Shin Hitachi

Factors related to successful outcome of conservative treatment for rotator cuff tears

Abstract Background. Much controversy exists as to the management of full-thickness tears of the rotator cuff. Not all patients with rotator cuff tears require surgical treatment. We have little information whether there are factors that are related to successful outcome of conservative treatment. Aim. The purpose of this study was to determine the factors related to the successful outcome following conservative treatment. Methods. This study included 123 shoulders in 118 patients with full-thickness tears of the rotator cuff diagnosed by high-resolution magnetic resonance imaging with a microscopy coil. All patients were treated conservatively for at least 3 months. Clinical symptoms improved in 65 shoulders in 62 patients by conservative treatment (conservative group), but remained unchanged or aggravated in 58 shoulders in 56 patients, who eventually underwent surgical repair (surgical group). Results. The following parameters showed significant differences: 1) integrity of the intramuscular tendon of the supraspinatus (24.1% in the surgical group and 58.4% in the conservative group showed an intact intramuscular tendon); 2) supraspinatus muscle atrophy (occupancy ratio was 69.8% in the surgical group and 78.0% in the conservative group); 3) impingement sign (positive in 79.3% in the surgical group and 30.7% in the conservative group); and 4) external rotation angle (35.0 degrees in the surgical group and 52.2 degrees in the conservative group). The success rate of conservative treatment was 87% in the cases with at least three of these four factors. Conclusion. These four factors are useful in selecting patients who will respond well to conservative treatment before initiating the treatment.

F-18 FDG PET/CT findings in two patients with hepatic angiomyolipoma with and without intratumoral hemorrhage.

Two female patients aged 62 and 74 years underwent F-18 FDG PET/CT for evaluation of a large hepatic tumor. Subsequently, both patients underwent a partial hepatectomy which histopathologically revealed benign hepatic angiomyolipomas (AMLs). One patient with AML with a massive intratumoral hemorrhage presented with multiple foci demonstrating an increased FDG uptake along the margin of the cold defects that corresponded to low density areas within the tumor on contrast-enhanced CT, whereas the other patient with AML without any hemorrhage presented with a low FDG uptake in the tumor. This report demonstrates that benign hepatic AMLs may demonstrate increased FDG uptake if there is hemorrhage and a related inflammatory response.

Arm Abduction Provides a Better Reduction of the Bankart Lesion During Immobilization in External Rotation After an Initial Shoulder Dislocation

Background: Shoulder dislocation often recurs, especially in the younger population. Immobilization in external rotation, in which a Bankart lesion is displaced in the anterior, medial, and inferior directions, was introduced as a new method of nonoperative treatment, but its clinical efficiency is controversial. In terms of reducing the lesion, it is reasonable to incorporate not only external rotation, which makes the anterior soft tissues tight to push the lesion posteriorly and laterally, but also abduction, which makes the inferior soft tissues tight to push the lesion superiorly. Hypothesis: Abducting the arm during immobilization in external rotation will improve the reduction of a Bankart lesion. Study Design: Controlled laboratory study. Methods: There were 37 patients with initial shoulder dislocation enrolled in this study. After reduction, MRI was taken in 4 positions of the shoulder: adduction and internal rotation (Add-IR), adduction and external rotation (Add-ER), 30° of abduction and 30° of external rotation (Abd-30ER), and 30° of abduction and 60° of external rotation (Abd-60ER). On radial slices, the separation, displacement of the labrum, and opening angle of the capsule were measured. Results: Add-ER improved the reduction of the anterior labrum but not the inferior labrum when compared with Add-IR. Both Abd-30ER and Abd-60ER improved the reduction of the inferior labrum as compared with Add-IR. Furthermore, Abd-60ER improved the reduction more than Add-ER. Conclusion: Among the 4 positions tested, Abd-60ER is the best position in terms of reducing the Bankart lesion. Clinical Relevance: Abducting the shoulder during immobilization in external rotation is demonstrated to improve the reduction of the Bankart lesion. Therefore, this position is expected to reduce the recurrence rate after initial dislocation of the shoulder. Future clinical trials are necessary.

High-resolution magnetic resonance imaging of rotator cuff tears using a microscopy coil: noninvasive detection without intraarticular contrast material

PurposeThe aim of this study was to evaluate the feasibility of high-resolution magnetic resonance imaging (MRI) using a microscopy coil for the diagnosis of rotator cuff tears by comparing the method to conventional MRI and MRI arthrography.Materials and methodsA total of 68 shoulders were prospectively studied using a 1.5-T MRI unit. Conventional MRI scans were obtained with a surface coil and high-resolution MRI scans with a microscopy coil. MRI arthrography was performed in 28 shoulders using a surface coil. MRI evaluation of tears of rotator cuff tendons was compared with arthroscopic findings and surgical results.ResultsThe surgery revealed 40 full-thickness tears, 13 partial-thickness tears, and 15 intact cuffs. In all, 35 (88%) full-thickness tears were correctly diagnosed on conventional MRI and 40 (100%) on high-resolution MRI. MR arthrography delineated 11 of 12 (92%) full-thickness tears. Altogether, 5 (38%) of the partial-thickness tears were detected on conventional MRI, and 12 (92%) were clearly demonstrated on high-resolution MRI. MRI arthrography depicted three (60%) of five partial-thickness tears. High-resolution MRI showed higher sensitivity than conventional MRI (P < 0.05) and had values equivalent to those of MRI arthrography for diagnosing partial-thickness tears.ConclusionHigh-resolution MRI with a microscopy coil is a feasible, noninvasive technique for diagnosing rotator cuff tears.

Clinical features and radiological findings of 67 patients with SAPHO syndrome

Abstract Objectives: The purpose of this study was to facilitate the understanding of the SAPHO (Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis) syndrome by analyzing the clinical and radiological features of 67 Japanese patients with SAPHO syndrome. Methods: Sixty-seven Japanese patients (female/male: 44/23, mean age at onset: 48.5 years) were diagnosed with SAPHO syndrome from 2002 to 2013 at our hospital. Medical records and radiological imaging of these patients were retrospectively reviewed. Results: Among the 67 patients, 41 had dermatological manifestations, such as palmoplantar pustulosis, acne, and psoriasis. Initial symptom was local pain in all patients, and the most common initial site of the symptom was the anterior chest. Bacterial and fungal cultures from 20 bone biopsies were all negative. Histopathological diagnosis of the specimens was non-specific inflammation in all cases. Bone lesions were observed in 65 patients (97.0%). On the other hand, articular lesions including enthesitis were found in 31 patients (46.2%). Conclusion: SAPHO syndrome had different clinical and radiological aspects. The clinical features were not remarkable, except the dermatological manifestations and the involvement of the anterior chest. Bone lesions including hyperostosis and osteitis were found radiographically in the majority of patients with SAPHO syndrome. These are the characteristics of the SAPHO syndrome, with the exclusion of other bone diseases.

Imaging of the Normal Rotator Cuff

In this chapter, we show how the normal rotator cuff tendons and muscles look like on MRI and ultrasonography. By looking at the inclination of the superior surface of the greater tuberosity (footprint of the rotator cuff), we can identify the superior and middle facets, and accordingly we can identify the supraspinatus and infraspinatus tendons as well. The rotator cuff tendons appear as a homogeneous thick tendinous band with low signal on MRI and the fibrillar pattern on ultrasound. The intramuscular tendons of the rotator cuff muscles and the deltoid are clearly depicted on MRI as a low signal band inside the muscle belly.

Imaging of the Labrum

Imaging of the labrum can be done by MRI , MR a rthrography, CT arthrography , and ultrasonography. Among these imaging modalities, MR arthrography is the best in depicting the lesion of the labrum such as a Bankart lesion and SLAP lesion. Various methods to improve the accuracy of MR arthrography have been introduced such as radial sequences of MRI, arm position in abduction and external rotation, or application of downward traction to the arm.

Diagnosis of benign notochordal cell tumor of the spine: is a biopsy necessary?

Benign notochordal cell tumor is a benign intraosseous lesion, demonstrates characteristic imaging features. The lesion demonstrates low‐signal intensity in T1‐weighted images, high‐signal intensity in T2‐weighted images, and no enhancement with contrast medium in MRI and slight osteosclerosis in CT. If typical imaging findings are identified, biopsy is not necessary.

Calcific myonecrosis arising in the bilateral deltoid muscles: A case report.

Calcific myonecrosis is a rare soft tissue condition, usually occurring from the lower limb [1e5]. This condition was first described by Gallie and Thompson in 1960, characterized by slowly expanding soft tissue mass with necrotic tissue and calcification [6]. It is said to have a relationship with compartment syndrome, traumatic condition, or neurovascular compromise, although it is still not well understood [3,4,7e10]. Over 50 cases of calcific myonecrosis have been reported. All of them are related to lower limbs except for 2 reports [11,12], but no other reports have presented a case with bilateral upper limb occurrence. This paper reports a case with bilateral upper limb occurrence of calcific myonecrosis.

External Rotation and Abduction Bracing in the Management of First-Time Anterior Shoulder Dislocation: Response

Dear Editor: We read the article entitled ‘‘Arm Abduction Provides a Better Reduction of the Bankart Lesion During Immobilization in External Rotation After an Initial Shoulder Dislocation’’ by Itoi et al with great interest. The authors demonstrated a statistically significant improvement in the separation and displacement of the labrum, with greater degrees of external rotation and abduction when compared to lesser degrees or when compared to an adducted and internally rotated position. However, it is important to recognize that a statistically significant difference does not necessarily represent a clinically important difference. Although the results of this study concur with data from Hart and Kelly, who in their arthroscopic study demonstrated anatomic reduction of the labrum in approximately 85% of patients when placed in a similar position, it should be noted that the limitations of that study were that it was performed under anesthesia, and the effects of muscle relaxation, the presence of an arthroscope in the joint, and fluid distension on labral reduction are not known. We therefore believe that if Itoi et al would have reported the rate of anatomic or near-anatomic reduction of the labrum that they found in the various positions they assessed in this study, it would greatly add to the existing understanding and current knowledge on this topic. It can be seen from the box-and-whisker plots provided by Itoi et al that even in the most extreme position tested (30 abduction and 60 external rotation), in some patients the labrum was still separated by 10 mm and displaced by 13 mm, and the opening angle remained as wide as 30 . Surely, it is a leap of faith to expect a reduction in the rate of redislocation in the face of such wide displacement and failure to restore anatomy? In our recent systematic review published in AJSM, we reported that anatomic reduction of the labrum is only achieved in approximately 35% of cases (in MRI studies) even when using extreme degrees of external rotation that typically exceed those values used/tolerated in published clinical studies. Although the degree of reduction of the labrum that is required to confer a clinical benefit is unknown, we postulate that failure to reduce the labrum may be a potential explanation for the conflicting outcomes of external rotation bracing reported in the literature. Another potential explanation is variation in patient compliance. In a previous study, Itoi et al reported this to be as low as 60%, even with much smaller degrees of external rotation than described in their current study. Heidari et al reported a .3-fold increase in the rate of noncompliance in patients treated with an external rotation brace when compared to a standard sling. In addition, it is also recognized that more extreme positions are associated with greater discomfort and are therefore less likely to be tolerated. We consider that it is very unlikely that patients can realistically be expected to tolerate immobilization in 30 of abduction and 60 of external rotation for any meaningful length of time, and therefore an assessment of labral reduction in such extreme positions is really only of academic interest rather than of clinical relevance. Itoi et al cited 2 clinical studies to support their findings. The first was a randomized controlled trial presented by Nagaraj et al at the 11th International Congress of Shoulder and Elbow Surgery in 2010. It has not been subsequently published, and therefore we feel it should not have been included. The second study cited was a randomized controlled trial reported by Heidari et al. These authors reported a remarkably low redislocation rate of only 3.9% after treatment of first-time anterior dislocations in 15 of abduction and 10 of external rotation. It is interesting to note that when the results were stratified by age, there was no significant difference in redislocation rate in any of the age groups except for the 31to 40-year group. Furthermore, the redislocation rate in the control group (adduction, internal rotation) in this age category was almost 2.7 times higher than that in the control group in the 21to 30-year category, which suggests that the results should be interpreted with caution. In their current study, Itoi et al have focused on trying to establish the optimal arm position for labral reduction. However, in clinical practice this is limited by patient discomfort and compliance with what is recognized to be an uncomfortable, cumbersome, and inconvenient position of immobilization. In view of this, we suggested that there may be a role for acute MRI: to exclude the patients in whom external rotation bracing will not achieve labral reduction and for other patients to create an individualized treatment plan coupling comfort with a position that achieves anatomic or near-anatomic reduction and therefore the potential to reduce the redislocation rate. Although Itoi et al have demonstrated a statistically significant improvement in displacement, separation, and opening angles, the concern is that the data suggest that the labrum and capsule may still remain far from being anatomically located and that therefore this improvement may not be clinically important. It would be of great value if Itoi et al were to report the rate of failure to achieve anatomic reduction of the labrum in their study. If the rate is considered to be high, even in such an extreme position, then it is difficult to justify subjecting patients to any form of external rotation bracing without confirming by MRI that the labrum is actually reduced.