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Subscapularis tendon tears underdiagnosed? Comparison of diagnostic tests and MRI Retrospective study of 55 rotator cuff arthroscopic surgeries Clara Azevedo, Carla Madaíl, Susana Vinga, Patrícia Rodrigues, Nuno Oliveira, Bárbara Campos
SECEC, Dubrovnik 19-22 September 2012
Introduction
Literature review
Subscapularis tendon tear
• Incidence
– Isolated: rare5,16
– + other RC tendon tear:
• Cadaver/open surgery = 3,5 - 37%9,14,21,24 • Arthroscopic surgery = 19 - 29,4%1,2,20
• Clinical diagnosis
– difficult, using established clinical tests:
• Lift-off+belly-press+Napoleon+bear-hug missed 40%2 • Lift-off+modified belly-press +belly-off+IRLS missed 15%3
• Examinations - MRI
– complete/partial rotator cuff tear 60-100% sensitivity11,27
– subscapularis tendinopathy/tear 78,9% Sen / 71,8% Spec23
• Treatment
– Partial articular tears: open surgery underestimates subscapularis tendon tear frequency7,19
2. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006; 22(10):1076-84 3. Bartsch M, Greiner S, Haas NP, Scheibel M. Diagnostic values of clinical tests for subscapularis lesions. Knee Surg Sports Traumatol Arthrosc. 2010 7. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 2002; 18(5):454-63 19. Kim S, Oh I, Park J, Shin S, Jeong W. Intra-articular repair of an isolated partial articular-surface tear of the subscapularis tendon. Am J Sports Med 2005; 33(12):1825-1830
23. Mohtadi NG, Vellet AD, Clark ML, Hollinshead RM, Sasyniuk TM, Fick GH, Burton PJ. A prospective, double-blind comparison of magnetic resonance imaging and arthroscopy in the evaluation of patients presenting with shoulder pain. J Shoulder Elbow Surg. 2004;13(3):258-65. doi:10.1016/j.jse.2004.01.003
Introduction
Hipothesis • Subscapularis tendon tear combined with other RC lesions:
– High incidence? Underdiagnosed lesion? – Difficult clinical and imaging evaluation? Diagnostic value of clinical tests and MRI? – Surgical approach and repair: does underdiagnosing have treatment implications?
Methods
Study Design • Target-population: refractory to conservative
treatment tendinopathy or rotator cuff tendon tear • Reference standard: arthroscopic diagnosis – Subscapularis tendon tear’s incidence? – Diagnostic tests Vs examinations:
lift-off, belly-press Vs Magnetic Resonance Imaging
Methods
Patient Selection • Prospectively collected data • arthroscopic shoulder surgery patients retrospectively reviewed – Inclusion criteria: • Rotator cuff tendinopathy or tendon tear • November 2008 – May 2010 • Operated on by the the first author
– Exclusion criteria : • Revision surgery
Methods
55 patients • 5/55 patients without MRI (4 ultrasound; 1 CAT-scan) = excluded from comparative analysis of tests vs MRI
lift-off and belly-press (55/55) MRI (50/55) Arthroscopic surgery (55/55)
Lift-off15
Belly-press15
15. Gerber C, Hersche O, Farron A. Isolated Rupture of the Subscapularis Tendon. Results of Operative Repair. J. Bone Joint Surg. Am. 1996; 78: 1015 – 23
Methods
Methods
Magnetic Resonance Imaging
Arthroscopy
Classification22, 26
Methods
Debridement
Repair (suture anchor fixation – single row) and LHB tendon intra-articular tenotomy/tenodesis
Statistics - Logistic regression analysis 22. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007; 89(6): 1184-1193.
26. Snyder SJ: Arthroscopic classification of rotator cuff lesions and surgical decision making. In: Snyder SJ, editor. Shoulder arthroscopy. Philadelphia: Lippincott Williams and Wilkins; 2003. 201-207.
Results
Demographics Age (years)
53 ± 9.0* (range 32-73)
Sex Male
19
34.5%
Female
36
65.5%
Time elapsed from onset of pain to surgery (months)
13.9 ± 15.3* (range 0.9-63.9)
Operated side Right
30
54.5%
Left
25
45.5%
31
56.4%
– active
48
87.3%
– retired
4
7.3%
Intellectual worker – active
2
3.6%
– retired
1
1.8%
In situ
52
94.5%
Dislocated
3
5.5%
Dominant side operated Occupation type - work status Manual worker
Long Head of Biceps status at arthroscopy
* mean ± standard deviation
Results
15 subscapularis tendon tears 27.27%
8 partial articular-sided tears (type I) + 7 upper third complete tears (type II) 10 9
9
No subscapularis tendon tear
Subscapularis tendon tear (Lafosse et al)
9 8
Type I subscapularis tendon tear
7 7 6
Type II subscapularis tendon tear
6 5 4 4 3 3 2
2
2
2 1 1
1
1
1
1
1
1
1 1
1
1 0
0
0
0
AIII
AIV
0 0
0 0
0 0
0 0
AI
AII
Rotator cuff lesion (Snyder)
BI
BIII
CII
CIII
CIV
Clinical tests/MRI diagnostic value Tests Subscapularis tendon tear
sensitivity %
specificity %
PPV %
NPV %
accuracy %
Lift-off*
60,0
80,0
52,9
84,2
74,5
Belly-press*
40,0
97,5
85,7
81,3
81,8
MRI†
46,7
97,1
87,5
81,0
82,0
Belly-press/MRI†
73,3
94,3
84,6
89,2
88,0
Lift-off*
62,5
74,5
29,4
92,1
72,7
Belly-press*
62,5
95,7
71,4
93,8
90,9
MRI†
50,0
90,5
50,0
90,5
84,0
Belly-press/MRI*†‡
100,0
88,1
61,5
100,0
90,0
Subscapularis tendon tear repair
PPV= positive preditive value; NPV= negative preditive value *N=55 †N=50 ‡ subscapularis tendon tear repair when at least one is positive
Belly-press= Less sensitive. More specific. Belly-press/MRI= More accurate (4 false-/2 false+)
Results
Results
Treatment implications?
Subscapularis surgery and MRI results No lesion/tendinopathy/strain
Tear
Total
Simple lesion debridement
4
1
5
Lesion debridement and coracoidoplasty
0
1
1
Repair
4
4
8
None
34
2
36
Total
42
8
50
8/15 (14,5%) subscapularis tendon tears 4/8 missed by the MRI (2 strain + 2 tendinopathy) Tears to repair – MRI: Sen 50%, Spe 90,5% – lift-off: Sen 62,5% (5/8), Spe 74,5% – belly-press: Sen 62,5%, Spe 95,7%
Discussion
Incidence
27,27%
29,4%2 ; 27,4%1 ; 19%20
Belly-press
Sen 40%, Spe 97,5%
Sen 40%, Spe 97,9%2
Lift-off
Sen 60%, Spe 80%
Sen 59-62%, Spe 85-100%4
MRI
Sen 46,7%, Spe 97,1%
Sen ? Spe ? For subscapularis tendon tear?23
Belly-press/MRI (for repair) Sen 100%, Spe 88,1% Sen ? Spe ? For subscapularis tendon tear repair? 1. Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K. Subscapularis Tendon Tear: An Anatomic and Clinical Investigation. Arthroscopy. 2008 2. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006; 22(10):1076-84 4. Beaudreuil J et al. Contribution of clinical tests to the diagnosis of rotator cuff disease: A systematic literature review. Joint Bone Spine 2009 20. Kim TK et al. Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases. Am J Sports Med 2003 23. Mohtadi NG, Vellet AD, Clark ML, Hollinshead RM, Sasyniuk TM, Fick GH, Burton PJ. A prospective, double-blind comparison of magnetic resonance imaging and arthroscopy in the evaluation of patients presenting with shoulder pain. J Shoulder Elbow Surg. 2004;13(3):258-65
MRI Sen 46,7%, Spe 97,1%
Discussion
Subscapularis tendon tear
• Sen too low: low accuracy (82%) • Diagnostic tests and arthroscopies performed by first author: ≠ 7 MRI centres ≠ 15 radiologists Ξ experience level/protocols/MRI acquisition techniques ≠ confounding variables
• MRI is reader and operator dependent28 28. Torstensen ET, Hollinshead RM. Comparison of magnetic resonance imaging and arthroscopy in the evaluation of shoulder pathology. J Shoulder Elbow Surg. 1999. 8(1):42-5.
Conclusion
Subscapularis tendon tears underdiagnosed? • Partial articular or upper third complete tears associated to other rotator cuff tendon tears or tendinopathy are frequent • Clinical and imaging diagnosis may be difficult: lift-off , belly-press and MRI have insufficient sensitivity and specificity • Underdiagnosing may have treatment implications: most undiagnosed tears would require repair • Arthroscopy allows for the identification and repair of partial tears
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.
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