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MR Imaging and MR Arthrography of the Postoperative Shoulder: Spectrum of Normal and Abnormal Findings¹

¹ From the Department of Radiology, Veterans Administration Medical Center, 3350 La Jolla Village Dr, San Diego, CA 92161. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received March 25, 2003; revision requested April 28 and received June 16; accepted June 18. All authors have no financial relationships to disclose. Address correspondence to C.B.C. (e-mail: cbchung@ucsd.edu).

View larger version (86K): [in a new window]   Figure 1a.  Schematics in the sagittal plane show acromial morphology before (a) and after (b) subacromial decompression. (a) Subacromial enthesophyte (E) projects from the anteroinferior surface of the acromion (A) and impinges on the adjacent rotator cuff tendon. Note the relationship of the subacromial enthesophyte to the coracoacromial ligament (CAL). (b) After surgery, the curved undersurface of the acromion (A) is flatter. Resection of the coracoacromial ligament (CAL) is represented by the absence of acromial attachment. (Compare with Fig 8.)

View larger version (86K): [in a new window]   Figure 1b.  Schematics in the sagittal plane show acromial morphology before (a) and after (b) subacromial decompression. (a) Subacromial enthesophyte (E) projects from the anteroinferior surface of the acromion (A) and impinges on the adjacent rotator cuff tendon. Note the relationship of the subacromial enthesophyte to the coracoacromial ligament (CAL). (b) After surgery, the curved undersurface of the acromion (A) is flatter. Resection of the coracoacromial ligament (CAL) is represented by the absence of acromial attachment. (Compare with Fig 8.)

View larger version (63K): [in a new window]   Figure 2a.  Schematics in the axial plane show clavicular morphology before (a) and after (b) the Mumford procedure. (a) Note the proximity of the distal part of the clavicle (C) to the acromion (A) prior to the procedure. (b) With resection of the distal part of the clavicle, acromioclavicular distance increases 1-2 cm. (Compare with Fig 9.)

View larger version (66K): [in a new window]   Figure 2b.  Schematics in the axial plane show clavicular morphology before (a) and after (b) the Mumford procedure. (a) Note the proximity of the distal part of the clavicle (C) to the acromion (A) prior to the procedure. (b) With resection of the distal part of the clavicle, acromioclavicular distance increases 1-2 cm. (Compare with Fig 9.)

View larger version (85K): [in a new window]   Figure 3a.  Schematics in the coronal plane show the typical results of surgical repair of bursal-sided (a), articular-sided (b), and full-thickness (c) tears of the rotator cuff. A = acromion, E = enthesophyte.

View larger version (88K): [in a new window]   Figure 3b.  Schematics in the coronal plane show the typical results of surgical repair of bursal-sided (a), articular-sided (b), and full-thickness (c) tears of the rotator cuff. A = acromion, E = enthesophyte.

View larger version (88K): [in a new window]   Figure 3c.  Schematics in the coronal plane show the typical results of surgical repair of bursal-sided (a), articular-sided (b), and full-thickness (c) tears of the rotator cuff. A = acromion, E = enthesophyte.

View larger version (160K): [in a new window]   Figure 4a.  Schematics in the sagittal plane show Bankart lesion before (a), during (b, c), and after (d) surgical treatment. (a) Bankart lesion is represented by separation of the anteroinferior labrum from the glenoid bone (arrow). (b) Holes are drilled in the glenoid bone at 3-, 4-, and 5-o’clock positions. (c) Suture anchors are passed through the drill holes. (d) The labrum is reattached to the glenoid bone. AB = anterior band of the inferior glenohumeral ligament complex, B = biceps tendon, IGHLC = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament, PB = posterior band of the inferior glenohumeral ligament complex, SGHL = superior glenohumeral ligament.

View larger version (168K): [in a new window]   Figure 4b.  Schematics in the sagittal plane show Bankart lesion before (a), during (b, c), and after (d) surgical treatment. (a) Bankart lesion is represented by separation of the anteroinferior labrum from the glenoid bone (arrow). (b) Holes are drilled in the glenoid bone at 3-, 4-, and 5-o’clock positions. (c) Suture anchors are passed through the drill holes. (d) The labrum is reattached to the glenoid bone. AB = anterior band of the inferior glenohumeral ligament complex, B = biceps tendon, IGHLC = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament, PB = posterior band of the inferior glenohumeral ligament complex, SGHL = superior glenohumeral ligament.

View larger version (169K): [in a new window]   Figure 4c.  Schematics in the sagittal plane show Bankart lesion before (a), during (b, c), and after (d) surgical treatment. (a) Bankart lesion is represented by separation of the anteroinferior labrum from the glenoid bone (arrow). (b) Holes are drilled in the glenoid bone at 3-, 4-, and 5-o’clock positions. (c) Suture anchors are passed through the drill holes. (d) The labrum is reattached to the glenoid bone. AB = anterior band of the inferior glenohumeral ligament complex, B = biceps tendon, IGHLC = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament, PB = posterior band of the inferior glenohumeral ligament complex, SGHL = superior glenohumeral ligament.

View larger version (174K): [in a new window]   Figure 4d.  Schematics in the sagittal plane show Bankart lesion before (a), during (b, c), and after (d) surgical treatment. (a) Bankart lesion is represented by separation of the anteroinferior labrum from the glenoid bone (arrow). (b) Holes are drilled in the glenoid bone at 3-, 4-, and 5-o’clock positions. (c) Suture anchors are passed through the drill holes. (d) The labrum is reattached to the glenoid bone. AB = anterior band of the inferior glenohumeral ligament complex, B = biceps tendon, IGHLC = inferior glenohumeral ligament complex, MGHL = middle glenohumeral ligament, PB = posterior band of the inferior glenohumeral ligament complex, SGHL = superior glenohumeral ligament.

View larger version (107K): [in a new window]   Figure 5a.  Schematics of the Putti-Platt procedure. (a) In the first stage of the procedure, parts of the anterior capsule and tendons A and B of the subscapularis muscle are resected and shortened. (b) In the second stage, the lateral tendon stump (B) is attached to the most accessible soft-tissue structure along the anterior rim of the glenoid cavity. The medial tendon stump (A) is overlapped with the lateral tendon stump and reattached to the lesser tuberosity of the humerus. IR = internal rotation of the humerus.

View larger version (124K): [in a new window]   Figure 5b.  Schematics of the Putti-Platt procedure. (a) In the first stage of the procedure, parts of the anterior capsule and tendons A and B of the subscapularis muscle are resected and shortened. (b) In the second stage, the lateral tendon stump (B) is attached to the most accessible soft-tissue structure along the anterior rim of the glenoid cavity. The medial tendon stump (A) is overlapped with the lateral tendon stump and reattached to the lesser tuberosity of the humerus. IR = internal rotation of the humerus.

View larger version (108K): [in a new window]   Figure 6.  Schematic of the Bristow-Helfet procedure. The coracoid process and the short head of the biceps tendon are transferred to the anteroinferior glenoid rim through the split subscapularis tendon.

View larger version (101K): [in a new window]   Figure 7a.  Schematics of the capsular shift procedure. (a) A horizontal T-shaped incision is made in the anterior part of the capsule. Note the closure of the rotator interval (RI). (b) The inferior part of the capsule (B) is shifted in the superior direction, and the superior part of the capsule (A) is shifted in the anteroinferior direction to overlap it. (c) The margins of the incision are sutured to hold the overlapping parts of the capsule together.

View larger version (103K): [in a new window]   Figure 7b.  Schematics of the capsular shift procedure. (a) A horizontal T-shaped incision is made in the anterior part of the capsule. Note the closure of the rotator interval (RI). (b) The inferior part of the capsule (B) is shifted in the superior direction, and the superior part of the capsule (A) is shifted in the anteroinferior direction to overlap it. (c) The margins of the incision are sutured to hold the overlapping parts of the capsule together.

View larger version (103K): [in a new window]   Figure 7c.  Schematics of the capsular shift procedure. (a) A horizontal T-shaped incision is made in the anterior part of the capsule. Note the closure of the rotator interval (RI). (b) The inferior part of the capsule (B) is shifted in the superior direction, and the superior part of the capsule (A) is shifted in the anteroinferior direction to overlap it. (c) The margins of the incision are sutured to hold the overlapping parts of the capsule together.

View larger version (129K): [in a new window]   Figure 8a.  Sagittal T1-weighted (500/12) images show the morphology of the coracoacromial ligament (straight arrow) and the acromion (curved arrow) before (a) and after (b) coracoacromial ligament resection and anterior acromioplasty. (Compare with Fig 1.) HH = humeral head.

View larger version (144K): [in a new window]   Figure 8b.  Sagittal T1-weighted (500/12) images show the morphology of the coracoacromial ligament (straight arrow) and the acromion (curved arrow) before (a) and after (b) coracoacromial ligament resection and anterior acromioplasty. (Compare with Fig 1.) HH = humeral head.

View larger version (117K): [in a new window]   Figure 9a.  Subacromial decompression (Mumford procedure). (a) Axial proton-density-weighted (2,800/10) fat-suppressed image shows the proximity of the distal part of the clavicle (C) to the acromion (A). (b) T1-weighted fat-suppressed image obtained after resection of the distal part of the clavicle shows an increase of 1-2 cm in the acromioclavicular distance. (Compare with Fig 2.) A = acromion, C = clavicle.

View larger version (127K): [in a new window]   Figure 9b.  Subacromial decompression (Mumford procedure). (a) Axial proton-density-weighted (2,800/10) fat-suppressed image shows the proximity of the distal part of the clavicle (C) to the acromion (A). (b) T1-weighted fat-suppressed image obtained after resection of the distal part of the clavicle shows an increase of 1-2 cm in the acromioclavicular distance. (Compare with Fig 2.) A = acromion, C = clavicle.

View larger version (132K): [in a new window]   Figure 10.  Rotator cuff repair and arthroscopic subacromial decompression in a middle-aged man. Coronal T1-weighted (500/12) fat-suppressed MR arthrogram shows intact supraspinatus tendon. Note the artifacts in the area of the repaired tendon (straight arrow) and the undersurface of the acromion (curved arrow). G = glenoid, HH = humeral head.

View larger version (143K): [in a new window]   Figure 11a.  Bankart repair 2 years previous in a 37-year-old man. Sagittal T1-weighted (600/13) fat-suppressed MR arthrograms (b more medial than a) depict capsular thickening (curved arrow) and metallic artifacts (straight arrows) from suture anchors in the anteroinferior glenoid quadrant.

View larger version (142K): [in a new window]   Figure 11b.  Bankart repair 2 years previous in a 37-year-old man. Sagittal T1-weighted (600/13) fat-suppressed MR arthrograms (b more medial than a) depict capsular thickening (curved arrow) and metallic artifacts (straight arrows) from suture anchors in the anteroinferior glenoid quadrant.

View larger version (132K): [in a new window]   Figure 12.  Capsular shift procedure in a middle-aged man. Axial T1-weighted (500/12) fat-suppressed MR arthrogram shows postoperative thickening of the anteroinferior part of the capsule (straight arrow) and overlying subscapularis tendon (curved arrow). G = glenoid, HH = humeral head.

View larger version (112K): [in a new window]   Figure 13a.  Repair of superior labral anterior-to-posterior tear in a middle-aged woman. Axial T1-weighted (450/12) fat-suppressed sequential images (a at a higher level than b) show postoperative thickening of the superior glenohumeral ligament and rotator interval capsule (arrows). G = glenoid, HH = humeral head.

View larger version (113K): [in a new window]   Figure 13b.  Repair of superior labral anterior-to-posterior tear in a middle-aged woman. Axial T1-weighted (450/12) fat-suppressed sequential images (a at a higher level than b) show postoperative thickening of the superior glenohumeral ligament and rotator interval capsule (arrows). G = glenoid, HH = humeral head.

View larger version (127K): [in a new window]   Figure 14a.  Mumford procedure in a young man. (a) Coronal T2-weighted fast spin-echo image depicts fatty atrophy (straight arrow) and dehiscence (curved arrow) of the deltoid muscle. (b) Axial T1-weighted fat-suppressed image shows extensive acromioplasty (arrow), a probable cause of deltoid muscle abnormalities identified in this patient. A = acromion, C = clavicle, G = glenoid, HH = humeral head.

View larger version (129K): [in a new window]   Figure 14b.  Mumford procedure in a young man. (a) Coronal T2-weighted fast spin-echo image depicts fatty atrophy (straight arrow) and dehiscence (curved arrow) of the deltoid muscle. (b) Axial T1-weighted fat-suppressed image shows extensive acromioplasty (arrow), a probable cause of deltoid muscle abnormalities identified in this patient. A = acromion, C = clavicle, G = glenoid, HH = humeral head.

View larger version (93K): [in a new window]   Figure 15.  Schematic representation of the axillary nerve and its correlation with shoulder surgeries. The axillary nerve originates from the posterior cord of the brachial plexus and crosses the inferolateral surface of the subscapularis muscle and the inferior glenohumeral joint capsule, where it is vulnerable to injury during surgery for glenohumeral instability. From here it branches through quadrilateral space to the teres minor muscle (TmB). At the posterior surface of the humerus, the nerve divides into a posterior branch (PB) and an anterior branch (AB). The anterior branch curves downward to innervate the lateral and anterior heads of the deltoid muscle. At these sites the nerve is vulnerable to injury during open subacromial decompression surgery and rotator cuff repair if the deltoid muscle is split anteriorly for a distance greater than 5 cm. Ant = anterior, Lat = lateral, N. = nerve, SR = subscapular recess.

View larger version (124K): [in a new window]   Figure 16a.  Septic arthritis in a 47-year-old woman with progressive shoulder pain for 2 months after rotator cuff repair. Axial (a) and coronal (b) T1-weighted fat-suppressed images obtained with intravenous administration of gadolinium-based contrast material show synovial, capsular, and soft-tissue enhancement (arrows in a), marginal erosion (arrow in b), and capsular laxity. Note the high-grade partial tear of the supraspinatus tendon in b. G = glenoid, HH = humeral head.

View larger version (134K): [in a new window]   Figure 16b.  Septic arthritis in a 47-year-old woman with progressive shoulder pain for 2 months after rotator cuff repair. Axial (a) and coronal (b) T1-weighted fat-suppressed images obtained with intravenous administration of gadolinium-based contrast material show synovial, capsular, and soft-tissue enhancement (arrows in a), marginal erosion (arrow in b), and capsular laxity. Note the high-grade partial tear of the supraspinatus tendon in b. G = glenoid, HH = humeral head.

View larger version (123K): [in a new window]   Figure 17a.  Subscapularis tendon tear and capsular rupture in a 17-year-old male patient after arthroscopic surgery. Axial T1-weighted fat-suppressed MR arthrograms show the tear (arrow in a) and extravasation of contrast material (arrows in b) into soft tissues around the capsule, in the region of the axillary pouch. G = glenoid, HH = humeral head.

View larger version (122K): [in a new window]   Figure 17b.  Subscapularis tendon tear and capsular rupture in a 17-year-old male patient after arthroscopic surgery. Axial T1-weighted fat-suppressed MR arthrograms show the tear (arrow in a) and extravasation of contrast material (arrows in b) into soft tissues around the capsule, in the region of the axillary pouch. G = glenoid, HH = humeral head.

View larger version (130K): [in a new window]   Figure 18a.  Full-thickness recurrent tendon tear and retraction in a 49-year-old man with a history of rotator cuff repair. Coronal proton-density-weighted MR arthrograms obtained without (a) and with (b) fat suppression depict tendon retraction (straight arrow in a), associated synovitis (curved arrow in a), and the so-called geyser sign (arrow in b) produced by the extension of contrast material into acromioclavicular space (arrowhead in b) as a result of injury to the undersurface of the acromioclavicular joint. G = glenoid, HH = humeral head.

View larger version (109K): [in a new window]   Figure 18b.  Full-thickness recurrent tendon tear and retraction in a 49-year-old man with a history of rotator cuff repair. Coronal proton-density-weighted MR arthrograms obtained without (a) and with (b) fat suppression depict tendon retraction (straight arrow in a), associated synovitis (curved arrow in a), and the so-called geyser sign (arrow in b) produced by the extension of contrast material into acromioclavicular space (arrowhead in b) as a result of injury to the undersurface of the acromioclavicular joint. G = glenoid, HH = humeral head.

View larger version (146K): [in a new window]   Figure 19.  Superior labral tear in a middle-aged woman with persistent shoulder pain after arthroscopic subacromial decompression and rotator cuff repair. Coronal T1-weighted fat-suppressed MR arthrogram clearly shows the tear (arrow), which was missed during surgery.

View larger version (116K): [in a new window]   Figure 20a.  Comparison of the severity of metallic artifacts on coronal MR images obtained with different pulse sequences. Magnetic susceptibility artifacts (arrows) obscure the underlying tendon on the gradient-echo image (a) but are barely noticeable on the proton-density-weighted image (b).

View larger version (114K): [in a new window]   Figure 20b.  Comparison of the severity of metallic artifacts on coronal MR images obtained with different pulse sequences. Magnetic susceptibility artifacts (arrows) obscure the underlying tendon on the gradient-echo image (a) but are barely noticeable on the proton-density-weighted image (b).

View larger version (128K): [in a new window]   Figure 21a.  Bursitis in a 63-year-old man after rotator cuff repair. (a) Coronal T2-weighted fat-suppressed image depicts heterogeneous signal intensity in the supraspinatus tendon (arrow) because of a moderate fluid accumulation in the subacromial-subdeltoid bursa, a finding indicative of a possible full-thickness tear at the attachment site. (b) Coronal T1-weighted fat-suppressed MR arthrogram depicts an irregular but intact tendon (arrows). Note the absence of contrast material in the subacromial-subdeltoid space.

View larger version (121K): [in a new window]   Figure 21b.  Bursitis in a 63-year-old man after rotator cuff repair. (a) Coronal T2-weighted fat-suppressed image depicts heterogeneous signal intensity in the supraspinatus tendon (arrow) because of a moderate fluid accumulation in the subacromial-subdeltoid bursa, a finding indicative of a possible full-thickness tear at the attachment site. (b) Coronal T1-weighted fat-suppressed MR arthrogram depicts an irregular but intact tendon (arrows). Note the absence of contrast material in the subacromial-subdeltoid space.

View larger version (148K): [in a new window]   Figure 22a.  Abscess in a middle-aged man after surgical reconstruction of the coracoclavicular ligament. (a) Coronal T2-weighted fat-suppressed image shows an area of high signal intensity (arrow) in the region of the coracoclavicular ligament. (b) Axial T1-weighted fat-suppressed image obtained after intravenous administration of gadolinium depicts an abscess in the region of the ligament (arrow) and enhancement of the surrounding tissues. A = acromion, C = clavicle.

View larger version (136K): [in a new window]   Figure 22b.  Abscess in a middle-aged man after surgical reconstruction of the coracoclavicular ligament. (a) Coronal T2-weighted fat-suppressed image shows an area of high signal intensity (arrow) in the region of the coracoclavicular ligament. (b) Axial T1-weighted fat-suppressed image obtained after intravenous administration of gadolinium depicts an abscess in the region of the ligament (arrow) and enhancement of the surrounding tissues. A = acromion, C = clavicle.