MedPix Medical Image Database

COW - Case of the WeekCase Contributor: Yuqi MaoAffiliation: SUNY at Buffalo

MedPix No: 14307 - HistoryPt Demographics: Age = 67 y.o. Gender = womanPatient is a 67-year-old AA woman. Four years ago, she was a belted driver of a compact SUV hit by a vehicle that ran a red light and struck her vehicle on the passenger side and causing her to spin around and hit a light pole head-on. The airbags deployed but she did not have any loss of consciousness or acute blood loss. She was evaluated at a local ER and released. Subsequently, she began to complain of severe left shoulder pain and was evaluated further. MRI of the left shoulder showed extensive injury of the rotator cuff tendons, a superior labral from anterior to posterior (SLAP) lesion, as well as a partial tear of the proximal biceps tendon. Conservative management including NSAIDs and physical therapy did not resolve her shoulder pain, thus she underwent surgical intervention 3 months after the accident which included left shoulder arthroscopic decompression, distal clavicle excision, rotator cuff repair, and biceps tenotomy.An EMG study was performed on bilateral upper extremities 5 months after the accident and 2 months s/p surgical repair of her left shoulder. There were no abnormalities noted from this study. Only a physical exam at this time showed 1+ bilateral UE reflexes as well as left biceps brachii and left deltoid strengths of 4/5. At a follow-up exam 3 months later, the patient reported progressive improvement in left shoulder function since the surgery. A physical exam showed tenderness to palpation of the left shoulder, 170 degree forward flexion and 45 degree external rotation of the left shoulder. She had 5/5 strength in the rotator cuff muscles and showed good stability 5 mos s/p surgery.Two and a half years s/p surgical repair of her left shoulder, she began to complain of progressive pain and weakness. Repeat MRI of her left shoulder demonstrated significant recurrent pathology of her rotator cuff tendon along with atrophy of the supraspinatus and infraspinatus muscles, and suspicion for developing avascular necrosis of in the head of the humerus. She revisited the shoulder surgeon who recommended a shoulder replacement, which the patient is reluctant to undergo. She is seen 3 and a half years post surgery.

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MedPix No: 14307 - EXAM & LABSGeneral: She appears her stated age, not in apparent distress, maintains good grooming and hygiene. She is AAOx3 and cooperative. Her vital signs are stable.Musculoskeletal Exam: Bilateral biceps and triceps reflexes are 2/4. Cervical distraction is negative. Cervical compression produces nonradiating neck pain. Neers testing is limited to 90 degrees on the left with associated left shoulder pain and negative on the right. The Hawkins-Kennedy procedure is positive on the left and negative on the right. The supraspinatus test is positive with strengths 4/5 bilaterally. Arm circles produce significant crepitus in the left shoulder. Bilateral shoulder depression testing produces neck pain extending into the ipsilateral shoulder. Patient is right-handed and grip strength is 50 pounds on the left and 60 pounds on the right. Cervical flexion, right rotation, and right lateral bending produce neck pain radiating into the right shoulder, while cervical extension caused lower back pain. Active range of motion in the thoracolumbar spine reveals lower back pain with extension as well. Straight leg raises bilaterally cause ispilateral radiating lower back pain to the toes on the left and to the knee on the right. Computerized muscle testing indicates weakness of the left elbow extensor and flexor, left shoulder abductor, left toe flexor and extensors.Monofilament Testing: Hypesthesia of the thumb and first digit of the left hand is noted along with the radial side of the distal forearm in the C6 dermatome. There is generalized hypesthesia in the plantar aspects of both feet.

Complete tear of supraspinatus tendon

One month s/p MVC:- Left: Coronal T2 weighted image showing complete tear of the supraspinatus tendon (red arrow). - Right: Sagittal T2 weighted image.

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Subscapularis tear and Osteoarthrosis of AC joint

One month s/p MVC:- Left: Sagittal T2 weighted image showing high-grade partial tear of the distal subscapularis tendon (red arrow) and osteoarthrosis of the acromioclavicular joint (green arrow).- Right: Coronal T2 weighted image.

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Infraspinatus Tear

One month s/p MVC:- Left: Sagittal T2 weighted image showing intrasubstance partial tear of the infraspinatus tendon (red arrow).- Right: Coronal T2 weighted image.

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Proximal biceps tendon partial tear.

One month s/p MVC:- Left: Coronal T2 weighted image showing partial tear of the proximal biceps tendon (red arrow).- Right: Sagital T2 weighted image.

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SLAP tear and OA of glenohumeral joint

One month s/p MVC:- Left: Coronal T2 weighted image showing a superior labral from anterior to posterior (SLAP) tear (green arrow) and osteoarthritis of the glenohumeral joint with cyst formation.- Right: Sagital T2 weighted image.

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Recurrent supraspinatus tear and suspected avascular necrosis

Two and a half years s/p surgical repair of shoulder:- Left: Coronal proton density image showing a large recurrent full thickness tear of the supraspinatus tendon (green arrow) and post surgical osteoarthritic changes with an area of suspected avascular necrosis (red arrow).- Right: Axial T2 weighted image.

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Large joint effusion associated with recurrent supraspinatus tear

Two and half years s/p surgical repair of shoulder:- Left: Coronal proton density image showing the large joint effusion communicating with the subacromion and the subdeltoid bursa with marked distention of the bursae (green arrow).- Right: Sagittal proton density image further delineating the extent of the effusion.

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Supraspinatus muscle atrophy

Two and a half years s/p surgical repair of shoulder:- Left: Coronal T1 weighted image showing atrophy of supraspinatus muscle belly with fatty changes (green arrow).- Right: Sagittal proton density image.

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Infraspinatus tear with muscle atrophy

Two and a half years s/p surgical repair of shoulder:- Left: Coronal T1 weighted image showing atrophy with fatty replacement of the infraspinatus muscle belly with the partial thickness tendon tear extending into the distal belly of the muscle (green arrow).- Right: Sagittal proton density image showing more clearly the tendon tear with fluid around it extending into the muscle belly (green arrow).

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Infraspinatus tear with muscle atrophy

Two and a half years s/p surgical repair of shoulder:- Left: Sagittal T2 weighted fat suppressed image showing infraspinatus partial thickness tear and fluid-filled space adjacent to the tendon and surrounding atrophy (green arrow).- Right: Coronal proton density image.

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FINDINGSOne month s/p MVC, MRI evaluation revealed:1.Complete tear of the supraspinatus tendon with retraction.2.High-grade partial tear of the distal subscapularis tendon.3.Intrasubstance partial tear of the infraspinatus tendon.4.Partial tear of the proximal biceps tendon.5.Superior labral from anterior to posterior (SLAP) tear.6.Osteoarthritis of the glenohumeral joint and osteoarthrosis of the acromioclavicular joint.Two and a half years s/p surgical repair of shoulder, MRI revealed:1.Old post-surgical changes of left humerus with associated osteoarthritic changes and suspicious for developing avascular necrosis.2.Large recurrent full thickness tear of the supraspinatus tendon with muscle atrophy and associated large joint effusion communicating with the subacromion and subdeltoid bursa with marked distention of the bursa.3.Partial thickness tear of the infraspinatus tendon extending into muscular tendinous junction and the muscle belly consistent with atrophy.4.Subscapularis tendon is improved and within normal limits.

DIFFERENTIAL DIAGNOSISWhat is your Differential Diagnosis?1.   Extensive rotator cuff injury from the MVC and recurrent injury 2+ years after surgical repair.- 2.   Impingement syndrome.- 3.   Cervical radiculopathy. - 4.   Adhesive capsulitis with atrophy from disuse.- 5.   Avascular necrosis of head of humerus.- 6.   Angina pectoris masked by old left shoulder injury.- 7.   Acromioclavicular osteoarthritis or injury.- 8. Cervical Angina-

Diagnosis: Recurrent rotator cuff tears, suspicion for avascular necrosis of head of humerusDx Confirmed by: MRI studies

DISCUSSIONRotator Cuff Repair Failure- - Anatomical failure of rotator cuff repair has a relatively high rate, with the overall rate suggested of 35-68% [1,2]. The first three months post repair accounts for 74% of the failures, while 85% of all failures may have occurred by the six-month mark [1]. A more recent study shows that a more significant portion of additional injury after surgical repair may occur between three and six months [3]. By the sixth month, whether the tendon healed or had been reinjured, as can be seen on MRI and US imaging, seems to correlate with long-term outcomes at 7 years post repair [1].- - For this patient, even though neither study was performed on her shoulder at the six-month mark post surgery, she seemed to have been steadily improving from her clinical history. Her post-operative history suggests no notable trauma until the progressively worsening pain and weaknesspresumably due to reinjury. Trauma and sports injuries account for most of these reinjury events between 2 and 5 years after repair [1]. In addition, multiple risk factors were described for another tendon defect after arthroscopic rotator cuff repair, including advanced age, large tear size repaired, multiple-tendon tear, biceps tenotomy or tenodesis, AC joint coplaning or distal clavicle excision, and poor tendon tissue quality [4]. Unfortunately for this patient, she qualified for most of these poor prognostic factors.- - Interestingly enough, anatomical failure may not be too significant in broader picture, which should include patients optimal function after repair of injury. A prospective study investigated clinical outcomes in a group of patients with consecutive series of rotator cuff reruptures after repair and demonstrated attempted rotator cuff repair significantly decreases pain and improves function and strength even in light of MRI documentation of repair failure at 38 months after surgery [5]. The study concluded that the potential for failure should not prevent an attempt at surgical repair if the desired endpoint is optimal functional recovery [5].- - To complicate matters further, a cohort study evaluated the consistency of seven fellowship-trained orthopedic surgeons in reproducibly identifying rotator cuff retears after surgery [6]. While they had reasonable agreement regarding full-thickness retears, they had only fair to poor agreement on many factors that are used to evaluate the success of rotator cuff repair, such as tear size, footprint coverage, and repair integrity after MRI evaluation [6]. Thus, the true values regarding successful surgical treatment of rotator cuff tears are still elusive.- - References:- - [1]    R. Kluger, P. Bock, M. Mittlbock, W. Krampla and A. Engel, *Long-term Survivorship of Rotator Cuff Repairs Using Ultrasound and Magnetic Resonance Imaging Analysis,* Am J Sports Med, vol. 39, pp. 2071-81, 2011. - [2]    D. Harryman, L. Mack, K. Wang, S. Jackins and M. M. F. Richardson, *Reparis of the rotator cuff. Correlation of functional results with integrity of the cuff.,* J Bone and Joint Surg., vol. 73, pp. 982-89, 1991. - [3]    J. Iannotti, A. Deutsch, A. Green, S. Rudicel, J. Christensen, S. Marraffino and S. Rodeo, *Time to failure after rotator cuff repair: a prospective imaging study,* J Bone and Joint Surg., vol. 95, pp. 965-71, 2013. - [4]    S. Nho, B. Brown, S. Lyman, R. Adler, D. Altchek and J. MacGillivray,*Prospective analysis of arthroscopic rotator cuff repair: Prognostic factors affecting clinical and ultrasound outcome.,* J Shoulder Elbow Surg, vol. 18, pp. 13-20, 2009. - [5]    B. Jost, C. Pfirrmann and C. Gerber, *Clinical outcome after structural failure of rotator cuff repairs.,* J Bone and Joint Surg, vol. 82, pp. 304-314, 2000. - [6]    M. Khazzam, J. Kuhn, E. Mulligan, J. Abboud, K. Baumgarten, R. Brophy, G. Jones, B. Miller, M. Smith and R. Wright, *Magnetic resonance imaging identification of rotator cuff retears after repair.,* Am J Sports Med, vol. 40, pp. 1722-27, 2012. -