Air Bubble Saline Arthrosonography in Imaging Rotator Cuff Tears

Air Bubble Saline Arthrosonography in Imaging Rotator Cuff Tears

By David Martin, MBBS, BMed Sc(Hons), FRACS, FAOrthA; Parminder J. S. Jeer, MBBS, FRCS, FRCS(Tr&Orth); Yegappan Kalairajah, MA, MPhil, MBBChir, FRCS; Mark Falworth, MBBS, FRCS(Eng), FRCS (Tr&Orth); Steven Zadow, MBBS(Hons), FRANZCR; Neil Simmons, MBBS, FRACR
ORTHOPEDICS 2008; 31:140

February 2008

Air bubble saline arthrosonography decreases user dependency and increases accuracy in the identification and characterization of rotator cuff tears.

The accurate identification and characterization of rotator cuff tears is important when planning surgical intervention and determining the prognosis in patients with rotator cuff pathology.^1,2 Imaging modalities used to investigate a suspected rotator cuff tear include plain radiography, magnetic resonance imaging (MRI), and ultrasonography scanning, all of which can be combined with arthrography.

Magnetic resonance imaging and ultrasonography scanning have been reported to be highly accurate in detecting rotator cuff tears.^3-10 Reports comparing ultrasonography scanning and MRI findings with arthrography and surgical findings suggest similar specificity but lower sensitivity of ultrasonography scanning in the detection of full and partial thickness tears.^11,12 These studies demonstrated the possibility of limited accuracy of ultrasonography scanning diagnosis when lower frequency transducers were used, along with high operator dependency.^11,12 However, compared with MRI, ultrasonography scanning is more readily available, more economical, and less time-consuming. Despite these advantages, ultrasonography scanning has not been widely accepted in the orthopedic community, particularly as an office tool in the investigation of rotator cuff pathology.^13,14

This article describes a new method of combining ultrasonography scanning with an air bubble and saline arthrogram to improve the ease of identification and characterization of rotator cuff tears.

Technique

Air bubble arthrosonogram improves the investigator’s ability to recognize and characterize rotator cuff tears. The technique involves shaking 15 mL of saline with 3 to 5 mL of air in a 20-mL syringe to generate numerous air bubbles. The ultrasonography scanning probe is positioned posteriorly over the infraspinatus tendon with the patient facing the monitor. The mixture is then injected into the glenohumeral joint using a 22-gauge, 50-mm–long needle, which is inserted beneath the probe using a standard posterior approach to the shoulder. After retracting the needle, the patient is encouraged to exercise the shoulder for 30 seconds to aid the distribution of the air bubbles and saline. If pain is a limiting factor when performing shoulder movements, the saline can be substituted with a local anesthetic. Standard ultrasonography scanning of the shoulder is then performed.

Improved visualization of the rotator cuff tear is possible due to the air bubble–tissue interface. In rotator cuff tears, the bubbles are seen escaping from the glenohumeral joint. The bubbles that adhere to the tear edge help to characterize the nature and extent of the tear. Partial tears are more easily identified, as the defect is more clearly visualized.

Figure 1: Left shoulder sta Standard ultrasonography scan along the long axis of the supraspinatus tendon. It is not clear from this image as to whether the previous cuff repair is intact. The bursa, humeral head, and trough from previous repair are seen (A). Left shoulder air bubble saline arthrogram demonstrating no significant differences compared with standard ultrasonography. With no fluid or bubbles in the bursa, the integrity of the previous supraspinatus tendon repair is confirmed. The humeral head and trough from previous repair are seen (B). Postgadolinium T1 fat saturated magnetic resonance image of the left shoulder demonstrating a thin and irregular supraspinatus tendon in the presence of a previous repair. No contrast has entered the bursa confirming an intact cuff repair, although there are irregularities on the articular surface of the supraspinatus. The metal artifact, humeral head, and corocoid process are seen (C). Abbreviations: A=metal artifact, B=bursa, CP=corocoid process, HH=humeral head, SS=supraspinatus tendon, and T=trough.

The resulting images of this technique, performed on the left and right shoulders of a 45-year-old man with previous cuff repairs, are presented in Figures 1 and 2. Four years after the cuff repairs, the patient reported discomfort and weakness in both shoulders. Standard ultrasonography scanning was performed (Figures 1A, 2A). Due to the difficulty in a definitive diagnosis, an air bubble saline arthrogram was performed in each case (Figures 1B, 2B). Magnetic resonance imaging was performed to confirm the ultrasonography findings (Figures 1C, 2C, 2D). An Acuson sequoia ultrasound machine with a 15- to 8-MHz–wide linear array (Acuson, Mountain View, California) was used to create these images.

Discussion

A diagnostic test is judged by its accuracy, sensitivity, and specificity. This modified technique improves upon conventional ultrasonography scanning in fulfilling these criteria.

This technique has been helpful in the diagnosis of rotator cuff pathology while also being simple, safe, and without complications. It has the advantages of arthrography without the possible complications linked to contrast media.¹⁵ Furthermore, it is quicker, more economical, and more accessible than MRI and sensitive enough to aid in the diagnosis of rotator cuff pathology. The ability to characterize tear size, thickness, and edge morphology is also improved on. It is particularly useful as an adjunct to ultrasonography scanning if there is a thickened subacromial bursa, which can make the diagnosis of a rotator cuff tear more difficult. The echogenic shadowing produced around the cuff tear is also helpful if a clear ultrasound image is not produced due to prior surgery, or if the anatomy is too distorted to confidently diagnose using standard ultrasound techniques. Air bubble saline arthrosonography can be used in these cases rather than MRI, which is more expensive and may not be as readily accessible.

Figure 2: Right shoulder standard ultrasonography scan along the long axis of the supraspinatus tendon at its anterior aspect. It is difficult to define the difference between the tendon and bursa, and the integrity of the previous cuff repair is not conclusive. The humeral head, cartilage, and trough from previous repair are seen (A). Right shoulder air bubble saline arthrogram demonstrating distension of the bursa and a more defined edge to the torn supraspinatus tendon. This confirms a full thickness tear of the previous repair. The humeral head, cartilage, and trough from previous repair are seen (B). Postgadolinium T1 fat saturated magnetic resonance image of the right shoulder demonstrating a more posterior aspect of the supraspinatus tendon which is irregular on its articular surface. Contrast in the bursal space suggests a torn cuff repair. The humeral head is seen (C). Postgadolinium T1 fat saturated magnetic resonance image of the right shoulder demonstrating contrast in the bursal space, confirming a full thickness tear of the supraspinatus tendon. The long head biceps, humeral head, and corocoid process are seen (D). Abbreviations: B=bursa, C=cartilage, CP=corocoid process, FTT=full thickness tear, HH=humeral head, LHB=long head biceps, SS=supraspinatus tendon, and T=trough.

Previous concerns with ultrasonography scanning were based on its operator and equipment dependency. This dependence should be reduced by the greater ease of interpretation of the ultrasonography images using the air bubble saline arthrosonogram technique. Furthermore, this technique should allow orthopedic surgeons performing office-based ultrasonography scanning greater diagnostic accuracy, thereby aiding in the management of rotator cuff disease.

We acknowledge that validation of the technique with a prospective study correlating ultrasonography scanning appearance with operative findings at surgery and MRI are needed.

References

1. Yamaguchi K, Levine WN, Marra G, Galatz LM, Klepps S, Flatow EL. Transitioning to arthroscopic rotator cuff repair: the pros and cons. Instr Course Lect. 2003; 52:81-92.
2. Warner JJ, Goltz RJ, Irrgang JJ, Groff YJ. Arthroscopic-assisted rotator cuff repair: patient selection and treatment outcome. J Shoulder Elbow Surg. 1997; 6(5):463-472.
3. Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000; 82(4):498-504.
4. Brenneke SL, Morgan CJ. Evaluation of ultrsonography as a diagnostic technique in the assessment of rotator cuff tendon tears. Am J Sports Med. 1992; 20(3):287-289.
5. van Holsbeeck MT, Kolowich PA, Eyler WR, et al. US depiction of partial-thickness tear of the rotator cuff tear. Radiology. 1995; 197(2):443-446.
6. Wiener SN, Seitz WH Jr. Sonography of the shoulder in patients with tears of the rotator cuff: accuracy and value for selecting surgical options. AJR Am J Roentgenol. 1993; 160(1):103-110.
7. Hodler J, Fretz CJ, Terrier F, Gerber C. Rotator cuff tears: a correlation of sonographic and surgical findings. Radiology. 1988; 169(3):791-794.
8. Ziatkin MB, Iannotti JP, Roberts MC, et al. Rotator cuff tears: diagnostic performance of MR imaging. Radiology. 1989; 172(1):223-229.
9. Robertson PL, Schweltzer ME, Mitchell DG, et al. Rotator cuff disorders: interobserver and intraobserver variation in diagnosis with MR imaging. Radiology. 1995; 194(3):831-835.
10. Wnorowski DC, Levinsohn M, Chamberlain BC, McAndrew DL. Magnetic resonance imaging assessment of the rotator cuff: is it really accurate? Arthroscopy. 1997; 13(6):710-719.
11. Martin-Hervas C, Romero J, Navas-Acien A, Reboiras JJ, Munuera L. Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings. J Shoulder Elbow Surg. 2001; 10(5):410-415.
12. Nelson MC, Leather GP, Nirschl RP, Pettrone FA, Freedman MT. Evaluation of the painful shoulder. A prospective comparison of magnetic resonance imaging, computerized tomographic arthrography, ultrasonography, and operative findings. J Bone Joint Surg Am. 1991; 73(5):707-716.
13. Hollister MS, Mack LA, Patten RM, Winter TC 3rd, Matsen FA 3rd, Veith RR. Association of sonographically detected subacromial/subdeltoid bursal effusion and intraarticular fluid with rotator cuff tear. AJR Am J Roentgenol. 1995; 165(3):605-608.
14. Milgram C, Shaffer M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995; 77(2):296-298.
15. Newberg AH, Munn CS, Robbins AH. Complications of arthrography. Radiology. 1985; 155(3):605-606.

Authors

Drs Martin, Jeer, Kalairajah, and Falworth are from SPORTSMED SA; and Drs Zadow and Simmons are from Jones and Partners, Adelaide, Australia.

Drs Martin, Jeer, Kalairajah, Falworth, Zadow, and Simmons have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mark Falworth, MBBS, FRCS(Eng), FRCS (Tr&Orth), SPORTSMED SA, 32 Payneham Rd, Stepney Adelaide, SA 5069, Australia.

Surgical treatment of acute versus chronic complete proximal hamstring ruptures: results of a new allograft technique for chronic reconstructions.

Am J Sports Med. 2008 Jan;36(1):104-9. Epub 2007 Nov 30.

Folsom GJ, Larson CM.Minnesota Sports Medicine Orthopaedic Sports Medicine Fellowship Program, Twin Cities Orthopaedics, Eden Prairie, Minnesota 55344, USA.BACKGROUND: Acute surgical repair of proximal hamstring ruptures has been shown to result in a high return to preinjury activity level. HYPOTHESIS: Achilles allograft reconstruction of chronic complete proximal hamstring ruptures results in improved function and strength that approaches that of acute surgical repairs. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 2002 and 2005, 26 patients underwent surgical treatment for complete proximal hamstring ruptures. Twenty-one were acute primary repairs. Five chronic ruptures were treated with Achilles allograft reconstruction with (n = 2) or without (n = 2) interference screw fixation or mobilization and primary repair (n = 1). Isokinetic strength testing was conducted postoperatively in 11 acute and 3 chronic cases, and a functional questionnaire was given at most recent follow-up.

RESULTS: Subjective results for all patients at a mean follow-up of 20 months revealed good leg control in 96%, no pain in 80%, and return to sporting activities in 76%. Ninety-six percent of patients said they would have the procedure done again. With the isokinetic testing available at most recent follow-up, there was no significant difference in the mean hamstring strength deficits for the acute versus chronic groups tested at 60 deg/s (8% vs 21%, P =.295) and 180 deg/s (12% vs 2%, P = .294). Overall, there were 3 major adverse events and 5 patients with superficial wound drainage treated with antibiotics. CONCLUSION: Surgical treatment of acute and chronic complete proximal hamstring ruptures can result in a high return to full activity. Reconstruction of chronic ruptures with Achilles allograft appears to restore function and strength comparable to acute repairs.

Topical glyceryl trinitrate for chronic Achilles tendinopathy.

Hunte G,
Lloyd-Smith R.
University of British Columbia, Vancouver, British Columbia, Canada.
OBJECTIVE: To determine whether continuous application of topical glyceryl trinitrate decreases pain and symptoms in chronic noninsertional Achilles tendinopathy. DESIGN: Randomized double-blind placebo-controlled study of 6-months' duration. SETTING: Community and referral study at an Australian University Hospital. PARTICIPANTS: Recruitment was through newspaper advertisements and private consulting rooms. Eligibility criteria were age >18 years, a history of insidious onset of Achilles tendon pain, a tender nodule localized to the region of the calcaneal insertion, and an ultrasound examination that excluded a tendon tear. Exclusion criteria were Achilles tendinopathy of <3 months' duration, a previous operation on, or dislocation of, the affected ankle or leg, distal neurologic signs, a local corticosteroid injection in the previous 3 months, and current pregnancy. The 65 participants (84 affected tendons; 62% men) had a median age of 49 years (range, 24-79 years), with a median duration of symptoms of 16 months (range, 4-147 months). INTERVENTION: Participants were assigned an active transdermal patch (1/4 of a Nitro-Dur 5 [Schering-Plough] glyceryl trinitrate patch), which delivered 1.25 mg of glyceryl trinitrate over 24 hours, or a placebo patch. Patients were required to cut the patches into quarters and apply 1/d to the site of maximal tenderness for the 24-week duration of the study. All patients were also given 500-mg paracetamol tablets for use with headaches, and instructed in a rehabilitation program that comprised rest from aggravating activities, the use of heel-raise wedges, prolonged daily stretching of the gastrocnemius and soleus musculature, and an eccentric calf muscle-strengthening program. MAIN OUTCOME MEASURES: At the baseline, 2, 6, 12, and 24-week examinations the patient completed a symptom assessment sheet to rate the severity of Achilles pain with activity, at rest, and at night (0 = no pain, 4 = very severe pain). The single assessor used the same scale to measure local tenderness; an 11-point scale for the patient to report pain after the single-leg 10-hop test; and also measured the ankle plantar flexor mean peak force and ankle plantar flexor work. Follow-up was 89% complete. MAIN RESULTS: The groups did not differ in pain with activity, night pain, or local tenderness until the 12-week assessment when participants in the glyceryl trinitrate group reported less pain on each measure (mean scores, 0.9 vs. 1.6 [P = 0.02]; 0.2 vs. 0.7 [P = 0.04]; and 0.9 vs. 1.6 [P = 0.02], respectively). The difference was maintained at 24 weeks for pain with activity (mean scores, 0.4 vs. 1.0 [P = 0.03]). At 24 weeks the glyceryl trinitrate group reported less pain on the 10-hop test than the placebo group (mean scores, 0.5 vs. 1.6 [P = 0.005]). Although the intervention group showed a greater increase in plantar flexor mean total work at 24 weeks than the placebo group, the baseline scores were significantly different. The groups did not differ in pain at rest or in ankle plantar flexor peak force. Combining all the measures showed an estimated 14% (95% CI, 9%-19%) excess of asymptomatic tendons in the intervention group at 6 months. Reported main side effects were headaches (glyceryl trinitrate group, 53%; placebo group, 45%) and rashes (glyceryl trinitrate group, 16%%; placebo group, 12%). CONCLUSION: A topical glyceryl trinitrate patch was more effective than placebo for reducing pain from chronic noninsertional Achilles tendonitis in the first 12 and 24 weeks of use.

The Effect of Pes Cavus on Foot Pain and Plantar Pressure

Joshua Burnsa, Jack Crosbiea, Adrienne Hunta, Robert Ouvrierb
Received 19 October 2004; accepted 10 March 2005 published online 9 May 2005.
Abstract
Background. Clinical management of patients with painful pes cavus is challenging because the mechanism of foot pain is poorly understood. The purpose of this study was to explore the influence of various pes cavus aetiologies on foot pain and plantar pressure characteristics, and to identify the relationship between foot pain and plantar pressure.
Methods. Seventy subjects were recruited for this study. They included 30 subjects with pes cavus of unknown aetiology (idiopathic), 10 subjects with pes cavus of neurological aetiology (neurogenic) and 30 subjects with a normal foot type. The presence and location of foot pain was recorded and barefoot plantar pressures were measured using the EMED-SF platform for the whole foot, rearfoot, midfoot and forefoot regions.
Findings. Subjects with pes cavus of either idiopathic or neurogenic aetiology reported a higher proportion of foot pain (60%) compared to subjects with a normal foot type (23%) (P=0.009). Pressure–time integrals under the whole foot, rearfoot and forefoot regions in pes cavus, of both idiopathic and neurogenic origin, were higher than in the normal foot type (P<0.01). Pressure–time integrals in subjects reporting foot pain were higher than for pain free subjects (P<0.001). There was a significant correlation between pressure–time integral and foot pain (r=0.49, P<0.001).
Interpretation. Foot pain is a common finding among individuals with pes cavus. Regardless of aetiology, pes cavus is characterized by abnormally high pressure–time integrals which are significantly related to foot pain. An understanding of the relationship between pes cavus pressure patterns and foot pain will improve the clinical management of these patients.