Postoperative shoulder : what the radiologist needs to know

Poster No.: C-1244

Congress: ECR 2013
Type: Educational Exhibit
Authors: 1 2 2
M. D. Lopez Parra , J. Acosta Batlle , A. Garca de Vicente , S.
3 1 2
Hernandez Muiz , B. Palomino Aguado , J. C. Albillos Merino ;
1 2 3
Madrid/ES, San Sebastin de los Reyes/ES, san sebastian de
los reyes/ES
Keywords: Musculoskeletal joint, MR, Treatment effects, Surgery, Education
and training
DOI: 10.1594/ecr2013/C-1244

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Page 1 of 20
Learning objectives

- Describe those surgical procedures used for the treatment of rotator cuff lesion,
subacromial impingement and glenohumeral instability.

- Explain the imaging findings in each post-operative situation, taking into account that
certain radiological findings do not have the same significance in patients who have not
undergone surgery as in post-operative patients.

- Review the most common pos-toperative complications.

Background

Various imaging modalities can be used to evaluate the post-operative shoulder,

including: conventional radiography, computed tomography (CT), magnetic resonance
(MRI), MR artrography and ultrasound (US).

The radiographs represent the baseline imaging modality for any postoperative
examination of the shoulder and must precede any advanced imaging.

In our institution an anteroposterior and axillar views are routinely performed.

The radiograph serves to identify the type of surgery and helps to estimate the degree
of artefact that may occur due to a metallic implant.

In the same way, plain radiographs will allow us to make the diagnosis of recurrent
dislocation, implant displacement or loosening, avoiding more complex imaging
modalities.

Page 2 of 20
Fig. 1
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

However, many of the complications, especially those affecting the soft tissues cannot
be detected with radiography.

In general, to reach the highest diagnostic accuracy, we will choose the proper imaging
technique depending on the symptomatology.

US is adequate in the evaluation of recurrent tear of the rotator cuff and detection of
synovitis, but it is operator dependent and has limitations in the evaluation of bone or
labral abnormalities.

In MR imaging, to avoid magnetic susceptibility artefacts, we use inversion recovery

sequence instead of fat saturation. Also, fast spin echo sequences may be used instead
of conventional spin echo sequences or gradient echo sequences.

MR arthrography is the imaging modality of choice for proper assessment of the rotator
cuff, capsulolabral structures, and tendon defects.

Page 3 of 20
Imaging findings OR Procedure details

The most frequently performed surgeries of the shoulder are subacromial decompression
for impingement, rotator cuff repair, and repair of glenohumeral instability.

1.- Subacromial Decompression for Impingement

1.1 Surgical Procedure

The surgical technique of choice in patients with subacromial impingement and intact
rotator cuff is the surgery named: Arthroscopic subacromial decompression (ASD).

ASD consists of diagnostic arthroscopy, anterior and posterior acromion resection,

resection of acromioclavicular joint osteophytes and bursectomy.

Certain cases of acromioclavicular osteoarthritis and clavicular osteophytosis may

require a more extensive surgery with arthroscopic resection of the acromioclavicular
joint (ARAC) and resection of the distal clavicula (Mumford procedure), respectively.

Resection of the coracoacromial ligament is also commonly performed.

In patients associating defects of rotator cuff the procedure is performed in combination

with arthroscopic or mini-open repair.

1.2 Postoperative Imaging Findings

Normal findings in MR imaging after arthroscopic subacromial decompression include:

- Morphologic changes in the acromion (must be evaluated in Sagital images): from a

type 2 / 3 to a type 1 acromion shape. It might be accompanied by edema-like changes
or signal loss within the acromial marrow (owing to fibrosis and sclerosis).

Page 4 of 20
Fig. 2
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

- widening of the acromioclavicular distance: if the Mumford procedure was performed,

the acromioclavicular distance is increased to 1-2 cm.

- the coracoacromial ligament might be absent or replaced by scar tissue formation.

- If bursectomy, the subacromial space may appear hypointense on T1-weighted

sequences due to the presence of granulation or scar tissue.

- Acromioclavicular osteoarthritis may become apparent during correlation of

postoperative images with preoperative image.

Page 5 of 20
Fig. 3
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

- A very common postoperative finding is the presence of liquid in asymptomatic

patients, especially in those who have undergone ARAC. The subacromial fluid might
communicate with fluid within the acromioclavicular joint (geyser sign).

Page 6 of 20
Fig. 4
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

1.3 Complications

The complications after an ASD are rare and include:

- Postoperative defects of the deltoid muscle

- Heterotopic ossification and

- Acromial fracture

The last two are unusual complications, which are usually easily demonstrated by
conventional radiograph.

After surgery, the persistence of symptoms may be secondary to incomplete

decompression or any other pathology overlooked before surgery.

Page 7 of 20
2.- Rotator Cuff Lesion

2.1 Surgical procedure

The type of surgery will depend on many factors, among which are mainly considered:
the age and activity of the patient, size and depth of the rupture and the coexistence of
shoulder pathology.

Surgery of the rotator cuff may involve simple debridement of granulation tissue in
a partial thickness tear, tendon-to-tendon suturing, or tendon to bone repair of a full
thickness tear. It is essential to know the type of surgical procedure to perform an
adequate interpretation of postsurgical imaging findings.

Fig. 5
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

We describe three main types of surgery:

Page 8 of 20
- Arthroscopic rotator cuff repair: especially indicated in partial bursal-sided tears (mainly
those associated with morphologic changes in the coracoacromial arch, as is done in
conjunction with ASD) and in small full-thickness tears in the absence of significant
tendon retraction.

- Mini-open repairs: Is less invasive than open surgery, the deltoid muscle is not detached
from the acromion during the procedure. Debridement of any unhealthy rotator cuff
tissues is performed, side-to-side suturing of the torn ends, and reattachment of the
tendon to the greater tuberosity with sutures anchored to various fixation devices. ASD
and resection of the distal clavicle are usually performed.

- Open surgery: indicated in full thickness tears with significant tendon retraction. The
deltoid is detached from the acromion and the defect is repaired by tendon-to-tendon
suturing or tendon reinsertion to bone with the use of transosseous sutures or suture
anchors.

2.2 Postoperative Imaging Findings

- Subacromial bursitis and signal alterations in the humeral head, especially if

transosseous sutures were used.

Page 9 of 20
Fig. 6
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

- A repaired tendon may show the following characteristics:

It may appear thickened or thinned, and with irregular margin

Low signal in T2 images, similar to normal tendon, though there may be
increased T2-weighted signal intensity from tendinosis or related to suture
artefact.

Page 10 of 20


Fig. 7
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

Page 11 of 20


Fig. 8
References: Radiology, Hospital, Infanta Sofia - Madrid/ES
Is very important to note that sometimes, surgeons reattach torn tendons,
but they do not always make the rotator cuff watertight. Therefore, the
presence of fluid signal traverses the entire thickness of the tendon; it does
not allow differentiation of a full-thickness re-tear from a primarily non-
watertight surgical closure. Thus, the presence of communication from
the glenohumeral joint to the subacromial / subdeltoid bursa may be an
expected finding after the rotator cuff repair.

Page 12 of 20
Fig. 9
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

However, the presence of the following radiographic findings may help to guide the
diagnosis of a possible recurrent tendon tear:

Full- thickness tears larger than1 cm.

Page 13 of 20
 Fig. 10
References: Radiology, Hospital, Infanta Sofia - Madrid/ES
Change from prior examination, if available.
Large amount of fluid in subacromial/subdeltoid bursa.
Displaced/broken sutures.
Retraction of rotator cuff tendons.
Superior migration of the humeral head

Page 14 of 20
Fig. 11
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

2.3 Complications

- The most common complication is the presence of recurrent tear.

- The Deltoid Dehiscence is an uncommon complication; in this case, we find fluid

extending through the deltoid muscle, usually near the acromial attachment.

3.- Glenohumeral instability

3.1 Surgical procedure

- There are multiple types of surgery for glenohumeral instability, open or arthroscopic.

Page 15 of 20
- Open surgery can be classified into anatomic or non-anatomic, according to preserve
or not the anatomy.

- Non-anatomic reconstructions are generally used only in revision surgery.

- Patients with labral tears may undergo debridement or repair using sutures anchors,
for example SLAP lesions are generally debrided or reattached to the glenoid rim with
sutures.

Fig. 12
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

- Anteroinferior labral lesions often involve capsular stripping or tear; therefore,

reattachment of the anterior capsule to the glenoid is often performed in conjunction with
anteroinferior labral repair (Bankart procedure).

Page 16 of 20
Fig. 13
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

- In anterior capsular laxity associated with multidirectional instability, inferior capsular

shift may be performed, in which the anteroinferior capsule is tightened and tacked down
to the glenoid or to the proximal humerus.

- Isolated capsular lesions are typically sutured. This repaired capsule may appear
thickened in MR images, but should be watertight, without discontinuity.

3.2 Postoperative Imaging Findings

- In Bankart repair we will find the presence of paramagnetic artefacts or anchor tracks
in the anterior glenoid bone and the reattachment of the capsulolabral complex to the
glenoid. Suture anchors, in particular bioabsorbable anchors, do not usually create a
significant artefact.

Page 17 of 20
- The postoperative labrum can be evaluated using the same criteria as the non-surgical
labrum: if fluid or contrast extends into or under the labrum, it is compatible with a re-tear.
It may appear decreased in size or truncated due to debridement of the tear.

Fig. 14
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

- Capsular thickening is a common finding after surgical repair of instability and labral
tears.

- In postoperative MRI-arthrography evaluation of surgery of capsular tear, if contrast

leaks anteriorly or inferiorly into the axilla, capsular re-tear should be considered.

- Marked thickening of the subscapularis tendon at its attachment into the lesser
tuberosity is a common finding in patients who have undergone the Putti-Platt procedure
(shortening of the anterior capsule and subscapularis muscle).

3.3 Complications

Page 18 of 20
The following structures may be injured during surgery of glenohumeral instability:

The axillary nerve (adjacent to the inferior border of the joint capsule), with
subsequent denervation of the deltoid and teres minor muscles
The subscapularis muscle

Fig. 15
References: Radiology, Hospital, Infanta Sofia - Madrid/ES

Conclusion

- It is essential to know the type of shoulder surgery to perform an adequate radiological

interpretation of postsurgical findings.

- Pathologic findings in non-surgical patients may be a "normal" finding in postoperative

situation.

- MRI of the postoperative rotator cuff is difficult to interpret. In the first year after surgery,
MRI appearance of the cuff is variable and should be interpreted with caution.

Page 19 of 20
- In rotator cuff repair, clinical information concerning current symptoms and function are
indispensible prerequisites for an adequate interpretation of imaging findings.

References

1.- Aurea V.R., Mohana-Borges, MD. MR imaging and MR Arthrography of the

posoperative shoulder: spectrum of Normal and Abnormal findings. Radiographics 2004;
24: 69-85.

2.- Laura M. Fayad MD. Imaging of the post-operative shoulder. Proc. Int. Soc. Mag.
Reso. Med. 19 (2011).

Personal Information

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