Surgeon-Operated In-Office Ultrasonography for the Diagnosis of Rotator Cuff Tears: A Comparison with Magnetic Resonance Imaging

doi:10.4236/ss.2013.49A002

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Surgical Science, 2013, 4, 6-14

http://dx.doi.org/10.4236/ss.2013.49A002 Published Online September 2013 (http://www.scirp.org/journal/ss)

Surgeon-Operated In-Office Ultrasonography for the

Diagnosis of Rotator Cuff Tears: A Comparison with

Magnetic Resonance Imaging

Tsutomu Kobayashi1*#, Atsushi Yamamoto1*, Hitoshi Shitara1, Tsuyoshi Ichinose1, Eiji Takasawa1,

Daisuke Shimoyama1, Toshihisa Osawa2, Kenji Takagishi1

1Department of Orthopaedi c Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan

2Department of Orthopae d ic Surgery, Takasaki General Medical Center, Takasaki, Japa n

Email: #[email protected]

Received May 26, 2013; revised June 27, 2013; accepted July 6, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Obje ctive: Few investigators have evaluated whether ultrasonography operated by a surgeon during a patient’s clinic

visit is capable of obtaining a similar degree of accuracy as magnetic resonance imaging in regard to the diagnosis of

rotator cuff tears and lesions of the biceps tendon. Th e purpose of this study was to clarify the accur acy of in-office ul-

trasonography for the diagnosis of rotator cuff tears in comp arison to magnetic resonance imaging. Methods: One hun -

dred and three patients (105 shoulders) with a clinical diagnosis of impingement and suspected rotator cuff tear, who

subsequently underwent arthroscopic surgery were retrospectively enrolled in this study, including 7 males with 89

shoulders, and 33 females with 33 shoulders, and their mean age was 60.9 years (range, 30 to 83 years). The subjects

were examined using ultrasonography and magnetic resonance imaging within three months pre-operatively per normal

practice of the outpatient clinic. The two modalities were then compared to the reference standard, arthrosco pic finding s.

Results: Intra-operatively, 79 full-thickness and 15 partial-thickness rotator cuff tears were found. The agreement be-

tween ultrasonography and magnetic resonance imaging for diagnosis of rotator cuff tears was statistically good; ob-

served degree of agreement was 87 % with Kappa coefficient of 0.73. Ultrasonograph y showed a sensitiv ity of 94% an d

a specificity of 100% for full-thickness tears, and a sensitivity of 80% and a specificity of 91% for partial-thickness

tears. The agreement of the two modalities for diagno sis of lesions of the biceps ten don was also good; observed degree

of agreement was 93% with Kappa coefficient of 0.76. In addition, ultrasonography showed comparable accuracy for

classifying the size of rotator cuff tears to that of magnetic resonance imaging. Conclusion: Surgeon-operated in-office

ultrasonography is an appropriate technique for the assessment of rotator cuff tears with a comparable sensitivity and

specificity to that of magnetic resonance imaging.

Keywords: Diagnostic Accuracy; Magnetic Resonance Imaging; Rotator Cuff Tear; Ultrasonography; Arthroscopic

Surgery

1. Introduction

A rotator cuff tear is one of the most common disorders

affecting the shoulder and a recent population-based

study showed that approximately one-fourth of residents

of a rural area over 50 years of age had full-thickness

rotator cuff tears [1]. A proper diagnosis based on accu-

rate imaging is indispensable for deciding on the appro-

priate management.

The first study using ultrasonography to detect rotator

cuff tears was reported in 1979 by Seltzer et al. [2]. Al-

though several studies tried to develop accurate diagnos-

tic methods, the early reports of ultrasonography for ro-

tator cuff tears were not able to show favorable results,

probably due to the immaturity of the technique related

to the procedure and the instrument itself [3,4]. Thus,

magnetic resonance imaging had been considered the

first-choice imaging modality for the detection of rotator

cuff tears because of its high accuracy, despite its rela-

tively high cost and occasional limited availability [5,6].

However, following the development of new devices,

such as high-frequency transducers and improvements in

*Both authors contributed equally to this work.

#Corresponding author.

T. KOBAYASHI ET AL. 7

real-time imaging, a number of studies have reported the

high accuracy of ultrasonography for detecting rotator

cuff tears [7-9]. Ultrasonography of the shoulder has be-

come an accepted method for evaluating rotator cuff

tears.

Although both ultrasonography and magnetic reso-

nance imaging are highly accurate, widely-used and non-

invasive imaging modalities for the diagnosis of rotator

cuff tears [10] ultrasonography is relatively less expen-

sive, less time-consuming, and permits a dynamic eval-

uation of the shoulder. Furthermore, the portability of

ultrasonography means that the integrity of the rotator

cuff can be assessed in geographically isolated locations

or by a surgeon during a clinic session to allow more ef-

ficient planning of treatment [8]. There have been several

studies that compared the accuracy of ultrasonography

and magnetic resonance imaging [9,11,12], however, few

investigators have evaluated whether ultrasonography

performed by a surgeon during the patient’s clinic visit is

capable of obtaining a similar degree of accuracy as

magnetic resonance imaging with regard to the diagnosis

of rotator cuff tears and lesions of the biceps tendon. The

purpose of this study was to compare the accuracy of

surgeon-operated in-office ultrasonography and magnetic

resonance imaging for the detection and measurement of

the size of rotator cuff tears, with the results of arthro-

scopic surgery as the reference standard.

2. Materials and Methods

2.1. Subjects

After institutional review board approval was obtained,

122 patients (122 shoulders) with a clinical diagnosis of

impingement and a suspected rotator cuff tear, experi-

encing pain, decreased function, and/or weakness, who

subsequently underwent arthroscopic surgery in our in-

stitute from January 2010 to August 2012, were retro-

spectively enrolled in th is study.

All patients gave informed consent to particip ate in the

study. The patients were allocated to one of three ortho-

paedic surgeo ns, with a specialist interest in the shoulder

for more than 7 years. And these surgeons have more

than 5-years experiences of orthopaedic ultrasonography.

Each of these surgeons performed a preoperative evalua-

tion including ultrasonography and magnetic resonance

imaging, and subsequently performed arthroscopic sur-

gery, independently. This process occurred as part of the

standard outpatient allo cation, but did not involve patient

pre-selection by the clinicians. Of these pa tients, the sub-

jects who were involved in the study included patients

who 1) had undergone a preoperative examination by

both ultrasonography and magnetic resonance imaging

within three months before surgery, 2) had complete data

of all target evaluation items.

The exclusion criteria were patients 1) with claustro-

phobia, 2) who had metal devices in the field of view, 3)

has undergone a previous surgery, 4) had a previous

fracture, or 5) had a known inflammatory arthropathy.

Based on these criteria, one patient was excluded because

of claustrophobia and 16 patients were excluded because

they had incomplete data.

Thus, this study comprised 103 patients (105 shoul-

ders); there were 87 males with 89 shoulders, and 33

females with 33 shoulders, and their mean age was 60.9

years (range, 30 to 83 years).

2.2. Ultrasonography

All ultrasonographic examinations were performed be-

fore MRI within the normal flow of the outpatient clinic

by one of the three aforementioned orthopaedic surgeons,

using a LOGIQ e instrument (GE Healthcare, Bucking-

hamshire, England) with linear-array probes at 12 MHz.

The standard technique was a modification of the

technique described by Middleton et al. [13] and Teefey

et al. [14]. Parameters such as the scanning frequency,

focal zone number and placement, field of view, and gain

were not standardized, but left to the discretion of the

observer.

Both the patient and the observer were seated on

backless stools facing each other. First, the biceps tendon

was examined in front of the shoulder by transverse and

longitudinal scans. Then the patient was asked to hold

the arm in external rotation, and the lon gitudinal scans of

the subscapularis tendon were examined. Next, the lon-

gitudinal scans of the supraspinatus tendon was exam-

ined with the shoulder extended, the elbow flexed, and

the hand placed on the iliac wing to expose as much of

the supraspinatus tendon as possible from under the ac-

romion. The transducer was moved anteriorly to posteri-

orly in order to provide the best longitudinal scans of the

infraspinatus tendon. The transducer was then rotated 90

degrees in order to examine the transverse areas of the

supraspinatus and infrasupinatus tendons.

A full-thickness rotator cuff tear was diagnosed when

there was a focal discontinuity or thinning of the rotator

cuff or when the cuff could not be visualized because of

complete avulsion and retraction under the acromion [14,

15]. A partial-thickness tear was diagnosed when there

was minimal flattening of the bursal side of the rotator

cuff or a distinct hypoechoic or mixed hyperechoic and

hypoechoic defect was visualized in both the longitudinal

and the transverse planes at the deep articular side of the

rotator cuff [14].

The size of the tear in centimeters was also measured

directly on freeze-frame images with use of the cursor

software function. When the torn cuff was retracted un-

der the acromion, the size was recorded as a “not lower

than” measured length. Additionally, a finding of a rup-

T. KOBAYASHI ET AL.

ture of the biceps tendon was recorded when the tendon

was not identified within or medial to the intertubercular

sulcus. Dislocation of the biceps tendon was recorded

when the tendon was anterior or medial to the lesser tu-

berosity [14].

2.3. Magnetic Resonance Imaging

After examining clinical findings and ultrasonography,

magnetic resonance imaging was performed with the

same equipment at various facilities, but all examinations

were performed under the same standardized conditions.

Patients were positioned in the supine positio n with their

arms in a neutral position. A 1.5-T system with standard

coil was used. The slice thickness was 3 - 4 mm, the field

of view was small (12 - 16 cm) and the imaging matrix

was 256 mm × 192 mm or higher. The sequences per-

formed in all patients were T1- and T2-weighted images

in the oblique coronal, oblique sagittal and axial planes.

All magnetic resonance imaging was also referred blind-

ly within the normal flow of the outpatient clinic by an-

other orthopaedic surgeon who ultrasonographically ex-

amined the patient.

A full-thickness rotator cuff tear was diagnosed if

there was a fluid-filled gap on the T2-weighted oblique

coronal or oblique sagittal plane that extended through

the entire thickness of the tendon, or a complete disrupt-

tion of all tendon fibers with retraction. A partial-thick-

ness tear was defined as an increase in the signal noted

on the T1-weighted images with a brighter signal on the

T2-weighted images, as well as an identification of a

focal defect on either the bursal or the articular surface of

the involved tendon [16]. The size of the tear was meas-

ured in centimeters with use of the magnetic resonance

imaging scale noted on the images. Additionally, a find-

ing of a rupture and dislocation of the biceps tendon was

recorded.

2.4. Arthroscopic Surgery

One of the three aforementioned orthopaedic surgeons

who examined the ultrasonography scans and magnetic

resonance images of the patient performed the same pa-

tient’s surgery independently. There were 92 cases of

arthroscopic rotator cuff repair and 13 cases of arthro-

scopic subacromial decompression. A capsular release

was added in five cases, biceps tenotomy was added in

three cases and resection of the distal clavicle was added

in one case.

All surgeries were performed with completely arthro-

scopic techniques, placing the patient in the beach-chair

position under general anesthesia. Intraoperatively, the

following findings were recorded: the presence or ab-

sence of a rotator cuff tear, the type (full- or partial-

thickness) of the tear and the size of the tear in centime-

ters. A calibrated arthroscopic probe was used to define

both the anteroposterior and the medilolateral size of the

tear. In addition, the presence or absence of a complete

rupture and complete dislocation of the biceps tendon

were recorded. Any suspected cases of partial-thickness

tears and subluxation of the biceps tendon were consid-

ered to be negative findings in this study.

2.5. Data Analysis

First, the accuracy of ultrasonography and magnetic reso-

nance imaging for the diagnosis of rotator cuff tears was

calculated with 95% con fidence intervals (95% CI) using

the arthroscopic diagnosis as the reference standard. The

two modalities were then compared with regard to the

observed degree of agreement, with Cohen’s Kappa co-

efficient and McNemar’s test for paired proportions.

Subsequently, the diagnostic parameters for a diagnosis

of full- and partial-thickness rotator cuff tears, such as

the sensitivit y, specif icity, po sitive pr edictive value (PPV),

negative predictive value (NPV) and accuracy, were cal-

culated with the 95% CI. When counting the full-thick-

ness rotator cuff tears, partial-thickness tears were con-

sid ered to be no tear, and when counting for partial-thick -

ness tears, full-thickness tears were considered to be par-

tial-thickness tears, because a tear was identified [14].

Second, the accuracy of ultrasonography and magnetic

resonance imaging for the diagnosis of the lesions of the

biceps tendon was calculated and data were compared in

the same way. When counting for the rupture of the bi-

ceps tendon, the dislocation of the biceps tendon was

considered to be a negative finding, because the tendon

was assumed to be visualized, and when counting for the

dislocation of the biceps tendon, a rupture of the biceps

tendon was considered to be a positive finding, because

the tendon w as assume d to h ave not be en visualized.

Finally, the size of the tear was examined. According

to the classification of DeOrio and Cofield [17], th e leng-

th of the greatest diameter was used to divide the tear

int o one of four categories: small (one centimeter or less) ,

medium (one to three centimeters), large (three to five

centimeters), massive (greater than five centimeters). Be-

cause ultrasonography could not measure the exact di-

ameter of a huge tear due to the interference of the ac-

romion, the categories of large and massive wer e counted

together.

Thus, each case was classified as following four cate-

gories in this study; no tear, small (one centimeter or

less), medium (one to three centimeters), large/massive

(greater than three centimeters). The accuracy of ultra-

sonography and magnetic resonance imaging for the

classification of the tear size was calculated with the 95%

CI. In addition, the agreement of the two modalities was

examined with the observed degree of agreement, and

T. KOBAYASHI ET AL.

Cohen’s Kappa coefficient and McNemer’s test were

used for paired proportions.

All statistical analyses were performed by using the R

software program, version 2.15.0

(http://www.R-project.org) [18], and the critical value for

significance was set at P < 0.05. The Kappa coefficient

was interpreted as follows: 0.00 - 0.20, poor agreement;

0.21 - 0.40, fair agreement; 0.41 - 0.60, moderate agree-

ment; 0.61 - 0.80, good agreement; and 0.81 - 1.00, ex-

cellent agreement.

3. Results

3.1. Diagnosis of Rotator Cuff Tears

At arthroscopic surgery, 79 full-thickness and 15 par-

tial-thickness rotator cuff tears were found. The overall

accuracy of ultrasonography and magnetic resonance

imaging for the diagnosis of rotator cuff tears was 93%

and 84%, respectively (Table 1). The agreeme nt b etwe en

the ultrasonography and magnetic resonance imaging

findings was good: the observed degree of agreement

was 87% and the weighted Cohen’s Kappa coefficient

was 0.73. The McNemar test showed that the differences

between the two modalities were not statistically signifi-

cant (Table 2). The diagnostic parameters of ultrasono-

graphy and magnetic resonance imaging for the diagnosis

of rotator cuff tears are shown in Table 3.

3.2. Diagnosis of Lesions of the Biceps Tendon

At arthroscopic surgery, 11 ruptures and nine disloca-

tions of the biceps tendon were found. The overall accu-

racy of ultrasonography and magnetic resonance imaging

for the diagnosis of lesion s of the bicep s tendon was 93%

and 92%, respectively (Table 4). The agreeme nt b etwe en

the ultrasonography and magnetic resonance imaging

findings was good: the observed degree of agreement

was 93% and Cohen’s Kappa coefficient was 0.76. The

McNemar test showed that the differences between the

two modalities were not statistically significan t (Table 5).

The diagnostic parameters of ultrasonography and mag-

netic resonance imaging for the diagnosis of lesions of

the biceps tendon are shown in Table 6.

3.3. Accuracy for the Classification of the Tear

Size

Table 7 shows the comparison between the arthroscopic

classification of the size of the rotator cuff tears and the

classification made with ultrasonography and magnetic

resonance imaging. The overall accuracy of ultrasono-

graphy and magnetic resonance imaging for the classifi-

cation of the size of rotator cuff tears was 74% and 75%,

respectively. The agreement between the ultrasonogra-

phy and magnetic resonance imaging findings was good:

the observed degree of agreement was 79%, and the wei-

ghted Cohen’s Kappa coefficient was 0.77. The McNe-

mar test showed that the differences between the two

modalities were not statistically significant (Table 8).

4. Discussion

There have been a number of studies presenting the ac-

sess its diagnostic ability, and showed a sensitivity of

92% - 96% and a specificity of 93% - 96% for full-

thickness tears, and a sensitivity of 67% - 84% and a

specificity of 89% - 94% for partial-thickness tears [7,8,

10]. They all agreed that ultrasonography is an appropri-

ate technique for assessing rotator cuff tears with an ac-

ceptable sensitivity and specificity, despite the fact that

the diagnostic accuracy for partial-thickness tears is

somewhat inferior to that for full-thickness tears. The

current study showed almost the same results as these

meta-analyses, with a sensitivity of 94 % and a specificity

of 100% for full-thickness ro tator cuff tears, and a sensi-

tivity of 80% and a specificity of 91% for partial-thick-

ness rotator cuff tears.

Regarding the comparison between ultrasonography

and magnetic resonance imaging for the diagnosis of

rotator cuff tears, only two studies have directly com-

pared the two modalities with the use of surgery as the

reference standard. Martín-Hervás et al. [11] prospec-

tively assessed 61 painful shoulders and found that the

diagnosis of full-thickness tears was highly specific by

both imaging techniques (100% for ultrasonography and

97% for magnetic resonance imaging) but was not as

sensitive, (58% for ultrasonography and 81% for magnetic

Table 1. Comparison of the arthroscopic diagnosis of rotator cuff tears with the ultrasonography and magnetic resonance

imaging findings.

Ultrasonography Magnetic reso nance imaging

FTT PTT No tear Total FTT PTT No tear Total

Arthroscopic diagnosis

FTT 74 3 2 79 74 5 0 79

PTT 8 4 3 15 7 5 3 15

No tear 0 1 10 11 0 2 9 11

Total 82 8 15 105 81 12 12 105

Accuracy* 98/105 (93% [87% - 97%]) 88/105 (84% [75% - 90%])

*The 95% confidence interval is given in brackets. FTT: full-thickness rotator cuff tears, PTT: partial-thickness rotator cuff tears.

T. KOBAYASHI ET AL.

Table 2. Agreement between the ultrasonography and magnetic resonance imaging findings for the diagnosis of rotator cuff

tears.

Magnetic resona n ce imaging

FTT PTT No tear

Ultrasonography

FTT 78 3 1

PTT 2 4 2

No tear 1 5 9

Observed degree of agreement* 91/105 (87% [79% - 93%])

Weighted Cohen’s Kappa coefficient* 0.73 [0.60 - 0.87]

McNemar test P = 0.79

*The 95% confidence interval is given in brackets. FTT: full-thickness rotator cuff tears, PTT: partial-thickness rotator cuff tears.

Table 3. The diagnostic parameters of ultrasonography and magnetic resonance imaging for the diagnosis of rotator cuff

tears.

Ultrasonography Magnetic reso nance imaging

FTT PTT FTT PTT

Sensitivity 74/79 (94% [86% - 98%]) 12/15 (80% [52% - 96%]) 74/79 (94% [86% - 98%]) 12/15 (80% [52% - 96%])

Specificity 11/11 (100% [76% - 100%]) 10/11 (91% [59% - 100%])11/11 (100% [76% - 100%]) 9/11 (82% [48% - 98%])

PPV 74/74 (100% [96% - 100%]) 12/13 (92% [64% - 100%])74/74 (100% [96% - 1 00 %]) 12/14 (86% [57% - 98 %])

NPV 11/16 (69% [41% - 89%]) 10/13 (77% [46% - 95%]) 11/16 (69% [41% - 89%]) 9/12 (75% [43% - 95 %])

Accuracy 85/90 (94% [88% - 98 %]) 22/26 (85% [65% - 96%]) 85/90 (94% [88% - 98%]) 21/26 (81% [61% - 93%])

The 95% confidence interval is given in brackets. PPV: positive predictive value, NPV: negative predictive value, FTT: full-thickness rotator cuff tears, PTT:

partial-thickness rotator cuff tears.

Table 4. Comparison of the arthroscopic diagnosis of lesions of the biceps tendon with the ultrasonography and magnetic

resonance imaging findings.

Ultrasonography Magnetic resonance imaging

Rupture Dislocation Normal Total Rupture Dislocation Normal Total

Arthroscopic diagnosis

Rupture 10 1 0 11 8 1 2 11

Dislocation 2 4 3 9 3 4 2 9

Normal 0 1 84 85 0 0 85 85

Total 12 6 87 105 11 5 89 105

Accuracy* 98/105 (93% [87% - 97%]) 97/105 (92% [86% - 97%])

*The 95% conf i d ence interval is given in brackets.

Table 5. Agreement betw een the ultrasonography and magnetic re sonance imaging findings for the diagnosis of lesions of the

biceps tendon.

Magnetic r esonance imaging

Rupture Dislocation Normal

Ultrasonography

Rupture 9 1 2

Dislocation 0 4 2

Normal 2 0 85

Observed degree of agreement* 98/105 (93% [87% - 97%])

Cohen’s Kappa coefficient* 0.76 [0.60 - 0.93]

McNemar test P = 0.45

*The 95% conf i d ence interval is given in brackets.

T. KOBAYASHI ET AL.

Table 6. The diagnostic parameters of ultrasonography and magnetic resonance imaging for the diagnosis of lesions of the

biceps tendon.

Ultrasonography Magnetic reso nance imaging

Rupture Dislocation Rupture Dislocation

Sensitivity 10/11 (91% [59% - 100%]) 6/9 (67% [30% - 93%]) 8/11 (73% [39% - 94%]) 7/9 (78% [40% - 97%])

Specificity 85/85 (100% [97% - 100%]) 84/85 (99% [94% - 100%])85/85 (100% [97% - 100%]) 85/85 (100% [97% - 100%])

PPV 10/10 (100% [74% - 100%]) 6/7 (86% [42% - 100%]) 8/8 (100% [69% - 100%]) 7/7 (100% [65% - 100%])

NPV 85/86 (99% [94% - 100%]) 84/87 (97% [90% - 99% ])85/88 (97% [90% - 99%]) 85/87 (98% [92% - 10 0%])

Accuracy 95/96 (99% [94% - 10 0% ]) 90/94 (96% [90% - 99%])93/96 (97% [91% - 99% ]) 92/94 (98% [93% - 100%])

*The 95% conf i d ence interval is given in brackets. PPV: positive predictive value, NPV: negative predictive value.

Table 7. Comparison between the arthroscopic classification of the size of rotator cuff tears and the classification made based

on ultrasonography and magnetic resonance imaging.

Ultrasonography Magnetic reso nance imaging

No tear Small Medium Large/MassiveTotal No tearSmallMedium Large/Massive Total

Arthroscopic diagnosis

No tear 13 2 0 0 15 11 3 1 0 15

Small 4 3 0 0 7 2 4 1 0 7

Medium 2 3 37 1 43 2 4 34 3 43

Large/Massive 0 0 15 25 40 0 0 10 30 40

Total 19 8 52 26 105 15 11 46 33 105

Accuracy* 78/105 (74% [65% - 82%]) 79/105 (75% [66% - 83%])

*The 95% conf i d ence interval is given in brackets.

Table 8. Agreement between the ultrasonography and magnetic resonance imaging findings for the classification of the size of

rotator cuff tears.

Magnetic resonance imaging

No tear Small Medium Large/Massive

Ultrasonography

No tear 12 4 3 0

Small 2 5 1 0

Medium 1 2 41 8

Large/Massive 0 0 1 25

Observed degree of agreement* 83/105 (79% [70% - 86%])

Weighted Cohen’s Kappa coefficient* 0.77 [0.67 - 0.86]

McNemar test P = 0.05

*The 95% confi dence interval is given in bracket.

resonance imaging). This low specificity of ultrasono-

graphy may be due to the use of older equipment with a

lower-frequency transducer. Teefey et al. [9] prospec-

tively studied 71 patients with shoulder pain by ultra-

son ogr aphy using a high-frequency transducer, and sho w-

ed that ultrasonography and magnetic resonance imaging

have comparable degrees of accuracy for diagnosing ro-

tator cuff tears; a sensitivity of 98% for ultrasonography

and 100% for magnetic resonance imaging, and a speci-

ficity of 80% for ultrasonography and 68% for magnetic

resonance imaging. The current study showed that there

was a good agreement between the ultrasonography and

magnetic resonance imaging findings for detecting both

full-thickness and partial-thickness rotator cuff tears, and

the differences between the two modalities were not sta-

tistically significant.

Ultrasonography of the shoulder is considered to be

operator-dependent, with its accuracy being related to the

operator’s level of experience. In their systemic review,

Smith et al. described that the diagnostic test accuracy

was greatest under the direction of a musculoskeletal

radiologist, followed by orthopaedic surgeons.

T. KOBAYASHI ET AL.

There were lower levels of diagnostic test accuracy for

ultrasonographers and general radiologists who did not

express a particular specialist interest in musculoskeletal

radiology [8]. There have been two studies regarding the

accuracy of surgeon-operated in-office shoulder ultra-

sonography. Al-Sh awi et al. [19] examined 143 consecu-

tive ultrasonographic scans of patients who subsequently

underwent shoulder arthroscopy. All the scans were per-

formed by an orthopaedic surgeon using portable ultra-

sonography in a one-stop clinic, and sho wed a sensitivity

of 96%, a specificity of 95%, a positive predictive value

of 96% and a negative predictive value of 95% for the

dia gno sis of f ull- thic kness rotator cuff tears. Ziegler et al.

[20] examined 282 in-office ultrasonographic scans per-

formed by an attending orthopaedic surgeon.

Using the findings at surgery as the standard reference,

the sensitivity, specificity, positive predictive value and

negativ e p r ed ictiv e v alu e w ere 96 %, 94 %, 93 % a nd 97 %,

re sp ect iv el y, for full-thick ness tears; and wer e 9 4% , 96 %,

97% and 93%, respectively, for partial-thickn ess tears. In

addition, Iannotti et al. [21] assessed the accuracy of a

surgeon interpreting office-based ultrasonography scans

for the diagn osis of rotator cuff tears. Although the scans

were performed not by a surgeon, but by a physician-

assistant or nurse clinician who had undergone six hours

of formal training and 30 supervised scans, the sensitivity

was 88% for full-thickness tears and 70% for partial-

thickness tears in 98 patients who subsequently under-

went rotator cuff surgery. The current study showed that

the sensitivity and the specificity were as high as these

results for both full-thickness and partial-thickness rota-

tor cuff tears.

There have been several studies regarding the diagnos-

tic accuracy of ultrasonography for lesions of the biceps

tendon [14,22-24]. According to these studies, ultrasono-

graphy showed a sensitivity of 64% - 100% and a speci-

ficity of 98% - 100% for ruptures, and a sensitivity of

83% - 100% and a specificity of 100% for dislocations.

However, few studies have directly compared ultrasono-

graphy and magnetic resonance imaging. The current stu-

dy showed that ultrasonography and magnetic resonance

imaging have comparable degrees of accuracy for diag-

nosing ruptures and dislocations of the biceps tendon.

The diagnostic accuracy was characterized by a sensitiv-

ity of 91% and a specificity of 100% for ruptures, and a

sensitivity of 67% and a specificity of 99% for disloca-

tions. The sensitivity for dislocation in the current study

was inferior to the previously reported accuracy. This

may have been due to the differences in the diagnostic

criteria used for the dislocation of the biceps tendon. We

performed ultrasonography only in th e static position. At

surgery, any suspected cases of subluxation of the biceps

tendon, which were found during the dynamic evaluation

with an arthroscopic probe, were counted as negative

findings in this study.

The size of rotator cuff tears is essential for planning

proper treatment and advising patients regarding their

prognosis and outcome. Moosmayer et al. [25] ultra-

sonographically assessed 58 shoulders to quantify the

tears. Using the surgical findings as the standard refer-

ence, they achieved a 95% range of agreement for tear

size measurement, with less than ±1 cm. Teefey et al. [9]

prospectively examined 71 patients by ultrasonography

and magnetic resonance imaging and compared the ac-

curacy of the two tests for measuring the size of tears.

They found that ultrasonography correctly predicted the

degree of retraction in 73% of the full-th ickness tears and

the length of 85% of the partial-thickness tears, and the

width of 87% of the full-thickness tears and 54% of the

partial-thickness tears. They concluded that these results

were not significantly different in comparison with mag-

netic resonance imaging. In the current study, we as-

sessed the size of tears using four categories, because

ultrasonograp hy could not measure the exact diameter of

huge tears due to the interference of the acromion. The

overall accuracy of ultrasonography and magnetic reso-

nance imaging for the classification of tears was 74% and

75%, respectively. Although a simple comparison is not

accurate, this result seems to be comparable to the pre-

vious studies.

The current study showed that ultrasonography per-

formed by a surgeon during the patient’s clinic visit had

comparable accuracy to magnetic resonance imaging for

identifying rotator cuff tears and lesions of the biceps

tendon, and for classifying the size of rotator cuff tears.

Seagger et al. [26] showed that the use of a portable ul-

trasonography machine by an orthopaedic surgeon in a

shoulder clinic can significantly reduce the time to treat-

ment and the financial cost for patients with rotator cuff

tears. Moreover, Middleton et al. [27] showed that most

patients with shoulder pain prefer ultrasonography to

magnetic resonance imaging. As Teefey et al. [9] de-

scribed, when an investigator has comparable experience

with both imaging tests, the decision regarding which test

to perform for rotator cuff assessment does not need to

be based on accuracy concerns. The choice can be based

on other factors, such as the importance of ancillary

clinical information , the presence of an implanted device,

patient tolerance and co st.

Our study has a limitation that should be kept in mind

when interpreting the results. The intra-rater and in-

ter-rater reliability were not assessed. This was due to the

limitation of the study design, and a prospective study

would be necessary to address such a limitation.

5. Conclusion

In conclusion, the accuracy of surgeon-operated in-office

shoulder ultrasonography was investigated. In-office shoul-

T. KOBAYASHI ET AL. 13

der ultrasonography had comparable accuracy to mag-

netic resonance imaging for detecting rotator cuff tears

and lesions of the biceps tendon, as well as for classify-

ing the size of rotator cuff tears.

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