Indirect magnetic resonance arthrography of the shoulder; a reliable diagnostic tool for investigation of suspected labral pathology

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1 Skeletl Rdiol (2013) 42: DOI /s SCIENTIFIC ARTICLE Indirect mgnetic resonnce rthrogrphy of the shoulder; relile dignostic tool for investigtion of suspected lrl pthology Frshid Fllhi & Nick Green & Srt Gdde & Lis Jevons & Ptrick Armstrong & Leon Jonker Received: 13 Novemer 2012 /Revised: 22 April 2013 /Accepted: 30 April 2013 /Pulished online: 30 My 2013 # The Author(s) This rticle is pulished with open ccess t Springerlink.com Astrct Purpose Indirect mgnetic resonnce rthrogrphy (I-MRA) confers significnt logisticl dvntges over direct MRA nd does not require rticulr injection. In this study, we determined the dignostic performnce of I-MRA in reltion to conventionl MRI nd rthroscopy or surgery in detecting ters of the glenoid lrum, including Bnkrt lesions nd superior lrl ntero-posterior (SLAP) ters in stndrd clinicl setting. Ptients nd methods Ninety-one symptomtic ptients underwent conventionl MRI nd I-MRA of the ffected shoulder, followed y either rthroscopy or open surgery. The scns were interpreted independently y two experienced rdiology consultnts with specil interest in musculoskeletl rdiology. Using the surgicl findings s the F. Fllhi : N. Green : S. Gdde : L. Jevons : P. Armstrong : L. Jonker North Cumri University Hospitls NHS Trust, Cumerlnd Infirmry, Crlisle CA2 7HY, UK N. Green e-mil: nicholsgreen@doctors.org.uk S. Gdde e-mil: srt.gdde@ncuh.nhs.uk L. Jevons e-mil: lis.jevons@ncuh.nhs.uk P. Armstrong e-mil: ptrick.rmstrong@ncuh.nhs.uk L. Jonker e-mil: leon.jonker@ncuh.nhs.uk F. Fllhi (*) Deprtment of Rdiology, North Cumri University Hospitls, Cumerlnd Infirmry, Crlisle CA2 7HY, UK e-mil: frshid.fllhi@ncuh.nhs.uk stndrd of reference, sensitivity, specificity, nd dignostic ccurcy of conventionl non-contrst MRI nd I-MRA in the detection of lrl ters were clculted. Results The sensitivity of I-MRA ws 95 nd 97 %, respectively, for two rdiologists s opposed to 79 nd 83 % for conventionl MRI. For oth rdiologists, the specificity of I-MRA, s well s MRI, ws 91 % for detection of lrl ters of ll types. Accurcy of dignosis ws 93 nd 95 %, respectively, for two rdiologists with indirect MRA, compred to 84 nd 86 % with non-contrst MRI. Conclusions This retrospective study shows tht I-MRA is highly ccurte nd sensitive method for the detection of lrl ters. The dt otined supports the use of I-MRA s stndrd prctice in ptients with shoulder instility due to suspected lrl pthology where further investigtive imging is indicted. Keywords Mgnetic resonnce imging. Indirect rthrogrphy. Shoulder. Bnkrt lesion. Superior lrl nterior to posterior (SLAP) lesion Introduction MRI hs n importnt role in identifying the cuse of shoulder instility nd helping orthopedic surgeons in deciding who might enefit from surgery. MR imging for shoulder instility is mostly performed s directcontrst rthrogrphy due to its higher ccurcy over non-contrst MRI [1]. Direct mgnetic resonnce rthrogrphy (D-MRA), which involves intr-rticulr dministrtion of gdolinium, hs ecome n estlished imging modlity for ssessing different types of shoulder instility. Most pulished ppers hve reported sensitivities nd specificities of over 90 % in detecting

2 1226 Skeletl Rdiol (2013) 42: Tle 1 MRI imging prmeters Echo time (ms) Repetition time (ms) Imging time (m:s) Excittions (n) Mtrix Coronl T : Coronl PDFS 38 2,580 2: Sgittl STIR 26 5,130 4: Axil T2 GRE : Coronl T1FS : Axil T1FS : lrl lesions with this technique [1 3]. An lterntive nd less invsive technique ws proposed over 20 yers go y Winlski [4], where intrvenously dministered contrst enhnces the joint spce nd indirectly produces n rthrogrphic effect. This technique, indirect MRA (I-MRA), hs ovious dvntges over D-MRA with etter ptient complince nd logisticl preferences to rdiology service [5]. A perceived wekness of shoulder I-MRA is the sence of controlled joint cpsule fluid distension, which mny uthors feel is necessry for improving the dignostic ccurcy of sutle lrl detchments [6, 7]. This concern led to erly recommendtions tht I-MRA should not e used for the detection of lrl ters [6]. There hs since een surprising pucity of widely pulished reserch in this re nd the true ccurcy of I-MRA hs not yet een estlished. A reltively recent nd lrger-scle study only evluted superior lrl lesions nd utilized non-exercise protocol for the I-MRA [8]. This therefore limits its relevnce somewht s it contrdicts the recognized technique descried y Vhlensieck, which requires exercise to fcilitte contrst enhncement within the joint spce [9]. Jung et l. reported high level of ccurcy for I-MRA in detecting lrl ters, with no significnt difference when compred to D-MRA. However, the strength of these findings ws limited y the smll smple size, involving only 19 ptients nd other methodologicl issues [10]. The purpose of our study, s prt of stndrd clinicl setup, ws to determine the dignostic performnce of I-MRA in detecting ters of the glenoid lrum, including Bnkrt lesions nd superior lrl nterior to posterior (SLAP) lesions in comprison with conventionl MRI nd surgicl findings. Mteril nd methods Ptients In this retrospective study, we reviewed the records of ll ptients who hd I-MRA nd rthroscopy or open surgery of shoulder t our institution etween Jnury 2009 nd Decemer The technique of I-MRA s stndrd prctice ws greed etween the rdiology nd orthopedic deprtments of North Cumri University Hospitls. Forml consent ws otined from ll ptients for iv-gdolinium dministrtion. Those who fulfilled the following criteri were included in this study: () I-MRA of the shoulder hd een performed ccording to stndrdized protocol t our institution; () rthroscopic or open evlution of the shoulder hd een performed post-imging on the ipsilterl shoulder y specilist orthopedic surgeon t our institution; (c) the opertive note provided precise detils of the intropertive findings, crucilly regrding lrl pthology. Fig. 1 Ter of superior lrum. Multidirectionl instility with nterior nd posterior ters s well s lrl deformity. Pr-coronl T1 FS imge shows sence of norml superior lrum (see rrow). T1 FS xil imge showing frgmenttion nd displcement of nterior nd posterior lrum

3 Skeletl Rdiol (2013) 42: Fig. 2 Post-contrst T1 FS xil imge showing frying of nterior lrum. Post-contrst T1FS pr-coronl imge showing contrst dissection to cleft of inferior lrum with mild frgmenttion of lrum Exclusion criteri were surgery for infection, tumor or open surgery without lrl ssessment, renl impirment (cretinine clernce less thn 30 ml/min), known llergy to contrst gent nd pregnncy. I-MRA imging protocol Imging ws performed using 1.5-Tesl Siemens Avnto scnner with shoulder Arry coil (four-element coil design with four integrted premplifiers). The shoulder ws plced in the dedicted shoulder coil with the rm in externl rottion nd hnd in supintion, with position stilized y snd g in the hnd to minimize rm movement. Following stndrd MRI sequences of the shoulder including prcoronl T1, prcoronl PDFS, sgittl STIR, nd xil T2 MEDIC sequences, ptients were given n intrvenous injection of gdoteridol [ProHnce/BRACCO, FAMAR S.A., Ag. Dimitriou 63, Alimos 17456, Athenes, Greece] t dose of0.2ml/kgodyweightuptomximumof15ml. Therefter, ptients performed succession of stndrd exercises consisting of duction, dduction, nd rottion of the shoulder for 15 min [11]. Post-contrst nd post-exercise prcoronl T1FS nd xil T1FS imges were otined. Slice thickness ws 3 mm nd inter-slice gp ws 10 % for ll settings; the field of view dimension ws 160 mm. Tle 1 shows MRI imging protocol detils. Anlysis of MR imges All studies were reviewed independently y two consultnt rdiologists with specil interest in musculoskeletl imging with 14 [F.F] nd 6 [S.G] yers of experience. The rdiologists were linded to ech other t the time of reporting nd linded to the results of rthroscopy or open surgery. The dignostic criteri pplied were those descried in the literture including high signl in the lrum reching rticulr surfce, contour irregulrity, contrst mteril dissection into cleft in the lrum; sence of lrum round the glenoid; mrked lrl deformtion; frgmenttion of the lrum; displcement of the lrum from its ntomicl position [12, 13]. Figures 1, 2, 3, 4, 5, 6, 7, nd 8 show different types of lrl pthologies on post-contrst T1 FS imges with regrds to our dignostics criteri. Lesions reported on MR were recorded ccording to their loction s nterior, superior, or s comintion of those. The distriution of dignostics findings nd individul reporting re summrized in Tle 2. The dignostic ccurcy of MRI nd I-MRA for lrl ters is summrized in Tle 4. Fig. 3, Bony Bnkrt lesion. Post-contrst T1FS pr-coronl nd xil imges showing mrked lrl deformtion with defect of nterior ony glenoid

4 1228 Skeletl Rdiol (2013) 42: Fig. 4 Lrl ter. Superior lrl ter. Post-contrst T1FS xil imges showing contrst dissecting into cleft of slightly displced superior lrum. Anterior lrl ter. Postcontrst T1FS xil imge showing enhncement etween lrum nd glenoid Surgicl evlution Records of the study popultion were otined nd the opertive notes were exmined. Lrl ssessment hd een undertken in ll cses using open or rthroscopic mens nd ws clerly documented. Surgery hd een performed or supervised y consultnt orthopedic upper lim specilist. Arthroscopic procedures utilized posterior portl for inspection of the glenohumerl joint nd dditionl portls hd een creted s required. Open nterior stiliztions utilized stndrd delto-pectorl pproch. The operting surgeon hd een wre of the MR findings t the time of surgery nd the presence or sence of lrl lesions including their loction, suggested y reporting rdiologists on the sis of the I-MRA, hd een recorded. These surgicl findings constituted the reference stndrd ginst which MR findings were compred. Sttisticl nlysis Dt ws collted in Microsoft Excel 2007, nd further nlyzed nd interpreted using SPSS Sttisticl Pckge for Socil Sciences (SPSS) version 17.0 (SPSS Inc. Chicgo, IL, USA, 2007). As mesure of exctness, sensitivity, specificity, ccurcy, positive predictive vlue (PPV), nd negtive predictive vlue (NPV) were clculted. Kpp sttistic ws clculted to determine the level of inter-rter greement for the two reporting rdiologists. The surgicl finding ws considered the gold stndrd. Results The primry referrl indiction for I-MRA t our institution ws instility (70 ptients), mnifested y prior disloction, suluxtion, pin, nd clicking. Less common indictions included pinful restricted rnge of motion (16 ptients) nd stiffness (five ptients). The ptient group included 17 women (men ge 35 yers; rnge, yers) nd 74 men (men ge 32 yers; rnge, yers). Two of the mle ptients, nd none of the femle ptients, hd previously undergone surgery in their symptomtic shoulders oth were nterior stiliztions of Bnkrt lesions. The MRI reports on the presence or sence of lrl pthology were correlted with the intr-opertive findings. Of the 91 ptients, in 33 ptients no lrl pthology could e detected during the surgicl procedure. In three ptients of this group, lrl ter ws reported on I-MRA nd conventionl MRI y oth rdiologists. These ptients underwent surgicl intervention due to other pthologies seen on I-MRA including rottor cuff ters, AC joint osteorthritis with sucromil ursitis, nd synovitis, however, the lrum ws precisely evluted during Fig. 5,, c Lrl ter. Postcontrst T1FS pr coronl () nd xil (, c) imges showing sence of ntero-inferior lrum. See lso enhncing synovium (rrow in ) c

5 Skeletl Rdiol (2013) 42: Fig. 6 Axil T2 MEDIC sequence filed to demonstrte convincing lrl pthology. Axil post-contrst imge showing contrst dissection into cleft in the lrum Fig. 7 Axil T2 MEDIC sequence filed to demonstrte convincing lrl pthology. Axil post-contrst imge showing contrst dissection into cleft in the lrum the surgicl procedure. Of the 58 who did hve lrl pthology, dignosed upon rthroscopy, five hd SLAP lesion nd 53 n nterior lesion. In eight ptients of this group with surgicl confirmtion of lrl ter, the conventionl MRI filed to demonstrte this y oth reders, however, the I-MRA correctly dignosed the lrl ter. One SLAP ter ws misinterpreted s norml lrum y reder 2 on oth conventionl nd I-MRA. An nterior lrl lesion ws not identified y reder2 on conventionl MRI, however, it ws dignosed on I- MRA. In ll other ptients, oth non-contrst MRI nd I-MRA showed lrl ter y oth reders. Tle 3 summrizes the distriution of dignostic findings vi different modlities. None of the 91 ptients experienced ny dverse events during the I-MRA protocol. For the clcultion of specificity, sensitivity, nd ccurcy of conventionl MRI nd I-MRA, the surgicl findings were clssed s the true result. Tle 4 Fig. 8 Bnkrt lesion., Post-contrst T1FS xil nd pr-coronl imges showing contrst etween the ntero inferior lrum nd glenoid, consistent with Bnkrt lesion

6 1230 Skeletl Rdiol (2013) 42: Tle 2 Distriution of dignostic findings individul reporting MRI I-MRA Surgery Reder 1 Reder 2 Reder 1 Reder 2 Reder n/ No lesion SLAP lesion Anterior lesion Kpp sttistic Tle 4 Dignostic ccurcy of MRI nd I-MRA for lrl ters compred to surgery MRI I-MRA Reder 1 Reder 2 Reder 1 Reder 2 Specificity (%) Sensitivity (%) Accurcy (%) Positive predictive vlue (%) Negtive predictive vlue (%) summrizes the findings with specificity, sensitivity, ccurcy, positive nd negtive predictive vlues for MRI nd I-MRA for oth reders. In totl, with I-MRA, for five ptients the dignostic nd surgicl findings did not mtch for reder 1 nd for six ptients for reder 2. In the two ptients tht were deemed negtive for ny lrl pthology y I-MRA y oth reders, the respective dignoses sucromil sudeltoid (SASD) ursitis nd synovitis were mde; however, for the ltter, lrl ter ws not discounted. In three ptients in whom flse-positive I-MRA pthology ws estlished, one ptient hd full-thickness ter of the suprspintus tendon, lso dignosed on I-MRA wheres in the other ptients no lesion ws found during surgery. Discussion MRI is sensitive nd highly useful technique in the ssessment of shoulder instility. Conventionl MR without intrvenous or intr rticulr contrst ws shown to e sensitive nd ccurte in detection of nterior lrl ters, ut less ccurte for superior lrl ters [12]. A more recent study y Phillips et l. hs lso concluded tht conventionl MR is poorly specific nd less ccurte in detection of superior lrl ters [14]. Conventionl MR imging with 3-T scnners ppers more promising. Thoms Mgee nd Dvid Willims hve retrospectively compred non-contrst Tle 3 Distriution of dignostic findings vi different modlities for two reders MRI reder 1 MRI reder 2 I-MRA reder 1 True-positive results Flse-positive results True-negtive results Flse-negtive results I-MRA reder 2 MR otined on 3-T scnner with rthroscopy nd demonstrted high sensitivity etween 86 nd 90 % nd 100 % specificity for dignosing SLAP ters, nterior nd posterior lrl ters [15]. Our study, performed on 1.5-T scnner, hs shown non-contrst MRI to hve slightly lower sensitivity etween 79 nd 83 % nd specificity of 91 % for detection of ll types of lrl ters. Eight lrl ters seen on I-MRA y reder one nd nine lrl ters seen on I-MRA y reder two were not seen on conventionl MRI (Figs. 6 nd 7). Direct MRI rthrogrphy is well estlished for ssessment of shoulder instility [1, 2, 16]. Compred to rthroscopy s the gold stndrd, D-MRA hs shown sensitivity of 82 % nd specificity of 98 % for overll detection of SLAP lesions nd 66 % of SLAP lesions could e clssified correctly [17]. Wldt et l., in retrospective evlution of ccurcy of MRA in clssifiction of ntero-inferior lrl injuries, showed sensitivity of 88 %, specificity of 91 %, ccurcy of 89 %, nd negtive nd positive predictive vlues of 88 nd 91 %, respectively [18]. Despite ovious superiority of D-MRA over non-contrst MRI, D-MRA is n invsive investigtion requiring intr-rticulr contrst injection under fluoroscopic or ultrsound guidnce, which demnds dditionl rdiologist time nd expertise. The technique of fluoroscopic guidnce is more widely prcticed, which requires ionizing rdition. Intr-rticulr positioning of the needle, lthough usully sfe, my contriute to ptient moridity. In review of 135 ptients who underwent D-MRA, 66 % experienced trnsient, ut significnt delyed onset pin in the joint [19]. Indirect MRA with intrvenous dministrtion of gdolinium hs een investigted s n lterntive less invsive technique. MR studies in Germn cdemic journls from the lte 1990s nd 2000 hve presented promising results with I-MRA. These initil smll studies reported specificities of 85 to 92 % nd sensitivities of 90 to 91 % for dignosing lrl ters. Studies hve shown tht 15 min of exercise following intrvenous gdolinium injection prior to MRI, increses signl intensity in the joint nd improves the sensitivity in the detection of shoulder pthology [20, 21]. A study y Oh et l., encompssing 36 ptients, reported lower specificity nd

7 Skeletl Rdiol (2013) 42: Fig. 9 Flse-positive findings on I-MRA (surgery did not confirm lrl ter). Sutle enhncement within the nterior lrum. Enhncement in sulrl recess Fig. 10 Flse-negtive finding on I-MRA. A cler lrl ter could not e seen even in retrospect ( lrl ter ws found on rthroscopy) sensitivity in the detection of superior lrl ters, ut etter results in detection of nterior lrl ters y I-MRA [22]. In our study compring conventionl MRI with I-MRA, lrl ters were dignosed with sensitivity, specificity, nd ccurcy of 79 nd 83 %, 91 % (identicl outcome for ech rdiologist), nd 84 nd 86 %, respectively, with conventionl MRI nd 95 nd 97 %, 91 % (identicl outcome for ech rdiologist) nd 93 nd 95 %, respectively, with I-MRA. A prospective study of 35 ptients ssessed the vlue of I-MRA with exercise in detecting SLAP lesions nd hs shown sensitivity, specificity, nd ccurcy of 91, 85, nd 77 %, respectively [23]. Our study results of I-MRA re lrgely comprle nd etter thn the erlier results pulished in the literture. Three ptients were incorrectly dignosed to hve lrl ter on I-MRA. In two of these ptients, sutle enhncement in the lrum ws reported s ter nd in nother ptient su-lrl recess ws mistken for ter (Fig. 9). I-MRA hs lso filed to clerly demonstrte two ters seen t rthroscopy y reder1 nd three ters y reder 2. In two of these cses, the ter could e seen retrospectively; in one other cse, it ws difficult to detect the ter even in retrospect (Fig. 10). A lrge study comprising 104 ptients, compring non-contrst MRI with non-exercise I-MRA in ssessment of superior lrl lesions, non-contrst conventionl MR hs shown ccurcy of % s compred to % for I-MRA. The sme study hs lso shown I-MRA to e more sensitive ut less specific thn conventionl MR in detection of superior lrl lesions[8]. Our study, which incorported 15-min exercise regime, supports the theory tht exercise prior to scnning improves dignostic ccurcy. I-MRA is lso reported to e ccurte in the ssessment of post-opertive shoulder. A retrospective review of smll numer of ptients in ssessment of recurrent injury fter Fig. 11 Recurrent lrl ter post-bnkrt repir. Conventionl xil T2 MEDIC nd xil T1 FS of I-MRA., oth demonstrte recurrent Bnkrt lesion

8 1232 Skeletl Rdiol (2013) 42: surgery hs shown indirect MR rthrogrphy hd 100 % ccurcy for recurrent lrl ter detection, wheres direct MR rthrogrphy nd non-enhnced MR imging hd ccurcies of 67 nd 75 %, respectively [24]. Our study hs only two ptients with previous shoulder surgery nd in oth of these cses, I-MRA nd non-contrst MRI hve shown recurrent ter y oth reders (Fig. 11). The min limittion of this study concerns the retrospective nlysis of dt otined in everydy prctice. Only ptients from one hospitl were included. However, the demogrphics of this cohort were very similr to those reported in the literture; more men thn women hve SLAP lesions nd on verge they present in their mid-thirties [25]. In order to e le to drw definitive conclusions on the merits of I-MRA in reltion to D-MRA, comprtive prospective study needs to e conducted compring oth techniques. Currently, one such clinicl tril is registered on the We site clinicltrils.gov [26]. The outcome of this study my provide further evidence to estlish whether I-MRA should e replcing D-MRA or if they hve n equl level of sensitivity, specificity, nd ccurcy. If the ltter is the cse, then I-MRA should hve the edge ecuse of superior sfety profile s procedure nd its lesser impct on the logistics within rdiology deprtment. Conclusions Results from this study mtch or surpss the sensitivity, specificity, nd ccurcy of I-MRA reported in erlier pulished literture. This study provides further evidence tht I-MRA performed following stndrd exercise is highly ccurte in dignosing lrl ters nd cn e very useful tool in ssessing ptients with shoulder instility. Acknowledgments We re grteful to Mr. Arvind Desi for ssisting in collection of some of the orthopedic clinicl dt. Furthermore, we re indeted to Mr. Guy Broome, Mr. Dvid Mcky, nd Dr. Peter Jennings, without whom the I-MRA pthwy could not hve een successfully implemented in our Hospitl Trust. Conflict of interest of interest. The uthors declre tht they hve no conflicts Open Access This rticle is distriuted under the terms of the Cretive Commons Attriution License which permits ny use, distriution, nd reproduction in ny medium, provided the originl uthor(s) nd the source re credited. References 1. Fritts HM, Crig EV. MRI of the shoulder. Semin Ultrsound CT MR. 1994;15: Flnnign B, Kursunoglu-Brhme S, Snyder S, Krzel R, Del Pizzo W, Resnick D. MR Arthrogrphy of the shoulder: comprison with conventionl MR imging. AJR Am J Roentgenol. 1990;155: Plmer WE, Cslowitz PL. Anterior shoulder instility: dignostic criteri determined from prospective nlysis of 121 MR rthrogrms. Rdiology. 1995;197: Winlski CS, Weismnn BN, Alidi P, et l. Intrvenous GD- DTPA enhncement of joint fluid: less invsive lterntive for MR rthrogrphy. Rdiology. 1991;181: Vhlensieck M, Sommer T. Rdiologe. Indirect MR rthrogrphy of the shoulder. An lterntive to direct MR rthrogrphy? 1996; 36: Steinch LS, Plmer WE, Schweitzer ME. Specil focus session. MR rthrogrphy. Rdiogrphics. 2002;22: Bergin D, Schweitzer ME. Indirect mgnetic resonnce rthrogrphy. Skeletl Rdiol. 2003;32: Dinuer PA, Flemming DJ, Murphy KP, Douks WC. Dignosis of superior lrl lesions: comprison of noncontrst MRI with indirect MR rthrogrphy in unexercised shoulders. Skeletl Rdiol. 2007;36: Vhlensieck M, Lng P, Sommer T, Gennt HK, Schild HH. Indirect MR rthrogrphy: techniques nd pplictions. Semin Ultrsound CT MR. 1997;18: Jung JY, Yoon YC, Yi SK, Yoo J, Choe BK. Comprison study of indirect MR rthrogrphy nd direct MR rthrogrphy of the shoulder. Skeletl Rdiol. 2009;38: Wllny T, Sommer T, Steuer K, Vhlensieck M, Wgner UA, Schmitz A, et l. Clinicl nd nucler mgnetic resonnce tomogrphy dignosis of glenoid lrum injuries. Unfllchirurg. 1998;101: Legn JM, Burkhrd TK, Goff 2nd WB, et l. Ters of the glenoid lrum: MR imging of 88 rthroscopiclly confirmed cses. Rdiology. 1991;179: Proyn LJ, White LM, Slonen DC, Tomlinson G, Boynton EL. Recurrent symptoms fter shoulder instility repir: direct MR rthrogrphic ssessment correltion with second-look surgicl evlution. Rdiology. 2007;245: Phillips JC, Cook C, Bety S, Kissenerth MJ, Siffri P, Hwkins RJ. Vlidity of noncontrst mgnetic resonnce imging in dignosing superior lrum nterior-posterior ters. J Shoulder Elow Surg Aug. 15. Mgee TH, Willims D. Sensitivity nd specificity in detection of lrl ters with 3.0-T MRI of the shoulder. AJR Am J Roentgenol Dec;187(6): Chndnni VP, Yeger TD, DeBerrdino T, Christensen K, Gglirdi JA, Heitz DR, et l. Glenoid lrl ters: prospective evlution with MRI imging, MR rthrogrphy, nd CT rthrogrphy. AJR Am J Roentgenol. 1993;161: Wldt S, Burkrt A, Lnge P, Imhoff AB, Rummeny EJ, Woertler K. Dignostic performnce of MR rthrogrphy in the ssessment of superior lrl nteroposterior lesions of the shoulder. AJR Am J Roentgenol. 2004;182: Wldt S, Burkrt A, Imhoff AB, Bruegel M, Rummeny EJ, Woertler K. Anterior shoulder instility: ccurcy of MR rthrogrphy in the clssifiction of nteroinferior lroligmentous injuries. Rdiology. 2005;237: Giconi JC, Link TM, Vil TP, Fisher Z, Hong R, Singh R, et l. Moridity of direct MR rthrogrphy. AJR Am J Roentgenol. 2011;196: Vhlensieck M, Sommer T, Textor J, et l. Indirect MR rthrogrphy: technique nd pplictions. Eur Rdiol. 1998;8: Vhlensieck M, Peterfy CG, Wischer T, Sommer T, Lng P, Schlippert U, et l. Indirect MR rthrogrphy: optimiztion nd clinicl pplictions. Rdiology. 1996;200: Oh DK, Yoon YC, Kwon JW, Choi S-H, Jung JY, Be S, et l. Comprison of indirect isotropic MR rthrogrphy nd conventionl

9 Skeletl Rdiol (2013) 42: MR rthrogrphy of lrl lesions nd rottor cuff ters: prospective study. AJR. 2009;192: Herold T, Hente R, Zorger N, Finkenzeller T, Feuerch S, Lenhrt M, et l. Indirect MR-rthrogrphy of the shoulder-vlue in the detection of SLAP-lesions. Rofo. 2003;175: Wgner SC, Schweitzer ME, Morrison WB, Fenlin Jr JM, Brtolozzi AR. Shoulder instility: ccurcy of MR imging performed fter surgery in depicting recurrent injury initil findings. Rdiology Jn;222(1): Weer SC, Mrtin DF, Seiler III JG, Hrrst JJ. Superior lrum nterior nd posterior lesions of the shoulder: incidence rtes, complictions, nd outcomes s reported y Americn Bord of Orthopedic Surgery prt II cndidtes. Am J Sports Med doi: / A comprison of indirect nd direct MR rthrogrphy of the shoulder using rthroscopic correltion (sponsor: Milton S. Hershey Medicl Center), NCT , lst ccessed 2 July 2012.

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