The most common concern in the patient who has postoperative pain is retear of the rotator cuff repair. The patient usually presents with a known incident and details a history of acute pain associated with loss of motion. The diagnostic criteria are similar to the preoperative evaluation with the presence of fluid signal on a T2-weighted image that extends through the entire tendon substance. In the case of MR arthrography, simply seeing the contrast extend into the subacromial-subdeltoid space is not enough to diagnose a retear. The normal postoperative shoulder does not need to be watertight, so a small amount of leakage can be expected (Fig. 1). The presence of a definite gap in the tendon makes the diagnosis more substantial (Fig. 2).
The location of the retear usually occurs at the tendon-bone interface. In addition, some tears occur at a second site approximately 1.5 cm medial to the reattachment site (Fig. 3). This tear may result from increasing tension following reattachment in a tendon that already contains abnormal architecture. Slight irregularities of the undersurface of the tendon should not be called partial surface tears.
The time course following surgery is another important point in evaluating the patient who has postoperative pain. The concern for pain following surgery would be infection. As with any septic joint, the MRI appearance is one in which there is an effusion, and with the introduction of IV contrast there is
Fig. 1. Intact rotator cuff repair with small amount of leakage. (A) T1 fat-suppressed axial with contrast seen in the subdeltoid space (arrow). (B) T1 fat-suppressed coronal oblique with contrast seen in the subdeltoid space. The rotator cuff repair is maintained.
Fig. 2. Retear of the rotator cuff repair at the greater tuberosity. T1 fat-suppressed coronal oblique demonstrating a retear with retraction of the supraspinatus tendon and contrast extending up into the subacromial/subdeltoid space.
prompt enhancement not only to the joint but also to the surrounding musculature (Fig. 4). These patients often are tapped, cultured, and sent to surgery for a washout and possible removal of hardware.
Shortly following surgery and usually in the perioperative period two different types of problems arise. The first is adhesive capsulitis, in which there is a general inflammatory response with loss of motion and pain. The patient, if sent for arthrography, generally is uncomfortable and demonstrates pain as the needle approaches the shoulder capsule. The volume of contrast that is administered is reduced, usually to a total of less than 8 mL. The MRI
Fig. 3. Retear of the rotator cuff repair away from the greater tuberosity. T1 fat-suppressed coronal oblique demonstrating tear medial to the reattachment site. Contrast seen leaking into the subacromial-subdeltoid space (arrow).
Fig. 4. Osteomyelitis of the humerus and acromion. (A) T2 fat-suppressed coronal oblique with edema of the acromion (arrow), no evidence of rotator cuff, and an additional area of edema just medial to the site of attachment (open arrow). (B) Post IV Contrast fast spoiled gradient echo demonstrating enhancement of the soft tissues, acromion, and humerus consistent with infection (white arrows). In addition, serpiginous low signal structure (black arrow) represents necrotic supraspinatus tendon.
findings do not show a clear cause for the pain, but the patient's history and the lack of volume that can be injected point toward the diagnosis (Fig. 5). There were some nonspecific MRI findings, such as thickening of the axillary pouch and a lack of contrast flowing into the subcoracoid portion of the subscapularis bursa. These patients usually are treated with physical therapy, anti-inflammatory medications, and if necessary, surgical manipulation under anesthesia.
We have encountered several cases of subacromial bursitis; one case appeared to be a hypersensitivity reaction possibly attributable to the suture
Fig. 5. Adhesive capsulitis. T1 fat suppressed axial image demonstrates a paucity of contrast surrounding the humeral head consistent with lack of distention secondary to small injected volume. There is also contrast seen extending into the subcoracoid region of the subscapularis bursa.
material. MR arthrography is extremely useful in making this diagnosis. The MR arthrogram essentially is normal, with no contrast extending into the subacromial-subdeltoid bursae. Correspondingly, on the conventional T2-weighted image there is a large effusion with surrounding inflammation (Fig. 6). In our experience, a patient went back to surgery and the deltoid sutures were removed, with resolution of the pain syndrome. This diagnosis also can be considered if a subacromial injection of anesthetic relieves the pain syndrome.
There is no treatment algorithm available for the management of partial-thickness rotator cuff tears. Partial tears are a common finding in the asymptomatic aging athlete. In those patients who have shoulder pain, partial tears often are found in conjunction with other lesions. When such tears are found on imaging they are not necessarily the source of the patient's symptoms.
Most partial-thickness rotator cuff tears can be managed nonoperatively. Failure of improvement after 3 to 6 months of conservative treatment has been recommended before the consideration of surgery for symptomatic partial-thickness rotator cuff tears. Several factors, however, such as coexisting shoulder pathology, patient lifestyle, and activity level, also are important factors.
The operative treatment of partial-thickness tears includes two controversial considerations: debridement only versus rotator cuff repair, and whether to perform an acromioplasty or not. Although some surgeons perform the surgery entirely arthroscopically, others use arthroscopically assisted or open technique. In addition to assessment and repair of the cuff, arthroscopic technique allows for direct visualization of rotator cuff and other shoulder pathology in the glenohumeral and subacromial spaces.
Fig. 6. Subacromial bursitis. (A) T1 fat-suppressed image demonstrating no contrast extending into the subacromial bursa (small arrows). The rotator cuff repair is intact. (B) T2 fat-suppressed coronal oblique demonstrating edema and fluid consistent with inflammation of the bursa (small curved arrows).
Neer  proposed that partial-thickness tears represent an intermediate stage in the spectrum of impingement syndrome that ranges from edema in the tendons to full-thickness tear. The coracoacromial arch and osteophytes that form in this region have been implicated as the structures that impinge onto the rotator cuff tendon with repetitive shoulder elevation. This impingement is the basis for subacromial decompression surgery in which the anterior undersurface portion of the acromion is removed and the coracoacromial ligament is released . Some surgeons debride the rotator cuff tear, remove of the impinging structures, and perform a subacromial bursectomy for definitive treatment. Others debride the cuff without performing an acromioplasty.
Coinciding with improvements in arthroscopic technique, repairing the partially torn rotator cuff has gained more popularity recently. Though there is no consensus regarding the degree of tear depth that warrants repair, there is evidence that the depth of the tear is an important prognostic indicator . Many surgeons recommend repair for tears of greater than 50% depth . Operative treatment is most beneficial in active patients, traumatic tears, and in those with bursal-sided tears .
Repair of the partial tendon tear may involve an in situ repair of the tear or a completion of the tear followed by a repair [21,22]. In the arthroscopic repair technique, bioabsorbable or metallic anchors are placed lateral to the articular margin of the humeral head in the area of the rotator cuff footprint. Typically, one or two sutures are loaded onto the anchors. They are passed through the tendon and tied so as to attach the tendon to the bone. In the open technique, either anchors or transosseous tunnels are used for the same purpose.
Similar to partial tears, the mere presence of a full-thickness tear does not warrant operative treatment. For those tears that fail adequate nonoperative management, however, surgery has shown reliable pain relief and, to a lesser extent, improvement in strength and function. The surgeon may choose to perform a subacromial decompression with the repair. In addition, other findings, such as type II superior labrum anterior to posterior (SLAP) lesions, biceps ten-dinopathy, acromioclavicular (AC) joint arthrosis, or labral lesions, often are addressed at the time of the repair.
Repair can be performed arthroscopically, with arthroscopic assistance, or open. The advantages of using the arthroscope for diagnosis are the visualization of the cuff from the subacromial and glenohumeral joint spaces, the ability to use arthroscopic technique for cuff mobilization, and the assessment of other shoulder pathology.
When the tendon's distal attachment is intact the cuff defect is amenable to a side-to-side suture or marginal convergence repair. More commonly, however, the tendinous insertion has avulsed and a tendon-to-bone repair is necessary. For larger tears, a combination of side-to-side and end-to-side is used. In the setting of a chronic tear with significant retraction, stump immobility creates a challenge because repair of the tendon medial to the footprint, so-called ''partial repair,'' has led to poor clinical results. It is imperative that the cuff repair is not performed with excess tension. As such, for larger tears careful mobilization techniques are used.
The edges of the tendon are trimmed if they appear nonviable, and the attachment to bone begins. Some make a formal bony trough between the articular surface and the greater tuberosity; others rasp the bone to create a decorticated surface for the repair. Attachment of the tendon to bone is performed by way of bone tunnels, suture anchors, or a combination of the two.
Bone tunnels can be placed only by way of the open technique. As many tunnels as are necessary are placed at the greater tuberosity, approximately 0.5 in from each other. Nonabsorbable suture that is passed through the tendon is shuttled through the bone tunnels, reapproximating the tendon to the footprint.
For arthroscopic repair, suture anchors currently are the standard and tacks have fallen out of favor. Suture anchors may be used exclusively or in combination with bone tunnels in open repair. There are metallic and bioabsorbable anchors commercially available. Placement most often is in the sulcus that lies just medial to the greater tuberosity and lateral to the articular surface. Anchors can be single or double loaded with suture. The suture is placed through the tendon and tied, thus securing the tendon to bone. A double-row technique, unique in that it incorporates two coronal plane rows, is starting to gain favor because it increases the surface area of the tendon insertion to bone.
Although most rotator cuff tears are amenable to surgical repair, some are considered irreparable. Factors that may prevent successful repair include large size of the tear, immobility, and a high degree of fatty infiltration into the muscle. Historically, the management of these massive tears has included open or arthroscopic debridement, local tendon transposition (upper subscapularis, teres minor, teres major), extrinsic tendon transfer (trapezius), tendon autografts and allografts, synthetic grafts, and deltoid flap reconstruction.
Currently, the most common surgical treatment of massive rotator cuff tears is arthroscopic debridement. Muscle transfers do have a role in treatment, however. The indication for a latissimus dorsi tendon transfer is irreparable massive posterosuperior rotator cuff tear in a patient who has intolerable shoulder pain and subjectively unacceptable dysfunction . The functional goal of this surgery is to achieve active external rotation. The latissimus dorsi tendon is sharply dissected from its humeral insertion and pulled though the interval between the deltoid and teres minor where it is sutured over the humeral head to the upper subscapularis tendon.
Successful open surgical repair of the subscapularis has been reported when there is no advanced degeneration of the tendon [24,25]. When fatty degeneration is present in chronic tears, however, direct repair is less likely to yield success . For irreparable tears of the anterior portion of the rotator cuff that have failed conservative measures, pectoralis major transfer represents an option.
Either the superior portion or the entire pectoralis major tendon can be used for transfer [27,28]. The tendon can be passed over or under the conjoined tendon and is affixed to the medial aspect of the greater tuberosity by way of anchors or transosseous sutures. Using the entire pectoralis major muscle in the transfer, Gerber and associates  showed improvement in pain, abduction strength, and ability to perform activities of daily living in a group of 28 patients. Those patients who also had an irreparable supraspinatus tear had worse outcomes compared with those who had intact or reparable supraspinatus lesions.
The appearance of the shoulder following surgery for impingement depends on several factors, including the operative technique (open, mini-open, arthro-scopic), type of fixation devices used (transosseous sutures, suture anchors, tendon-to-tendon repairs), and whether or not subacromial decompression has been performed [1,5]. Open procedures are considered the gold standard and technically are easier to perform. No special equipment is necessary and there are good long-term results [3,30,31]. Open procedures are associated with higher morbidity, more blood loss, and longer initial recovery time, however . Moreover, in an open procedure the deltoid tendon is detached from its acromial attachment to expose the repair site and reattached at the conclusion of the surgery. Deltoid dehiscence thus can occur as a major complication (Fig. 7). Arthroscopic procedures cause less postoperative pain, enable faster rehabilitation, have fewer complications, and do not require takedown of the deltoid tendon; however, arthroscopy is more demanding technically and has slightly lower success rates than open repair [3,6,30,31].The mini-open procedure is a combination of the two techniques and involves a longitudinal split of the anterolateral deltoid muscle without takedown of the deltoid insertion [6,30]. The surgical technique depends on the presence and severity of impingement, degree and type of tendon tear, presence of other intra-articular pathology, and surgeon expertise and preference .
Fig. 7. Deltoid dehiscence. (A) T2 fat-suppressed coronal oblique demonstrating fluid within a space created by breakdown of the deltoid repair. (B) T1 fat-suppressed axial demonstrating the end of the retracted deltoid tendon floating in the fluid (arrow).
Partial rotator cuff tears involve debriding the frayed tissue, a procedure that typically is performed arthroscopically [1,6,32]. Large partial tears may be converted into full-thickness tears at surgery and repaired as full-thickness tears. Small proximal full-thickness tears can be debrided of frayed tissue and side-to-side tendon sutures can be applied . Larger tears greater than 3 cm and retracted tears require mobilization of the free end of the rotator cuff and reattachment of the tendon back to the tuberosity if possible [1,6]. The greater tuberosity often is freshened to expose bleeding bone to facilitate healing and attachment of the rotator cuff tendon [6,30]. The tendon is reattached with sutures or suture anchors. The suture anchors can be metallic, titanium, plastic, or bioabsorbable polymers, each creating various artifacts on MRI . At our institution, similar to other centers, repairs of partial tears are considered when the tear involves greater than 50% of the tendon thickness . Smaller tears often are managed by conservative measures .
MRI findings following rotator cuff surgery can be divided into intratendi-nous and extratendinous findings. For intratendinous findings, the repaired cuff tendons often demonstrate some signal abnormality following repair and many patients have occult partial- and small full-thickness tears [1,13,14]. Intermediate to high signal in the cuff tendon on T1-, proton density-, and T2-weighted sequences is common and expected [3,6]. Spielmann and colleagues  evaluated 15 asymptomatic patients following rotator cuff repair and found that only 10% had normal tendons on MRI imaging. In the remainder, tendi-nosis was seen in 53%, partial tears in 17%, and full-thickness tears in 20%. Za-netti and coworkers  evaluated full-thickness tears in asymptomatic and symptomatic patients following rotator cuff surgery and found similar numbers; however, asymptomatic full-thickness cuff tears averaged 0.8 cm in length and the symptomatic tears averaged 3.2 cm. Healing granulation tissue within the tendon can produce high T2 and STIR signal (fluid signal) within the tendon, mimicking a partial tear [1,8,14,15]. This signal may change from high (same as fluid) to intermediate signal with increasing time following surgery . In these cases, several authors advocate MR arthrography [1,3,14,15]. With MR arthrography, the tendon contour and contrast tracking into the defects can aid in the diagnosis of partial tears and better define the margins of torn tendons for surgical planning. Bursal or articular surface tendon irregularity is expected and should not be called a partial tear .
As for extratendinous findings, virtually all patients have loss of the subacro-mial and peribursal fat following rotator cuff surgery [1,6,8,13,15]. Joint effusion and fluid in the subacromial-subdeltoid space is expected even in asymptomatic patients [1,3,6,13,15]. Following repair, the joint is no longer watertight and observing contrast in the subacromial-subdeltoid space does not correlate with full-thickness rotator cuff tears [3,6]. Moreover, mild marrow edema in the humeral head can last for several years [1,6]. Susceptibility artifact is seen commonly at the site of repair from the various tendon attachment devices. In tendon-to-bone repair, a surgical trough with adjacent metallic susceptibility artifact is seen at the superolateral humeral head [6,8,15]. Mild superior subluxation of the humeral head can occur also because of capsular tightening, scarring, cuff atrophy, or bursectomy [3,8,15]. Scarring in the subacromial area, around tendons, the joint capsule, and adjacent soft tissues can occur and may influence repeat surgery or change surgical approach from open to arthroscopic . Artifact in the deltoid and at its proximal attachment can be seen following open or mini-open procedures .
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