Abstract
Purpose
To compare radiologist and surgeon magnetic resonance imaging (MRI) interpretations of subscapularis (SSC) tears against intraoperative arthroscopic examination.
Methods
We conducted a retrospective review of prospectively maintained data on patients who underwent arthroscopic rotator cuff repair with and without SSC tears between 2011 and 2022. The radiologists’ assessments of SSC integrity were extracted from the MRI reports. One high-volume fellowship-trained shoulder surgeon assessed all MRI scans for the presence or absence of SSC tears. Radiologist and surgeon MRI-based assessments were compared against the diagnostic gold standard (intraoperative arthroscopic examination) and classified according to the Lafosse classification. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated.
Results
A total of 1,090 patients were included for analysis, 839 with intraoperatively confirmed SSC tears (77%) and 251 without such tears (23%). Radiologists diagnosed SSC tears with a sensitivity of 56.0% (470 of 839 patients) and specificity of 67.3% (169 of 251 patients) via MRI, whereas the surgeon diagnosed SSC tears with a sensitivity of 71.4% (599 of 839 patients) and specificity of 78.1% (196 of 251 patients). Overall, radiologists only correctly identified 56% of SSC tears whereas the shoulder surgeon correctly identified approximately 71.4% of tears. When considering arthroscopically confirmed tear size, that is, intact, partial, full thickness [upper border], and complete, the radiologists’ diagnosis rates with MRI were 67.3%, 40.4%, 64.6%, and 78.3%, respectively, and the surgeon’s diagnosis rates were 78.1%, 52.7%, 81.9%, and 97.5%, respectively.
Conclusions
In a community practice, radiologists miss approximately 50% of SSC tears on MRI examination. A shoulder surgeon with the benefit of clinical examination misses 28.6% of tears on MRI. Accuracy increases as tear size increases, with radiologists detecting 40.4% of partial tears and 78.3% of complete tears and a surgeon detecting 52.7% and 97.5%, respectively.
Level of Evidence
Level III, diagnostic study (nonconsecutive patients).
The subscapularis (SSC) is an often overlooked and underdiagnosed unit of the rotator cuff muscles. SSC tears are often referred to as “hidden lesions” because of their high prevalence and under-detection.1,2 High-volume surgeons report that approximately 30% of patients who undergo arthroscopic rotator cuff repair (ARCR) have an SSC tear, indicating the importance of detecting this type of injury.3, 4, 5, 6
Although magnetic resonance imaging (MRI) is the most effective imaging modality for diagnosing rotator cuff tears, studies have reported that posterosuperior rotator cuff tears are more accurately detected by MRI than SSC tears, with sensitivity and specificity ranging from 25% to 94% and 67% to 100%, respectively.7, 8, 9, 10, 11 Furthermore, although MRI is commonly used as an imaging modality, ultrasound has shown superiority over MRI in identifying SSC tears through its dynamic approach.12,13 Because most SSC tears are articular-sided tears along the superior aspect of the lesser tuberosity footprint, they can be challenging to detect with MRI, making arthroscopic evaluation the preferred method.3,4,10 Failure to detect SSC tears has been shown to have implications on postoperative functional outcomes.14
There have been few high-quality studies comparing preoperative MRI evaluations of SSC tears between surgeons and radiologists. The existing literature is limited by small sample sizes and deficient standardization in MRI magnet strength.11,15,16 The purpose of this study was to compare radiologist and surgeon MRI interpretations of SSC tears against intraoperative arthroscopic examination. This study hypothesized that there would be a significant disparity in the accuracy of preoperative MRI interpretations of SSC tears between radiologists and a surgeon, with the surgeon exhibiting higher accuracy compared with radiologists.
Methods
Study Design
We conducted a retrospective review of prospectively collected data on patients who underwent ARCR between 2011 and 2022 at a single institution. The inclusion criteria included a preoperative noncontrast MRI scan with a minimum 1.5-T magnet and any SSC tear identified at the time of arthroscopic evaluation. Patients were excluded if there was a history of ipsilateral shoulder surgery, proximal humeral fracture or glenoid fracture, lack of preoperative MRI interpretation by the surgeon, lack of a preoperative MRI radiologist report, or incomplete or inadequate operative documentation.
Preoperative MRI Interpretation of SSC Tear
No intra-articular or intravenous gadolinium was administered during any of the examinations. The radiologists’ assessments of SSC integrity were extracted from the preoperative MRI reports. Because MRI scans were obtained at multiple facilities, there was no standardization in terms of the particular radiologist who reviewed each MRI scan. SSC tears were classified as present (yes or no) and as partial or full thickness based on the reports. One high-volume fellowship-trained shoulder surgeon’s (P.J.D) preoperative MRI interpretation at the time of the clinical evaluation was similarly extracted from the medical records. While interpreting the MRI scan, the surgeon was cognizant of the patient’s physical examination findings and medical history. A control group of patients was obtained to compare interpretations from patients who did not have SSC tears.
Surgical Technique and Arthroscopic Findings
All arthroscopic procedures were performed by 1 surgeon (P.J.D.). Patients were positioned in the lateral decubitus position, and conventional portals were used (i.e., posterior, anterosuperior, and lateral). SSC tendon integrity was evaluated with 30° and 70° arthroscopes inserted through the posterior portal. Intraoperatively, SSC tear type was documented according to the Lafosse classification17,18 and SSC tear size, as a percentage (i.e., percentage cephalad to caudal). On the basis of the Lafosse classification, tears were divided into partial (type I), upper border full thickness (type II-III), and complete (type IV-V).19,20 In addition, supraspinatus and infraspinatus tear types (i.e., intact, partial, or full) and the integrity of the long head of the biceps tendon (LHBT) (i.e., intact, subluxation, partial tear, or complete tear) were reported.17,18
Statistical Analysis
A power analysis was performed with the McNemar test using the G∗Power program (version 3.1) with the following parameters: odds ratio, 1.5; α error probe, 0.05; total sample size, 1,090 patients; proportion of discordant pairs at 0.5; and power (1 – β), 0.997. The estimated sample size showed a lower critical sample of 249 and an upper critical value of 296. Therefore, a control group of 251 patients who had undergone ARCR with an intact SSC tendon was randomly selected from the same study period and analyzed. Categorical data were described using absolute and proportional frequencies. Arthroscopy was used as the gold standard for accuracy and to determine sensitivity, specificity, and positive and negative predictive values. The Cohen κ coefficient was used to measure inter-rater reliability for qualitative (categorical) items. Evaluations were performed with the Cohen κ test (i.e., 2 × 2 contingency test) for intact and torn tendons: radiologist MRI interpretation versus surgeon MRI interpretation, radiologist MRI interpretation versus arthroscopic findings, and surgeon MRI interpretation versus arthroscopic findings. The Cohen κ coefficient was interpreted as follows, as classified by Landis and Koch.21: 0 or less indicated no agreement; 0.01 to 0.20, slight agreement; 0.21 to 0.40, fair agreement; 0.41 to 0.60, moderate agreement; 0.61 to 0.80, substantial agreement; and 0.81 to 1.00, nearly perfect agreement. Additionally, the McNemar-Bowker test (i.e., 3 × 3) was conducted to compare radiologist and surgeon MRI interpretations with arthroscopic findings for intact tendons, partial tears, and full-thickness tears in triplicate. The Fleiss κ test (i.e., 3 × 3 × 3) was used to analyze the SSC categorizations, including intact, partial tear, and full-thickness tear in triplicate while comparing results between arthroscopic findings, radiologist MRI interpretations, and surgeon MRI interpretations. The ability of the radiologists and surgeon to diagnose an intact tendon (coded as 0) and a tear (coded as 1) with MRI was regarded as the dependent variable and was analyzed with a backward binary logistic regression model. LHBT integrity (i.e., intact, subluxation, partial tear, or complete tear) and rotator cuff integrity (i.e., intact, partial posterosuperior cuff tear, full-thickness posterosuperior cuff tear, or massive cuff tear) were taken as independent variables for binary logistic regression analysis. A threshold of .05 was used to denote statistical significance. The data were evaluated with the SPSS program (version 25; IBM).
Results
A total of 2,480 ARCRs were performed during the study period; of the patients who underwent ARCR, 839 met the study criteria for the SSC group. The control group of patients with an intact SSC included 251 patients. The baseline characteristics of the 2 cohorts are summarized in Table 1. There was a male predominance among the patients with SSC tears (65.2%, n = 547) compared with those with intact SSC tendons (51%, n = 128; P < .001). In the SSC tear cohort, partial tears accounted for 43.6% of cases (n = 366) and associated posterosuperior cuff tears were full thickness in 44.1% of cases (n = 370). Compared with patients with intact SSC tendons, patients with SSC tears had a higher rate of associated massive rotator cuff tears (24.6% vs 17.6%, P < .001).
Table 1.
Descriptive Analysis of Patients With Intact Versus Torn Subscapularis Tendons According to Arthroscopic Findings
| Patients With Intact SSC (n = 251) | Patients With SSC Tendon Tear (n = 839) | P Value | |
|---|---|---|---|
| Age, median (range), yr | 61 (20-81) | 62 (32-88) | .004∗ |
| Sex, n (%) | <.001† | ||
| Male | 128 (51) | 547 (65.2) | |
| Female | 123 (49) | 292 (34.8) | |
| Shoulder, n (%) | .062† | ||
| Right | 149 (59.4) | 552 (65.8) | |
| Left | 102 (40.36) | 287 (34.2) | |
| Rotator cuff integrity, n (%) | |||
| Intact posterosuperior cuff | NA | 129 (15.4) | <.001† |
| Partial posterosuperior cuff tear, n (%) | 56 (21.6) | 134 (16) | |
| Full-thickness posterosuperior cuff tear, n (%) | 150 (60) | 370 (44.1) | |
| Massive rotator cuff tear, n (%) | 44 (17.6) | 206 (24.6) | |
| LHBT integrity, n (%) | <.001† | ||
| Intact | 127 (50.6) | 226 (26.6) | |
| Subluxation or dislocation | 33 (13.1) | 191 (22.8) | |
| Partial tear | 80 (31.9) | 294 (35) | |
| Complete or retracted tear | 11 (4.4) | 128 (15.3) | |
| Mean size of torn subscapularis tendon, % cephalad to caudal | NA | 49.9 | |
| SSC tear type, n (%) | |||
| Intact tendon, n | 251 | NA | |
| Partial tear | NA | 366 (43.6) | |
| Full-thickness upper-border tear | NA | 353 (42.1) | |
| Complete tear | NA | 120 (14.3) |
LHBT, long head of biceps tendon; NA, not applicable; SSC, subscapularis.
Independent t test.
χ2 Test.
Radiologists diagnosed SSC tears on MRI with a sensitivity of 56.0% (470 of 839 patients) and specificity of 67.3% (169 of 251 patients), whereas the surgeon interpretation had a sensitivity of 71.4% (599 of 839 patients) and specificity of 78.1% (196 of 251 patients). Radiologist and surgeon accuracy was 58.6% (639 of 1,090 patients) and 72.3% (795 of 1,090 patients), respectively (Table 2). The accuracy of diagnosis increased as tear size increased, with the radiologists detecting 40.4% of partial tears and 78.3% of complete tears and the surgeon detecting 52.7% and 97.5%, respectively (P < .001) (Table 3). In diagnosing tears on MRI, the radiologists showed a false-positive rate of 32.7% and false-negative rate of 44% whereas the surgeon showed rates of 21.9% and 28.6%, respectively (Table 4).
Table 2.
MRI Interpretation Results by Surgeon Versus Radiologists
| Radiologists, % (n) | Surgeon, % (n) | Cohen κ | |
|---|---|---|---|
| Sensitivity | 56 (470 of 839) | 71.4 (599 of 839) | P < .001 |
| Specificity | 67.3 (169 of 251) | 78.1 (196 of 251) | P < .001 |
| Positive predictive value | 85.1 (470 of 552) | 91.6 (599 of 654) | P < .001 |
| Negative predictive value | 31.4 (169 of 538) | 44.9 (196 of 436) | P < .001 |
| Accuracy | 58.6 (639 of 1,090) | 72.3 (795 of 1,090) | P < .001 |
MRI, magnetic resonance imaging.
Table 3.
Surgeon and Radiologist Accuracy With Different Subscapularis Tear Types
| Subscapularis Tear Type,∗ n (%) |
Statistical Analysis | ||||
|---|---|---|---|---|---|
| Intact Tendon | Partial Tear | Full Thickness (Upper Border) | Complete Tear | ||
| Radiologists | χ2 = 111.9, P < .001 | ||||
| Intact | 169 (67.3) | 218 (59.6) | 125 (35.4) | 26 (21.77) | |
| Tear | 82 (32.7) | 148 (40.4) | 228 (64.6) | 94 (78.3) | |
| Surgeon | χ2 = 300.4, P < .001 | ||||
| Intact | 196 (78.1) | 173 (47.3) | 64 (18.1) | 3 (2.5) | |
| Tear | 55 (21.9) | 193 (52.7) | 289 (81.9) | 117 (97.5) | |
| Total | 251 (100) | 366 (100) | 353 (100) | 120 (100) | |
The Lafosse classification divides tears into partial (type I), upper border full thickness (type II-III), and complete (type IV-V).
Table 4.
Diagnostic Performance of Radiologists and Surgeon in Preoperative MRI Interpretations According to Arthroscopic Findings
| Radiologist Diagnosis,∗ n (%) |
Surgeon Diagnosis,† n (%) |
Gold Standard (Arthroscopic Diagnosis): Total, n (%) | |||
|---|---|---|---|---|---|
| Intact | Torn | Intact | Torn | ||
| Intact | 169 (67.3) | 82 (32.7) | 196 (78.1) | 55 (21.9) | 251 (100) |
| Torn | 369 (44) | 470 (56) | 240 (28.6) | 599 (71.4) | 839 (100) |
| Total | 538 (49.4) | 552 (50.6) | 436 (40) | 654 (60) | 1,090 (100) |
| Surgeon diagnosis vs radiologist diagnosis‡ | |||||
| Intact | 394 (90.4) | 42 (9.6) | |||
| Torn | 144 (22) | 510 (78) | |||
MRI, magnetic resonance imaging.
For arthroscopic diagnosis versus radiologist diagnosis, the Cohen κ value was 0.17 (i.e., slight), with T = 6.106 and P < .001.
For arthroscopic diagnosis versus surgeon diagnosis, the Cohen κ value was 0.39 (i.e., fair), with T = 13.827 and P < .001.
For surgeon diagnosis versus radiologist diagnosis, the Cohen κ value was 0.66 (i.e., substantial), with T = 22.295 and P < .001. For the comparison of the subscapularis by the radiologists versus the surgeon, the Cochran Q test showed a value of 282.04, with P < .001.
Overall, the radiologists correctly identified 56% of SSC tears whereas the surgeon correctly identified 71.4% of SSC tears. When both the radiologists and the surgeon believed that the SSC was intact on MRI, the accuracy was 90.4%. When both believed that the SSC was torn, the accuracy was 78%. However, when there was disagreement, the accuracy was 9.6% to 22% (Table 4).
LHBT subluxation (B = 0.52, P = .01) and complete LHBT tears (B = 0.71, P = .01) were positively correlated with the surgeon’s diagnosis of SSC tears with preoperative MRI. Concomitant partial posterosuperior cuff tears (B = –0.59, P= .03) were negatively correlated with SSC tear diagnosis. Conversely, only partial LHBT tears (B = 0.41, P = .03) were positively correlated with the radiologists’ diagnosis of SSC tears.
Discussion
The most important finding of this study was that the MRI interpretation of SSC tears was different between radiologists and a surgeon. Overall, the radiologists correctly identified 56% of SSC tears whereas the surgeon correctly identified 71.4% of SSC tears. As SSC tear size increased, both the surgeon and radiologists were more accurate, with radiologists detecting 40.4% of partial tears and 78.3% of complete tears and the surgeon detecting 52.7% and 97.5%, respectively. These findings call attention to avoiding over-reliance on MRI reports for the diagnosis of SSC tears.
There have been several studies investigating the accuracy of MRI in detecting rotator cuff tears, but few of these studies have focused specifically on the SSC.7, 8, 9 According to previous studies, radiologists have a sensitivity of 57.9% to 100% and specificity of 41% to 100% in diagnosing SSC tears whereas the sensitivity of surgeons was between 51.1% and 73% and the specificity was between 91.7% and 94.4%.15,16,22 In our study, the surgeon’s sensitivity was 71.4% and specificity was 78.1% whereas the radiologists’ sensitivity and specificity were 56.0% and 67.3%, respectively. In contrast to our study, a study by Adams et al.15 reported comparable sensitivity and specificity between radiologists (61% and 96%, respectively) and surgeons (73% and 94%, respectively). This difference may be due to the surgeons and radiologists being aware of the study purpose in the previous study and the use of MRI interpretations from multiple radiologists in our study. One possible explanation for the surgeon’s higher specificity and sensitivity compared with the radiologists in our study is that the patient history and physical examination findings were available to the surgeon, which led to better interpretation of the imaging findings. However, one-third of cases were still missed by the surgeon. These findings highlight the need for careful routine inspection of the SSC at the time of arthroscopy.
In a meta-analysis conducted by Malavolta et al.,23 the diagnostic accuracy of MRI in detecting SSC tendon tears was evaluated, showing an overall sensitivity of 68% (95% confidence interval, 0.64-0.72) and specificity of 90% (95% confidence interval, 0.89-0.92). However, it is worth noting that the MRI interpretations in this study came solely from musculoskeletal radiologists, which may have resulted in more accurate interpretations.24 When these results are compared with our findings, the radiologists had lower sensitivity and specificity values in diagnosing SSC tears. Several factors could have contributed to this difference. The MRI scans were evaluated by only 1 or 2 radiologists (some of whom were musculoskeletal radiologists) in these studies. In our study, the MRI scans were reported by multiple radiologists with varying levels of musculoskeletal expertise. Additionally, these studies obtained data prospectively, whereas our study included retrospective data and a control group. These differences in study design may have contributed to the varying results. However, our data are valuable in that they reflect the broader community interpretation. It is important to note that the radiologists missed approximately 50% of tears. Thus, surgeons should not plan or reject operative treatment of the SSC based on MRI reports alone. Additionally, in the setting of failed conservative treatment and a clinically suspected SSC tear, insurance companies should not be allowed to reject surgery based on MRI reports.
Adams et al.15 found a diagnostic accuracy between 84% and 100% when SSC tears were at least 50% thick. Similarly, Furukawa et al.16 found an accuracy rate of 78.5% to 100% for full-thickness and complete tears. Likewise, our study found that radiologist and surgeon diagnostic accuracy increased with tear size. Most of the SSC tears in our study, as in other investigations, were partial tears or upper-border full-thickness tears. These results show that partial tears are more challenging to diagnose than full-thickness tears.4,10,25 Lädermann et al.26 reported that more than half of all revision cases had SSC tendon tears; another study similarly found neglected SSC tears in 43% of revision shoulder arthroscopies.27 As Koo and Burkhart28 pointed out, this occurs because the superior glenohumeral ligament can conceal the SSC tendon tear, which often manifests on the articular side first.29 To avoid missing an SSC tear during shoulder arthroscopy, a systematic approach is required and techniques such as the posterior lever push maneuver with an 70° arthroscope, as well as the application of forward flexion and internal rotation, should be used.30
Although SSC tears can be seen in isolation, they are more commonly found with concomitant pathology.3,10,31 In a cadaveric study, Sakurai et al.3 observed that SSC tears were accompanied by supraspinatus tears in 64.7% of cases and by LHBT pathology in 58.8% of cases. In our study, SSC tears were associated with posterosuperior cuff tears 84.5% of the time. Over 70% of SSC tears were accompanied by LHBT pathology. Thus, biceps pathology should alert the surgeon to carefully inspect the SSC for a tear.
Limitations
This study is not without limitations. The study involved 1 surgeon and many radiologists. Even though MRI scans were standardized, hospital records contained MRI scans and interpretations from a variety of centers. In addition, the surgical procedures were performed by a high-volume shoulder surgeon, which could limit the generalizability of the results. The retrospective evaluation is a limitation owing to the exclusion of patients with unavailable MRI scans or reports. The effect of such limitations on the study was minimized by including a large SSC tear group (n = 1,090) and a control group. Finally, there was no correlation with clinical outcome. The ideal treatment for a partial SSC tear, for instance, is not clearly defined.
Conclusions
In a community practice, radiologists miss approximately 50% of SSC tears on MRI examination. A shoulder surgeon with the benefit of clinical examination misses 28.6% of tears on MRI. Accuracy increases as tear size increases, with radiologists detecting 40.4% of partial tears and 78.3% of complete tears and a surgeon detecting 52.7% and 97.5%, respectively.
Disclosure
The authors report the following potential conflicts of interest or sources of funding: M.E.M. is a consultant for Arthrex, outside the submitted work. P.J.D. is a consultant for Arthrex, outside the submitted work. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
References
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