POSTOPERATIVE SHOULDER
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1 JEROEN BOSCH HOSPITAL POSTOPERATIVE SHOULDER Matthieu J.C.M. Rutten Musculoskeletal Ultrasound Society 22nd Annual Meeting, Sept 2012 Leuven, Belgium
2 JEROEN BOSCH HOSPITAL POSTOPERATIVE SHOULDER With courtesy of Raluca Avram Patricia Kolowich Marnix van Holsbeeck Henri Ford Hospital, Detroit, USA Bas Maresch Gelders Vallei Hospital, Ede, The Netherlands
3 INTRODUCTION Shoulder surgery Postoperative pain Postoperative imaging findings
4 SHOULDER SURGERY Coraco-acromial acromial arch decompression Rotator cuff repair Intraarticular surgery Instability repair (labrum, capsule) SLAP repair Biceps tendon repair Arthroplasty
5 SHOULDER SURGERY CA arch decompression Neer s s arthroplasty Osteotomy of hooked acromion CA ligament lysis AC \ distal clavicle resection (Mumford procedure) Bursectomie
6 SHOULDER SURGERY CA arch decompression Neer s s arthroplasty Osteotomy of hooked acromion AC \ distal clavicle resection (Mumford procedure) CA ligament lysis Bursectomie Rotator Cuff Repair
7 INDICATIONS RC REPAIR Relieve pain Restore shoulder function Prevent rotator cuff arthropathy PARTIAL-THICKNESS TEARS (<1/2-2/3) Debridement FULL-THICKNESS TEARS + extended PTT Bone through +/- suture bridge Bioabsorbable tacks / Suture anchors
8 INDICATIONS RC REPAIR Small partial-thickness RC tear in older patients: Conservative treatment only or debridement of frayed tendon tissue Small partial-thickness RC tear in young, active patients or in athletes: Debridement or a combined excision of the defect and repair of the healthy margins of RC Small full-thickness RC tear or "V-shaped" split tear: Side to side and tendon to tendon suturing technique, or tendon to bone repair with reattachment to the greater tuberosity in case of the distal lesion Large full-thickness RC tear: Tendon to tendon suturing technique or tendon reinsertion to bone with the use of transosseous sutures or suture anchors associated with acromioplasty Massive tear: Debridement alone for the most part
9 ROTATOR CUFF REPAIR HISTORY RC SURGERY : Codman - First report surgical RC repair : Neer - Modifications open technique: - Subacromial decompression - Meticulous repair of the deltoid origin - Transosseous fixation of the tendon to the tuberosity : Levy - mini open technique: - Arthroscopy for subacromial decompression - deltoid fibers split in line, avoiding the deltoid take down
10 METHODS SURGICAL RC REPAIR 1. Open surgery repair 2. Mini-open surgery repair 3. Arthroscopic repair Advantages mini-open compared to open : less post-operative pain decreased risk of deltoid dehiscence accelerated recovery and rehabilitation Galatz et al, JBJS 2004 Cho et al, Am J Sports Med 2010
11 METHODS SURGICAL RC REPAIR 1. Open surgery repair 2. Mini-open surgery repair 3. Arthroscopic repair Advantages of the arthroscopic method Glenohumeral joint inspection Treatment of intra-articular lesions Avoidance of deltoid avulsions and necrosis Decreased perioperative pain Easier restoration of motion Smaller incisions with improved cosmesis Shorter rehabilitation time
12 Single row repair Tendon Anatomic neck Tendon GT GT The anchor with 2 preloaded sutures is placed 1cm lateral to the anatomic neck at a dead man s angle to maximize pullout. One or more anchors can be placed on the same row for a single row repair. Anchor and sutures seen from the top of the greater tuberosity. The sutures are passed from the articular side of the tendon and stitched in a horizontal mattress fashion on the bursal side of the tendon.
13 Single row repair
14 Double row repair The medial row anchors are placed just off the articular margin. The second row of anchors are placed 1.5 cm lateral to the medial row. One or more anchors can be placed on the same row for a double row repair. The sutures are passed from the articular side of the tendon and stitched with a mattress suture technique on the bursal side of the tendon.
15 Double row repair
16 Supraspinatus tendon rupture after surgical repair with sutures Transverse sutures Transverse sutures Longitudinal sutures Longitudinal sutures
17 POSTOPERATIVE SHOULDER Shoulder surgery Postoperative pain Postoperative imaging findings
18 POSTOPERATIVE PAIN 25% of sympt postop pts Recurrent tear New site of RCT New tear more likely Large initial tear Muscle athrophy / fatty degeneration
19 Other causes PostOp pain Loose anchor / tack Hematoma, adhesions Infection AVN Deltoid dehiscence Biceps tendon tear / dislocation
20 Other causes PostOp pain Loose anchor / tack
21 POSTOPERATIVE SHOULDER Shoulder surgery Postoperative pain Postoperative imaging findings
22 NORMAL POSTOP FINDINGS ROTATOR CUFF Variable tendon thickness Most disorganized at 3 mos Most normalized at 1 yr, Increased size footprint Decreased MRI signal Remodel over a period of at least 2 yrs Hypoechoic defect in the repaired RC <3 months: do not diagnose these findings as a retear immediately. Wait for more than three months after surgical repair, check the US at regular intervals. Crim et al AJR 2010; 195:1361 Nho et al Am J Sports Med 2009
23 POSTOP. IMAGING FINDINGS ROTATOR CUFF 10%: normal imaging findings 20-50%: T2 signal 25% asymptomatics RC defect non- watertight seal common Postop intact cuff lack of complaints Spielmann et al - Radiology 1999; 213:705 Duc et al AJR 2006; 186:237
24 NORMAL POSTOP FINDINGS variable thickness RC tendons heterogeneous aspect RC hypoechoic with ultrasound intermediate signal with MRI tendon boundaries are slightly concave because of scarring and reduced in volume echogenic suture knots
25 POSTOP. IMAGING FINDINGS
26 NORMAL POSTOP FINDINGS GHJ fluid SASD fluid : 90% postop pts : 2/3 asymptomatic pts
27 Intact RC repair The sutures are tied on the bursal side of the tendon. The knots display posterior acoustic shadowing. SAG
28 Intact RC repair Sutures Sutures Suture longitudinal Suture longitudinal
29 NORMAL POSTOP FINDINGS Decreased edema Increased tendon echogenicity Ko et al. ECR 2011
30 NORMAL POSTOP FINDINGS Ko et al. ECR 2011
31 POSTOP. IMAGING FINDINGS Ultrasound for identifying rotator cuff integrity Sensitivity : 91% Specificity : 86% Accuracy : 89% During image interpretation, postoperative and preoperative images should be correlated closely Pricket et al JBJS 2003; 85-A:1084
32 US detection Rotator Cuff tears year author pat MHz rupt GS sens spec acc ppv npv 1984 Middelton T A Crass T C Mack 47 7,5 T C Hodler 51 7,5 P/T C Soble 30 7,5 T C Farin 102 7,5 T C Wiener 206 7,5 P/T C Moppes 41 7,5 P/T C/A Holsbeeck 52 7,5 P C Hedtmann ,5 P/T C Bachmann 38 7,5 P/T C Teefey 71 7,5-9 9 HI P/T A ,5-9 9 HI T A
33 Re-tear rate FFT-repair Full thickness re-tear Partial thickness re-tear - Poor quality tendon tissue - Suture breakage, surgical knot loosening Single row Double row 8-27% 30-38% 4-10% 17-27% - Pullout of suture anchor - Inappropriate rehabilitation - Galatz et al reported a re-tear rate of 94% for single row repairs of rotator cuff tears > 2cm Franceschi et al, Am J Sports Med 2007 Sugaya et al, Arthroscopy 2005 Cho et al, Am J Sports Med 2010 Galatz et al, JBJS 2004
34 RECURRENT RC TEAR? Loose anchors from rotator cuff repair The rotator cuff repair can be intact in the presence of loose anchors
35 US signs of recurrent RC tear Fluid gap/focal defect > 1cm Nonvisualization of the RC due to complete tendon avulsion and retraction Variable degree of tendon retraction Detection of sutures floating freely in the fluid
36 RC RE-TEAR Follow-up US at regular intervals is necessary Aggravation of thinning in the repaired RC Ko et al. ECR 2011
37 RC RE-TEAR Floating echogenic suture materials Seriel follow-up US: Full-thickness RC retear with progressive tendon retraction
38 Conditions to be differentiated of abnormal postoperative changes Anisotropy artifact Limited range of motion Calcific tendonitis Thickened bursa mimicking the RC Defect in the SST after SLAP repair Acoustic shadowing by suture knots Pain originated from an extra-articular structure
39 Conditions to be differentiated of abnormal postoperative changes Thickened bursa mimicking the RC
40 Infraspinatus tendon rupture caused by a penetrating screw in a patient with a surgicaly treated humerus fracture Penetrating screw Infraspinatus tendon rupture
41 Supraspinatus tendon and humeral head defect after removal of surgical fixation material Tendon and humeral head defect
42 SUMMARY POSTOP SHOULDER Radiography, CT, US and MRI have important roles in the evaluation of the postoperative shoulder patient US is an highly accurate imaging study for evaluating the integrity of the RC (Acc preop = Acc postop ) US Should, along with plain films, be regarded as the first line imaging modality of the (postoperative) shoulder During image interpretation, postoperative and preoperative images should be correlated closely Findings considered diagnostic or indicative of pathologic conditions in the preoperative shoulder may represent normal or improved conditions in the postoperative shoulder
43 THANK YOU FOR YOUR ATTENTION
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