Superior Labrum Anterior Posterior lesions: ultrasound evaluation

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1 Superior Labrum Anterior Posterior lesions: ultrasound evaluation Poster No.: C-0472 Congress: ECR 2017 Type: Scientific Exhibit Authors: D. Belyaev; Yaroslavl/RU Keywords: Trauma, Arthrography, Ultrasound, Musculoskeletal joint DOI: /ecr2017/C-0472 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 14

2 Aims and objectives to evaluate the diagnostic accuracy of shoulder sonography (US) for the diagnosis of superior labral (SLAP) tears using arthroscopy as the gold standard. Methods and materials We retrospectively reviewed the results of shoulder US in eighty-five patients (69 men and 16 women, average age 44 years), who underwent surgery in due to shoulder instability or obscure shoulder pain. Forty-five of them had arthroscopic manipulation on superior labrum, the other group of 40 patients had various rotator cuff pathology or inflammatory changes with no labral tear. A conventional US with special accent on glenoid labrum was performed before surgery. Convex and linear transducers of 2-5MHz and MHz respectively applied sequentially on supraspinatus fossa, behind the clavicle, and then, anterior to its distal part, with dynamic assessment. The following US direct and indirect signs specific for SLAP tears were determined: hypoechoic zones, especially linear-shaped (for SLAP 2-4 types), deformation of triangle shape of transverse labral section, capsular thickening in anterior aspect, paralabral cysts, and biceps tendon structural changes. We analyzed the sensitivity, specificity, diagnostic accuracy, positive predictive value (PPV), and negative predictive value (NPV) of US as compared with arthroscopic findings. Results The sensitivity, specificity, and diagnostic accuracy for the sonographic detection of labral tear were 82%, 78%, and 80%, accordingly. PPV and NPV - 80% and 79%, respectively. When the sonographic classification of lesions (between SLAP 1 and SLAP 2-4 types, according to S.J. Snyder) was compared with the arthroscopic findings, the accuracy of US in detection of labral avulsion was 72%. Differentiation principles were based on the morphology and the extent of changes. Degenerative changes of superior labrum (SLAP 1) were characterized with heterogeneous, hypoechoic, enlarged labrum with irregular and indistinct margins (Fig. 1-2). Local capsular thickness, extended to the anterior region, well-defined linear hypoechoic zones, paralabral cysts, and dynamic instability of the labrum were typical to labral avulsion in SLAP 2-4 lesions (Fig. 3-7). Sometimes, local labral defects were accompanied by hyperechoic micro-bubbles (Fig. 6). Instability of superior biceps-labral complex results in inflammatory or degenerative changes of biceps tendon, such as thickening and decreased echodensity of its proximal part (Fig. 8-9). At the same time progressive labral avulsion leads to accumulation of intra joint fluid in the tear zone. Chronic inflammatory and adherent processes in this Page 2 of 14

3 region result in development of paralabral cysts (Fig. 10). These changes coincide with arthroscopic features of SLAP tears. Detection of paralabral cysts and biceps tendon structural changes increased the accuracy of US up to 100% and 89%, respectively. Other indirect US signs of labral lesions, such as capsular thickening and hypoechoic granulations in anterior region, exhibited lower diagnostic accuracy. This may be the result of the large variety of pathological processes that affect subscapular recess. Therefore, above mentioned were revealed both among patients with and without SLAP tears (69% and 30% respectively). However, diagnostic value of these US signs is considerably higher in the presence of direct signs of labral lesions (Fig. 11). Images for this section: Fig. 1: SLAP 1 lesion. Hypo echoic zone of fibro-cartilaginous degeneration in superior labrum Page 3 of 14

4 Fig. 2: SLAP 1 lesion. Indistinct hypoechoic zone in superior-anterior labrum Page 4 of 14

5 Fig. 3: SLAP 2 lesion. Well-defined linear hypoechoic zone of labral avulsion Page 5 of 14

6 Fig. 4: Labral avulsion in comparison with normal contralateral shoulder Page 6 of 14

7 Fig. 5: SLAP tear, contrasted by synovial fluid Page 7 of 14

8 Fig. 6: SLAP tear, contrasted by hyperechoic micro-bubbles Page 8 of 14

9 Fig. 7: Superior-anterior labrum tear with absent edge Page 9 of 14

10 Fig. 8: Long head of biceps brachii. Tendinitis of intra joint part Page 10 of 14

11 Fig. 9: Synovial proliferation, capsular thickening in the region of biceps tendon attachment Page 11 of 14

12 Fig. 10: Paralabral cyst with direct signs of labral tear Page 12 of 14

13 Fig. 11: Inflammation of superior-anterior capsular-labral complex, SLAP lesion, enlarged fragmented labrum, capsular-synovial thickening Page 13 of 14

14 Conclusion Assessment of the glenoid labrum makes routine shoulder US a complete examination and influences further diagnostics and treatment. Personal information References 1. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal System. Springer Verlag, Berlin, Heidelberg 2007; 189 p. 2. Krzy#anowski W, Tarczy#ska M. The use of ultrasound in the assessment of the glenoid labrum of the glenohumeral joint. Part II: Examples of labral pathologies. J Ultrason Sep;12(50): Schydlowsky P, Strandberg C, Galbo H, Krogsgaard M, Jørgensen U. The value of ultrasonography in the diagnosis of labral lesions in patients with anterior shoulder dislocation. Eur J Ultrasound 1998; 8: Sencha AN, Belyaev DV. Ultrasonic diagnostics. Shoulder joint. Vidar-M Publishing House. 2014; 160 p. 5. Sugimoto K. Ultrasonographic evaluation of the Bankart lesion. J Shoulder Elbow Surg 2004; 13: Taljanovic MS, Carlson KL, Kuhn JE, Jacobson JA, Delaney-Sathy LO, Adler RS. Sonography of the glenoid labrum: a cadaveric study with arthroscopic correlation. AJR Am J Roentgenol 2000; 174: Page 14 of 14