21/03/2021 at 9:59 pm #12202DianeParticipant
I was wondering if you could help me make sense of this eldery male with a shoulder replacement. Just general pain.
1) He had a medially sublaxed biceps tendon. When I tried to do a butterfly image of the biceps muscles the long head biceps muscle was smaller than the short head muscle but it didn’t have the echogenic appearance? Does a muscle have to have an echogenic appearance to be considered atrophic or is just a smaller muscle volume enough?
2) The supraspinatus was where I got confused. I was totally expecting a full thickness complete tear (because he was ancient) but I think I saw some mid and posterior fibres at least and there wasn’t any overt enthesopathy? I was thinking that there could be a full thickness anterior tear but I really dont know if I was MSU. I think my orientation got thrown off of his presentation.
In the pictures where I’ve labelled Supra Long Mid-Posterior, do these look like intact fibres to you or are they supposed to be on the horizontal part of the bone there? (Image and cineloop attached)
3) Are they any characteristic features on a shoulder ultrasound for a shoulder replacement that we should be looking out for?
4) The AC joint had these echogenic structures within the joint capsule. I thought they were loose calcified bodies. Would this be the correct way of thinking or would these be hydroxyapatite? Pt was tender.
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24/03/2021 at 2:40 pm #12296Stephen BirdKeymaster
Personally I hate scanning reverse shoulder replacements!
I am not sure what we offer in the chronic pain setting,
By definition the cuff is usually severely damaged by the advanced OA disease that has led to the replacement in the first place.
In your case I must say that the cuff and associated muscles are in the best condition I have ever see.
Did this patient have the usual OA driven replacement or was this one of the rarer options like an avascular necrosis or trauma that led to the replacement.
If it is OA as the cause I am impressed by the quality of the cut and musculature.
Certainly if the LHBT is sublimed medially it does not necessarily cause muscle belly atrophy so the inbalance in size I would put down to muscle use patterns rather than atrophy. Atophy from a tendon rupture should always produce some increased echogenicity in the medium to long term.
I think the supraspinatus looks good for a post replacement cuff.
The AC joint is unlikely to be hydroxyapatite and more likely to be heterotypic calcification. If it is tender there may be some synovitis.
Your question about what we should be looking for in these patients is a question I wish I had an answer for. They are always tricky with the cuff being often extensively damaged from the OA. I just treat it like any post op shoulder and go through the cuff describing each component. The description is often “absent” !
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