Sunday, June 24, 2012

Diagnostic Performance and Reliability of Ultrasonography for Fatty Degeneration of the Rotator Cuff Muscles JBJS

 rotator cuff disease, and rotator cuff surgery

We use basic criteria for estimating the reparability of rotator cuff tears. When we perform cuff surgery, we always assure that the patient understands that repair will only be done if quality tendon can be reapproximated to the normal attachment site without undue tension. Such criteria as the age of the patient, the age of the tear, the degree of trauma that caused the tear, the health of the patient, smoking vs non smoking, the degree of weakness and the presence or absence of upward displacement of the humeral head provide a huge amount of information on cuff reparability. In cases where reparability is uncertain or when the shoulder demonstrates substantial subacromial crepitance, we will offer the patient a surgical exploration through the benign 'deltoid-on' approach and then, based on the quality and mobility of the torn tendon perform a repair or a 'smooth and move' procedure. For us, the degree of 'fatty infiltration' does not influence our decision making as much as the observations listed above.

 Others, however, prefer to base their patient management on imaging criteria.  In this article from Wash U, which specializes in high quality shoulder ultrasonography, the authors compared in a rigorous manner the degree of fatty degeneration seen on MRI (by four independent raters) with that seen by sonography (by one of three radiologists).  There was a high degree of agreement for the supra and infraspinatus and moderate agreement for the teres minor.

What is curious about this study is that while all were initially thought to have cuff tears, the shoulders included in this study had a variety of diagnoses such as tendinitis, labral tears, frozen shoulders, osteoarthritis, tuberosity contusions,  biceps tendinitis, pectoralis major tendinits, etc.  It is even more curious that the authors did not correlate the degree of fatty degeneration by MRI and ultrasound with the characteristics of the cuff (tear or not, size of tear, chronicity).

So we must ask, what factors drive surgical decision making for patients with cuff disease? How important is 'fatty degeneration' in choosing treatment?  If a young patient with a small tear had fat in the supraspinatus, would that preclude repair? Just wondering...


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