|Year : 2019 | Volume
| Issue : 3 | Page : 236-240
Accuracy of magnetic resonance imaging for subscapularis tendon tear comparison with arthroscopy
Hossein Saremi1, Soheyla Yousefi2, Shahram Rastgari3, Mohamad Ali Seif Rabiei2
1 Department of Orthopaedic, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
2 Department of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
3 Department of Radiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
|Date of Web Publication||6-Sep-2019|
Department of Orthopaedic, School of Medicine, Hamadan University of Medical Sciences, Hamadan
Source of Support: None, Conflict of Interest: None
Background: This study was conducted with the aim of determining the diagnostic accuracy of a magnetic resonance imaging (MRI) scan before surgery in evaluating the tear of the subscapularis tendon in comparison with the actual results obtained from arthroscopy. Materials and Methods: This retrospective study was conducted on medical records of 85 patients who underwent shoulder arthroscopic surgery suspected to subscapularis tendon tears which referred to the Besat Hospital (Hamadan, Iran) during 2012–2013. In the present study, the MRI was considered as a screening method and arthroscopy results were considered as the gold standard, and sensitivity, specificity, positive predictive value and negative predictive value were computed for MRI compared arthroscopy. Results: The sensitivity, specificity, positive predictive value and negative predictive value of MRI for the identification of incomplete tear were 28.57%, 100%, 100% and 63.77%, respectively, whereas had perfect sensitivity, specificity and positive and negative predictive value for detecting complete tear. In overall, sensitivity, specificity, positive and negative predictive values of MRI for detecting all types of ruptures were 39.02%, 100%, 100% and 63.77%, respectively. Conclusion: According to this study, MR images are a highly specific method with high positive and negative predictive values for the diagnosis of complete subscapularis tendon tear. However, the sensitivity for the incomplete tear of subscapularis tendon is not such high.
Keywords: Arthroscopy, magnetic resonance imaging, shoulder, subscapularis tendon
|How to cite this article:|
Saremi H, Yousefi S, Rastgari S, Seif Rabiei MA. Accuracy of magnetic resonance imaging for subscapularis tendon tear comparison with arthroscopy. Adv Hum Biol 2019;9:236-40
|How to cite this URL:|
Saremi H, Yousefi S, Rastgari S, Seif Rabiei MA. Accuracy of magnetic resonance imaging for subscapularis tendon tear comparison with arthroscopy. Adv Hum Biol [serial online] 2019 [cited 2020 Mar 28];9:236-40. Available from: http://www.aihbonline.com/text.asp?2019/9/3/236/262890
| Introduction|| |
One of the common causes of shoulder pain in the middle and old ages is the tear of rotator cuff tendons. The subscapularis is the largest and most powerful muscle of the rotator muscles wi and alone produces about 50% of the rotator cuff force, and it also plays an important role in raising the arm. It should be noted that the outstanding activity of the tendon of the subscapularis muscle in patients with an asymptomatic tear of rotator cuff shows that the subscapularis tendon plays an important role in maintaining shoulder stability in the upper posterior tear of the rotator cuff.
The limited diagnostic accuracy of individual physical examination tests has been shown in many studies. It is possible that some of the explained clinical tests are able to increase suspicion regarding a probable abnormality of the tendon; however, the test' specificity and sensitivity are still little.
Arthroscopy and magnetic resonance imaging (MRI) are diagnostic tools for this lesion. Due to the direct vision and relatively high diagnostic power, arthroscopy is considered as a gold criterion in detecting the tear of the rotator cuff. However, in this method, the bleeding must be carefully controlled; otherwise, the tear is not detected correctly.
Furthermore, shoulder MRI is used as a diagnostic tool to predict the presence of subscapularis tear in patients with rotator cuff injury., The subscapularis tendon is usually evaluated using the transverse MRI and sagittal oblique, but it is difficult to see lesions in the upper anterior region. Studies show that the MRI sensitivity for the detection of the supraspinatus and infraspinatus tendon tear is more than 90%, but the sensitivity for the tear of subscapularis tendon is not such high.,
In the study by Aslani et al., the sensitivity, specificity, positive predictive value, negative predictive value and for detecting rotator cuff tear were reported 0.97, 0.45, 0.86, 0.83 and 0.84, respectively. The results of this study showed that, although the MRI is reliable in the diagnosis of the complete tear of the rotator cuff, it is not reliable either in terms of the presence or absence or type of tear in the diagnosis of an incomplete tear; therefore, MRI results should be considered with the clinical symptoms of the disease.
The best non-invasive tool for evaluating the subscapularis tendon tears is MRI, but, on the other hand, there are cases of subscapularis tear in arthroscopy that are not diagnosed with MRI. Furthermore, because of common painful shoulder and the importance of quick and accurate diagnosis in the mentioned patients, the aim of this study was to determine the diagnostic accuracy of a MRI scan before surgery in evaluating the tear of the subscapularis tendon in comparison with the actual results obtained during the evaluation of arthroscopy from the same shoulder.
| Materials and Methods|| |
This retrospective study was conducted on medical records of 85 patients who underwent shoulder arthroscopic surgery suspected to have subscapularis tendon tears based on the physical examination and referred to the Besat Hospital (Hamadan-Iran) during 2012–2013. Patients with previous shoulder surgery, not having high-quality MRI results or incomplete data records were excluded from the study (47 patients).
At a 2-year interval (2012–2013), the MRI of all patients who referred with anterior shoulder pain and underwent arthroscopic surgery was reviewed by an experienced orthopaedic surgeon in the field of shoulder surgery and a radiologist. In cases in which the results from the two observers were inconsistent, a final consensus decision was made based on the discussion between the two observers. In the present study, the MRI was considered as a screening method, and arthroscopy results were considered as the gold standard. We used a researcher-made checklist, including participations' age, gender, subscapularis tendon tears type and MRI diagnostic values and arthroscopies results because of special insertion morphology of subscapularis tendon on the humeral head [Figure 1]. The morphology of the subscapularis tendon tears was classified according to the Lafosse classification as Type 1 partial lesion of superior one-third, Type 2 complete lesion of superior one-third [Figure 2], Type 3 complete lesion of superior two-thirds [Figure 3], Type 4 complete lesion of tendon but head centred and fatty degeneration classified as less than or equal to Stage 3 and Type 5 complete lesion of tendon, but eccentric head with coracoid impingement and fatty degeneration classified as more than or equal to Stage 3.
|Figure 1: Arthroscopic view of the insertion of subscapularis tendon on the humeral head.|
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|Figure 3: Type 2 subscapularis tendon tears with dislocation of the long head of biceps tendon.|
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Data were presented as mean ± standard deviation for continuous variables and frequency and percentage for qualitative variables. After determining the MRI and arthroscopy results and devote the results in the 2 × 2 table, sensitivity, specificity, positive predictive value and negative predictive value were computed for MRI compared arthroscopy as a gold standard. All the analyses were performed using Stata (Version 11.2, StataCorp, College Station, Texas, USA). The significance level was considered at P < 0.05.
Ethical approval for the study was obtained from the Institutional Review Board of the Hamadan University of Medical Sciences according to the Declaration of Helsinki (Registration Number: 9410225814).
| Results|| |
Among the 85 investigated patients, there were 53 (62.4%) males and 32 (37.6%) females. The mean age was 57.67 ± 8.75 years, with a range from 41 to 77 years. The frequency of subscapularis tendon tear was significantly higher in males as compared to females (P = 0.023). Sixty-five (76.5%) of them had surgery performed on their right shoulders, followed by 20 (23.5%) on their left hand (P < 0.001).
Results of MRI and arthroscopy for the diagnosis of subscapularis tendon tears are shown in [Table 1]. On the MRI images, 16 shoulders (18.8%) and by arthroscopy, 41 shoulders (48.2%) were positive for subscapularis tendon tears. Eight (80%) of Type 1 subscapularis tendon tears through arthroscopy was categorised negative by MRI. As well, 66.7% of Type 3 subscapularis tendon tears confirmed by arthroscopy, considered negative in MRI evaluation. However, in complete tear detection, there was complete agreement between MRI and arthroscopy. In other word, consistency between MRI and arthroscopy for the diagnosis of Type 1, 2, 3 and 4 tears was 0, 20%, 33.3% and 100%, respectively.
|Table 1: Frequency table regarding magnetic resonance imaging and arthroscopy results in patients with subscapularis tendon tears|
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Of the 35 detected patients with incomplete tear through arthroscopy, only 10 (28.57%) were identified on MRI. It means that the sensitivity, specificity, positive predictive value and negative predictive value of MRI for the identification of incomplete tear were 28.57%, 100%, 100% and 63.77%, respectively. Although all six positive complete rupture through arthroscopy diagnoses were confirmed by arthroscopy so that no false-positive findings were noted, and MRI had perfect (100%) sensitivity, specificity and positive and negative predictive value for detecting complete rupture. In overall, sensitivity, specificity, positive and negative predictive values of MRI for detecting all types of subscapularis tears were 39.02%, 100%, 100% and 63.77%, respectively [Table 2].
|Table 2: Comparison of magnetic resonance imaging diagnostic values versus arthroscopy for imperfect, complete and overall rupture|
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| Discussion|| |
This study was conducted with the aim of investigating the accuracy of MRI in the diagnosis of subscapularis tendon tears in comparison with diagnostic arthroscopy.
Since subscapularis is the most powerful and biggest muscle of the rotator cuff, and it plays a basic role in global shoulder function, the evaluation of diagnostic methods is of great importance. Arthroscopy is a gold standard for the diagnosis of subscapularis tears. In this study, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MRI in the diagnosis of subscapularis tendon tears were 39.02%, 100%, 100%, 63.77% and 70.59%, respectively. In the study by Adams et al., the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MRI in the diagnosis of subscapularis tendon tear were 56%, 100%, 100%, 62% and 69%, respectively, which are consistent with the results of this study.
Sensitivity and specificity have been reported 25%–80% and 91%–100%, respectively, for the accuracy of MRI in the diagnosis of the subscapularis tears by some researchers., The complete agreement between MRI and arthroscopy complete tear detection was observed in this study. It can be said that consistency between MRI and arthroscopy for the diagnosis of Type 1, 2, 3 and 4 tears was 0%, 20%, 33.3% and 100%, respectively.
One of the important factors affecting the diagnostic value of MRI was the extent of the subscapularis tendon tear. In partial tear of subscapularis tendon Types I–III by the Lafosse classification, the diagnostic value of MRI was less than the complete tear of the subscapularis tendon (Type 4). In contrast, the MRI test was differentiated positive and negative cases well in Type 4 (100% accuracy).
There are relatively many studies conducted on the diagnostic value of MRI in detecting the tear of the rotator cuff tendon, and the MRI sensitivity in detecting the tear of the rotator cuff tendon has been reported more than the tear of the subscapularis tendon.,
In the studies by Pfirrmann et al. and Fotiadou et al., 91% sensitivity and 100% accuracy for complete tears and 90% for partial tears, respectively, have been reported., The reason for this difference is also obvious; the rotator cuff tendon is described as the set of shoulder tendons, whereas the subscapularis tendon is a subset of rotator cuff that the diagnosis of its tear requires more precision and elegance due to the specific shape of the insertion of this tendon on the head of the humerus.
The study by Malavolta et al., in which the sensitivity and specificity were reported 78% and 86%, respectively, can be mentioned as one of the other works conducted in this regard. For the detection of partial tears (71%), the sensitivity value was less than that of complete tears (100%). The reason for this difference in the results of various studies, especially in the diagnosis of incomplete tears, may be due to the error caused by the expert experience.
In the present study, MRI did not have false-positive cases; that is the most important factor reducing the diagnostic value of MRI is false-negative cases all those who had positive subscapularis tendon tear through MRI; MRI positive result was also confirmed with arthroscopy of the shoulder. However, the most important factor that reduces the diagnostic value of MRI is false-negative cases. Of the 69 patients with negative MRI, 25 of them had positive arthroscopy.
Another finding of the recent study was that the accuracy of MRI was not affected by the time elapsed from injury to performing an MRI. No statistically significant difference was observed between positive and negative cases reported by MRI in terms of the average time elapsed from the incidence of symptoms. Although the diagnosis of rotator cuff tears has progressed greatly through MRI as well as the clinical examination tests has had some refinements, there is still an underdiagnosed condition for the lesions of the subscapularis tendon. It is not reliable, especially in false-negative cases and needs more accurate investigation. Finally, it is recommended that the MRI report should be confirmed with clinical symptoms in incomplete tears.
The main explanation of low sensitivity of MRI for subscapularis tendon tears compared to other rotator cuff tendons is special topography of the footprint of this tendon on the humeral head. Yoo et al. described a three-dimensional anatomic footprint of the tendon. Furthermore, there are some non-insertional types of subscapularis tears that may be difficult to be detected by MRI.
The high proportion of patients with low-quality MRI results or incomplete data records which we could not enter their records to the study was the main limitation of the study.
| Conclusion|| |
According to our study, MRI is highly specific method with high-positive predictive value for the diagnosis of subscapularis tendon tears, especially for complete tear. However, the sensitivity for the tear of subscapularis tendon is not such high. Hence, in the patients with clinical symptoms of subscapularis tendon tear, a negative MRI dose not rule out it and if conservative treatment fails, diagnostic and therapeutic shoulder arthroscopy is indicated even with a normal MRI.
This study was supported by the Hamadan University of Medical Sciences (UMSHA). We gratefully acknowledge the kind support of the staffs of the Besat Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]