Clinical Value of Multimodal imaging methods in the preoperative diagnosis of rotator cuff tears under arthroscopy

doi:10.21203/rs.3.rs-3344352/v1

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Clinical Value of Multimodal imaging methods in the preoperative diagnosis of rotator cuff tears under arthroscopy

https://doi.org/10.21203/rs.3.rs-3344352/v1

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Background:The current study aimed to evaluate the clinical value of conventional ultrasound(C-US),percutaneous ultrasound-guided subacromial bursography (PUSB), magnetic resonance imaging (MRI) and their combined imaging application in the preoperative arthroscopic diagnosis of rotator cuff tears(RCTs).

Methods:A total of 120 patients with suspected RCTs were included in this study. The cohort consisted of 38 males and 82 females participants, ranging in age from 14 to 77 years,with an average age of 56.9 ± 11.1 years.Prior to surgery, all patients underwent C-US, P-CEUS, and MRI. Subsequently, the imaging data were subjected to retrospective analysis. With shoulder arthroscopy as the "gold standard", the diagnostic efficacy of multimodal imaging methods for RCTs was assessed.

Results:The sensitivity, specificity and accuracy of C-US in the diagnosis of RCTs were 52%, 64% and 55%, For PUSB, specificity, specificity and accuracy in the diagnosis of RCTs were 90%, 80% and 88%, MRI, on the other hand, demonstrated a sensitivity of 91%, specificity of 84%, and accuracy of 90% in diagnosing RCTs. Notably, when the three imaging modalities were combined, the diagnostic performance significantly improved. The combined approach yielded a sensitivity of 99%, specificity of 92%, and accuracy of 97% in diagnosing RCTs, surpassing the performance of any single imaging method. These results highlight the enhanced diagnostic capability achieved through the utilization of multiple imaging modalities.

Conclusion:Multimodal imaging is of high diagnostic value in RCTs, and can accurately determine the location and degree of RCTs, which can be an important reference for improving arthroscopic surgery.

conventional ultrasound

percutaneous ultrasound-guided subacromial bursography

Magnetic resonance imaging

multimodal imaging methods

ratator cuff tears

arthroscopy

As the most flexible joint of human body, shoulder joint is a typical multi-axis ball-and-socket joint. The configuration and structure of the bones and tendons connected to the shoulder joint contribute to its expansive range of motion, albeit at the expense of its stability. Therefore, the muscles and ligaments around the shoulder joint play a very important role in its stability. Rotator cuff is composed of subscapular tendon, supraspinatus tendon, infraspinatus tendon and teres minor tendon, which is an important structure to maintain the stability of shoulder joint. Both degeneration and trauma can cause RCTs, especially the supraspinatus tendon[1–5]. The main clinical manifestations of RCTs are shoulder pain, limited movement and dysfunction, and severely affects the life quality of patients. The ongoing advancements in arthroscopic technology have led to remarkable breakthroughs in RCT treatment. Therefore, higher requirements have been put forward for the preoperative determination of injury site and injury degree, and the development of complete and systematic diagnostic data is conducive to the prognosis and rehabilitation of patients.

Imaging examination is an important method to diagnose RCTs, which not only plays an important role in judging the degree and type of injury, but also plays a significant role in the diagnosis, treatment and prognosis evaluation of injury[6, 7].

Various imaging modalities are routinely used in the diagnosis of RCT, including C-US,PUSB and MRI, which are often helpful in demonstrating supportive findings for RCTs, discovering alternative causes of shoulder pain, and disease staging. Both US and MRI have high soft tissue resolution, and both are sensitive and specific in the evaluation of rotator cuff pathology. MRI excels in areas like bone marrow and cartilage, but is limited by longer acquisition times and non-MR-compatible implants. In contrast, ultrasound is time-efficient, readily available, low-cost, and able to provide dynamic imaging, all of which make it suitable for image-guided therapeutic intervention.Contrast-enhanced ultrasound (CEUS) has been widely used to characterize the vascularity of lesions in organs of interest. the perfusion characteristics seen with CEUS reflect tumour blood supply, which is helpful in differentiating benign from malignant lesions. Hence, published guidelines have included the use of transabdominal CEUS for workup of liver, pancreatic, and kidney lesions and so on. In these procedures, contrast agents are often injected intravenously. More recently, many authors have investigated the intracavitary use of ultrasound contrast agents—for example, in the evaluation of obstructive bile duct diseases, tubal patency, and vesicoureteral reflux—with promising results[8, 9].In this study, we injected the contrast agent mixture into the subacromial bursa of patients with RCTs under sonographic guidance in order to observe the distribution of the mixture. To our knowledge, this is the first study to investigate the value of PUSB for assessing RCTs in patients by injecting into subacromial bursa.

The multimodal imaging approach combines C-US, PUSB, and MRI for comprehensive analysis.This approach enhances imaging clarity, enabling precise assessment of supraspinatus tendon degeneration degree and color Doppler flow imaging. These findings provide valuable information for early follow-up, monitoring, guidance, and rehabilitation training after arthroscopic surgery.

1.Patients and methods

1.1 Patients 120 patients with suspected RCTs were recruited.The patients were refered for C-US,PUSB and MRI of the shoulder between March 2021 and December 2022.The study is prospective with a surgical correlation. The inclusion criteria were as follows: (1) shoulder pain, weakness, limited function; (2) tenderness in the acromial segment, abnormal physical signs, or mobility impairment observed during physical examination; (3) failure of conservative treatment and agreement to undergo shoulder arthroscopic surgery, as well as willingness to cooperate with the interviewers. The exclusion criteria were as follows: (1) failure to complete all inspections; (2) the affected side had a history of shoulder surgery; (3) severe systemic diseases affecting the heart, brain, kidneys, or other organs; (4) coagulation dysfunction; (5) inability to cooperate with the interviewers during the rehabilitation process. This study was approved by the Ethics Committee of Jiangsu University Affiliated Hospital and all patients provided written informed consent.

1.2 Methods

1.2.1 C-US examination: US examinations were performed with a Esaote Mylab ultrasound system specifically a linear array probe with a frequency of 6–15 MHz. Musculoskeletal settings were selected for the examination, following the methodology described by TEEFEY et al.[10] .The patient was positioned in the upright position facing the examiner, Sequential scanning of the supraspinatus tendon, subscapular tendon, infraspinatus tendon, and teres minor tendon was conducted in both longitudinal and transverse sections.

1.2.2 PUSB examination: Immediately after US,CEUS was performed using the preset “contrast general” mode.First, the operator scanned the affected shoulder to locate the thickest area of the subacromial-subdeltoid (SASD) bursa in order to determine the best injection point and approach. Contrast pulse sequencing (CPS) was then initiated, and after sterilization of the skin on the lateral side of the affected arm, the contrast mixture was slowly injected into the subacromial bursa under US guidance. CEUS imaging was observed simultaneously. The contrast mixture comprised 0.5 ml of SonoVue (sulfur hexafluoride-based microbubbles at 8 µl (45 µg)/ml and 2.5 µm in diameter), 0.5 ml (20 mg/ml) lidocaine hydrochloride, 1.0 ml (5 + 2 mg/ml) compound betamethasone and 0.5 ml (9 mg/ml) sodium chloride. After the injection, the patient was asked to gently exercise the shoulder in order to distribute the mixture through the bursa, and the probe was moved in order to visualize the distribution of contrast mixture. The MI (mechanical index) value displayed on the screen was less than 0.2. Real-time contrast imaging was captured continuously for 5 minutes and stored on the hard drive of the system for documentation and analysis. All patients were reviewed 30 minutes after CEUS procedure.

1.2.3 MRI examination: The patients had MRI with a General Electric Signa HDxt. All scanners used were high field strength (1.5 T). The patient was supine with the upper limbs on both sides of the body, scanned in the hand standing position (thumb up or slightly external rotation), and the shoulder joint was wrapped with a wrapping surface coil.All magnetic resonance imaging was performed with a 16-cm field of view. Oblique sagittal and oblique coronal, fat-suppressed, fast-spin-echo images were acquired for all shoulders. Additional proton-density-weighted, spin-echo, or fast-spin-echo and transverse, T2-weighted, fast-spin-echo images with or without fat suppression were also acquired. Slice thickness was 3 to 4 mm, the imaging matrix was 256 × 192 or higher, and two or three signals were averaged for each pulse sequence.

1.3 Criteria for Diagnosis and Image Analysis

1.3.1 C-US criteria for diagnosing RCTs: During US examination, several parameters were assessed. These included evaluating The integrity of the rotator cuff tendons, the smoothness of the tubercular cortex of the humerus at the tendon attachment end, the wall thickness of the subacromial deltoid slide capsule, the presence of fluid in the bursae and synovial hyperplasia. Additionally, the presence or absence of effusion in the glenohumeral joint cavity and the tendon sheath of the long head of the biceps brachii was determined.

The criteria for diagnosing RCTs using US are as follows: Full-thickness tear: (1) invisible tendon, (2) local loss, discontinuity (3) absence of normal structure of supraspinatus tendon, resulting in increased gap between supraspinatus tendon and long head of biceps tendon (4) Hypoechoic or anechoic appearance indicating a complete tear throughout the entire tendon (5) Presence of fluid in the acromio-deltoid slide bursae.

Partial-thickness tears: (1) locally hypoechoic or anechoic on the bursae or articular surface of the tendon, (2) partial thinning of the tendon, (3) intratendon tears with uneven internal echoes that do not extend to the surface.

1.3.2 PUSB criteria for diagnosing RCTs: The distribution of contrast agent in tendon (focusing on observation of supraspinatus tendon) or joint cavity.

The P-CEUS criteria for diagnosing RCTs are as follows: 1. Partial-thickness tear: The subacromial sac is irregular in shape and extends deep;2. Full-layer tear: Contrast agent extends from the bursae surface to the articular surface.

1.3.3 MRI criteria for diagnosing RCTs: During the MRI observation, various structures and tissues in the shoulder joint were examined, including the supraspinatus tendon, infraspinatus tendon, subscapular tendon, glenohumeral ligament, coracohumeral ligament and so on.

The MRI diagnostic criteria for RCT are as follows: 1. Rotator cuff integrity: Tendon shape is normal in all sequential images, with good continuity and uniformly signal; 2.Partial-thickness tear:The shape of supraspinatus tendon was irregular, and high focal signal was seen in MRI T2 image, which did not involve the whole layer. Full-thickness tear : The supraspinatus tendon is thickened and twisted, showing high signals involving the whole layer.

All the aforementioned images were evaluated independently by two associate chief physicians, each possessing over 5 years of experience in musculoskeletal ultrasound diagnosis, using a double-blind method. If there were some disagreements, consensus was reached through mutual discussion. the results of arthroscopy were used as the gold standard, when even one of the three combined imaging modalities diagnosed an RCTs, RCTs are diagnosed.

1.4 Imaging image analysis

2. Statistical analysis

The IBM SPSS statistical software (version 21.0, IBM Corp., Armonk: NY) was used for data analysis. T-tests were used to evaluate continuous variables such as age. The chi-square test or Fisher’s exact probability method was used for measurable variables. The kappa value was used to evaluate consistency between the different imaging methods and type of RCTs. The results of arthroscopy were used as the gold standard to assess RCTs type, and the sensitivity, specificity, accuracy, false negative rate, and false positive rate for C-US, P-CEUS, MRI and the combined method for the diagnosis RCTs. P < 0.05 was considered statistically significant.

1.1 Comparison of RCTs Based on Clinical Characteristics

A total of 120 patients were included in the study, of which 95 were confirmed to have RCTs and 25 were determined to have no tears through arthroscopic examination. The average age of the patients was 56.9 ± 11.1 years, ranging from 14 to 77 years. Among the participants, 38 were males and 82 were females. Out of the 120 patients, 61 had injuries on the left shoulder and 59 had injuries on the right shoulder(Table 1).

Regarding the diagnostic methods, C-US detected 59 cases of RCTs, PUSB detected 91 cases, and MRI detected 91 cases,multimodal imaging detected 96 cases. Notably, arthroscopy confirmed the presence of RCTs in 95 cases, which was significantly higher than the number detected by C-US, PUSB, and MRI (see Table 1).

1.2 Comparison of the value of C-US,PUSB and MRI and multimodal imaging methods in detecting RCT

C-US was used to diagnose RCTs in 59 cases, with 50 cases confirmed as true positive and 16 cases as true negative when compared to arthroscopy results. The sensitivity of conventional ultrasound was 52%, specificity was 64%, and accuracy was 55%.

PUSB diagnosed 91 cases of RCTs and 29 cases without tears. When compared to arthroscopy results, there were 86 true positive cases and 20 true negative cases. The sensitivity of P-CEUS ultrasound was 90%, specificity was 80%, and accuracy was 88%.

MRI diagnosed 91 cases of RCTs and 29 cases without tears. There were 87 true positive cases and 21 true negative cases when compared to arthroscopy results. The sensitivity of MRI was 91%, specificity was 84%, and accuracy was 90%.

Multimodal imaging methods diagnosed 96 cases of RCTs and 24 cases without tears. When compared to arthroscopy results, there were 94 true positive cases and 23 true negative cases. The sensitivity of multimodal imaging was 99%, specificity was 92%, and accuracy was 97%.

The sensitivity, specificity, and accuracy of multimodal imaging in diagnosing RCTs were higher than one of the individual imaging methods, and the differences were statistically significant (P < 0.05). there were significant differences between C-US and PUSB,C-US and MRI. However, there were no significant differences in the diagnostic value among P-CEUS, and MRI (P > 0.05), as shown in Table 2.

1.3 Comparison of different types of RCTs detected by C-US, P-CEUS, MRI and multimodal imaging

In all 120 cases,25 cases were confirmed no tears by arthroscopy, 73 cases confirmed partical RCTs by arthroscopy,22 cases confirmed full RCTs by arthroscopy.C-US diagnosed 16 cases Non-RCTs,45 cases with partial RCTs, 5 cases with full RCTs; By PUSB,There were 20 cases Non-RCTs ,65 cases with partial RCTs,21 cases with full RCTs; MRI diagnosed 21 cases non-RCTs, 72 cases partial RCTs, 15 cases full RCTs;by multimodal imaging,There were 23 cases Non-RCTs 73 cases with partial RCTs,21 cases with full RCTs diagnosed. The sensitivity, specificity and accuracy of multimodal imaging in the diagnosis of RCTs were higher than that of single imaging method, and the differences were statistically significant (P < 0.05)(Table 3).

Table 1

Comparison of clinical data of patients with rotator cuff tear(RCT)
parameters	arthroscopic diagnosis		t/X²	P value
parameters	rotator cuff tears(n = 95)	Intact supraspinatus tendon(n = 25)	t/X²	P value
sex			0.196	0.658
male	31	7
female	64	18
age	58.24 ± 10.62	51.72 ± 11.73	0.052	0.009
location			0.590	0.442
left	50	11
right	45	14
C-US			2.190	0.139
rotator cuff tears	50	9
Intact supraspinatus tendon	45	16
P-CEUS			53.717	0.000
rotator cuff tears	86	5
Intact supraspinatus tendon	9	20
MRI			61.689	0.000
rotator cuff tears	87	4
Intact supraspinatus tendon	8	21
Multimodal imaging modalities			102.316	0.000
rotator cuff tears	94	2
Intact supraspinatus tendon	1	23

Table 2

Comparison of the value of C-US, P-CEUS, MRI and multimodal imaging in the diagnosis of RCT
Parameter	Imaging Modality
Parameter	C-US	P-CEUS	MRI	Multimodal imaging methods
Sensitivity(%)	52.6	90.5	91.6	98.9
Specificity(%)	64.0	80.0	84.0	92.0
Positive predictive value(%)	84.7	94.5	95.6	98.9
Negative predictive value(%)	26.2	69.0	72.4	95.8
False positive(%)	36.0	20.0	16.0	8.0
False negative(%)	47.3	9.4	8.4	1.0
Diagnostic accuracy(%)	55.0	88.3	90.0	97.5

Table 3

Comparison of the value of C-US, P-CEUS, MRI and multimodal imaging in the diagnosis of RCT types
arthroscopic diagnosis	Imaging Modality	Sensitivity (%)	Specificity (%)	Diagnostic accuracy(%)
full rotator cuff tears	C-US	22.7	62.2	55.0
	P-CEUS	95.5	86.7	88.3
	MRI	68.2	94.9	90.0
	Multimodal imaging methods	95.5	98.0	97.5
Partial rotator cuff tear	C-US	61.6	44.7	55
	P-CEUS	89.0	87.2	88.3
	MRI	98.6	76.6	90.0
	Multimodal imaging methods	100	93.6	97.5
Intact supraspinatus tendon	C-US	64.0	52.6	55.0
	P-CEUS	80.0	90.5	88.3
	MRI	84.0	91.6	90.0
	Multimodal imaging methods	92.0	98.9	97.5

The shoulder joint is known as a typical "ball-socket" structure, with the glenohumeral joint consisting of the "ball" formed by the head of the humerus and the "socket" formed by the glenoid of the scapula. However, the extensive range of motion in the shoulder joint is not solely achieved by this structure but also relies on the coordinated movement of other joints, including the scapulothoracic joint, sternoclavicular joint, and acromioclavicular joint. Furthermore, the stability of the "ball-and-socket" structure is also dependent on the actions of surrounding muscles, tendons, ligaments, and other tissues. The rotator cuff plays a crucial role in shoulder joint stability. It consists of a cuff-like structure formed by muscles that extend from different directions to attach to the articular surfaces and tubercles of the upper, middle and lower parts of the greater tubercle of the humerus. Specifically, the supraspinatus muscle originates from above, while the teres minor and infraspinatus muscles originate from behind, and the subscapularis muscle originates from the front. The unique biomechanical structure of the shoulder joint allows these components to work together, achieving a state of balance that ensures the stability of the shoulder joint [11].

The supraspinatus tendon is the most commonly torn tendon in RCTs, and its injury can significantly affect shoulder joint abduction and forward flexion. The "vascularized danger zone," located 1cm above the greater tubercle of the humerus, has been identified as the most susceptible site for supraspinatus tendon tears [12–14].

Studies conducted by Jerosch et al[15]. involving the dissection of 122 cadaveric shoulder joints found that complete RCTs were more prevalent than partial RCTs, with the supraspinatus tendon being affected in 100% of cases.

The prevalence of RCTs increases with age. Approximately 40% of individuals over 50 years of age with shoulder pain have RCTs, and this percentage rises to over 60% in individuals over 60 years old. Among those over 70 years old, the prevalence reaches 90–100%. These findings highlight the correlation between RCTs and aging.

Arthroscopy is considered the gold standard for diagnosing RCTs; however, it is an invasive procedure associated with risks such as infection, brachial plexus injury, anesthesia accidents, and complications. As a result, arthroscopy is primarily used for surgical treatment rather than routine diagnostic purposes [16].

The diagnosis of RCTs typically involves a combination of physical examination and imaging techniques. Various imaging methods, including X-ray, CT, arthrography, ultrasound, and MRI, have their own advantages. X-ray and CT excel in detecting fractures and bone hyperplasia but fall short in visualizing soft tissues and revealing partial tears. Arthrography, while able to guide the diagnosis of RCTs, is an invasive procedure associated with radiation exposure. Musculoskeletal ultrasound, on the other hand, has gained popularity in recent years due to its non-invasiveness, real-time imaging capabilities, bilateral comparison, dynamic examination, and low cost. It is considered a valuable tool for screening RCTs and postoperative follow-up, and it has been widely implemented in the diagnosis of shoulder joint diseases in major hospitals[16] .

The sensitivity, specificity and accuracy of conventional musculoskeletal ultrasound in diagnosing full RCTs have been reported to be around 22.73%, 62.24%, and 55.00%, respectively, while for partial RCTs, these values were approximately 61.64%, 95.00%, and 89.29% [17]. However, C-US may have limitations in detecting certain types of RCTs, such as small tears on the bursal surface or synovial surface, tears with embedded synovial hyperplasia, or tears accompanied by hematoma or proliferative synovium and adipose tissue. Factors that can affect the accuracy of musculoskeletal ultrasound include the sensitivity and resolution of the ultrasound equipment, the presence of calcification in older patients, limitations in patient movement during the examination, and the need for complementary signs and multi-axis motion assessment[10, 17, 18].

In the study mentioned, conventional musculoskeletal ultrasound diagnosed a significant number of cases with RCTs. However, there were instances where the examination results were false negative. Among the 16 suspected patients with supraspinatus tendon tears, arthroscopy confirmed 10 cases, indicating a false negative diagnosis. Among them, 5 cases had small tears on the bursal surface, superficial tears on the synovial surface, and synovial hyperplasia embedded in the tear, which was not easy to be detected by conventional ultrasound. There were 5 cases with uneven local thickness of supraspinatus tendon, which may be misdiagnosed due to hematoma machinization at supraspinatus tendon tear and the filling of proliferative synovium and adipose tissue. The author believes that the following factors affect musculoskeletal ultrasonography in the diagnosis of RCTs :1. The sensitivity of the inspection instrument and the resolution of the probe will directly affect the analysis of the results by the sonographer; 2. For older patients with rotator cuff degeneration, the calcified part will cover the hypoechic area of RCT, affecting the interpretation of ultrasonic results. 3. The patient's shoulder joint pain was obvious, the position and active and passive activities during the examination were obviously limited, and the dynamic observation was not sufficient and the image was not clear, which led to the examination results. In high-frequency ultrasound, intra-tendon tears, tendon degeneration, and granulation tissue growth often present similar ultrasonic image manifestations. Hence, the interpretation of ultrasound images should be complemented by considering the patient's clinical signs and symptoms around the shoulder joint. In some cases, it may even necessitate the patient to perform multi-axis motion while the examiner conducts a multi-sectional examination for a comprehensive assessment.

The expertise and proficiency of the sonographer also play a role in the accuracy of the diagnosis. Professional training can improve the sensitivity of sonographers in diagnosing full RCTs and partial RCTs [19]. Additionally, high-frequency ultrasound has shown advantages in displaying calcifications and fat infiltration after RCTs, providing valuable information for surgical planning and postoperative recovery [20, 21].

PUSB, another imaging technique mentioned in the study, demonstrated good sensitivity, specificity, and accuracy in diagnosing both full and partial RCTs. However, there were three cases in which internal tears of the supraspinatus tendon were falsely diagnosed, and arthroscopy revealed that these cases had normal supraspinatus tendons. This misdiagnosis may have occurred due to small hypoechoic areas caused by irregular scattering of the sound beam[22]. It is important to consider these factors and limitations when interpreting the results of musculoskeletal ultrasound in the diagnosis of RCTs. Combining the ultrasound findings with clinical signs and symptoms, as well as performing multi-axis motion assessments, can enhance the accuracy of the diagnosis.

In the study mentioned, PUSB examination showed limitations in the diagnosis of supraspinatus tendon tears. Among the 5 suspected patients, arthroscopy confirmed that 3 of them had partial tears of the supraspinatus tendon, indicating false negative results. The cause of these false negatives was attributed to small tears located within the healthy body of the supraspinatus tendon, which did not result in damage to the shoulder joint capsule, preventing the contrast agent from entering the tendon. Additionally, irregular scattering of the ultrasound beam could lead to mis-diagnosis due to small pieces of hypoecho, and tears on the supraspinatus tendon bursal surface, intramuscular tendon, and articular surface were collectively referred to as supraspinatus tendon partial tears, potentially reducing the diagnosis of bursal surface partial tears using the PUSB examination. Small localized tears within the healthy body of the supraspinatus tendon could also be missed by PUSB.

MRI has advantages in examining soft tissue injuries and is widely used in the diagnosis of RCTs due to its non-invasive nature and absence of radiation. MRI has shown high sensitivity and specificity in diagnosing RCTs, with reported sensitivity and specificity for full-thickness tears ranging from 83–100% and 86–100%, respectively. In the mentioned study, the sensitivity and specificity of MRI for diagnosing partial RCTs were 68.18% and 94.89%, respectively, and for partial RCTs, the sensitivity and specificity were 98.63% and 76.59%, respectively. These results were comparable to or higher than those reported in the literature[23, 24]. However, there were cases of false positives and false negatives in MRI diagnosis, which could be attributed to factors such as the size and course of the tear, oblique or irregular tear shapes, presence of hyperplasia of granulation tissue, interference from tendon inflammation and synovial fragments, and the "magic Angle effect." Other factors that can limit the use of MRI include its cost, long waiting times for appointments, and limited availability in primary hospitals and community health centers. Additionally, MRI may not be suitable for patients with certain conditions such as pacemaker implantation, metal implants, and claustrophobia [25].

It is crucial to weigh the merits and demerits of each imaging modality, such as musculoskeletal ultrasound and MRI, along with their individual diagnostic accuracies within the realm of RCT diagnosis. Clinical judgment, coupled with a holistic strategy that integrates multiple diagnostic approaches, can significantly enhance diagnostic precision.

In the study mentioned, the utilization of multimodal imaging, which encompassed C-US, PUSB, and MRI, exhibited superior sensitivity, specificity, and overall accuracy in the diagnosis of RCTs when compared to individual modalities. Specifically, for complete tears, multimodal imaging displayed a sensitivity of 95.45%, specificity of 97.96%, and accuracy of 97.50%. Regarding partial RCTs, the sensitivity reached 100%, with a specificity of 93.62% and an overall accuracy of 97.50%. These results underscore the potential for enhanced diagnostic performance in rotator cuff injuries through the combined use of multiple imaging modalities.

Each imaging modality has its own unique characteristics and can reflect RCTs to varying degrees. Combining the strengths of different modalities can help overcome the limitations of individual techniques and enhance the diagnostic accuracy.Particularly in challenging cases or when minor tears are suspected, the synergy of multimodal ultrasound coupled with MRI can prove invaluable for achieving a qualitative diagnosis.

However, it is important to acknowledge the limitations of the study. The sample size of patients with RCTs was relatively small, potentially impacting the generalizability of the findings. Moreover, the study emphasized the substantial clinical expertise needed for musculoskeletal ultrasound examinations, which could introduce variability influenced by personal subjective experience. Furthermore, the imaging resolution may have been constrained by the equipment and technical capabilities employed in the study. The authors themselves acknowledged these limitations and underscored the necessity for larger sample sizes and the integration of advanced techniques, such as omics and artificial intelligence, to more comprehensively assess and predict patient prognoses.

Multimodal imaging methods, combining C-US, PUSB and MRI, exhibited enhanced diagnostic efficacy when contrasted with individual modalities for RCTs diagnosis. These non-invasive imaging techniques can be valuable for selecting appropriate treatment strategies and evaluating the prognosis of patients with RCTs. Further research should aim to clarify the role of these combined imaging approaches in surgical management based on the identified injury patterns .

DATA AVAILABILITY STATEMENT

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

ETHICS STATEMENT

The studies involving human participants were reviewed and approved by Ethics Committee of Jiangsu University Affifiliated People’s Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

AUTHOR CONTRIBUTIONS

QZ, WZ contributed to the conception and design of the study. ZYL ,CJ performed the statistical analysis. YZ,HZ,WH carried out the compilation of data and tables; XQQ carried out the revision of the article and the guiding role in the research process. All authors contributed to the article and approved the submitted version.

FUNDING

This study was financially supported by the National Natural Science Foundation of China (Project No.:81971629)

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflflict of interest.

Acknowledgements

Not applicable.

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No competing interests reported.

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Clinical Value of Multimodal imaging methods in the preoperative diagnosis of rotator cuff tears under arthroscopy

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