Contrast-Enhanced Sonographic Characterization of the Vascularity of the Repaired Rotator Cuff

Objectives To characterize the distribution of vascularity of the postoperative rotator cuff tendon using a maximum intensity projection technique after contrast-enhanced sonography. Methods We retrospectively evaluated image data on 23 patients (11 male and 12 female) with intact rotator cuff repairs who had previously undergone contrast-enhanced sonography of their shoulders using lipid microspheres before and after a standardized exercise protocol. The patients were on average 3 months out from their surgery. Using offline image analysis software, a maximum intensity projection image was obtained for each patient, reflecting the regional vascular distribution within the repair and adjacent soft tissue. Subjective analysis was performed in 4 regions of interest: peribursal, articular medial, articular lateral, and suture anchor, independently by 2 musculoskeletal radiologists using a semiquantitative scale ranging from 0 to 4 for each region (0, no enhancement; 1, 1%–25% enhancement; 2, 26%–50%; 3, 51%–75%; and 4, 76%–100%). A combined vascularity score (0–8) was produced for each region and formed the basis for the subjective analysis. Results Using a Mann-Whitney nonparametric test, the data showed significantly higher regional enhancement in the peribursal and suture anchor regions compared to the tendon (P < .001). Exercise resulted in a statistically significant increase in the extent of enhancement in all regions (P < .002). Inter-rater reliability analysis using a weighted κ statistic showed strong agreement (0.63–0.64) for the suture anchor site and moderate agreement for the others (peribursal, 0.35–0.39; articular medial, 0.45–0.55; and articular lateral 0.32–0.33). Conclusions The maximum intensity projection technique after contrast-enhanced sonography provides a topographic map of rotator cuff vascularity; the latter has been implicated as an important factor in promoting bone-tendon healing. Approximately 3 months after rotator cuff repair, the suture anchor and peribursal regions showed the most robust vascularity. Maximum intensity projection imaging further establishes that there is a global increase in vascular response at the repair site after exercise.