Post Surgical Shoulder

[Amanda Leaw]

Hi Steve, I was wondering if you had any pointers in regards to the post surgical shoulder.
I was a little stressed a few months ago, as a newbie scanning a shoulder I had to ask for extra assistance after a patient came in with a post op shoulder that could not rely on MRI as it had metal artefact from the previous surgeries, so ultrasound was the last go before extra surgery. I can’t quite remember what he had, but it was something along the lines of a supraspinatus repair previous, but biceps was gone as well. And they wanted to find out how much of subscap was left.

I’ve been hearing different things about the surgery, and I was a little confused as I saw sutures that were not wavy and buckling but the MRI,and the sono said there was a Full thickness tear. I should try and find the pictures but I was just wondering if you had a few tips on how to tackle these. Is it important to show all the sutures? Is there a number of sutures I should be looking at? Can it be torn if the sutures are still in place? Are there typical signs of a tear after surgery?

[Stephen Bird]

Hi Amanda,

this is a great question with a long answer.

I have a nice post op shoulder lecture and I will record it into a webinar for the website as this will answer your questions plus other things that are important.

To answer your questions before the webinar is loaded up:

The long head of biceps tendon is often absent in the area of the rotator cuff interval and may look thin in the bicipital groove. This is not pathological, but rather a normal post op appearance as the surgeon often performs a biceps tenodesis.

The AC joint may also be vert wide if they have had a mumford procedure.

The CA ligament is often busy, hypo echoic and not tight as it has been disconnected from the acromiale ens as part of an acromioplasty.

Sutures are variable depending on the number of bone anchors used. Look at the x-ray first as if the anchors are red-opaque you can see how many there are and the locations. If you can’t see them on the x-ray you can see them on the ultrasound as a divot in the location of the native supraspinatus enthesis on the greater tuberosity. Arising from these anchors you will see the suture material spreading out through the repaired supraspinatus tendon. If the repair is good the sutures will be within the tendon and if the repair has failed you often see sutures running along the bony enthesis and over the humeral head hyaline cartilage. So sutures running along bone is a bad sign. If you see this internally and externally rotate the shoulder while watching the suture(s) in short axis and you will see the sutures moving independent to the overlong soft tissue proving they are no longer in the tendon.

Anchors rarely fall out.

Most re-tears happen at the proximal junction between the sutures and the native tendon. This is called a proximal re-tear.
To see this area you may need to use a full Crass position.

Other things to consider are that adhesive capsulitis is common in the post op shoulder as is bursitis.

There will be more detail in the webinar,

I will get it recorded and loaded up for you.

Steve.

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