DOI:10.2214/AJR.08.1223
AJR 2009; 192:473-479
© American Roentgen Ray Society
Comparison of Indirect Isotropic MR Arthrography and Conventional MR Arthrography of Labral Lesions and Rotator Cuff Tears: A Prospective Study
Dae Kun Oh1,
Young Cheol Yoon1,
Jong Won Kwon1,
Sang-Hee Choi1,
Jee Young Jung1,
Sooho Bae1 and
Jaechul Yoo2
1 Department of Radiology, Samsung Medical Center, School of Medicine,
Sungkyunkwan University, 50 Ilwon-dong, Kangnam-ku, Seoul, 135-710, Republic
of Korea.
2 Department of Orthopedic Surgery, School of Medicine, Sungkyunkwan University,
Seoul, Republic of Korea.
Received May 12, 2008;
accepted after revision July 30, 2008.
Address correspondence to Y. C. Yoon
(ycyoon{at}skku.edu).
Abstract
OBJECTIVE. The purpose of our study was to prospectively compare the
diagnostic accuracy of 3D isotropic indirect MR arthrography with conventional
sequences of indirect MR arthrography for the diagnosis of labral and rotator
cuff lesions on a 3-T MR unit.
SUBJECTS AND METHODS. Thirty-six consecutive patients who were
scheduled for shoulder arthroscopic surgery at our institution underwent
indirect MR arthrography. Both conventional sequences and an additional 3D
isotropic sequence were obtained 1 day before arthroscopic surgery. Two
musculoskeletal radiologists prospectively evaluated the images in consensus
for the presence of superior and anterior labral lesions and subscapularis and
supraspinatus–infraspinatus tendon tears using the conventional
sequences and the 3D isotropic sequence. We analyzed the statistical
difference between the sensitivities and specificities of both methods using
arthroscopic findings as the reference standard.
RESULTS. Surgical findings confirmed the presence of 23 superior
labral lesions, eight anterior labral lesions, 21 subscapularis tears, and 24
supraspinatus–infraspinatus tears. The sensitivity and specificity of
the conventional sequences were 74% and 54% for superior labral lesions, 88%
and 96% for anterior labral lesions, 67% and 85% for subscapularis tendon
tears, and 96% and 75% for supraspinatus–infraspinatus tendon tears. The
sensitivity and specificity of the 3D isotropic sequence were 70% and 85% for
superior labral lesions, 100% and 100% for anterior labral lesions, 67% and
85% for subscapularis tendon tears, and 96% and 67% for
supraspinatus–infraspinatus tendon tears. No statistically significant
difference was seen in sensitivities and specificities for both methods.
CONCLUSION. Three-dimensional isotropic MR arthrography sequences
with multiplanar reconstruction can provide a similar capability for the
diagnosis of labral and rotator cuff lesions as conventional MR arthrography
sequences but in a shorter imaging time.
Keywords: arthrography • MR; MRI • 3D; MRI • high field strength; MRI • rapid imaging; shoulder
Introduction
In the diagnosis of disorders of the glenoid labrum and rotator cuffs,
indirect and direct MR arthrography has been reported to be superior to
conventional MRI, particularly for superior labral anterior to posterior
(SLAP) lesions and for partial-thickness rotator cuff tears
[1–5].
In addition, the recently introduced 3-T MRI systems have provided an
increased signal-to-noise ratio (SNR) for use when it is feasible to achieve
faster and high resolution. Faster imaging will lead to decreased motion
artifacts, increased convenience of the patient, and improved and more
accurate diagnosis because of increased resolution
[6]. Recently, isotropic
imaging that allowed saving imaging time by using a single acquisition and by
obtaining diverse images using reformation in arbitrary planes has been tested
as an alternative method [7].
In retrospective studies, Magee and Williams
[8,
9] reported that shoulder
imaging on a 3-T system showed high accuracy for the diagnosis of
supraspinatus tendon and labral lesions; and isotropic imaging using a fast
gradient on a 3-T system showed labral lesions and rotator cuff lesions as
well as conventional imaging in a short time
[10]. To our knowledge, no
prospective study has described the usefulness of isotropic imaging of the
shoulder. The purpose of this study was to compare prospectively the
diagnostic accuracy of 3D isotropic MR arthrography using a gradient-refocused
echo (GRE) technique with conventional MR arthrography for the diagnosis of
labral and rotator cuff lesions on a 3-T MR unit.
Subjects and Methods
Patients
The institutional review board approved the study, which was conducted in
compliance with HIPAA regulations. Patient informed consent was obtained.
Between March 2006 and June 2006, 36 consecutive patients who were
scheduled for shoulder arthroscopic surgery at our institution were enrolled
in this prospective study. Arthroscopic surgery was indicated on the basis of
clinical symptoms and signs and MRI findings. The study population consisted
of 16 men (age range, 20–71 years; mean age, 47.1 years) and 20 women
(age range, 27–77 years; mean age, 59.3 years). Six patients presented
with shoulder instability and the remaining 30 patients with shoulder pain and
motion limitation. Exclusion criteria were a history of shoulder surgery,
surgery for infection or tumor, and contraindications to MRI.
MRI Protocol
All MR examinations were performed 1 day before arthroscopic surgery.
According to our standard protocol, 0.1 mmol/kg of gadopentetate dimeglumine
(Magnevist, Bayer Schering Pharma) was injected IV, and patients were
instructed to exercise for 15 minutes. After active exercise, MRI was
performed with a 3-T whole-body MR scanner (Gyroscan Intera Achieva, Philips
Healthcare) with a dedicated receive-only shoulder coil. Patients were
positioned with the humerus in a neutral position and the thumb pointing
upward.
The following conventional MR arthrography sequences were obtained:
Fat-suppressed T1-weighted fast spin-echo sequences were obtained in the axial
plane (TR range/TE range, 434–565/18–24; section thickness, 3 mm;
field of view, 15 cm; matrix dimensions, 224 x 224); in the coronal
oblique plane parallel to the long axis of the supraspinatus tendon
(434–565/20–24; section thickness, 3 mm; field of view, 15 cm;
matrix, 224 x 224); and in the sagittal oblique plane perpendicular to
the long axis of the supraspinatus tendon (434–561/18–24; section
thickness, 4 mm; field of view, 15 cm; matrix dimensions, 256 x 256).
T2-weighted fast spin-echo sequences were obtained in the axial plane (TR
range/TE, 2,868–3,184/80; section thickness, 3 mm; field of view, 15 cm;
matrix dimensions, 224 x 224) and in the coronal oblique plane
(2,661–2,906/80; section thickness, 3 mm; field of view, 15 cm; matrix
dimensions, 224 x 224). The number of excitations for conventional MR
arthrography was 2. The echo-train length of the T2-weighted fast spin-echo
sequence was 16. The total scanning time for conventional MR arthrography was
16 minutes 40 seconds. Subsequently, a 3D fast GRE technique with fat
suppression (THRIVE: T1-weighted high-resolution isotropic volume examination)
was performed in the axial plane to obtain additional 3D isotropic MR images
using the following imaging parameters: TR/TE, 7.8/3.4; section thickness, 0.6
mm; field of view, 18 cm; matrix dimensions, 300 x 300; voxel size, 0.6
x 0.6 x 0.6 mm; sensitivity encoding (SENSE), 2; number of
excitations, 2; flip angle, 7°; number of slices, 120. The total scanning
time was 5 minutes 32 seconds.
Image Analysis
MR images were prospectively evaluated by two musculoskeletal radiologists,
one with 5 years of experience in musculoskeletal MRI and one with 2 years of
experience in musculoskeletal MRI, by consensus. We analyzed labral lesions,
subscapularis tendon tears, and supraspinatus–infraspinatus tendon
tears. The criteria for defining a labral lesion were as follows
[11,
12]: identification of
contrast material extending into a linear or complex tear cleft in the labrum;
the absence of the labrum; a marked deformity of the labrum; intralabral high
signal intensity reaching the articular surface of the labrum; truncation or
fragmentation of the labrum; and displacement of the labrum from its expected
anatomic location. These labral lesions were evaluated and were recorded as
present or absent according to location.
In addition, the following imaging features were used to differentiate
between a SLAP type II lesion and a sublabral recess. Lateral or superior
extension of contrast medium into the superior labrum and the biceps anchor
indicated a SLAP type II lesion, whereas medial extension of the contrast
medium with a smooth linear appearance between the superior labrum and the
glenoid rim was indicative of a sublabral recess
[13]. A Buford complex
consisting of an absent anterosuperior labrum and a thick cordlike middle
glenohumeral ligament [14]
that may be mistaken for a displaced labral fragment on arthrography was
excluded [15]. Subscapularis
tendon tears were defined as follows: discontinuity of the tendon, contrast
med ium entering the tendon, abnormal signal intensity, and caliber change.
Furthermore, ancillary signs of subscapularis tendon abnormality were
considered [16]. These signs
included the presence of fatty infiltration in the subscapularis muscle and
abnormalities in the course of the long biceps tendon. A
supraspinatus–infraspinatus tear was graded as either a full-thickness
tear or a partial-thickness tear. A partial-thickness tear was classified as
an articular surface or bursal surface tear. The imaging criterion of a
full-thickness tear was complete discontinuity in the tendon. The criteria for
partial-thickness articular surface tears included focal discontinuity of the
under surface of the supraspinatus–infraspinatus tendon. The criteria of
partial-thickness bursal surface tears were abnormal signal intensity of the
bursal surface of the tendon or focal disruption of the bursal surface of the
tendon [17].
Two observers evaluated labral lesions, subscapularis tendon tears, and
supraspinatus–infraspinatus tendon tears with conventional MR
arthrography sequences (method A). The evaluation was repeated after 2 weeks
with the 3D isotropic MR arthrography sequence (method B). Images were
presented in random order at each reading session and were evaluated using a
PACS (Centricity Radiology RA 1000, GE Healthcare). The reformation in method
B was performed simultaneously during image analysis using commercially
available software (Advantage Windows suite 1.0, GE Healthcare) according to
oblique coronal and oblique sagittal plane images and additional images in
arbitrary planes if needed.
Arthroscopic Surgery
An arthroscopic finding was considered the reference standard. One
orthopedic surgeon with 6 years of experience in shoulder surgery who was not
blinded to the indirect MR arthrographic images performed the arthroscopic
surgery. The surgeon recorded the presence or absence of a superior labral
lesion, including significant degeneration and fraying requiring treatment.
Anterior labral lesions, subscapularis tendon tears, and
supraspinatus–infraspinatus tendon tears were recorded in the same
manner.
Statistical Analysis
The sensitivity, specificity, and accuracy of both method A and method B
were calculated. For calculation of the sensitivity, specificity, and accuracy
of supraspinatus–infraspinatus tendon tears, grades of the tear (a full-
or partial-thickness tear) were not considered. Sensitivity for each type of
supraspinatus–infraspinatus tendon tear as determined by both methods
was also calculated. We analyzed the statistical difference of the
sensitivities, specificities, and accuracies in diagnosing labral lesions,
subscapularis tendon tears, and supraspinatus–infraspinatus tendon
tears, as well as the sensitivities for each type of supra
spinatus–infraspinatus tendon tear for methods A and B using the McNemar
test. A p value of less than 0.05 was considered a statistically
significant difference.
To calculate the adequate sample size, we hypothesized that sensitivity and
specificity for the diagnosis of labral and rotator cuff lesions using method
B would be equal to those of method A on a 3-T MR unit. If a difference in
sensitivity and specificity of method A versus method B was less than 20%, it
was regarded as not meaningful. We assumed that the sensitivity of method A
for the diagnosis of rotator cuff tear was 80%. An 
error level or
confidence level of 5% and a β error level or statistical power (1
– β) of 80% were used. The calculated sample size was 36 (SPSS,
version 12).
Results
Patient data and results are summarized in
Table 1. After arthroscopic
surgery, 23 patients were identified as having superior labral lesions, eight
as having anterior labral lesions, 21 as having subscapularis tendon tears,
and 24 as having supraspinatus–infraspinatus tendon tears. Among
supraspinatus–infraspinatus tendon tears, there were 14 full-thickness
tears in 14 patients, six articular surface partial-thickness tears in six
patients, and six bursa surface partial-thickness tears in six patients. Two
patients had both articular and bursal surface partial-thickness tears
simultaneously.
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TABLE 1: Findings with Conventional MR Arthrography (Method A), 3D Isotropic MR
Arthrography (Method B), and Arthroscopic Surgery
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Seventeen of 23 patients with superior labral lesions were correctly
diagnosed using method A and 16 patients using method B (Fig.
1A,
1B). Superior labral lesions in
two patients were missed using method A only, and lesions in another three
patients were missed using method B only. Superior labral lesions in four
patients were missed using both methods A and B, and a patient with no
superior labral lesion detected at arthroscopy was misdiagnosed as having a
superior labral lesion using both methods. Seven of eight patients with
anterior labral lesions were correctly diagnosed using method A, and all eight
patients were correctly diagnosed using method B (Fig.
2A,
2B). One false-positive
diagnosis each and one false-negative diagnosis each were generated using only
method A. Fourteen of 21 patients with subscapularis tendon tears were
correctly diagnosed using methods A and B. Four false-negative diagnoses were
generated using both methods (Fig.
3A,
3B). Each method showed three
false-positive diagnoses. Twenty-three of 24 patients with a
supraspinatus–infraspinatus tendon tear were correctly diagnosed using
methods A and B (Fig. 4A,
4B,
4C,
4D). One false-negative
diagnosis was generated by both methods. Method A showed three
false-positives, and method B, four false-positives. Among these
false-positive diagnoses, two were misdiagnosed by both methods (Fig.
5A,
5B). Diagnostic values of both
methods for evaluating the labral abnormalities and rotator cuff tears are
summarized in Table 2. No
statistically significant difference was seen between the diagnostic efficacy
of method A and method B for a labral lesion and rotator cuff tear.
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Fig. 1A —Arthroscopically proven superior labral lesion in 53-year-old
woman. Fat-suppressed T1-weighted oblique coronal image shows increased signal
intensity between superior labrum and glenoid rim (arrow), which was
interpreted as superior labral lesion.
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Fig. 1B —Arthroscopically proven superior labral lesion in 53-year-old
woman. Three-dimensional isotropic MR arthrography sequence with oblique
coronal reformatted image shows similar findings (arrow). Lesion was
interpreted as superior labral lesion.
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Fig. 2A —Arthroscopically proven anterior labral lesion in 22-year-old
man with recurrent shoulder dislocation. Fat-suppressed T1-weighted axial
image shows contrast material extending into bony labrum (arrow),
which was interpreted as anterior labral lesion.
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Fig. 2B —Arthroscopically proven anterior labral lesion in 22-year-old
man with recurrent shoulder dislocation. Axial 3D isotropic MR arthrography
image again shows lesion (arrow), which was interpreted as anterior
labral lesion.
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Fig. 3A —Arthroscopically proven subscapularis tendon tear in
57-year-old man. Fat-suppressed T1-weighted (A) and 3D isotropic MR
arthrography (B) axial images show subtle high signal intensity at
articular side of cranial portion of subscapularis tendon (arrows),
which was interpreted as normal subscapularis tendon.
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Fig. 3B —Arthroscopically proven subscapularis tendon tear in
57-year-old man. Fat-suppressed T1-weighted (A) and 3D isotropic MR
arthrography (B) axial images show subtle high signal intensity at
articular side of cranial portion of subscapularis tendon (arrows),
which was interpreted as normal subscapularis tendon.
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Fig. 4A —Arthroscopically proven partial-thickness articular surface
tear of supraspinatus tendon in 54-year-old man. Fat-suppressed T1-weighted
oblique coronal (A) and oblique sagittal (B) images show focal
accumulation of contrast material and indistinct margin at articular surface
of supraspinatus tendon (arrows), which was interpreted as
partial-thickness articular surface tear of supraspinatus–infraspinatus
tendon.
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Fig. 4B —Arthroscopically proven partial-thickness articular surface
tear of supraspinatus tendon in 54-year-old man. Fat-suppressed T1-weighted
oblique coronal (A) and oblique sagittal (B) images show focal
accumulation of contrast material and indistinct margin at articular surface
of supraspinatus tendon (arrows), which was interpreted as
partial-thickness articular surface tear of supraspinatus–infraspinatus
tendon.
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Fig. 4C —Arthroscopically proven partial-thickness articular surface
tear of supraspinatus tendon in 54-year-old man. Three-dimensional isotropic
MR arthrography oblique coronal (C) and sagittal (D) reformatted
images again show identical findings (arrows). Lesion was interpreted
as partial-thickness articular surface tear of
supraspinatus–infraspinatus tendon.
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Fig. 4D —Arthroscopically proven partial-thickness articular surface
tear of supraspinatus tendon in 54-year-old man. Three-dimensional isotropic
MR arthrography oblique coronal (C) and sagittal (D) reformatted
images again show identical findings (arrows). Lesion was interpreted
as partial-thickness articular surface tear of
supraspinatus–infraspinatus tendon.
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Fig. 5A —Arthroscopically proven calcific tendinosis with no tear of
supraspinatus tendon in 57-year-old woman. Fat-suppressed T1-weighted oblique
coronal (A) and 3D isotropic MR arthrography oblique coronal
reformatted (B) images show accumulation of contrast material at
articular side of supraspinatus tendon (arrows), which was
interpreted as articular side partial-thickness
supraspinatus–infraspinatus tendon tear.
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Fig. 5B —Arthroscopically proven calcific tendinosis with no tear of
supraspinatus tendon in 57-year-old woman. Fat-suppressed T1-weighted oblique
coronal (A) and 3D isotropic MR arthrography oblique coronal
reformatted (B) images show accumulation of contrast material at
articular side of supraspinatus tendon (arrows), which was
interpreted as articular side partial-thickness
supraspinatus–infraspinatus tendon tear.
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TABLE 2: Diagnostic Values of Conventional MR Arthrography (Method A) and 3D
Isotropic MR Arthrography (Method B) for Labral Abnormalities and Rotator Cuff
Tears
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For lesion-to-lesion evaluation of supraspinatus–infraspinatus tendon
tears, the detection rate of both methods for a full-thickness tear was 100%
(14/14). A full-thickness tear, however, was reported as a partial-thickness
tear by both methods. For partial-thickness articular surface tears, the
detection rates were 83% (5/6) for method A and 50% (3/6) for method B (Fig.
4A,
4B,
4C,
4D). Two partial-thickness
articular surface tears that coexisted with a bursal surface tear were missed
by method B. In addition, one of the tears was thought to be a full-thickness
tear using method A. For partial-thickness bursal surface tears, the detection
rate was 83% (5/6) for method A and 100% (6/6) for method B. A
partial-thickness bursal surface tear that coexisted with an articular surface
tear was missed, and another tear was regarded as a full-thickness tear by
method A. Overall detection rates for supraspinatus–infraspinatus tears
on a lesion-to-lesion basis were 92% with both methods. With method B, another
partial-thickness bursal surface tear was considered a full-thickness tear.
The overall detection rates for supraspinatus–infraspinatus tendon tears
were 92% (24/26) for method A and 88% (23/26) for method B. This difference
was not statistically significant.
Discussion
Three-dimensional Fourier transformation imaging techniques using GRE
sequences have been applied to various structures, including cartilage of the
knee and the ligaments of the wrist and ankle. The use of these techniques has
several advantages, such as high spatial resolution and the opportunity of
postprocessing
[18–20].
In addition, a recent study showed that a combination of higher field strength
and a parallel imaging technique led to improved diagnostic ability and a
reduction of scanning time in imaging of the ankle
[21]. THRIVE, which was used
in this study, is a T1-weighted turbo field echo 3D scan with spectral
attenuated inversion recovery (SPAIR) fat suppression using sensitivity
encoding (SENSE). The ability of THRIVE for isotropic voxel imaging permits
multiplanar reconstruction (MPR) without loss of image conspicuity. Its T1
nature and its faster image acquisition because of its short TE (3–5
milliseconds) and TR (7–10 milliseconds) (1–2.5 seconds per slice)
are other features that made THRIVE suitable for MR arthrography in this
study.
In this study, although no statistically significant difference was seen,
the sensitivity and specificity of the 3D isotropic MR sequence for the
diagnosis of anterior labral lesions and the specificity for the superior
labrum were slightly higher than the sensitivity and specificity of
conventional MR arthrography sequences. The sensitivity for a superior labral
lesion on a 3D isotropic MR sequence was slightly less than that reported in a
previous study (74–96%)
[22]. The small number of
enrolled patients and the delay in obtaining the 3D isotropic MR sequence
after performing conventional MR arthrography may be an explanation for the
difference. Sensitivities, specificities, and accuracies for diagnosing
anterior labral tears, subscapularis tendon tears, and
supraspinatus–infraspinatus tendon tears were comparable to those of
previous investigations [5,
23] and showed no
statistically significant difference between the two methods. For a
lesion-to-lesion diagnosis of a supraspinatus–infraspinatus tendon tear,
the sensitivity of 3D isotropic MR arthrography for a partial-thickness
articular surface tear was 50% (3/6), which was relatively lower than the
sensitivity reported in previous studies with 3-T imaging
[9] or imaging with abduction
and an external rotation position
[24]. The small number of
tears may be responsible for this difference. The sensitivities and
specificities for a full-thickness tear and a partial-thickness bursal surface
tear were comparable to the sensitivities and specificities reported in
previous studies and showed no statistically significant differences between
the two methods.
Although the imaging time for the 3D isotropic MR arthrography sequence was
much shorter than that of conventional MR arthrography sequences, MPR required
additional time. In this study, we were able to minimize the time for MPR by
using a PACS-embedded program that supplied the capability of simultaneous
MPR. If MPR was to be performed at another console by a technician or another
radiologist, the advantages of the 3D isotropic MR arthrography sequence,
including timesaving and the ability to reconstruct in an arbitrary plane,
would be decreased.
This study has several limitations. First, patient selection bias may have
been introduced and resulted in the overestimation of diagnostic performance
because we enrolled in our study only patients who underwent arthroscopic
shoulder surgery. Second, although arthroscopy was regarded as the reference
standard for this study, it is an operator-dependent method. Thus,
misinterpretation during arthroscopy was a probable source of error. Third, 3D
isotropic MR images were obtained, followed by 2D conventional MR arthrography
30 minutes after IV contrast injection. This procedure might cause an
underestimation of the diagnostic value of 3D isotropic MR arthrography in the
diagnosis of a shoulder lesion. Fourth, we evaluated images by a consensus
instead of independent reviewer observation. Thus, we were not able to obtain
interobserver agreement. Finally, we did not compare the image quality of an
axial source image of 3D isotropic MR arthrography and the reformatted image.
In theory, however, the quality of reformatted images is comparable to that of
axial source images on a 3D isotropic MR arthrography sequence because 3D
isotropic MR arthrography consists of isotropic voxels.
In conclusion, 3D isotropic MR arthrography with MPR is a method for the
diagnosis of labral and rotator cuff lesions that is comparable to
conventional MR arthrography but has a shorter imaging time.
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Abstract
Introduction
