Postoperative shoulder 20-9-12

JEROEN BOSCH
HOSPITAL
POSTOPERATIVE SHOULDER
Matthieu J.C.M. Rutten
Musculoskeletal Ultrasound Society
22nd Annual Meeting, 19 – 22 Sept 2012
Leuven, Belgium
JEROEN BOSCH
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
HOSPITAL
INTRODUCTION
• Shoulder surgery
• Postoperative pain
• Postoperative imaging findings
SHOULDER SURGERY
• Coraco-acromial arch decompression
• Rotator cuff repair
• Intraarticular surgery
• Instability repair (labrum, capsule)
• SLAP repair
• Biceps tendon repair
• Arthroplasty
SHOULDER SURGERY
• CA arch decompression
– Neer’s arthroplasty
– Osteotomy of hooked acromion
– CA ligament lysis
– AC \ distal clavicle resection (Mumford procedure)
– Bursectomie
SHOULDER SURGERY
• CA arch decompression
– Neer’s arthroplasty
– Osteotomy of hooked acromion
– AC \ distal clavicle resection (Mumford procedure)
– CA ligament lysis
– Bursectomie
• Rotator Cuff Repair
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
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
ROTATOR CUFF REPAIR
HISTORY RC SURGERY
- 1911: Codman - First report surgical RC repair
- 1972: Neer - Modifications open technique:
- Subacromial decompression
- Meticulous repair of the deltoid origin
- Transosseous fixation of the tendon to the tuberosity
- 1994: Levy - “mini open” technique:
- Arthroscopy for subacromial decompression
- deltoid fibers split in line, avoiding the deltoid take
down
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
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
Single row repair
Tendon
Tendon
Anatomic
neck
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.
GT
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.
Single row repair
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.
Double row repair
Supraspinatus tendon rupture
after surgical repair with sutures
Transverse sutures
Longitudinal sutures
Transverse sutures
Longitudinal sutures
POSTOPERATIVE SHOULDER
• Shoulder surgery
• Postoperative pain
• Postoperative imaging findings
POSTOPERATIVE PAIN
• 25% of sympt postop pts
• Recurrent tear
• New site of RCT
• New tear more likely
• Large initial tear
• Muscle athrophy / fatty degeneration
Other causes PostOp pain
• Loose anchor / tack
• Hematoma, adhesions
• Infection
• AVN
• Deltoid dehiscence
• Biceps tendon tear / dislocation
Other causes PostOp pain
• Loose anchor / tack
POSTOPERATIVE SHOULDER
• Shoulder surgery
• Postoperative pain
• Postoperative imaging findings
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
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
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
POSTOP. IMAGING FINDINGS
NORMAL POSTOP FINDINGS
• GHJ fluid
• SASD fluid
: 90% postop pts
: 2/3 asymptomatic pts
Intact RC repair
The sutures are
tied on the
bursal side of the
tendon.
The knots display
posterior
acoustic
shadowing.
SAG
Intact RC repair
Sutures
Suture longitudinal
Sutures
Suture longitudinal
NORMAL POSTOP FINDINGS
•
Decreased edema
•
Increased tendon
echogenicity
Ko et al. ECR 2011
NORMAL POSTOP FINDINGS
Ko et al. ECR 2011
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
US detection
Rotator Cuff tears
year
author
pat
MHz
rupt
GS
sens
spec
acc
ppv
npv
1984
Middelton
38
10
T
A
93
83
87
78
95
1985
Crass
41
10
T
C
100
94
97
94
100
1985
Mack
47
7,5
T
C
91
100
94
100
81
1988
Hodler
51
7,5
P/T
C
100
75
92
90
100
1989
Soble
30
7,5
T
C
93
73
83
78
92
1990
Farin
Farin
102 7,5
T
C
81
95
90
91
90
1993
Wiener
206 7,5 P/T
C
95
94
92
97
89
1995
Moppes
41
7,5
P/T
C/A
86
91
88
96
73
1995
Holsbeeck
52
7,5
P
C
93
94
94
82
98
1995
Hedtmann
1227 7,5
P/T
C
95
95
95
87
92
1997
Bachmann
P/T
C
100
67
90
87
100
2004
Teefey
71 7,57,5-9 HI P/T A
97
67
94
97
67
7,57,5-9 HI T
98
80
94
90
95
38
7,5
A
Re-tear rate FFT-repair
Full
thickness
re-tear
Partial
thickness
re-tear
Single
row
8-27%
30-38%
Double
row
4-10%
- Poor quality tendon tissue
- Suture breakage, surgical knot
loosening
- Pullout of suture anchor
- Inappropriate rehabilitation
17-27%
Franceschi et al, Am J Sports Med 2007
Sugaya et al, Arthroscopy 2005
- Galatz et al reported a re-tear rate
of 94% for single row repairs of
rotator cuff tears > 2cm
Cho et al, Am J Sports Med 2010
Galatz et al, JBJS 2004
RECURRENT RC TEAR?
•
Loose anchors from
rotator cuff repair
The rotator cuff repair can be intact in the presence of loose anchors
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
RC RE-TEAR
•
Follow-up US at regular intervals is necessary
•
Aggravation of thinning in the repaired RC
Ko et al. ECR 2011
RC RE-TEAR
•
•
Floating echogenic suture materials
Seriel followfollow-up US: FullFull-thickness RC retear with progressive tendon retraction
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
Conditions to be differentiated of
abnormal postoperative changes
• Thickened bursa mimicking the RC
Infraspinatus tendon rupture caused
by a penetrating screw in a patient with
a surgicaly treated humerus fracture
Penetrating screw
Infraspinatus tendon rupture
Supraspinatus tendon and humeral
head defect after removal of surgical
fixation material
Tendon and humeral head defect
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
THANK YOU FOR YOUR
ATTENTION