RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

|1 |Name of the Candidate |Dr. NITIN GOYAL |

| |and Address |S/o MR. M.L.GOYAL, |

| |(in Block Letters) |HOUSE NO-1179 |

| | |SECTOR-43 B |

| | |CHANDIGARH-160022 |

|2 |Name of the Institution |J.J.M. MEDICAL COLLEGE, |

| | |DAVANGERE – 577 004. |

|3 |Course of the Study and Subject |POSTGRADUATE |

| | |M.D. IN RADIO-DIAGNOSIS |

|4 |Date of Admission to Course |1st JUNE, 2012 |

|5 |Title of the Topic |“ULTRASOUND AND MRI CORRELATION OF ROTATOR CUFF INJURIES”. |

|6 |BRIEF RESUME OF THE INTENDED WORK |

| |6.1 Need for the Study: |

| |Rotator cuff disease is one of the most common causes of shoulder pain. In addition to history and physical examination, evaluation |

| |of a patient with shoulder pain often involves assessment of the rotator cuff with a diagnostic test such as high resolution |

| |ultrasonography or MRI2. |

| |Several radiological techniques have been used to detect tears of the rotator cuff. Each has limitations and no clear consensus on |

| |the optimum diagnostic study has emerged1. |

| |The radiological diagnosis of rotator cuff tears has traditionally been performed with arthrography and more recently with |

| |ultrasonography and MRI3. |

| |Arthrography is quite accurate in detecting complete tears but it is an invasive procedure with some associated risk and |

| |discomfort, in addition it is insensitive to partial tears involving superficial surface or substance of the cuff. The diagnosis of|

| |partial tears, however, is important because many orthopedic surgeons will operate to relieve impingement of supraspinatus tendon |

| |before it progresses to full thickness tear. The relative ease with which they are seen on MRI suggests that MRI may have a role in|

| |their diagnosis3. |

| |MRI can provide information about rotator cuff tears such as tear dimensions, tear depth or thickness and tear shape, involvement |

| |of adjacent structures (eg, rotator interval, long head of biceps brachii tendon etc) and muscle atrophy, all of which have |

| |implications for rotator cuff treatment and prognosis. Information about coracoacromial arch and impingement as it relates to |

| |rotator cuff tears can also be obtained with MRI4. |

| |Although non-invasive, MRI is considerably more expensive than ultrasonography and will probably not replace it as a screening |

| |procedure for those trained in its use. For those cases in which the sonogram yields indeterminate results or in those institutions|

| |in which no one is trained to do sonography of the shoulder, MRI may be a useful screening test3. |

| |The major disadvantages of MRI are the long examination time, expense and that the study may be unsuccessful in very large or |

| |claustrophobic patients5. |

| |Ultrasonography is effective for detecting tears of the rotator cuff. The size of the tears can be classified and the findings used|

| |as a basis for management decisions1. |

| |Ultrasonography can also reveal the presence of other abnormalities that may mimic rotator cuff tear including tendinosis, calcific|

| |tendinitis, subacromial subdeltoid bursitis, greater tuberosity fracture and adhesive capsulitis7. |

| |Ultrasonography of rotator cuff is quick and painless. There is no risk of infection and in contrast to arthrography there is no |

| |discomfort following the procedure8. The simplicity, rapidity, low cost and accuracy of the examination make it especially |

| |attractive as a screening and presurgical staging study1. |

| |Arthrography appears to be more accurate in diagnosing rotator cuff injuries than either MRI or ultrasound but that benefit must be|

| |set against the invasiveness and potential discomfort to patients. Ultrasonography is as accurate as MRI for both full thickness |

| |and partial thickness tears, these results combined with low cost for ultrasound suggests that ultrasound may be the most cost |

| |effective imaging method of screening for rotator cuff injuries provided that the examiner is trained in this operator dependent |

| |technique. For practitioners without ultrasound expertise, MRI can be used. Arthrography can be performed in those cases in which |

| |ultrasound and MRI are not definitive6. |

| |Thus a study design for evaluation of role of USG and MRI in rotator cuff injuries and correlation of their findings. |

| |6.2 Review of Literatures: |

| |Both USG and MRI are widely used for evaluation of shoulder joint pathology and essentially obviate the need for conventional |

| |arthrography. The first article about the use of USG in the assessment of rotator cuff was published in 1979 by seltzer SE, Finberg|

| |HG and Weissman BN, that for MRI in 1986 by Kneeland JB, Carrea GF and Middleton WD. Technical improvements coupled with advances |

| |in understanding of anatomic and pathological characteristics of the rotator cuff, have resulted in the maturation of these two |

| |modalities. |

| |J.G Smith (1984) first describes the rotator cuff tears in his report published in the London medical gazette. He described a |

| |series of traumatic rotator cuff ruptures in seven patients9. |

| |Codman EA was the first to perform the surgical repair of the rotator cuff. In 1911 he published the tendon repair results in two |

| |patients. He proposed the pathogenesis of cuff tears as traumatic. He published his classic book ‘The Shoulder’ IN 1934. In 1934 |

| |Codman published that of his 30 clinically diagnosed rotator cuff tears; only 21 cases had tears at surgery10. |

| |Fred Moseley H and Ian Goldie (1963) studied the arterial pattern of rotator cuff and suggested that the morphological pattern of |

| |arteries in the rotator cuff does not produce any evidence that the ‘critical zone’ for ruptures and calcified deposits is much |

| |less vascularised than any other part of the tendinous cuff. But showed conclusively that the critical zone of the rotator cuff |

| |corresponds to the zone of anastomoses between the osseous and tendinous vessels. They also described that the age does not seem to|

| |have a decisive influence on the morphological pattern of the arteries11. |

| |Dennis S Weiner and Ian Macnab(1970) studied the acromio-humeral interval in sixty normal and fifty-nine shoulders with known |

| |rotator cuff tears. Wherein, they found the acromio-humeral interval to range between seven to fourteen millimeters and narrowing |

| |was a frequent finding in rotator cuff tears. An interval of five millimeters or less was considered compatible with a tear and was|

| |due to upward migration of humeral head because of action of deltoid muscle, following a complete tear of supraspinatus12. |

| |Kenneth Mugde M et al (1984) studies eight patients with shoulder pain, one with bilateral involvement, who had a rotator cuff tear|

| |and an associated lesion delineated roentgenographic a separate fragment of the acromian that was believed to be an ununited |

| |ossification centre of the acromian( os acromiale). It was thought unlikely that such an association is coincidental because it |

| |appeared that patients showed an abnormal motion existed the site of fibrous union of the acromian and may have contributed to the |

| |impingement of the acromian on the rotator cuff. Six patients underwent repair of the rotator cuff with removal of the loose |

| |fragment of the acromian13. |

| |Jeffrey R. Crass (1985) did a study on patients with shoulder pain, who underwent bilateral shoulder USG and found that |

| |ultrasonography was more reliable than arthrography in the diagnosis of the normal rotator cuff. They found no patients to have a |

| |normal sonographic pattern in patients who had an abnormal surgical exploration. However, they found calcified and postoperative |

| |tendon as major diagnostic pitfalls8. |

| |William D. Middleton et al (1985) studied thirty–nine consecutive patients referred for shoulder arthrography, underwent shoulder |

| |sonography to determine the ability of sonography to detect rotator cuff tears. Fifteen patients has arthrographically proven |

| |rotator cuff tears. Of these, fourteen were detected by sonography, with a sensitivity of 93%. Three sonographic criteria |

| |indicative of rotator cuff tear were postulated: |

| |Discontinuity in the normal homogenous echogenicity of the rotator cuff. |

| |Replacement of the normal homogenous echogenicity by a central echogenic band; and |

| |Non-visualization of the rotator cuff. |

| |Out of the thirty-nine patients, twenty patients had normal sonographic examinations, nineteen of which were normal by |

| |arthrography. Therefore the predictive value of negative sonogram was 95%. They described focal thinning of rotator cuff has a 100%|

| |predictive value in diagnosing rotator cuff tears. Discontinuity in the homogenous echogenicity of the rotator cuff is another |

| |sonographic finding of rotator cuff tear14. |

| |Thomas D. Brandt (1989) conducted a retrospective and prospective evaluation of clinical usefulness of shoulder sonography, which |

| |was done with ninety-eight patients having rotator cuff tears. Sixty-two patients underwent double contrast arthrography on the |

| |same day as sonography, and thirty-eight patients underwent surgery after sonography. Rotator cuff injuries have been classified as|

| |incomplete or complete ruptures. A comparison of sonography with surgery, using this study criteria, demonstrated a sensitivity of |

| |57% and specificity of 76%. Complete ruptures are further classified as (a) pure transverse tears (b) pure vertical or longitudinal|

| |tears, (c) tears with retraction of tendon edges, (d) massive avulsion of the cuff (global tear)15. |

| |Soble MG (1989) described the major sonographic diagnostic criteria for diagnosing rotator cuff tear, which included (a) a well |

| |defined discontinuity usually visible as a hypoechoic focus within the cuff, (b) non-visualization of the cuff and (c) an echogenic|

| |focus within the cuff. In his study seventy-five patients underwent both sonography and arthrography. Compared with arthrography |

| |alone, ultrasound examinations enabled detection of 92% of rotator cuff tears (24 of 26 tears), with a specificity of 84% and a |

| |negative predictive value of 95%. Correlation was obtained in 30 of these patients who underwent surgery for rotator cuff tear or |

| |otherwise soft tissue abnormality. In this group, the sensitivity of sonography for detection of a tear was 93%, with a specificity|

| |of 73%, while for arthrography, sensitivity was 87% and specificity was 100%16. |

| |Burk DL Jr and his associates (1989), in their prospective study, examined 38 patients with suspected rotator cuff tears at 1.5 T |

| |MRI and the findings were compared prospectively in a blinded fashion with positive results from double contrast arthrography in |

| |all 38 patients, high resolution sonography in 23 patients and surgically in 16 patients. MRI and arthrography are comparable both |

| |in sensitivity and specificity. In the study sonography was not accurate as were the other two techniques. These results suggest |

| |that MRI should be considered as the non-invasive test of choice for patients with suspected rotator cuff disease5. |

| |Timothy E., Farle Christian H., Neumann Lynn S., Steinabah Arlon (1992) studied the MRI findings in full thickness tears of the |

| |rotator cuff and conclude that interruption of the tendon continuity is the most specific MRI finding of full thickness rotator |

| |cuff tears, while subacromial fluid is the most common finding17. |

| |Kumagai, H. Ito and Kubo A. (1994) performed sonography on 41 patients with symptoms referable to rotator cuff. Sonography was |

| |performed immediately after MRI, so that the information obtained by MRI could be applied to sonographic diagnosis. Twenty patients|

| |were diagnosed from T2-weighted images as having complete tears of the rotator cuff. Sonography showed full thickness anechoic area|

| |in 12 0f the 20 patients, heterogeneous hyperechoic areas in 12, but no abnormal findings in the other one. Thirteen patients were |

| |diagnosed as having incomplete tears with MRI. Sonography showed heterogeneous hyperechoic areas |

| |in 12, but no abnormal findings in one of the 13. Hyperechoic areas in the rotator cuff were shown in four of eight patients who |

| |had been diagnosed from T2-weighted images as not having tears. They considered anechoic areas to be specific findings of complete |

| |tears, although some patients with rotator cuff tears did not show this finding18. |

| |Van Moppes FI (1995) determined the accuracy of USG in the detection of rotator cuff tears. In his prospective study of 41 |

| |patients, the ultrasound results could be compared with the combined results of CT arthrography, arthroscopy and operation. The |

| |sensitivity of sonography in the detection of partial and total rotator cuff tears was 86%, the specificity 91%, the positive |

| |predictive value 96% and the negative predictive value 73%19. |

| |Mary S. Hollister et al (1995) retrospectively reviewed the preoperative shoulder sonography reports of 163 patients for the |

| |presence of fluid in the subacromial-subdeltoid bursa or glenohumeral joint. Sixty seven (41%) of the 163 patients had joint |

| |effusion, bursal fluid or both. Joint effusion alone was seen in 35 patients. Fourteen of these had a normal rotator cuff at |

| |surgery, and 21 had a rotator cuff tear (sensitivity, 22%; specificity 79%; positive predictive value 70%). In 22 patients fluid |

| |was seen in both the bursa and the joint, 21 had surgically proven rotator cuff tears (sensitivity 22%; specificity 99%; positive |

| |predictive value 99%). The sonographic finding of intra-articular fluid alone (without bursal fluid) has both low sensitivity and |

| |specificity for the diagnosis of rotator cuff tears. However, the finding of fluid in the subacromial-subdeltiod bursa especially |

| |when combined with a joint effusion is highly specific and has a high positive predictive value for associated rotator cuff |

| |tears20. |

| |Marnix T.van Holsbeeck et al (1995) tested previously defined ultrasound criteria for identification of partial thickness tears of |

| |the rotator cuff. 52 patients were examined. The criteria used to detect partial–thickness tears of the rotator cuff were (a) mixed|

| |hyper and hypoechoic lesion visualized in two orthogonal imaging planes with either articular or bursal extension. The sensitivity |

| |of USG in depicting partial thickness tears was 93% and specificity was 94%21. |

| | Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M et al (1998) predicted the burden of shoulder disorders in the |

| |community. They concluded that rotator cuff tears tend to prevail in the dominant arm and occupational history may reveal heavy |

| |lifting or repetitive movements, especially above the level of the shoulder22. |

| |Wallny T (1999) from Germany developed a sonographic index to diagnose rotator cuff tears. Ratio of the thickness of the biceps |

| |tendon to the thickness of the supraspinatus tendon, of more than 0.8 is considered diagnostic of rotator cuff tear23. |

| |Shalene A. Teefey (1999) stated that shoulder ultrasonography was improving over the last decade, with the advent of high frequency|

| |probes. He emphasizes on musculoskeletal anatomy, sonographic technique, normal sonographical anatomy, pathophysiology of rotator |

| |cuff and bicep tendon disease and sonographic findings of rotator cuff tears24. |

| |Martin Hervas .C and his associates in another study (2001), who examined all painful shoulders in 1998 by subjecting them to USG |

| |and MRI, have stated that the diagnosis of full thickness rotator cuff tears was highly specific on both imaging techniques (100% |

| |for USG and 97.1% for MRI) but was not as sensitive using USG (67.9% for USG and 75.5% for MRI). Thus they concluded that USG |

| |should be a good imaging technique based on its specificity for the initial study of all painful shoulder joints. But the low |

| |sensitivity makes it necessary to undertake an additional MRI25. |

| |Bryant L. et al (2002) compared the ability of clinical estimation, diagnostic USG, MRI and arthroscopy to estimate the size of |

| |rotator cuff tears. Estimates of rotator cuff tear size were compared with findings at open operation in 33 consecutive patients |

| |with a presumptive diagnosis of rotator cuff tear. Arthroscopy of rotator cuff tear size correlated best with actual tear size |

| |(Pearson correlation coefficient r = 0.92; p ................
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