Tears: Simple Versus Everted Type.

BACKGROUND: No studies have focused on the everted type of bursal-sided partial-thickness rotator cuff tears (PTRCTs). PURPOSE: To evaluate the radiological characteristics, arthroscopic findings, and clinical and structural outcomes after arthroscopic repair of the everted type of bursal-sided PTRCTs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Two groups of patients with bursal-sided PTRCTs (simple type, 25 shoulders; everted type, 25 shoulders) were enrolled. The mean age was 59.6 years (range, 47-73 years) and 60.8 years (range, 48-72 years) among patients with the simple and everted type, respectively. The mean follow-up period was 2.7 years (range, 2.0-5.1 years). RESULTS: The everted type always exhibited an acromial spur (hat-shaped, 52%; heel-shaped, 48%) and bony changes in the greater tuberosity (bony spur, 52%; sclerotic changes, 48%). Hat-shaped spurs of the acromion were not observed in the simple type. The everted type showed significantly thicker tendon on magnetic resonance imaging (MRI), as the stump was retracted superomedially (mean thickness: 8.1 ± 1.2 mm vs 5.5 ± 1.1 mm for the everted and simple type, respectively). During arthroscopic repair, additional sutures were needed more often for the everted type than for the simple type (64% vs 16%, respectively). After repair, the tendon margin was uneven and ragged in 16% of shoulders with the everted type. Preoperatively, the visual analog scale (VAS) score for pain during motion and range of motion (ROM) were significantly worse in patients with the everted type than in those with the simple type (VAS score, 7.2 vs 5.6, respectively; ROM for forward flexion, 146.8° vs 156.4°, respectively). Postoperatively, no significant differences in the VAS score, ROM, or clinical outcomes were observed between the 2 groups, with no retears on follow-up MRI in either group. CONCLUSION: The everted type of bursal-sided PTRCTs showed a characteristic hat-shaped acromion, often with bony spurs of the greater tuberosity. On MRI, the tendon stump appeared thickened because of the everted flap. The everted type was more likely to require additional sutures because of an uneven or ragged tendon margin. However, satisfactory clinical and structural outcomes were observed for both the simple and everted types.

Tratamiento quirúrgico de las lesiones del manguito de los rotadores. Indicación y planificación preoperatoria / Surgical treatment of rotator cuff lesions. Indication and preoperative planning

La lesión del manguito de los rotadores es el síndrome doloroso más frecuente en la articulación del hombro. El tratamiento conservador ofrece resultados satisfactorios en la mayoría de los casos. No obstante, muchos pacientes no evolucionan de forma adecuada con las medidas conservadoras y requieren tratamiento quirúrgico. El objetivo de este trabajo es revisar las indicaciones quirúrgicas actuales, así como evaluar numerosos parámetros, tanto clínicos como radiológicos, que resultan fundamentales en la planificación de una intervención quirúrgica dirigida a la reparación de lesiones en el manguito de los rotadores

Rotator cuff injuries are the most frequent painful, shoulder joint disorders. Conservative treatments provide satisfactory results in the majority of cases, however, many patients do not evolve satisfactorily with these measures and require surgical intervention. The present study reviewed the surgical indications as well as the numerous radiological and clinical parameters that were fundamental when planning surgical interventions aimed at repairing rotator cuff lesions

Limited diagnostic accuracy of magnetic resonance imaging and clinical tests for detecting partial-thickness tears of the rotator cuff.

INTRODUCTION: The reliable diagnosis of partial-thickness tears of the rotator cuff is still elusive in clinical practise. Therefore, the purpose of the study was to determine the diagnostic accuracy of MR imaging and clinical tests for detecting partial-thickness tears of the rotator cuff as well as the combination of these parameters. MATERIALS AND METHODS: 334 consecutive shoulder arthroscopies for rotator cuff pathologies performed during the time period between 2010 and 2012 were analyzed retrospectively for the findings of common clinical signs for rotator cuff lesions and preoperative MR imaging. These were compared with the intraoperative arthroscopic findings as "gold standard". The reports of the MR imaging were evaluated with regard to the integrity of the rotator cuff. The Ellman Classification was used to define partial-thickness tears of the rotator cuff in accordance with the arthroscopic findings. Descriptive statistics, sensitivity, specificity, positive and negative predictive value were calculated. RESULTS: MR imaging showed 80 partial-thickness and 70 full-thickness tears of the rotator cuff. The arthroscopic examination confirmed 64 partial-thickness tears of which 52 needed debridement or refixation of the rotator cuff. Sensitivity for MR imaging to identify partial-thickness tears was 51.6%, specificity 77.2%, positive predictive value 41.3% and negative predictive value 83.7%. For the Jobe-test, sensitivity was 64.1%, specificity 43.2%, positive predictive value 25.9% and negative predictive value 79.5%. Sensitivity for the Impingement-sign was 76.7%, specificity 46.6%, positive predictive value 30.8% and negative predictive value 86.5%. For the combination of MR imaging, Jobe-test and Impingement-sign sensitivity was 46.9%, specificity 85.4%, positive predictive value 50% and negative predictive value 83.8%. CONCLUSIONS: The diagnostic accuracy of MR imaging and clinical tests (Jobe-test and Impingement-sign) alone is limited for detecting partial-thickness tears of the rotator cuff. Additionally, the combination of MR imaging and clinical tests does not improve diagnostic accuracy. LEVEL OF EVIDENCE: Level II, Diagnostic study.

Intra- and inter-observer agreement in MRI assessment of rotator cuff healing using the Sugaya classification 10years after surgery.

BACKGROUND: The long-term outcomes of rotator cuff repair are unclear. Recurrent tears are common, although their reported frequency varies depending on the type and interpretation challenges of the imaging method used. The primary objective of this study was to assess the intra- and inter-observer reproducibility of the MRI assessment of rotator cuff repair using the Sugaya classification 10years after surgery. The secondary objective was to determine whether poor reproducibility, if found, could be improved by using a simplified yet clinically relevant classification. HYPOTHESIS: Our hypothesis was that reproducibility was limited but could be improved by simplifying the classification. MATERIAL AND METHOD: In a retrospective study, we assessed intra- and inter-observer agreement in interpreting 49 magnetic resonance imaging (MRI) scans performed 10years after rotator cuff repair. These 49 scans were taken at random among 609 cases that underwent re-evaluation, with imaging, for the 2015 SoFCOT symposium on 10-year and 20-year clinical and anatomical outcomes of rotator cuff repair for full-thickness tears. Each of three observers read each of the 49 scans on two separate occasions. At each reading, they assessed the supra-spinatus tendon according to the Sugaya classification in five types. RESULTS: Intra-observer agreement for the Sugaya type was substantial (κ=0.64) but inter-observer agreement was only fair (κ=0.39). Agreement improved when the five Sugaya types were collapsed into two categories (1-2-3 and 4-5) (intra-observer κ=0.74 and inter-observer κ=0.68). CONCLUSION: Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement. A simpler classification into two categories improved agreement while remaining clinically relevant. LEVEL OF EVIDENCE: II, prospective randomised low-power study.