The fibrous frame of the deltoid muscle. Its functional and surgical relevance.

Black lines seen on magnetic resonance imaging in the middle part of the deltoid suggest the presence of fibrous bands. Anatomic study of 30 deltoid muscles was done. Eight half-cone shaped distal fibrous structures merged together into the distal tendon of the deltoid muscle. The middle part of the deltoid muscle contains four deep fibrous bands that glide inside the distal half-cones. The anterior and posterior parts of the deltoid muscle lacked such bands. Histologic study confirmed the presence of the bands and cones. In the middle part of the deltoid, muscle fibers are oblique between the bands or between the bands and the half-cones. This multipennate structure favors strength instead of range of excursion of the muscle. Because of its significant change of direction around the humeral head, at the onset of elevation of the arm, the deltoid muscle sustains forces that press the muscle against the head which then leads to deformation of the muscle. The fibrous bands make the muscle strong enough to support these forces. The middle part of the muscle is of greatest importance in comparison with the other parts. This should be considered during shoulder rehabilitation. The presence of the fibrous band originating from the anterior corner of the acromion may help create a strong repair after splitting the deltoid.

The hyperabduction test.

We studied 100 fresh human shoulders in cadavers (mean age 76 years), and the range of passive abduction (RPA) in 100 volunteers with normal shoulders and in 90 patients with instability of the joint, over a period of six years. The anatomical and clinical findings showed that passive abduction occurs within the glenohumeral joint only, is controlled by the inferior glenohumeral ligament and has a constant value in 95% of both shoulders in normal subjects. In patients with instability, 85% showed an RPA of over 105 degrees with 90 degrees in the contralateral shoulder. In the remaining patients a strongly positive apprehension test suggested a diagnosis of instability. An RPA of more than 105 degrees is associated with lengthening and laxity of the inferior glenohumeral ligament.

Anastomoses between the spermatic and visceral veins: a retrospective study of 500 consecutive patients.

BACKGROUND: Do visceral-spermatic vein shunts have any clinical impact on sclerotherapy of varicoceles? METHODS: The spermatic venograms of 500 consecutive patients were retrospectively reviewed to classify visceral-spermatic communications. Men with an average age of 27.8 years (range 11-65 years old) underwent sclerotherapy of a varicocele. Of the 500 men, 445 were referred for oligoasthenospermia (89%), 45 for pain (9%), and 10 for prevention of infertility (2%). After bilateral catheterization, percutaneous sclerosis was performed below the upper third of the sacroiliac joint. RESULTS: Three hundred forty patients (68%) had left-sided, 10 (2%) had right-sided, and 150 (30%) had bilateral varicoceles. Left side: Of 46 (9.4%) anastomoses, one (0.2%) communicated with the splenic vein and 45 (9.2%) with the inferior mesenteric vein of which 25 (5.1%) were a colic trunk with a competent valve, 15 (3.1%) were venules, and five (1%) were a single or double anastomosis. Right side: Of 48 (29.6%) anastomoses to the superior mesenteric vein, 34 (21%) were venules, 12 (7.4%) were a colic trunk with a competent valve, and two (1.2%) were a single or double vein. Our varicocele recurrence rate was only 1.2%. CONCLUSION: Visceral-spermatic vein communications are classified by number, morphology, and site. Percutaneous sclerotherapy could be optimized when performed caudally to these communications.

Three dimensional reconstruction of the fibrous frame of the rotator cuff.

The authors present the methodology and the results of a trial of 3D-reconstruction of the fibrous frame of the rotator cuff taken from high resolution MRI. The accuracy of the method used is discussed. A precise reconstruction of the soft tissues is possible and provides an interesting model to study the mechanical role of the rotator cuff muscles. An example of biomechanical application of the 3D images is given.

Tendon of the normal supraspinatus muscle: correlations between MR imaging and histology.

The aim of this study was to attempt to specify the nature of the signal modifications observed in MRI in the supraspinatus tendon apart from any pathology of the shoulder, and due, according to certain authors, to an artefact associated with MRI. Five macroscopically normal supraspinatus tendons were removed from 4 young subjects (14-28 years), 30 min after cardiac arrest, with the authorization of the ethical committee. These tendons were examined by MRI in the frontal oblique plane along the axis of the muscle with a surface coil of 4 cm diameter, using a T2-weighted spin-echo sequence, and then studied histologically using the same plane of section. 22 control subjects (18-24 years) were examined by MRI with the same T2-weighted spin echo sequence. All the tendons examined possessed a dark signal with zones of intermediate signal on the first echo of the sequence. There was a complete correlation between the MRI appearances of the 5 tendons and their histologic description. Three histologic appearances were described : fibrillary degeneration, fibrous dystrophy, and eosinophil transformation of the tendinous collagen. All the tendons examined in healthy volunteers exhibited heterogenic images at the first echo, in the second echo the hyposignal was uniform and obvious. The good correlation obtained suggests that modifications of the tendon signal from the supraspinatus m. are not related to an artefact described in MRI, but are linked with premature degeneration of this tendon, probably associated with the severity of the mechanical constraints to which it is subject.

[Cytopuncture: an alternative to pelviscopy in the diagnosis of lymphatic metastases of urologic pelvic tumors]. / Cytoponction: une alternative à la pelviscopie dans le diagnostic des métastases ganglionnaires des tumeurs urologiques pelviennes.

119 patients with prostatic or vesical tumours without metastases were studied by lymphography-aspiration cytology to detect lymph node metastases. 12% of aspiration cytologies were uninterpretable, corresponding to N-patients. 12% of the 105 interpretable cases were positive. Some of the patients with negative biopsies were treated nonsurgically. 28 bladder tumours were treated intravesically. 11 prostatic cancers were treated by radiotherapy and 63 patients underwent surgical resection. These 63 patients had an interpretable aspiration cytology and surgical control. Aspiration cytology was falsely negative in 7 cases: 4 microscopic metastases and 3 macroscopic metastases. The sensitivity of aspiration cytology after lymphography is 66% and its specificity is 100%. The positive predictive value is 100% and the negative predictive value is 92.3%. These 7 false-negative results included 3 macroscopic metastases already identified on CT scan and 4 micrometastases in which surgical resection was legitimate.

Anatomy of the acromial arch: correlation of anatomy and magnetic resonance imaging.

Based on a retrospective study of 179 MRI records covering four populations (patients presenting with impingement without known injury (n = 90), post-traumatic shoulder pain (n = 28), instability or dislocation (n = 36) and controls (n = 25)), morphologic criteria are suggested to define presumedly normal arches and arches compatible with subacromial impingement. The subacromial arch is presumed normal or without impingement if the sagittal and frontal views show it to be parallel to the humeral head, and/or if there is a fatty layer interposed between the arch and the supraspinatus m. The arch is presumed "aggressive" or actually capable of giving rise to impingement if, in either the sagittal or frontal view, there is a zone of narrowing of the subacromial passage with an impression of the arch on the supraspinatus tendon or tendinous thinning at this level or just lateral to this narrowed zone. Based on these criteria, study of the 179 MRI records demonstrated a significant difference of distribution of the arches in the four populations. "Aggressive" arches were found in 45.5% of patients with impingement, 25% of patients with posttraumatic pain, 8.9% of patients with an acute or recurrent dislocation and 12% of controls. Conversely, a presumedly normal arch was found in 56% of the controls, 55% of patients with dislocation, 25% of posttraumatic painful shoulders and only 5.5% of patients with clinical impingement. Subacromial impingement may be due to the type 3 acromial dysplasia described by Bigliani or to a thickening of the coracoacromial ligament at its acromial attachment. This study was supplemented by 15 anatomic dissections which confirmed the regularity of attachment of the coracoacromial ligament at the inferior aspect of the acromion along its lateral border.

[Experimental study of dislocations of the scapulohumeral joint]. / Etude expérimentale des luxations antéro-internes ou erecta de l'articulation scapulo-humérale.

One may produce easily an experimental dislocation (anterior or erecta) of the scapulohumeral joint. The authors discuss, the experimental model then they describe the anatomical lesion produced through the experimental dislocation of 32 shoulders and the correlation observed after RMI assessment of 24 recurrent dislocations. The tear of the inferior glenohumeral ligament is constant, in 20 per cent of the cases the tear lies on the anterior aspect of the glenoid, in the other cases the tear was found on its humeral side. Whatever the situation of the tear of the inferior glenohumeral ligament, the lesion of the labrum was constant. The erecta dislocation was produced with the same movement but with a particular tear of the glenohumeral ligament: the tear was longitudinal. The experimental dislocation needs, in 7 or 8 cases, a desinsertion of the deep aspect of the rotator cuff. The Hill Sachs lesion occurs when the humerus falls along the chest wall after the dislocation. In 50 per cent of the patients, MRI shows modifications of the cuff which are compatible with our results. Hills Sachs lesions appear to be constant after MRI examination.

[Fibrous frame of the rotator cuff. The concept of fibrous lock]. / Le squelette fibreux de la coiffe des rotateurs. La notion de verrou fibreux.

MRI assessment of shoulder suggests the presence of a strong fibrous structure in the depth of the supra spinatus muscle. An anatomical study has been performed in 20 fresh human shoulders. There was a very strong fibrous frame within the anterior part of the supra spinatus m. and within the upper part of the sub scapularis. The upper part of the infra spinatus m. contained a significant fibrous reinforcement too so as in the teres minor m. The authors describe fibrous structures around the rotator interval, which constitute an antero-superior Fibrous Lock of the scapulo humeral joint and may help the repair of the full thickness tears of the rotator cuff.

[MRI in the pre-operative evaluation of lesions of the rotator cuff]. / Apport de l'IRM dans le bilan pré-chirurgical des lésions de la coiffe des rotateurs.

The authors report a series of 38 patients who had been examined by MRI and then operated for a rotator cuff syndrome. The correlation between the description of the cuff lesions after MRI and the surgical observations were excellent for 37 patients. In one case MRI showed a false image of tear of the supra spinatus m. on its anterior edge. This was due to a bad knowledge of the anatomy of the muscle and tendon and to a poor orientation of the frontal cut plane. This study was complete with MRI and anatomic study of 12 non embalmed cadaveric shoulders. The results showed that MRI was very sensitive (0.93) and specific (0.94) for the diagnosis of rotator cuff tears. MRI allowed also to show partial tears of the tendons of the rotator cuff. The authors propose a MRI classification of cuff lesions which permits to establish a good surgical planning.

[Diagnosis of lymphatic metastases in pelvic urologic tumors. Value of puncture biopsy]. / Diagnostic des métastases ganglionnaires des tumeurs urologiques pelviennes. Valeur de la cytoponction.

In 119 patients with pelvic urogenital tumours the diagnosis of lymph node metastasis was made by lymphography-guided fine needle biopsy. The results of this technique, performed without anaesthesia and devoid of morbidity, could be interpreted in 88 percent of the cases. In the search for micro- and macroscopically invaded lymph nodes fine needle biopsy had a sensitivity of 66 percent, a specificity of 100 percent, a positive predictive value of 100 percent and a negative predictive value of 92.3 percent. In cases with macroscopically invaded nodes its sensitivity was 82.3 percent.

[Contribution of MRI to the preoperative evaluation of rotator cuff tears]. / Apport de l'IRM dans le bilan pré-chirurgical des lésions de la coiffe des rotateurs.

The authors report a series of 38 patients who had been examined by MRI and then operated for a rotator cuff syndrome. The correlation between the description of the cuff lesions after MRI and the surgical observations were excellent for 37 patients. In one case MRI showed a false image of tear of the supra spinatus m. on its anterior edge. This was due to a bad knowledge of the anatomy of the muscle and tendon and to a poor orientation of the frontal cut plane. This study was completed with MRI and anatomic study of 12 non embalmed cadaveric shoulders. The results showed that MRI was very sensitive (0.93) and specific (0.94) for the diagnosis of rotator cuff tears. MRI allowed also to show partial tears of the tendons of the rotator cuff. The authors propose a MRI classification of cuff lesions which permits to establish a good surgical planning.

Contribution of MRI to the diagnosis and post-therapeutic monitoring of brain stem tumours.

MRI has become indispensable to the positive diagnosis of brain stem tumours which develop preferentially in young people. The prognosis of these tumours, especially infiltrating gliomas, being relatively sombre, it is important to make a precise morphological diagnosis of the lesions (increase in size, signal abnormalities) which will help both neurosurgeons and radiotherapists. As regards post-therapeutic monitoring, MRI with gadolinium contrast injection is harmless and will make it possible to follow these patients regularly and to detect recurrences.

The fibrous frame of the supraspinatus muscle. Correlations between anatomy and MRI findings.

30 MRI investigations of shoulders and 20 dissections of non embalmed cadaveric shoulders allowed us to demonstrate a particular organization of the supraspinatus muscle. In the anterior part of the muscle is an important fibrous frame with obliquely inserted muscle fibers. This organization suggests that this part of the supraspinatus muscle works as a "contractile tendon".

[Role of MRI in the study of the Achilles tendon and patellar tendon]. / Place de l'IRM dans l'étude du tendon d'Achille et du tendon rotulien.

The possibilities of MRI and radiography with mammogram to diagnose mechanical tendinitis have been prospectively evaluated in thirty sportsmen. Sixteen had Achilles tendon lesion, fourteen had patellar ligament lesion. Each patient included in the study was programmed for radiography with mammogram and MRI of the pathologic tendon and the controlateral tendon. These examinations were separately interpreted by two reviewers who had no knowledge of pain location. The number of tendinitis diagnosis based on X-ray and MRI was approximatively the same. But the microtearings were more often diagnosed on MRI data than on X-ray data (10/1). Eight patients underwent an operation. The surgery findings always confirmed the MRI diagnoses. MRI seems to be the examination of choice to evaluate the tendon injuries and particularly microtearings before surgery.