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Mri in corellation to surgery

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Mri in corellation to surgery

  1. 1. Manos Antonogiannakis O r t h o p a e d i c S u r g e o n Director Center for Shoulder Arthroscopy IASO General Hospital Athens, Greece www.shoulder.gr
  2. 2. Restore the anatomy even partially in an atraumatic way
  3. 3. And by bad tissue quality we mean
  4. 4.  Demonstrate the extent and the configuration of rot cuff abnormalities  Suggest mechanical imbalance of the cuff  Document abnormalities of the adjacent muscles. With the use of the pre-operative MRI the surgeon is able to predict the rotator cuff tear pattern, the appropriate method for repairing and the prognosis .
  5. 5. Field strength : High field strength 1, 1.5, 3 Tesla Low field strength 0.5 Tesla Low field strength : longer time to generate images High signal to noise ratio Surface coils (transmitter and receiver of radiofrequency pulses) that generate Pulse sequences T1-weighted sequence (fat bright,- water , muscle intermediate – fibrous, calcioum dark) T2-weighted sequence(water ,fat bright-muscle intermediete-fibrous, calcioum dark Proton density Gradient echo Fat saturation techniques (supress the signal from fat so that pathology to be more obvious) MRI nomenclature The patient is placed into a magnetic field created by a strong magnet
  6. 6. A: Articular B: Bursal C: Intresubstance
  7. 7. Partial tears are better imaged by MR direct arthrography High(fluid) signal intensity due to Gadolinioum through a portion of the tendon Common in young athletes in combination with SLAP tears
  8. 8. Many classification systems have been described But we use the 2-dimensional classification system described by S. Burkhart that links preoperative MRI imaging to operative treatment and prognosis
  9. 9. Measure L (medial to lateral length) Blunt Taper ed Wisp y Measure from here Measure W (anterior to posterior length) Measurment in two dimensions Length medial to lateral. Width anterior to posterior Good quality T2 weighted fat suppressed coronal oblique and sagital oblique MRI images are used for the calculations
  10. 10. Type Description Preoperative MRI Findings Treatment Prognosis 1 Crescent Short and wide tear End-to-bone repair Good to excellent 2 Longitudinal (L or U) Long and narrow tear Margin convergence Good to excellent 3 Massive contracted Long and wide > (2 x 2 cm) Interval slides or partial repair Fair to good 4 Cuff tear arthropathy Cuff tear arthropathy Arthroplasty Fair to good.
  11. 11. Type Description Preoperative MRI Findings Treatment Prognosis 1 Crescent Short and wide tear L < W End-to-bone repair Good to excellent
  12. 12. Bursal side Articular side Final repair
  13. 13. Type Description Preoperative MRI Findings Treatment Prognosis 2 Longitudinal (L or U) Long and narrow tear L > W Margin convergence Good to excellent
  14. 14. Type Description Preoperative MRI Findings Treatment Prognosis 3 Massive contracted Long and wide > (2 x 2 cm) Interval slides or partial repair Fair to good
  15. 15. Preoperative estimation of fatty infiltration of infraspinatus and supraspinatus muscle bellies affects the prognosis
  16. 16. 0 Normal 1 Some fatty streaks 2 More muscle 3 Muscle = Fat 4 More fat According to Goutallier et al. in C/T scan
  17. 17. Arthroscopic repair of massive rot cuff tears with stage 3 and 4 fatty degenaration S.S. Burkhart et al Arthroscopy 2007 22 patients, Mean age 66.5 Massive 2 and 3 tendon tears Mean F.U. 39 months Mean UCLA score; pre-op 12.3 post-op 29.5 Mean active FF: preoperative 103.2° and postoperatively: 156.9°). Mean active ext rot: preoperative 35.7° and postoperative: 54.8° Better results in patients with 50-75% Fatty degeneration of infraspinatus than in more than 75% Fair to good prognosis
  18. 18.  2 years (January 2011– December 2012)  28 patients with an average age of 66 years  Chronic tears: 57% - Acute on chronic tears: 43%  Tangent sign positive: 82%  Repair: Complete - 68%, Medialized – 20% - Partial 12% Following these guidelines and classification system We had similar results
  19. 19.  Mean VAS: from 7 pre-op to 0.3 post-op From preoperatively to One year postoperatively  Mean active FF: from 141 to 171 degrees  Mean active ER in 0 degrees abduction: from 54 to 69 degrees  Mean active IR: from L3 to Th11  Mean Constant Score: from 35 to 73  Mean ASES: from 48 to 93  Mean Power in ER: from 1.6 to 6
  20. 20. Important is that by preoperative MRI imaging we can plan the operation and have a fairly accurate prediction of the outcome
  21. 21. Visible in plain X-rays
  22. 22. FROZEN SHOULDER when overestimation of MRI reports can lead to clinical mistakes
  23. 23.  Thickened coracohumeral ligament  Thickening of soft tissue in the rotator interval  Thickened inferior glenohumeral ligament
  24. 24. The diagnosis of frozen shoulder is clinical Be aware of MRI reports of tendinosis or partial thickness rot cuff tears or narrow subacromial space in a clinically diagnosed frozen shoulder They are misleading and can drive the surgeon to wrong decisions regarding the best treatment The signs of frozen shoulder in MRI are subtle but very obvious in clinical examination And remember the radiologist has not examined the patient and usually has very litle information about the clinical condition of the patient
  25. 25. There is no need for evaluating with MRI in order to be detected even though the accuracy of MRI for finding calcification is more than 95%. Only an x-ray of the shoulder is needed for the diagnosis of calcific tendonitis especially in the acute face
  26. 26. Interpreting MR images of the post-operative shoulder can be daunting because of the artifacts from implants that often make the study harder to evaluate.
  27. 27. Conventional MRI provides a good overview of shoulder lesions and anatomy, particularly the soft-tissue structures. However, it is less accurate than MR arthrography for depiction of small labroligamentous lesions associated with shoulder dislocation. MR arthrography is the imaging modality of choice to evaluate the labrum. It has the highest sensitivity and specificity of all available modalities. But it is invasive and inconvenient for the patient
  28. 28. Differences in the type of soft tissue lesions have little influence to the planning of the operation ,but significant bone loss either of the glenoid or the humeral head has
  29. 29. Traumatic Glenohumeral bone defects and Their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion S.S. Burkhart and J. F. De Beer, M.D. Arthroscopy,October 2000
  30. 30.  Total group: 194 patients  173 pt without significant bone defects : 7 pt sustained a recurrence (4%)  21 pt with significant bone defects: 14 pt developed rec instability (67%)
  31. 31. The inferior 2/3 of the glenoid is nearly a perfect circle with avg diameter 24mm Huysman et al. JSES 2006
  32. 32. Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  33. 33. Loss of 8.6mm of anterior radius of glenoid at the level of the bare spot corresponds to 35% of the normal anteroposterior width Lo, Burkhart Arthroscopy 2004
  34. 34. >25 – 30% bone loss 6.5 – 8.6mm AP width Inverted pear appearance Bone block procedures Piasecki et al. AAOS J17 (8): 482. (2009)
  35. 35. Although a bony bankart and glenoid and humeral bone defects are being depicted on MRI at present CT-scans are better for the quantification of the defects
  36. 36.  Glenoid Index in 3D CT scan of both shoulders  Critical Limit Glenoid index 0.75 SS Burkhart Arthroscopy: Vol 24, No 4 (April), 2008: pp 376-382
  37. 37.  Taverna et al. Pico Method 2D CT – measurement of glenoid surface Critical Limit 25% loss of glenoid surface
  38. 38.  Our practice The percentage of the glenoid defect was evaluated on the en face reconstructed view with the humeral head eliminated Sugaya et al (2005) Joint Surg Am
  39. 39.  Glenoid Bone Loss >25-30% Arthroscopic or open Latarjet procedure L. Lafosse Arthroscopic shoulder stabilization with a bone block E. Taverna
  40. 40. Engaging Hill-Sachs
  41. 41.  Engaging Hill-Sachs-glenoid bone loss Hill- Sachs Remplisage: An arthroscopic surgical solution for the engaging Hill-Sachs E.M. Wolf
  42. 42. OOF SHOULDER1 2 Midterm outcomes of arthroscopic remplissage 3 for the management of recurrent anterior shoulder instability 4 Emmanouil Brilakis • Elias Mataragas • 5 Anastasios Deligeorgis • Vasilios Maniatis • 6 Emmanouil Antonogiannakis 7 Received: 14 April 2013/Accepted: 12 January 2014 8 Ó Springer-Verlag Berlin Heidelberg 2014 9 Abstract 27returned to their previous everyday activities while 70.8 % Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2848-1 AuthorProof
  43. 43.  4 years (January 2007– December 2010)  48 patients with an average age of 28.9 ± 7.8 years  Positive apprehension sign pre-operatively  79% of these patients were involved in sport activities of different levels.  Mean follow-up period: 37.2 ± 9.9 months UNCO RRECTED PRO O F SHOUL DER1 2 M idter m outcomes of ar thr oscopic r emplissage 3 for the management of r ecur r ent anter ior shoulder instability 4 Emmanouil Br ilakis • Elias M atar agas • 5 Anastasios Deligeor gis • Vasilios M aniatis • 6 Emmanouil Antonogiannakis 7 Received: 14 April 2013 / Accepted: 12 January 2014 8 Ó Springer-Verlag Berlin Heidelberg 2014 9 Abstr act 10 Purpose The purpose of the study was to present midterm 11 results concerning the management of recurrent anterior 12 shoulder instability with the remplissage technique in 13 addition to the classic Bankart repair, in patients with 14 engaging Hill–Sachs lesions. 15 Methods During a time period of 4 years (January 2007– 16 December 2010), 48 patients with an average age of 17 28.9 ± 7.8 years were operated on in our department. 18 They all had a positive apprehension sign pre-operatively 19 and satisfied the inclusion criteria of this study. Seventy- 20 nine per cent of these patients were involved in sport 21 activities of different levels. The mean follow-up period 22 was 37.2 ± 9.9 months. 23 Results Three patients (6.3 %) had suffered a new dis- 24 location: one of them after a low-energy trauma and the 25 two other after a high-energy trauma. The rest of the 26 patients (93.7 %) were satisfied with the surgical result and 27returned to their previous everyday activities while 70.8 % 28continued to participate in sporting activities without 29restrictions. The ASES score increased from 67.7 ± 21.5 30points pre-operatively to 90.8 ± 21.7 points post-opera- 31tively (p 0.01), the modified Rowe score from 38 ± 17.3 32to 93.8 ± 14.5 (p 0.001) and the Oxford Instability score 33from 27.6 ± 11.1 to 45.1 ± 8.3 (p 0.001). No signifi- 34cant restriction in shoulder range of motion was 35documented. 36Conclusions The outcome of the enhancement of the 37classic Bankart repair with tenodesis of the infraspinatus 38and posterior capsular plication is very good as far as the 39management of recurrent anterior shoulder instability is 40concerned, without significantly influencing the range of 41motion of the shoulder. 42Level of evidence Therapeutic study—case series with no 43comparison group, Level IV. 44 45K eywor ds Arthroscopy Shoulder Remplissage 46Recurrent anterior shoulder instability Engaging Hill– 47Sachs lesion 48I ntr oduction 49Arthroscopic Bankart repair is nowadays widely accepted 50as the treatment of choice for the management of patients 51with traumatic unidirectional anterior shoulder instability. 52However, when a marked glenoid defect is discovered, the 53Bristow, the Latarjet or other bone grafting procedures are 54indicated. On the other hand, when large Hill–Sachs 55lesions exist, the optimal treatment is controversial. 56According to Burkhart and De Beer [2], large osseous 57defects of the postero-superior aspect of the humeral head 58can engage the glenoid rim and cause recurrent instability A1 E. Brilakis (& ) E. Mataragas A. Deligeorgis A2 E. Antonogiannakis A3 2nd Orthopaedic Department, Shoulder Arthroscopy and Surgery A4 Center, IASO General Hospital, 44-46 Str. Sevastopoulou, A5 115 24 Athens, Greece A6 e-mail: emmanuel.brilakis@gmail.com A7 E. Mataragas A8 e-mail: eliasmataragas@gmail.com A9 A. Deligeorgis A10 e-mail: delitasos@hotmail.com A11 E. Antonogiannakis A12 e-mail: manosanton@gmail.com A13 V. Maniatis A14 Department of Radiology, IASO General Hospital, Athens, A15 Greece A16 e-mail: vmaniatis67@gmail.com 123 Journal : L ar ge 167 Dispatch : 23-1-2014 Pages : 8 Article No. : 2848 h LE h TYPESET MS Code : K SST-D-13-00348 h CP h DISK4 4 Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2848-1 AuthorProof
  44. 44.  Failure rate: 6.3 %  93.7 % satisfied with the surgical result and returned to their previous everyday activities  70.8 % continued to participate in sporting activities without restrictions.  ASES score: increased from 67.7 ± 21.5 29 to 90.8 ± 21.7 points (p<0.01),  Modified Rowe score increased from 38 ± 17.3 to 93.8 ± 14.5 (p<0.001)  Oxford Instability score increased from 27.6 ± 11.1 to 45.1 ± 8.3 (p<0.001).  No significant restriction in shoulder range of motion UNCO RRECTED PRO O F SHOUL DER1 2 M idter m outcomes of ar thr oscopic r emplissage 3 for the management of r ecur r ent anter ior shoulder instability 4 Emmanouil Br ilakis • Elias M atar agas • 5 Anastasios Deligeor gis • Vasilios M aniatis • 6 Emmanouil Antonogiannakis 7 Received: 14 April 2013 / Accepted: 12 January 2014 8 Ó Springer-Verlag Berlin Heidelberg 2014 9 Abstr act 10 Purpose The purpose of the study was to present midterm 11 results concerning the management of recurrent anterior 12 shoulder instability with the remplissage technique in 13 addition to the classic Bankart repair, in patients with 14 engaging Hill–Sachs lesions. 15 Methods During a time period of 4 years (January 2007– 16 December 2010), 48 patients with an average age of 17 28.9 ± 7.8 years were operated on in our department. 18 They all had a positive apprehension sign pre-operatively 19 and satisfied the inclusion criteria of this study. Seventy- 20 nine per cent of these patients were involved in sport 21 activities of different levels. The mean follow-up period 22 was 37.2 ± 9.9 months. 23 Results Three patients (6.3 %) had suffered a new dis- 24 location: one of them after a low-energy trauma and the 25 two other after a high-energy trauma. The rest of the 26 patients (93.7 %) were satisfied with the surgical result and 27returned to their previous everyday activities while 70.8 % 28continued to participate in sporting activities without 29restrictions. The ASES score increased from 67.7 ± 21.5 30points pre-operatively to 90.8 ± 21.7 points post-opera- 31tively (p 0.01), the modified Rowe score from 38 ± 17.3 32to 93.8 ± 14.5 (p 0.001) and the Oxford Instability score 33from 27.6 ± 11.1 to 45.1 ± 8.3 (p 0.001). No signifi- 34cant restriction in shoulder range of motion was 35documented. 36Conclusions The outcome of the enhancement of the 37classic Bankart repair with tenodesis of the infraspinatus 38and posterior capsular plication is very good as far as the 39management of recurrent anterior shoulder instability is 40concerned, without significantly influencing the range of 41motion of the shoulder. 42Level of evidence Therapeutic study—case series with no 43comparison group, Level IV. 44 45K eywor ds Arthroscopy Shoulder Remplissage 46Recurrent anterior shoulder instability Engaging Hill– 47Sachs lesion 48I ntr oduction 49Arthroscopic Bankart repair is nowadays widely accepted 50as the treatment of choice for the management of patients 51with traumatic unidirectional anterior shoulder instability. 52However, when a marked glenoid defect is discovered, the 53Bristow, the Latarjet or other bone grafting procedures are 54indicated. On the other hand, when large Hill–Sachs 55lesions exist, the optimal treatment is controversial. 56According to Burkhart and De Beer [2], large osseous 57defects of the postero-superior aspect of the humeral head 58can engage the glenoid rim and cause recurrent instability A1 E. Brilakis (& ) E. Mataragas A. Deligeorgis A2 E. Antonogiannakis A3 2nd Orthopaedic Department, Shoulder Arthroscopy and Surgery A4 Center, IASO General Hospital, 44-46 Str. Sevastopoulou, A5 115 24 Athens, Greece A6 e-mail: emmanuel.brilakis@gmail.com A7 E. Mataragas A8 e-mail: eliasmataragas@gmail.com A9 A. Deligeorgis A10 e-mail: delitasos@hotmail.com A11 E. Antonogiannakis A12 e-mail: manosanton@gmail.com A13 V. Maniatis A14 Department of Radiology, IASO General Hospital, Athens, A15 Greece A16 e-mail: vmaniatis67@gmail.com 123 Journal : L ar ge 167 Dispatch : 23-1-2014 Pages : 8 Article No. : 2848 h LE h TYPESET MS Code : K SST-D-13-00348 h CP h DISK4 4 Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2848-1 AuthorProof
  45. 45.  Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:  From “Engaging/Non-Engaging” Lesion to “On- Track/Off-Track” Lesion  Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart Or when to perform a soft tissue Bankart repair only Or in combination with Remplisage or a Latarget procedure
  46. 46. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head The width of the glenoid track without a glenoid defect is 83% of the glenoid width. Glenoid track= the width of the posterior lateral part of the humeral that is in contact with the glenoid in abduction – ext rotation
  47. 47. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart A. 3D CT scan with en face view of a glenoid with bone loss of width d. In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d. .
  48. 48. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart The width of the glenoid track of the humeral head bigger than the Hill-Sachs= non engaging ,on track
  49. 49. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart The width of the glenoid track of the humeral head smaller than the Hill-Sachs= engaging ,off track
  50. 50. Off track = Engaging Hill-Sachs Evaluation during arthroscopy Engagement of the Hill-Sachs can be evaluated preoperatively
  51. 51. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment 1 <25% On track Arthroscopic Bankart repair 2 <25% Off track Arthroscopic Bankart repair plus remplissage 3 >25% On track Latarjet procedure 4 >25% Off track Latarjet procedure with or without humeral-sided procedure (humeral bone graft or remplissage), depending on engagement of Hill-Sachs lesion after Latarjet procedure and the operation planned accordingly At present we are evaluating the preoperative calculation with direct arthoscopic confirmation of engagement but the results are promising
  52. 52.  Benign tumors around the shoulder  Primary and metastatic malignant tumors  Subtle fractures of the upper part of the humerous or the scapula  Sinovial diseases ( osteochondromatosis , PVS)  Neuropathies of the peripheral nerves that innervate the muscles of the scapula and the shoulder Be especially suspicious when the clinical presentation is not familiar
  53. 53. 1. MRI is helpful in Rot Cuff tears depicting not only the existence but also the size, morphology, condition of the rot cuff muscles and prognosis 2.In frozen shoulder the diagnosis may be missed beware of reports of supraspinatus tendinosis or calcifications of the supraspinatus in a clinical diagnosed frozen shoulder 3. Partial rot cuff tears and labral tears especially in young overhead athletes are best depicted with MR Arthrogram 4. Although Glenoid bone loss and Hill-Sachs lesions are depicted with MRI, are better quantitated at present by a 3D CT-scan 5.Unfamiliar clinical presentations need further imaging
  54. 54. Thank you for staying awake

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