0:00

Okay, the next patient is a 56-year-old man.

0:04

He's got right shoulder pain

0:06

and decreased range of motion.

0:09

All right, so let's go three up.

0:12

We have an axial GRE on the left.

0:15

Remember, this is your joint cartilage fibrocartilage

0:20

hyaline cartilage sequence.

0:22

Great for finding calcium,

0:23

great for finding blood, great for finding metal.

0:26

Let's throw up a T1 spin echo

0:28

anatomic fat-weighted image.

0:32

And we'll do a little scrolling of that.

0:35

And let's put up the T2-weighted image.

0:41

Shortly,

0:41

we will substitute the heavily water-weighted

0:44

sequences for the axial gradient echo image.

0:48

So right now we have a T1 scrolling together with

0:51

a T2. Why don't you say a high-grade tear

0:54

of the supraspinatus and Terry's?

0:57

All right,

0:58

the supraspinatus does have a fair amount of

1:02

intermediate signal intensity

1:04

along its undercarriage.

1:06

This area right here is known

1:08

as the rotator cuff table.

1:10

It's a little hard to appreciate because it's

1:12

all gray. It's this condensed, thick,

1:15

dark area right here.

1:18

I'm going to draw over it,

1:20

and I'm going to take my little yellow.

1:21

Mark away, and you'll see it right there.

1:25

Right there. And that area is infiltrated.

1:28

There's some of the cable right here.

1:31

So this is diffusely thickened tendinotic rotator

1:36

cuff. And let's scroll back and forth on it.

1:39

And there's a little bit of linear signal here

1:42

and there, little bits and knits of signal,

1:45

really too small

1:47

to put much stock in.

1:49

And some of you reasonably might say, well,

1:51

I happen to know, Dr.

1:53

Pomerance,

1:54

that T2 is not that effective in picking up

1:58

rotator cuff tears unless they're acute.

2:00

If they're chronic,

2:01

the rotator cuff tear may fill in with scar,

2:04

which is dark, and old blood and hemosiderin,

2:07

which is dark,

2:08

and make the rotator cuff look normal.

2:10

So let's take a look at the proton

2:14

density fat suppression sequence,

2:15

which is the most sensitive rotator cuff sequence.

2:19

Right. Before we do that,

2:20

let's just scroll our gradient

2:21

echo before we dispose of it.

2:24

And I think you can all appreciate some

2:27

irregularity of the posterior capsule,

2:29

some narrowing of the anterior joint space.

2:32

And granted, this patient did move a little bit.

2:34

The biceps sits a little bit in a medial position.

2:38

And the relationship,

2:40

the actual conformity of a round structure

2:45

fitting perfectly in a cup.

2:47

In other words, here's.

2:48

Your cup

2:50

is a little off.

2:51

It looks like the humeral head is doing this.

2:54

It's kind of lurching back a little bit.

2:56

Let me take that away.

2:57

And here's the lurching right there.

2:59

So we're seeing the humeral head dislocate

3:03

posteriorly, and the labrum is detaching,

3:07

and the periosteum is detaching.

3:09

That's the periosteum.

3:10

It should be right on there.

3:12

And the capsule is very irregular.

3:14

So this patient has what we call posterior

3:17

glenoid deficiency syndrome, which is a.

3:21

Common accompaniment of osteoarthritis.

3:25

Now, there are some big spurs here.

3:27

And why is this important?

3:29

Here's some more labor tearing.

3:30

This is important because the amount of glenoid

3:34

cup deformity and insufficiency is going to

3:36

dictate whether you put in a standard arthroplasty

3:41

or reverse hemiarthroplasty or arthroplasty.

3:46

And this patient's posterior glenoid

3:49

does look insufficient.

3:50

If you actually look at the slope of the glenoid,

3:54

it slopes back a little bit.

3:56

Now, normally, the glenoid,

3:58

if you draw a line along the spine,

4:00

the glenoid should make a line that's perfectly

4:02

perpendicular to that line of the scapular spine.

4:06

That is not the case here.

4:07

There's an angle right here,

4:09

and this is known as the retroversion angle.

4:12

So the patient has glenoid retroversion.

4:15

You don't have to measure it necessarily.

4:16

Has glenoid retroversion,

4:18

has a posterior laboral tear,

4:20

has posterior capsuler disease,

4:22

has posterior glenoid deficiency syndrome as

4:25

a manifestation of chronic Oa with

4:28

large hypertrophic spurring.

4:29

And now let's put up our proton

4:32

density fat suppression image.

4:34

Oops.

4:34

It's not very proton density ish.

4:37

It's certainly fat suppressed, though.

4:39

But I like the Te to be around 40.

4:42

Let's see if the sagittal has a better t.

4:44

It doesn't. So it's a little T2 ish for my taste,

4:48

but still the fat suppression is here and not on

4:52

the T1 So it is a much more sensitive sequence

4:55

for looking at the rotator cuff tear.

4:58

In fact, it's pretty good.

4:59

You can see there is a little tear here.

5:02

There's a little bone penetration,

5:03

which I refer to as rim rent.

5:05

Bone penetration.

5:07

The term rim rent has sort of fallen

5:09

into disfavor, so I still use it.

5:11

But if you want to say there's

5:13

a small under surface,

5:14

humeral sided rotator cuff tear with a little bit

5:18

of bone penetration, that would be reasonable.

5:21

The rest of the cuff demonstrates generalized

5:24

swelling and hypertrophy and what we

5:26

would call generalized tendinosis.

5:28

We don't use the term tendinitis anymore.

5:31

There's a little bit of fluid in the subacromial,

5:33

subdeltoid space.

5:35

There's a little bit of fluid in the joint.

5:37

Clinicians like to know that.

5:38

And you can see how these penetrating cysts and

5:41

pseudocysts are quite large in this humeral head.

5:45

Now,

5:45

this rotator cuff tear has really not a

5:49

lot of significance unless it's large.

5:52

clinicians absolutely like to know

5:54

when they're doing a repair,

5:57

whether the rotator cuff is intact or not.

5:59

But most of these degenerated shoulders have

6:02

small tears, as this patient does.

6:04

And for the most part the.

6:06

Cuff is still there other than this focal defect.

6:10

Now, why do I say it's not as important?

6:14

Because this patient isn't moving their arm.

6:17

This patient's arm is somewhat frozen.

6:20

They can't pick their arm up beyond

6:22

the 90 degree position.

6:24

And the reason is they've got this goat beard

6:27

deformity. So when they try and pick their arm up,

6:30

the goat beard deformity slams into the labrum.

6:33

Look what it's doing to the glenoid.

6:35

It's hollowing out the glenoid.

6:38

So this osteoarthropathy is producing decreased

6:41

range of motion, and in some ways, it.

6:43

Has protected

6:45

the rotator cuff from further.

6:47

Insult by restricting the patient's motion.

6:51

I don't know if that's an evolutionary thing

6:53

or not, but it's rather interesting.

6:55

We go to the sagittal projection and

6:58

we see a few other findings.

7:00

We see some signal back here in the infraspinatus,

7:04

which suggests that there's a strain back here,

7:08

probably on a more chronic basis.

7:11

And then we also see the region of our rotator

7:14

cuff tear. Once again, small humeral sided.

7:18

Notice I didn't say that it was articular sided

7:21

because there's no articular surface here.

7:24

There's no synovium here.

7:25

There's no highland cartilage here.

7:27

That's an articular surface.

7:28

That's known as the bare area of the articular

7:31

surface where there's no cartilage,

7:32

that is the rest of the articular surface.

7:35

This is a humeral sided,

7:37

concealed delamination tear with

7:40

some bony penetration.

7:42

That is not the main finding in this case.

7:44

The main finding in this case is osteoarthritis,

7:49

hypertrophic,

7:50

with a large goat beard deformity and moderate

7:53

posterior glenoid deficiency syndrome.

7:57

So some of you said high grade rotator

8:00

cuff tear of the supraspinatus.

8:03

I would not call this high grade.

8:05

I'd call it a diminutive concealed,

8:06

interstitial delamination footprint tear that is

8:10

humeral sided. That would go in my report, body.

8:12

And in the conclusion,

8:14

I would say the rotator cuff is mostly intact,

8:17

diffusely tendonotic and described

8:19

as a diminutive tear.

8:22

I would mention in the bile report that there

8:24

is subachromial, subdeltoid fluid.

8:26

And one of you said,

8:28

as a secondary or tertiary finding that

8:31

there is gross DJD of the AC joint.

8:33

And I would say that is absolutely true.

8:36

Very few people don't have DJD of the AC joint.

8:41

How advanced is it? Well, for a 56 year old man,

8:45

I think this is more than I would expect.

8:48

But I try to grade these by how much hypertrophy

8:53

and also how much signal there is on the T2

8:56

weighted image. So there is some signal,

8:59

high signal on the T2 weighted image.

9:01

So I would say that there's mild to modest active

9:04

inflammation of this moderately

9:06

hypertrophic AC joint.

9:08

And I would agree that that is a

9:10

secondary or tertiary finding.

9:13

Some of you said adhesive capsulitis in a man.

9:17

Well,

9:19

I usually don't commingle adhesive capsulitis in

9:22

somebody who can't move their shoulder from OA.

9:24

So it's probably an irrelevant statement

9:28

and not a true statement.

9:32

Some of you said concealed minor tearing of the

9:35

supraspinatus at the insertion is favored

9:38

to be chronic and degenerative,

9:39

and that is absolutely true.

9:42

And there were a few other correct comments

9:45

that were made. The superior labrum,

9:47

amazingly looks pretty good.

9:49

And the reason is can't pick their arm up, right.

9:52

So when you can't pick your arm up,

9:53

you don't get much bouncing behavior of

9:56

the humeral head against the glenoid.

9:58

So the glenoid superior anatomy is preserved.

10:02

And you can see the biceps take off right there.

10:05

Here's the SGHL coming straight at you.

10:08

Here's the coracohumeral ligament right there.

10:11

And there is your tendon of the supraspinatus.

10:13

One, two, three, and four.

10:17

Four layers of hypointensity on the fossa.