Postoperative Evaluation of the Pectoralis Major Transfer for the Rotator Cuff Tear in Shoulder: Focusing on MR and US

Transcription

1 Postoperative Evaluation of the Pectoralis Major Transfer for the Rotator Cuff Tear in Shoulder: Focusing on MR and US Poster No.: C-2337 Congress: ECR 2012 Type: Scientific Exhibit Authors: S. T. Kwon, K. C. Kim, Y. C. Yoon, J. Y. Park; Daejeon/KR Keywords: Tissue characterisation, Surgery, Comparative studies, Ultrasound, MR, Musculoskeletal joint DOI: /ecr2012/C-2337 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 17

2 Purpose Background Pectoralis major transfer is an possible indication in the case of irreparable subscapularis tendon (SSC) tears in association with anterior glenohumeral instability. This type of tear involves complete rupture of the subscapularis in combination with either the supraspinatus alone or the supraspinatus and infraspinatus. Assessment of these postoperative images is difficult without knowledge of the detailed anatomy for the operation or discussion with the surgeon. Purpose To evaluate the MR image and ultrasonographic (US) findings of the pectoralis major (PM) transfer for the rotator cuff tear in shoulder. Page 2 of 17

3 Images for this section: Fig. 1: Schematic views of the surgical technique. A common surgical medthod is deltopectoral approach and transfer of the clavicular part or total of the pectoralis major (perforated line) from the proximal humerus to the lesser tuberosity and to the anterior part of the greater tuberosity (asterisk in Lt. figure). Note-. PM has oblique axial course to the anterior aspect of the proximal humerus in normal anatomy (Lt. Fig.).The partial or total detached PM from the humerus has more transverse course (Rt. Fig.). Jost et al. J Bone Joint Surg Am. 2003; 85-A(10): Page 3 of 17

4 Methods and Materials MR and US images in eight patients (all men, age range years) with irreparable tear of the subscapularis tendon (SSC) were analyzed. The imaging was performed 5-9 months after operation. Six patients were asymptomatic. Symptomatic three patients are radiologically diagnosed as partial tear (n=2) of the supraspinatus and infraspinatus (n=1) tendon, respectively. Tenotomy and/or tenodesis of the long head of the biceps tendon was done except one case. The best imaging plane for the evaluation of the transferred PM including morphology, continuity, and signal intensity/echogenicity in postoperative MR images and US, were assessed. Page 4 of 17

5 Images for this section: Fig. 2: 53-year-male patient with irreparable tear of the subscapularis (SSC) and supraspinatus tendon (SST) in left shouler. (A) and (B) shows irreparable tear of the SSC and SST, but intact infraspinatus and teres minor tendon. Fig. 3: Postoperative craniocaudal consecutive axial FS T2 weighted images 5 months after operation. (B) and (C) show subcoracoidal transfered pectoralis major (asterisk) which is attached to the lesser tuberosity and medial aspect of the greater tuberosity using an anchor screw (white arrow). Note-. Thick arrow; coracobrachialis muscle. White arrow in (A) is an anchor screw for the remnant subscapularis tendon. Page 5 of 17

6 Fig. 4: Anterior transverse scan of the Lt. shoulder during external rotation of the arm. Combined images(a) and (B)show the whole course of the transfered pectoralis major muscle and tendon which is well attached to the lesser tuberosity and medial aspect of the greater tuberosity. Note-. PM=pectoralis major, LT=lesser tuberosity. Page 6 of 17

7 Fig. 5: Consecutive oblique sagittal FS T2 weighted MR images show short axis view of the pectoralis major tendon (asterisk) which is attached to the lesser tuberosity using an anchor screw (thin black arrow)(c)and (D). Note-. Thick arrow; An anchor screw for the tenodesis of the long head of the biceps tendon. Page 7 of 17

8 Fig. 6: Consecutive oblique coronal T1 weighted MR images partially show the course of the transfered pectoralis major tendon (asterisk)which is attached to the lesser tuberodity using a anchor screw (arrow)(a)and (B). Note-. The consistency of the transfered tendon is not well evalusted in these planes compared with axial images. Page 8 of 17

9 Results Almost all transferred PM was well visualized on axial MR images (n=7) and anterior transverse scan on US (n=8). Short axis of the PM tendon was evaluated on oblique sagittal and oblique coronal images. Postoperative tendinitis of the PM tendon was still noted in this stage (n=6, 75%). Tenotomy and/or tenodesis of the long head of the biceps tendon was assessed on MR images (n=6) and US (n=7). Page 9 of 17

10 Images for this section: Fig. 7: 71-year-old patient with irreparable subscapularis tendon (SSC) tear and associated partial anteior articular side tear of the supraspinatus tendon in right shoulder. Postoperative craniocaudal consecutive axial FS T2 weighted images 5 months after operation. (C) and (D) show subcoracoidal transfered pectoralis major (asterisk) which is attached to the lesser tuberosity and medial aspect of the greater tuberosity using anchor screw (white arrow). Note-. Thick arrow in (A) and (B); coracoid proces,thick arrow in (B) and (D); coracobrachialis muscle. White arrow in (A) is anchor screws for the SST. Page 10 of 17

11 Fig. 8: Consecutive oblique sagittal FS T2 weighted MR images show short axis view of the pectoralis major tendon(asterisk)which is attached to the lesser tuberosity using two anchor screws (arrows)(b). Note-. Arrow in (A) and (B); An anchor screw for the SST, but SST is noted complete retear with medial retraction (C). Page 11 of 17

12 Fig. 9: Anterior transverse scan of the Rt. shoulder during external rotation of the arm. Combined images show the whole course of the transfered pectoralis major (PM) muscle and tendon which is well attached to the lesser tuberosity and medial aspect of the greater tuberosity. Note-. Subcoracoid course (posterior to the CB) of the PM, ER=external rotation of the arm, LT=lesser tuberosity. CB=coracobrachialis muscle. Page 12 of 17

13 Fig. 10: Ultrasonography of the tenodesis of the long head of the BCT (LBCT). Longitudinal scan along the LBCT at the anterior aspect of the proximal humerus shows well attached tendon using two anchor screws (white arrows). Page 13 of 17

14 Fig. 11: Ultrasonographic dynamic scan. Anterior transverse scan of the Rt. shoulder during external rotation of the arm. The dynamic scan shows the consistency including continuity, echogenicity, and appropriate tension of the transfered pectoralis major (PM) and tendon which is well attached to the lesser tuberosity and medial aspect of the greater tuberosity. Note-. Subcoracoid course (posterior to the coracobrachialis) of the PM. Page 14 of 17

15 Conclusion An axial image on MR and anterior transverse scan on US is best plane for the evaluation of the PMT for the irreparable SSC. A dynamic anterior transverse scan on US is synergic effect with MR in case of difficult evaluation of the PMT due to the postoperative tendinitis. Page 15 of 17

16 References 1. Tirman PFJ, Bost FW, Steinbach LS, et al. MR arthrography depiction of tears of the rotator cuff: Benefit of abduction and external rotation of the arm. Radiology 1994; 192: Klaus Woertler. Multimodality imaging of the postoperative Shoulder. Eur Radiol 2007; 17: Stoller DW, Wolf EM. The shoulder. In Stoller DW, eds. Magnetic resonance imaging in orthopaedics & sports medicine. 3rd ed. Philadelphia : Lippincott, 2007 : Magee TH, Gaenslen ES, Seitz R, Hinson GA, Wetzel LH. MR imaging of the shoulder after surgery. AJR Am J Roentgenol Apr; 168(4): Mohana-Borges AV, Chung CB, Resnick D. MR imaging and MR arthrography of the postoperative shoulder: spectrum of normal and abnormal findings. Radiographics. 2004; 24(1): Zanetti M, Hodler J. MR imaging of the shoulder after surgery. Radiol Clin North Am. 2006; 44(4): Sofka CM, Adler RS. Sonographic Evaluation of Shoulder Arthroplasty. AJR 2003;180: Nho SJ, Adler RS, Tomlinson DP, Allen AA, Cordasco FA, Warren RF, Altchek DW, Macgillivray JD. Arthroscopic Rotator Cuff Repair: Prospective Evaluation with Sequential Ultrasonography. Am J Sports Med Jun 16 [Epub ahead of print] 9. Spielmann AL, Foster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals-initial experience. Radiology 1999; 213: Magee T, Shapiro M, Hewell G, Williams D. Complications of rotator cuff surgery in which bioabsorbable anchors are used. AJR 2003;181(5): Jost B, Puskas GJ, Lustenberger A, Gerber C. Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears. J Bone Joint Surg Am. 2003; 85-A(10): Gavriilidis I, Kircher J, Magosch P, Lichtenberg S, Habermeyer P. Pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears. Int Orthop May 13. [Epub ahead of print] Page 16 of 17

17 Personal Information Soon Tae Kwon, Kyung Cheon Kim.*, Yeo Chang Yoon, Ju Young Park. Department of Radiology, Chungnam National University/Hospital. 33 Munwha-ro, Jung-gu, Daejeon, , Republic of Korea. Mail to: K. C. Kim*; Department of Orthopedic Surgery. Mail to Page 17 of 17