0:01

Um, discuss cases from week four or five and six.

0:05

Uh, if you all have any particular cases

0:09

that you would like me to go through,

0:11

I'll be more than happy to do so.

0:13

Uh, or else, um, I can go over some of the cases

0:18

that I think might be good to review

0:21

and have some challenging or interesting findings.

0:29

Any preferences? Okay, I have,

0:34

uh, I'm not seeing any so far, so I'll get started

0:37

with case one

0:38

and, uh, if y'all have any cases,

0:39

y'all can put it in the chat box

0:41

and then I can, uh, look at it

0:43

and review it once we are done with this case.

0:46

So I'm going, uh, through, uh, case one from week four,

0:55

and the history here was, uh, was a 52-year-old male

0:58

with right shoulder pain, limited range of motion ongoing

1:01

for three months, no known injury and no history of surgery.

1:05

So very common scenario for shoulder Mrs.

1:08

Middle-aged people, uh, they have shoulder pain,

1:11

doesn't get better with conservative therapy.

1:13

We get Mr to look for, uh, rotator cuff abnormalities.

1:16

That's usually the most common degenerative

1:18

phenomena happening at that age.

1:19

So let's start with this case.

1:20

This is an axial fat set, uh, sequence, uh, fluid sensitive.

1:25

And the abnormalities are marked with arrows here.

1:28

So, um, arrow one points to the biceps tendon

1:31

that is dislocated out of the bpal groove.

1:34

So this is the bi groove that should be the normal location

1:37

of the biceps tendon.

1:38

And here we see it has dislocated medially.

1:41

It's lying in front of the lesser tuberosity.

1:44

So why does that happen?

1:46

It happens when, um, the subscapularis fibers are torn

1:50

or the fibers, um, of transverse humeral ligament,

1:54

that those are the superficial fibers of subscapularis that

1:57

go over the bicipital groove

1:59

and, uh, keep the biceps tendon in place.

2:02

So those fibers are torn.

2:04

It allows the biceps tendon to dis dislocate medially, um,

2:09

within the subscap.

2:10

And as we, as we scroll the images, we also see

2:13

that there is an articular side as we go.

2:16

More superiorly, there is an high grade articular sided tear

2:19

of subscapular is slightly more inferiorly.

2:21

You get some fibers of the articular side back

2:24

and it's largely an interstitial tear more inferiorly.

2:27

So superiorly, it's a high grade partial articular sided

2:31

and inferiorly, slightly interstitial tear.

2:33

And it's in this gap

2:34

where the biceps tendon can easily dislocate medially.

2:37

So if you have a subscap tear like this, uh, make sure you,

2:41

uh, look at the biceps tendon, the position

2:43

of the biceps tendon,

2:44

and make sure it's not dislocated medially.

2:46

So that's a very important finding.

2:47

This is something that gets missed,

2:50

especially if the biceps tendon dislocates in an

2:52

interstitial tear of subscap.

2:54

It, it's also called as a hidden lesion

2:56

because, um, when the surgeon is doing a scope

2:59

and if they come either from the intra uh,

3:02

articular approach

3:03

or extra killer approach, they won't be able to see this

3:06

because both the bursal

3:07

and articular cider fiber sub subscap are intact.

3:10

So this is something that's happening in between

3:12

and they will completely miss it.

3:14

So it's very important for radiologists

3:15

to pick up those findings.

3:17

So make sure when you're looking at the subscap, uh,

3:20

and if there's a tear, also check for the position

3:23

of the bicep tendon.

3:24

And also the bicep,

3:26

the intraarticular biceps tendon has markedly abnormal

3:28

signal, um, within the substance.

3:30

So this will be tendinosis with interstitial tear,

3:33

most likely because it's almost fluid signal,

3:36

which goes all the way to the biceps labral anchor

3:39

and into the superior labral.

3:41

Okay, let's look at everything else.

3:42

Then we can go on to the coronal images.

3:44

So ac see joint looks.

3:45

Okay, we on axial images, we make sure there is no acro

3:48

because that might have important implications on

3:50

rotator cuff management.

3:52

Uh, can get the rasin supraspinatus muscle and tendon.

3:56

That's your in infraspinatus muscle

3:58

and tendon inserting onto the posterior greater

4:00

tuberosity is minor.

4:03

The labrum axial images are really good

4:05

to look at the anterior and posterior labrum.

4:07

So, um, some internal signals, so some freeing,

4:12

but there's no clean fluid cleft to suggest a tear.

4:15

Uh, posterior labrum looks fine.

4:17

Very smooth control labrum junctions,

4:19

both anteriorly and posteriorly.

4:22

And also we should also, uh,

4:24

look at the articular cartilage.

4:25

You have that nice gray strip of tissue,

4:27

overly the black cortex, that'ss articular cartilage, um,

4:30

just to get an assessment for if there is, uh, any arthritis

4:34

that's developing in the joint or not after that.

4:37

Moving on to the sagittal fluid sensitive, uh,

4:40

fat saturated sequences

4:42

and dmo image, that's the short

4:44

of the biceps from the corticoid process.

4:46

That's your subscap tendon.

4:48

And all that fluid signal is from that tear

4:51

that we saw on axial images.

4:53

You can see the biceps tendon through that tear

4:56

and it's immediately dislocated.

4:57

It should have been here in the groove,

4:59

but it's mely dislocated.

5:01

You see the tear in the biceps tendon, all

5:03

that fluid filter tear

5:05

that extends into the superior labrum.

5:07

So superior labral tear that extends into the biceps tendon.

5:10

It's a type four slap tear.

5:12

So slap tear has a classification. There's several subtypes.

5:16

And type four is

5:17

where the superior labral tear extends

5:19

into the biceps tendon.

5:20

So this is a type four slap.

5:22

Let's look at the, uh, uh, rot.

5:26

Um, other rotator cuff tendons.

5:28

Uh, coronal

5:29

and sagittal are excellent for looking at supraspinatus

5:32

and in infraspinatus tendon.

5:34

So right past the, so we should identify the biceps, uh,

5:38

or bicipital groove right past the bicipital groove

5:41

with the, is the anterior most part

5:42

of the greater tuberosity.

5:43

And this is where you should see the anterior mosts.

5:45

Fibers of suppress is, again, a very important area

5:49

because, uh, this is the area which will always be, uh,

5:53

it's the curvature, both

5:54

for coronal images and sagittal images.

5:57

It's difficult to, um,

6:00

or there's a learning curve to analyze the anterior

6:03

of rein tear in this location

6:04

because of the oblique orientation,

6:08

uh, relative to the co coronal plane.

6:10

So this is where you find the

6:12

anterior most fibers of suppress.

6:13

Again, most commonly missed cuff tears are the

6:16

anterior rein stairs.

6:18

So here we don't see an intact cuff,

6:20

so there is a focal full thickness tear of the rein.

6:23

And let's progress posteriorly.

6:25

Then you start getting the burs and articular fiber.

6:28

So more posteriorly in the region of the conjoin tendon.

6:30

It's a in concealed interstitial tear.

6:33

It's called a concealed interstitial tear

6:35

because interstitial, it's

6:37

because it's between the articular and bursal sided fibers

6:40

and a concealed, again, it's

6:42

because if when a surgeon does an arthroscopy

6:45

and puts the portal from the intraarticular side,

6:47

the fibers are intact from the bursal

6:49

side, fibers are intact.

6:50

So something that's happening in between, uh, it's

6:53

because it's, they don't see it, it's concealed

6:56

and it's an interstitial tear.

6:57

Another segment of concealed interstitial tear here, all

7:01

that gray signals suggest tendinosis.

7:03

And then there is fluid overlying the tendons.

7:06

That's your subacromial sub leftal perus.

7:09

Also, whenever you have cuff tears, one

7:12

of the most common causes

7:13

of cuff tear is subacromial impingement.

7:15

So we need to look at how, what's the shape of the acromion,

7:19

how it is oriented, and even the status of the AC joint.

7:22

So typically AC joint, uh,

7:24

shows degenerative changes in the form

7:26

of osseous hypertrophy, capsular thickening,

7:30

inferior osteophyte formation.

7:32

All these changes can impinge onto the supraspinatus tendon

7:36

and result in tendon tears.

7:37

But more important than the carac, uh,

7:40

acromial clavicle joint is the orientation of the acromion

7:43

and the caracal acromial ligament.

7:46

So I don't know if you can.

7:49

So, um, you, for the raco chromal ligament,

7:53

you find the OID process

7:54

and try to trace it back towards the acromion.

7:57

And this black structure

7:59

that extends from the coracoid process to the under surface

8:02

of the acromion is the coco chromal ligament.

8:05

And this is considered to be one

8:06

of the most important structures resulting in subacromial

8:09

impingement if it's thickened.

8:11

And it often gets thickened

8:12

with repetitive micro injury and overuse.

8:15

And that's the ligament

8:17

that will cause enthesopathy along the under surface

8:19

of the acromion and result in a bone spur along the under

8:22

surface of the acromion,

8:23

which will further worsen the subacromial impingement.

8:27

So all these changes, uh, we can evaluate on MRI

8:30

and see what's, what's causing

8:32

that subacromial impingement if there's a cuff tear.

8:35

So the sagittal image, again, are cooked

8:37

to localize the cuff tear.

8:38

So here we are on the anterior side,

8:40

so we have an anterior supinator there.

8:43

Uh, that's your subscap tear.

8:46

Um, the subscap tear here, more medially.

8:49

That's the, the bicep tendon there that you're seeing here.

8:52

So increasing signal within the bicep tendon

8:55

and the acromion,

9:01

not much changes along the, the surface of the acrom.

9:03

So, um, so those are the important findings in this case,

9:08

a subs captor with medial dislocation of the biceps tendon.

9:11

And, um, just a few

9:16

teaching points, uh, to know the anatomy in this area.

9:19

So these are called biceps pulley lesions

9:21

and the failure of the biceps pull mechanism

9:25

that results in this abnormality.

9:27

So this is a schematic, uh, from rat source

9:29

that shows the anatomy that's your subscap.

9:31

And in the superior fibers of the bursal sided fibers

9:34

of subscap crossover from the lateral, a lesser

9:38

to the greater tuberosity

9:39

to from the transverse humeral ligaments

9:41

that keeps the biceps tendon in place.

9:43

So if these fibers are torn,

9:45

it allows the biceps tendon to dislocate.

9:47

And even deeper to this,

9:49

if there is an interstitial subscap tear,

9:51

the biceps can dislocate in that tenter tear.

9:54

This is the area of biceps pull, the other rotator interval

9:58

between the subscap

9:59

and the suppress spinatus, where, um,

10:02

there is this raco humal ligament that also, um,

10:05

that overlies the, uh, the biceps tendon.

10:08

And underneath the biceps tendon in this area is the

10:11

superior glenohumeral ligament.

10:12

So both coracohumeral

10:13

and superior glenohumeral ligament,

10:15

they form a sling in the rotator interval,

10:18

which keeps the biceps tend in place.

10:20

So injury or tear of any of these structures, uh, will lead

10:24

to biceps instability

10:26

and, um, uh, eventually can lead to this pull,

10:30

um, uh, failure.

10:33

Uh, so this is, uh, the Haber, my where classification

10:37

that talks about, um, how, uh, different structures, uh,

10:41

when they're torn, they can result in biceps instability.

10:47

Okay, and then we talked about the slap tears.

10:49

So, uh, slap tears are the tears of the superior labrum,

10:52

and they can progress along the circumference of the labrum

10:55

or other structures that are attached to the joint capsule,

10:58

including the biceps tendon, the glenohumeral ligaments.

11:01

And based on the extension of the tear, there is, uh,

11:03

there are subtypes of, uh, slap tears

11:06

that the first four types are the most commonly seen.

11:09

Type one is where there's just freeing along the base

11:12

of the superior labrum.

11:13

Type two is when there is a linear cleft along

11:15

the superior labrum.

11:16

Type three is when the superior labrum is torn

11:19

and it flips the torn portion flips in the joint space.

11:22

That's the bucket handle tear.

11:23

Uh, but as a very subtle thing to, um,

11:26

and, um, you have to see a few cases to see how that,

11:29

it's not a very obvious bucket handle

11:31

that you see in knee cases.

11:32

It's just subtle inferior displacement of the torn fragment.

11:35

And type four is when

11:36

that tear extends into the bicep tendon.

11:41

So good with this case, I still don't have any other

11:44

specific requests, so let's move on and look at other cases.

11:48

I will also do case two, we briefly talked about it.

11:52

So, uh, probably will get done earlier.

11:55

So this one was where the patient had, um,

12:00

bike accident pain in the OID area,

12:02

soreness while raising arm overhead.

12:05

So sometimes when you get pain on the lateral aspect of the,

12:08

the biceps, um,

12:10

and especially when raising the arm overhead,

12:12

it's actually a symptom of rotator cuff tear.

12:15

So, okay, I, um, straight on the coronal images

12:20

and the abnormalities marked here we have the tear

12:23

of the rotator cuff.

12:25

So we already discussed such tears

12:27

where the ular sided fibers are intact,

12:30

the bursal sided fibers are intact.

12:32

There's a tear at the footprint in between the articular

12:35

and bursal sided fibers.

12:36

That's known as a concealed interstitial delaminating

12:39

delaminating because it, um, it, uh, can progress medially

12:44

and like can de laminate the tendon fibers.

12:47

So that's a nice example of a concealed interstitial tear.

12:51

And that's where it's progressing more posteriorly

12:53

as an interstitial tear into the in infraspinatus

12:56

and results in that fluid filled, um, gap.

13:00

And you can call that as a sentiment cyst.

13:03

So you can see that tear, um, in the, in infraspinatus,

13:07

that's an interstitial tear more medially along

13:10

the infraspinatus.

13:11

And that fluid tracking along that tear is the,

13:14

is the sentinel cyst.

13:15

Mm-hmm. Okay. Let's look at other findings on AAL images.

13:19

That's a gradient. I think

13:21

for some reason the axials in this case are only gradient.

13:25

So subscap, even on coronal images,

13:28

that's the mu MultiPlan subscapularis

13:30

tendon looks pretty good.

13:32

This is your biceps tendon in the bicep groove,

13:35

just posterior

13:36

to it are your anterior most fibers of resinate.

13:38

So there is severe tendinosis with, uh, with tearing

13:43

of the interstitial fibers,

13:45

becomes the tear becomes more clean

13:48

and well-defined more posteriorly.

13:50

So there's severe tendinosis with

13:51

that concealed interstitial tear

13:53

and an interstitial tear along the in infraspinatus.

13:57

We also have a nice superior labral tear.

14:03

Uh, and if it doesn't progress into any

14:05

of the adjacent structures, this will be a simple type two,

14:08

uh, which is, uh, a linear tear along the superior labrum.

14:12

We have ac arthrosis,

14:13

we have a laterally downsloping acromion,

14:16

and this is what the black thing is.

14:17

Your, uh, the acromial end of the

14:21

car acromial ligament, which gets thickened

14:24

and further narrows the subacromial space.

14:26

And it's an important, uh,

14:29

factor resulting in subacromial impingement.

14:32

So we see all of those changes.

14:33

So chro, this makes the acromion hook shaped with

14:36

that anterior inferior, um, uh, hypertrophy that's from

14:40

that enthesopathy pathy.

14:43

Okay, so the main findings here are a superior labeled tear,

14:47

severe tendinosis with concealed interstitial tear

14:49

and evidence of subacromial impingement

14:51

with a naturally downsloping acromion,

14:54

subacromial enteropathy, and subacromial sub bursitis.

15:01

Okay, what was this?

15:06

Uh, one of

15:08

say would do even K three of week four.

15:18

Okay. And we can look at the coronal

15:23

fluid sensitive sequences.

15:25

Uh, the subscap is looking okay,

15:27

the biceps tendon is looking okay.

15:29

Lot of bursitis, right?

15:31

Lot of sal inflammation

15:34

and the tendon appearance is, uh, dark

15:37

and hypertense like a normal tendon,

15:40

but has this very irregular margins, uh,

15:42

and it's causing a lot of bursitis

15:44

and edema in the humeral head and the greater tuberosity.

15:50

Let's look at, um, the sagittal images.

15:53

Again, looking at the cuff, subscap looks, okay,

15:56

that's your biceps tendon in the rotator interval.

15:58

And as you come here, looks almost looks like a normal cuff,

16:03

but the, it doesn't have

16:04

that normal parallel fiber, uh, arrangement.

16:07

It has more lobular con, uh, uh, contours and configuration

16:11

and is causing a lot of bursitis and maremma.

16:14

So these are the mr findings of what is known

16:17

as calcific tendonitis.

16:18

It's not a difficult diagnosis if you are used to,

16:21

of looking at radio crafts

16:23

before you start looking at the mr

16:25

because this calcification will be really obvious

16:27

on radio crafts.

16:28

And it's a, it's a lot

16:29

of calcification throughout the supraspinatus tendon,

16:32

so it can be easily picked up on radiographs,

16:34

but on mr it can completely be missed

16:37

because that hypo intensity from calcium is similar

16:41

to the hypo intensity of the, the tendons

16:44

and can totally blend in with the normal tendons.

16:47

And you may completely miss it in the beginning if you don't

16:50

know if that's how calcific tendonitis looks like.

16:52

But when you look at the radiographs, you have

16:55

that obvious homogenous, um,

16:56

calcification along the tuberosity.

16:59

So, um, again,

17:03

few teaching points, uh, on this one.

17:05

Um, so not all, uh,

17:07

hydroxy appetite calcium deposition in the

17:09

tendons is symptomatic.

17:11

Um, it only when, uh, it causes inflammation, uh,

17:15

is when you can call it

17:16

as calcific tendonitis on radiographs.

17:18

That hydroxyapatite is seen

17:20

as amorphous cloud-like calcification on mr,

17:24

it is dark on all pulse sequences just similar to tendons.

17:26

So it's easy to miss and that's why it's important

17:29

to look at the radiographs.

17:30

Important thing to know about this,

17:32

that this calcium can extrude in the overlying bursa

17:36

or in the underlying bone.

17:37

So, um, look for those hyperintense foa in the bursa

17:41

and in the adjacent bone as well.

17:43

And there are several stages in this calcium deposition.

17:46

The first stage is precalc,

17:48

whether there's fibro cartilaginous

17:50

metaplasia in the tendon.

17:51

Second is calcific stage where there's calcium deposition.

17:55

That's the formative phase.

17:57

Then the calcium deposition stays for some time.

17:59

That's the resting phase.

18:01

And then the body's, uh, immune mechanism kicks in

18:04

and tries to resolve that abnormal calcium

18:06

and the phagocytosis.

18:07

And it's this re disruptive phase where, uh,

18:10

there's an acute inflammatory response

18:12

and becomes an acute painful joint, uh, inflamed joint,

18:17

which mimics clinically septic arthritis.

18:20

And this is followed by post calcific or the healing phase.

18:23

So remember that, uh, hydroxyapatite deposition,

18:26

it becomes symptomatic in the resorptive phase.

18:29

And when it's symptomatic, it's only then when we call it

18:31

as calcific tendonitis.

18:33

Radiology not helps just in diagnosing this condition,

18:36

but can also help in the treatment part.

18:39

Uh, the preferred treatment of choice, uh,

18:41

for this is ultrasound guided needle lavage versus needle

18:45

barage is where you, uh, put in, um, uh,

18:49

the needle in the area of calcification within the tendon,

18:54

uh, under ultrasound guidance.

18:56

And, um, uh, just try to break that calcification with back

19:00

and forth movement and then try to aspirate that calcium out

19:03

because this calcium is not hard calcium, it's soft milk

19:07

of calcium like consistency, uh, like toothpaste,

19:09

like consistency and,

19:11

and can be aspirated with a, a wider bore needle.

19:15

So, um, that's known as babo, uh, or,

19:18

or you can even do lavage where inject saline

19:20

and then aspirated back

19:21

and hoping that a lot

19:23

of calcium will come back along with it.

19:25

So, uh, we can help both in terms of diagnosis

19:30

and treatment of this condition.

19:34

Okay, let's skip case four.

19:38

Let's look at now week five cases.

19:51

Okay, that's, uh, be five case two. It's an, uh,

20:01

I think we do the case one also.

20:03

This is, this is an, uh, easy straightforward case where

20:07

we have the axial images.

20:08

They're looking at everything

20:09

and the, obviously the, the finding

20:12

that stands out is this complete articular cartilage loss.

20:16

Uh, the humeral head shape is odd and it's

20:19

because of a slight flattening of the articular surface

20:23

and the bone spurs anteriorly

20:24

and posteriorly that is osteophyte formation.

20:27

Even the glenoid, um, the surface looks light resolved

20:31

and there's no articular cartilage.

20:34

So this is advanced glenoid humoral joint osteoarthritis.

20:37

There is joint effusion,

20:38

there are loose bodies in the joint space.

20:42

So why, uh, is imaging important in osteoarthritis cases

20:47

where you can see these findings on radiographs

20:50

and know that you know it's advanced osteoarthritis.

20:53

Uh, one of the reasons to do MR

20:56

and this is to assess the status of the rotator cuff tendons

21:00

because the treatment depends upon the integrity

21:03

of the rotator cuff tendons.

21:04

So the treatment of choice

21:06

for advanced shoulder arthritis is, uh,

21:09

shoulder arthroplasty.

21:10

Now the surgeon has to decide whether they wanna do total

21:13

shoulder arthroplasty versus a reverse

21:14

total shoulder arthroplasty.

21:16

And that depends on if the cuff is intact or not.

21:18

If the cuff is intact, they will prefer total shoulder.

21:21

If the cuff is to

21:22

or degenerated, they will go in for reverse total shoulder.

21:25

So in this case, the cuff actually looks pretty good.

21:28

Uh, little tendinosis, which is expected

21:30

because there's so much arthritis, but no big cuff there.

21:33

So on the coronal, uh, images, again,

21:35

we find the biceps tendon.

21:37

This is anterior or suppress spinatus moving forward,

21:40

conjoin tendon and infraspinatus, everything looks good

21:46

on the axial images.

21:48

Uh, we can look for the subscap.

21:50

Even the subscap attachment looks pretty good on

21:52

the lesser tuberosity.

21:54

This joint effusion synovitis biceps is also looking intact.

22:01

And when there is such bad arthritis with complete loss

22:04

of articular cartilage, um, the labrum,

22:06

which is at the margin, you expect that labrum

22:09

to be completely circumferentially torn and frayed.

22:11

And that's what's happening here.

22:13

Um, the labrum throughout is abnormal with frame

22:18

and, and a complex tear.

22:24

See the labrum being totally abnormal there

22:28

and even the intraocular biceps tendon has slightly

22:30

higher signal intensity.

22:31

So that's just tendinosis. Okay, so that was a quick case.

22:36

I will go to case one again

22:38

because we wanna discuss those partial rotator cuff tears.

22:49

Okay, so let's look at this case.

22:51

Um, again, the subscap looks pretty good.

22:55

Can't see the biceps tendon,

23:00

but this is where the bpal groove is.

23:02

And this is the anterior mo supra.

23:05

So you can see, uh, a tear of the mid to posterior fibrous

23:09

of supraspinatus more towards the articular side.

23:12

This is the tone end of the tendon,

23:14

and then the bursal sided fibers are intact.

23:16

So this is a partial articular sided tear of Linus

23:21

that extends, it's not right at the footprint, it's medial

23:25

to the footprint, but has that extension into the tendon.

23:27

So it's called a paint lesion.

23:30

Uh, and then the other findings I think

23:33

of we see susceptibility here.

23:35

So there has been prior biceps tenodesis

23:38

because we don't see the intraarticular biceps tendon.

23:40

A lot of cystic changes at the lesser tuberosity, which is,

23:43

uh, commonly seen phenomena

23:45

because that's where the bare area of the humeral head is

23:48

and the joint fluid can seep in.

23:50

And it's also, um, can be from raspin tendinopathy

23:54

or internal enrichment.

23:59

Other the findings again, yeah, absent biceps stand

24:01

and you see it here, that's where the ESIS is.

24:07

And the cough is, uh, we, we've discussed those findings.

24:10

So let's talk about these partial, um,

24:14

sorry about this slide.

24:20

Yeah, So there's something known as pasal lesion.

24:23

That was I think, uh, case five of week four,

24:26

which is partial articular sided supraspinatus aul lesion.

24:30

It's just a, like a footprint tear of the supraspinatus,

24:33

which is a partial tear towards the articular sided tear,

24:36

um, tendon

24:38

and sheer forces causing aul of the footprint attachment

24:41

with variable delamination of the deep tendon components.

24:44

So this is called a past.

24:45

For some reason, these s

24:47

around the shoulder have become really popular, uh,

24:50

and this is also known as a Rembrandt lesion.

24:53

Past and mbrt are synonymous.

24:55

Then if it happens on the, if there's a partial S sided tear

24:59

of subin at the footprint, that's your reverse pasta then,

25:04

uh, I've never used this, uh, being, uh,

25:07

used very frequently.

25:09

STAs lesion, which is again a partial suppress articular

25:12

side tear, but not at the footprint

25:14

but medial to the footprint.

25:15

But paint again, was a popular, uh, epidemic that was used.

25:19

Uh, uh,

25:22

but again, nowadays we're moving away

25:24

from using these terms.

25:26

It's better to just describe the finding as it is.

25:28

So there's no confusion between us

25:31

and the orthopedic surgeons

25:32

to keep the communication uniform and clear.

25:35

Um, just describe it rather than using

25:37

all these fancy terms.

25:38

Uh, but paint lesion is what this case is

25:41

where you have a partial articular tear

25:43

of the supraspinatus medial to the footprint

25:45

and the tear progresses within the substance of the tendon

25:48

and causes delamination.

25:50

So that's your past the lesion.

25:52

And we already talked about these.

25:53

So case of concealed interstitial delaminating tear also.

25:56

So, which is at the footprint between the bursal

25:59

and articular sided fibers so that you see the tear,

26:02

but it's hidden or an obscure finding for the surgeon

26:04

because you don't see it from the articular side

26:07

or from the bursal side.

26:09

So know these, uh, partials raspin stairs

26:12

and, uh, know how to describe.

26:16

Okay? Um, okay, we'll do this

26:21

case three week five,

26:30

nothing from the front.

26:32

Again, a big joint effusion.

26:37

Bice subin, not sure what's happening.

26:39

It's severely tend knots played. Part of it is gone.

26:42

Mely part of it is still in the groove

26:45

anterior most supraspinatus fibers, few of them are there,

26:48

but right after that there is a tear.

26:50

So complete tear complete, yeah.

26:52

So it's a com near complete supine

26:54

and infraspinatus stairs, I see some

26:56

of the in infraspinatus fibers still on getting

27:00

onto the tuberosity.

27:03

And then a lot of joint effusion.

27:05

All the debris that you see is

27:06

synovitis, Somebody saying something.

27:15

Okay. And then very narrowed, subacromial space,

27:19

superior migration of the humal head.

27:20

Again, that little enteropathy along the under surface

27:24

of the acromion.

27:26

So very narrow subacromial space. Massive.

27:29

So this is got a massive rotator cocktail

27:30

because two of the tendons are near completely torn.

27:39

Okay, let's see the images.

27:42

We see arthrosis, no acromial,

27:48

I'm trying to, so see the biceps is not in the groove.

27:51

And this is a massively swollen tendon otic biceps tendon,

27:55

which has, uh, dislocated medially.

27:59

It's deep to the sub.

28:00

And again, you can see a very nice interstitial tear

28:03

of the subscapular.

28:04

So the articular sided fibers are intact,

28:06

the bursal sided fibers are intact.

28:09

And these are your transverse humeral fibers.

28:11

But because there is an interstitial tear

28:13

that bicep tendon has dislocated, I a lot of bur, uh,

28:17

bursitis, lot of joint effusion, synovitis,

28:21

but the labrum isn't bad.

28:23

Labrum looks okay, articular cartilage looks okay.

28:28

So this is a case of massive rot cuff tear.

28:31

Uh, where, uh, there's a near complete tear of supra infra.

28:35

There is a high grade interstitial tear of the subscapularis

28:38

with medial dislocation of the bicep stent.

28:40

So the reason I was talking about,

28:41

we showed some partial suppress tears

28:43

and, uh, this is a complete rot cuff tear to how

28:48

to describe, uh, rotator cuff tears.

28:52

So once you have a rot cuff tear, um, this,

28:55

this is the information that we need

28:57

to put in the report for the surgeon.

28:58

You identify which tendon that tear is in.

29:01

Is it Subscapular Subin Raspin series minor.

29:05

Can you describe the tear?

29:07

Do you see a partial tear or a full thickness tear?

29:10

Is it an interstitial tear or a complete tear?

29:12

And also know the difference between

29:15

what is a full thickness tear versus a complete tear.

29:18

Full thickness tear is the tear

29:19

that extends all the way from the articular side

29:22

to the bursal side, but may not involve the entire

29:24

width of the tendon.

29:26

If it's a, a tear complete, uh, like the entire

29:31

one tendon is completely torn.

29:32

Like if it's a suppress atu, it's a full thickness tear

29:36

of the entire supraspinatus tendon from A to P,

29:40

then it's a complete tear.

29:41

So not all full thickness tears are complete tears,

29:45

but all complete tears are full thickness stairs.

29:47

I hope you understand what I'm saying.

29:50

And then if it's a partial tear, um, uh, we have

29:53

to talk in terms of whether it's a low grid partial versus a

29:56

high grid partial, because low grid partial

29:58

tears might be managed conservatively,

30:00

whereas high grade partial tears will be treated,

30:03

or the preference will be

30:04

to treat them surgically, affix them.

30:06

And when it's a partial tear, again, we have

30:08

to describe whether the partial tear is articular sided

30:11

or bursal sided, where it's at the footprint

30:13

or medial to the footprint.

30:14

All that description has to be, um, in the report.

30:19

And the sizes are important.

30:20

Are we talking about a small tear, moderate sized tear,

30:23

large tear, or a massive tear?

30:24

Again, because the management depends on it, small tears

30:27

more, uh, lean towards conservative management,

30:30

whereas massive tears, and if there's no arthritis,

30:33

the muscle bulk is good.

30:34

Uh, the surgeon might prefer doing a surgical repair

30:38

location, whether it is footprint versus medial

30:40

to the footprint, whether it's articular, ab,

30:43

bursal side I already talked about.

30:45

And when, um, whatever the tear is,

30:48

you talk about the retraction of the taunt tendon fibers,

30:50

how medially they're retracted,

30:52

because if the retraction is medial to the joint space

30:56

or the glenoid, then um, it's, it's difficult

30:59

to do a primary repair.

31:01

So the degree of retraction is important.

31:03

You can just be descriptive in the degree of retraction

31:06

or you can measure it from the footprint

31:08

and then talk in terms of measurement.

31:10

Uh, like so many centimeters of medial retraction

31:13

or just say the tendon is retracted to the level

31:16

of the superior humeral head to the level of the joint

31:18

or medial to the joint.

31:20

And one of the most important things is

31:22

to assess the muscle quality,

31:24

like go medial on the tal images on T one weight images

31:27

and try to,

31:35

I think one of the, uh, participants is not muted.

31:38

Will you please mute yourself if you're not asking?

31:43

Okay, so, uh, 10 quality, uh, muscle atrophy.

31:47

Uh, as I was saying, go median on the sagittal t even weight

31:50

images and determine, uh, how much is the degree

31:53

of muscle atrophy.

31:55

Um, if there's too much fatty atrophy of the muscle,

31:57

then again, a repair is not possible.

32:01

Okay, so that is all that was there.

32:07

Okay, any other interesting week five cases?

32:10

Yeah, let's do case five.

32:15

This is again, um, like rotator cuff is a big chunk

32:19

of shoulder cases, and this is like probably the,

32:23

another very common entity that we get to see,

32:26

and for which we routinely do.

32:29

Shoulder MS is, um, like see the findings on axial images.

32:34

You see, uh, an impaction along the poster,

32:38

superior humeral head with underlying marrow edema.

32:40

So that's your hill sac lesion.

32:42

Um, uh, the best way to identify hill sac lesion

32:46

and not to confuse for this normal constriction

32:49

that's on the posterior side of the humeral head,

32:51

this is a normal variation versus more superiorly.

32:54

If you see a similar depression that's in hill sax lesion,

32:57

uh, the way to differentiate is the location.

32:59

If you get this depression on the first two

33:02

or three axial slices of the humeral head, that's hill sax

33:06

and the normal variation is slightly

33:07

more inferiorly than that.

33:09

Uh, then again, in

33:11

these slices you can imagine a normal humeral head should be

33:15

like a perfect sphere.

33:17

And if it's blunted post superiorly,

33:19

that's your hill sax lesion.

33:21

So hill sax lesion, we know we are looking at a case

33:23

of anterior, like patient dislocated an

33:26

and, um, had an anterior shoulder

33:27

dislocation and has been reduced.

33:29

So the other common fine abnormality that you get along

33:33

with hill sax and anterior dislocation,

33:35

it's the anterior labral capsular or bony injury.

33:38

So that has been marked with the arrow here.

33:40

There's definitely an anterior inferior labral tear.

33:44

And if you wanna describe it, it's very ratty and irregular.

33:47

Um, uh,

33:48

the articular cartilages intact looks like

33:50

the bone is intact.

33:52

And then there is, uh, periosteal stripping

33:57

and the, this is the torn fragment that is slightly, uh,

34:01

has un undergone slight median displacement.

34:04

It's slightly medially located.

34:06

So if I had to pick up, uh, an um, acronym, um,

34:11

I will say it's an AA lesion,

34:13

but again, as I said, like it's better

34:15

to be descriptive rather than I call it as ssa,

34:18

but the surgeon thinks it's something else

34:20

and let's not get into that confusion, uh,

34:23

and just be descriptive about it.

34:25

So, um, other things that you look for.

34:28

Obviously everything else AC joint looks pretty good.

34:31

Um, no lateral, uh, d

34:35

or um, uh, tilt of the acromion,

34:40

the rotator cuff tendons are looking pretty normal.

34:43

You see that hill sacks again on coronal images

34:45

with a lot of edema around it.

34:47

That's your nice biceps tendon

34:50

and the bice bpal groove, you can see how, um,

34:55

it joins the superior labrum

34:57

to form the biceps labral anchor

34:58

and that's a superior labrum, which looks pretty normal.

35:02

Yeah, so, um,

35:04

and then also the imper joint capsule

35:06

where it's thickened at the glenoid attachment

35:08

where it's intact both at the glenoid

35:10

and the humeral attachments.

35:11

So you are ruling out the haggle and gaggle lesions.

35:16

Okay, so, um, picking up hill sacs

35:18

and anterior inferior labral, uh, uh, tears suggests

35:22

that there has been an anterior dislocation

35:25

and, um, recently there has been a rod that has added

35:29

to this entity, like we just not in our reports

35:33

now, describe that.

35:34

Okay, we see hill Sach tear, that's, it's a sequel

35:38

of anterior dislocation.

35:39

Um, once we identify there are two lesions,

35:43

like there's hills, sac and an

35:44

and uh, labral tear, that's called a bipolar lesion, right?

35:47

Sometimes you can only have hills sac

35:49

or only a ARD abnormality

35:51

or around labral tear, then it's not a bipolar lesion,

35:54

but if you have lesions on both sides,

35:56

that's a bipolar lesion.

35:58

And once you have a bipolar lesion, then we also have

36:01

to determine as radiologist whether the, uh, uh, uh,

36:05

to get introduced to the concept of glenoid track

36:09

and whether these lesions are on track or on off track.

36:13

Okay, a few slides that might make it easier for you all

36:16

to understand that

36:28

I have an article here also.

36:30

It's a nice radiographics article

36:32

where it talks about glenoid tract assessment at imaging in

36:36

anterior shoulder instability, step by step kite.

36:39

So I would recommend for you all to go through this article

36:41

because this explains the concept of glenoid tract.

36:44

Uh, what is, what are these bipolar bone lesions

36:48

and anterior shoulder instability?

36:50

The tract concept is that, um,

36:53

during abduction external rotation, it's only 83%

36:57

of the glenoid that is responsible for, uh,

37:01

stabilizing the humeral head.

37:02

So that's your tr. So when we are looking at imaging,

37:05

we are, and you're trying to determine the glenoid bone

37:08

stock or the loss of, uh, glenoid bone loss, um,

37:13

we have to take only 83% of the glenoid diameter

37:17

because that's what just contributes

37:20

to human health stability.

37:22

Um, then it also talks about like how

37:26

to do these measurements on imaging

37:30

in sex interval

37:34

and then how, uh, these, uh,

37:37

like determining all these things, um, affect management.

37:41

So that's, the surgeries are different when you get, um, uh,

37:44

if it's an on-track versus an off-track lesion,

37:47

the management is different.

37:48

So I can briefly or quickly tell you, uh,

37:59

this case.

38:00

So what we do in these cases is first measure the hill sac

38:03

index on the slice where it's

38:07

like clearly seen.

38:09

And um, obviously you measure the length

38:11

of the defect posteriorly, you go, you have to go

38:14

to the ridge, uh, that is the posterior part

38:16

of the insertion of the cuff.

38:18

So that's your cutoff point.

38:20

So here the hill sax, uh, index is 15.5 uh

38:25

millimeters or 1.55 centimeters.

38:27

And then, uh, go on the sagittal images

38:30

and try to determine the, the glenoid bone loss,

38:34

like if there's any.

38:35

But in this case, we know

38:36

that there is no glenoid bone loss,

38:38

so it'll be an on track lesion,

38:40

but imagine if there was glenoid bone loss.

38:43

So here what we do is we draw a best fit circle along the

38:47

inferior glenoid matching with the inferior

38:49

and the posterior corsis,

38:51

because those are the normal corsis.

38:52

Anterior cortex will be abnormal because of a ARD injury.

38:57

Then you measure the diameter of that circle.

38:59

That should, that's the expected width of the glenoid.

39:03

But with an anterior dislocation,

39:05

when there's a bank art injury,

39:06

that width will be smaller, right?

39:08

Or you measure how less of that width is,

39:11

and that's your glenoid bone loss.

39:13

Okay? So whatever, uh, diameter you get, you multiply that

39:17

by 0.3 because only that part is responsible

39:20

for humeral tank, uh, stabilizing the humeral hip.

39:24

And then from that you subtract the amount

39:27

of glenoid bone loss, the width that is missing anteriorly.

39:30

So that will give you the residual g glenoid tract. Okay?

39:34

And then you see which is bigger, is the hill sac, uh,

39:38

index bigger or the glenoid tract bigger?

39:41

The hill sac index is bigger than the G glenoid tract.

39:43

It's an engaging or an off track lesion in the sense that,

39:47

um, when there is an anterior dislocation, this humeral head

39:50

or this hill sacs has a very high chances of engagement

39:54

and, uh, reduction would be difficult in those cases.

39:57

So that's the concept of on track, off track lesions.

40:00

So, uh, read about that.

40:01

And then, uh, uh, so in, in cases of anterior, uh,

40:06

shoulder instability, we just don't, um,

40:10

diagnose the condition, the sense that there is hill sax

40:12

and ARD that suggest of bacteria instability.

40:15

We, uh, go a step forward and do these measurements

40:19

and tell the surgeons whether these are off track

40:21

or on track lesions in kids there is a bipolar lesion.

40:26

Okay, so let's now go to week six cases.

40:31

We only have 15 minutes left.

40:34

We have already discussed type slap four,

40:35

and it's the same case, case one of week four.

40:39

So we've already discussed that.

40:40

Let's look at the second case from week six.

40:43

So moving on to hip conditions now

40:47

we close out all the, okay.

40:52

Um, I start off with the coronal image of the hip, uh,

40:57

because, um, typically for evaluating hip pain, one

41:00

of the reasons to get an MR is to rule out AV N.

41:03

So here we can turn that there is no vascular necrosis,

41:06

there are no stress fractures.

41:08

Um, you look at assess the shoulder joint,

41:10

I know the obvious abnormalities here will come to it,

41:13

but let's do, uh, a systematic, uh, approach.

41:16

So look for any marrow changes like avian stress fractures.

41:20

Look at the labrum. So the hip labrum is very similar

41:22

to shoulder labrum, which should be a black

41:25

uniformly hypo intense triangle

41:28

with a smooth chondral labral junction.

41:31

So any abnormal signal in that would be worrisome,

41:34

especially if it goes into the substance of it.

41:36

And here you can see it has that, all

41:38

that gray intrasubstance signal.

41:39

So this and then becoming fluid signal here more laterally.

41:43

So that's your, this is your superior labral there.

41:46

And then you have to move to the sagittal images

41:47

to look at the intra superior and anterior labrum.

41:50

So you can see how that labrum is abnormal.

41:52

So there is an intra labral tear.

41:55

Again, the best way to describe the position

41:57

of the labral tear is like some people prefer oloc position

42:00

there, but there can be some confusion

42:02

between the right and left hip.

42:03

Um, so it's better d describe in terms of quadrants.

42:06

And the quadrants are interior intra superior, superior post

42:10

superior and post inferior.

42:12

So in this case, the labral tear is in the insuperior

42:15

and the superior quadrants, uh,

42:18

there's not much cartilage loss.

42:20

There is very minimal joint effusion, not much.

42:25

And then you're coming here, there's a lot of fluid overlay,

42:29

the roc canta,

42:30

we know when there's fluid overlay the roc canta,

42:33

we're thinking of roc bursitis.

42:35

And also we have to look at the integrity of the gluteal

42:39

tendons, especially the minimus

42:41

and medias that insert onto the roc canta.

42:44

So the axials are best to tell which tendons are affected,

42:48

whether it's the minimus or the medias.

42:50

So this, this is minimus then that's medias

42:54

and that's your magus maximus muscle fibers.

42:57

So you can follow. This is your minimus.

42:59

The minimus tendon inserts onto the anterior aspect

43:02

of the greater Trent.

43:04

And medias has the insertion is in a form

43:07

that it has a very thick posterior tendon

43:09

that inserts onto the posterior part

43:10

of the greater tru canter.

43:12

And the anterior fibers have a direct muscular attachment on

43:15

the lateral facet of the greater tru canter.

43:18

So this facet and the tendon, uh, uh, attachment is very,

43:21

uh, similar to, uh, your rotator cuff insertion

43:24

and the shoulder on the lesser and the greater tuberosity.

43:27

So how there's ity early onto the lesser tuberosity

43:30

and then supra on the, uh, the more, uh, lateral facet

43:35

of the greater tuberosity or the lateral part

43:37

of the greater tuberosity and infra

43:38

and t minor, more on the posterior aspect.

43:41

Very similar here, gluteus minimus on the anterior facet,

43:46

the anterior fibers of medias onto the lateral facet

43:49

and a thick tendon of medias onto the posterior facet.

43:53

So there's definitely here a tear, which involves the,

43:57

the anterior fibers, the direct muscular attachment

44:00

of the medias and the posterior tendon.

44:04

It's partly stripped up,

44:05

but largely intact is largely intact.

44:08

And there's also partials stripping of the,

44:11

the gluteus minimus, uh, tendon from the greater can.

44:14

So it's a, it's a focal full thickness here

44:17

that progresses more anteriorly

44:19

and posteriorly as partial articular sided tears,

44:23

but largely a full thickness tear

44:25

of the anterior gluteus minimals, sorry, medias

44:29

and obviously that overlying fluid is your side.

44:32

Yes. And so t twos are good for assessing, uh, the extent

44:37

of the tears which tendons are involved.

44:39

And T one is again, very important for anatomy

44:42

and also to determine muscle atrophy.

44:44

Often if these tears are either chronic

44:47

or acute on chronic, they will be associated

44:49

with muscle atrophy.

44:50

And if you see significant gluteal muscle atrophy need

44:53

to make sure that, uh,

44:55

look at the tendons and make sure they're intact.

44:57

So you can see the atrophy along the myotendinous junctions

45:00

of the minimals and mediacy.

45:04

That's everything, just looking okay.

45:06

So yeah, this wasn't, uh, uh, important thing.

45:09

A lot of these gluteal tears often get missed,

45:13

so it's very important to look for them on, on

45:17

and can be the cause of hip pain,

45:19

especially in an elderly population.

45:21

So just a schematic from Rat Source that shows, uh,

45:25

or explains this tendon insertion

45:27

and how these tendons are inserted onto different facets

45:30

of the greater trant.

45:32

And this is, um, again showing

45:35

this is the minimus tendon inserting onto the

45:38

anterior part of the facet.

45:39

That's the posterior medias inserting onto

45:41

the posterior facet.

45:43

And uh, that's again, minimus

45:46

and more posteriorly medias.

45:49

Okay.

45:57

Okay. Nothing.

46:02

Okay, let's do this last two cases, which might be quick.

46:06

Again, this is an easy diagnosis.

46:09

We all know, um,

46:11

that if you see such changes in the femoral head

46:15

where there is sub inness, um, hypo intense,

46:20

uh, signal, um, in the femoral head,

46:23

in the subc chondral region, that's your diagnostic feature

46:26

for, um, uh, avascular necrosis, uh,

46:30

on fluid sensitive sequences, you get the double line sign

46:34

where the inner bright line is.

46:36

The granulation tissue in the outer black line is the

46:38

dead sclerotic bone.

46:40

So, um, it has this classic ous appearance, um,

46:46

on, on mric.

46:48

So here there is a lot of mar edema.

46:51

So, um, this is an, um, acute on chronic in fact.

46:55

So just to make a diagnosis is not enough on MI imaging.

46:58

I know like in a lot of these hips, as I said, are done

47:01

for hip pain as to exclude underlying AV N

47:04

and it's a, it's an easy diagnosis.

47:05

You see those serpent changes, changes in the femoral head,

47:07

you know, it's AV N

47:09

but uh, our role as radiologist doesn't stop there.

47:13

There's more, uh, information that we need

47:16

to give on imaging and that is, uh,

47:18

to describe the associated findings,

47:20

where is this location of the avian?

47:22

So there's more superiorly,

47:23

which is the weight bearing portion has more

47:25

implications on management.

47:28

You described the location,

47:30

you described the extent in terms of percentages

47:32

of the femoral head, that how extensive is that avian?

47:35

Because if the avian involves more than 50%

47:37

of the femoral head, there's a high chance

47:40

of articular surface collapse.

47:41

That's the other thing that's important

47:43

to mention in these cases,

47:44

is there any articular surface collapse?

47:46

And in this case you see the

47:47

flacking of the articular surface.

47:49

So there is a collapse of the femoral head,

47:52

and sometimes you have this fracture line

47:54

developing parallel.

47:55

This is your crescent sign that you see on radiographs, uh,

47:57

you know, develop a subc chondral fracture in

48:00

these cases of avian.

48:01

Again, having that crescent as also a risk factor

48:04

for having an articular surface collapse.

48:06

This patient already has articular surface collapse.

48:08

And lastly, um, uh, is there any osteoarthritis

48:12

that has set in the joint?

48:13

Because all of these changes are going

48:15

to affect management in terms of if it's an acute phase

48:19

where there is no articular surface collapse,

48:20

there is no secondary osteoarthritis, people can try

48:23

and go decompression and try to restore the vascularity

48:27

and the integrity of the articular surface.

48:29

But if there is an articular surface collapse

48:32

that has already set in

48:34

and there is secondary osteoarthritis, then the treatment

48:36

of choice will be joint replacement or a hip arthroplasty.

48:39

So that's why we need to assess all these things.

48:42

So, um, again, we know this is avian of the femoral head

48:45

with edema in the head and the neck.

48:47

There's associated ticus surface his collapse.

48:50

The avian is in the superior, anterior superior portion

48:52

of the femoral head.

48:53

Then percentage wise, that's the

48:56

ticus surface of the femoral head.

48:58

So I would say this is 30 to 40% on the sagittals

49:02

and it's more of a subjective thing.

49:04

And again, similar 30 to 40% on the, so overall 30 to 40%

49:09

of the articular surface there is

49:11

articular surface collapse.

49:12

And I don't see any full thickness cartilage loss,

49:15

but there is a tear of the labrum.

49:17

So we'll mention that there is no full

49:19

thickness cartilage loss.

49:20

There is reactor joint effusion.

49:25

Yeah, I think those are the, the important things

49:28

that we need to mention in reports in these cases.

49:30

And that's why I wanted to discuss this case.

49:32

Okay, uh, let's do the very last case

49:36

of week six.

49:44

So this is a case of hip arthroplasty

49:47

and one of the important complications of hip arthroplasty.

49:50

So what we are seeing is a large soft tissue

49:53

around the hip arthroplasty that's within the asum.

49:56

It's eroding the asum causing expansion.

50:03

So, um, anytime you have, uh, soft tissue

50:07

around the hip arthroplasty, obviously the first thing

50:10

that you think of is, is a complication of hip arthroplasty,

50:13

which is known as adverse local tissue reaction.

50:16

It's a very common complication seen in arthroplasties

50:18

where, uh,

50:19

because of, uh, chronic rubbing of the parts,

50:22

these are these microparticles from the implant that shed in

50:26

and around the joint,

50:27

and that can eventually incite an immune mechanism, um,

50:30

and cause tissue destruction around the arthroplasty.

50:33

That tissue destruction will manifest in terms

50:35

of osteolysis, where there is bone destruction

50:38

and formation of these necrotic masses around the hip joint.

50:42

And every, like, um, this um,

50:48

uh, tissue complication

50:49

that comes from an arthroplasty comes under the umbrella

50:52

term of adverse local tissue reaction.

50:55

Um, it's the reaction immune reaction to the particles

50:58

of the arthroplasty, which causes tissue necrosis.

51:01

The path term for this is val.

51:04

Um, and,

51:06

and basically, um, it manifests

51:09

as complex soft tissue masses

51:11

and there is a classification for these, uh,

51:14

soft tissue masses, whether, um,

51:15

they can be completely fluid like when there is necrosis

51:18

or they can be, uh, um,

51:21

and complete breakdown of the tissues

51:23

or they can ha can be mixed solid cystic

51:26

and they can be completely solid looking when there is, um,

51:30

lot of, uh, um, metal deposition.

51:33

It's more commonly seen with metal

51:34

and metal arthroplasties where there's a lot of metal

51:36

and soft tissue deposition around the, the joint.

51:39

And, and that's, so the, the, it's like type one, two

51:42

and three, uh, based on imperial classification.

51:45

Type one is when it's largely cystic.

51:48

Type two is when it's solid and cystic

51:49

and type three it's predominantly solid.

51:51

So you've got to look for these again, you just

51:54

talk about the size, how extensive it is,

51:57

is it involving the bone

51:58

or getting out of the bone here it is predominantly

52:01

within the asum.

52:02

And then there is this little stuff extending along

52:05

the io o tendon.

52:06

So there is IO source bursitis

52:08

and these things can extend along the bursa.

52:12

So I think there's some extension along the bursa here.

52:17

So the other differentials would be like if this

52:19

arthroplasty was done for, uh, uh, a neoplasm.

52:23

So if it's recurrence of neoplasm,

52:25

but again, like very few occasional cases

52:28

where you'll have history suggestive of it, most

52:31

of the time the soft tissue masses that develop

52:33

around the hip arthroplasty are going

52:35

to be local tissue reaction,

52:40

right, for this as well.

52:43

Yeah, so I was talking about that this is, um,

52:47

immunologic inflammatory response

52:49

to debris, any sort of debris.

52:50

And it was more commonly seen with metal on metal

52:53

and all the initial studies describe in terms

52:56

of metal debris, but it can be plastic debris, any debris

52:59

that comes from the implant

53:01

and histologically you get a delayed

53:03

or type four allergic hypersensitivity response.

53:06

The cells in inside a lymphocyte mediated inflammatory

53:09

response resulting in soft tissue destruction

53:11

and that soft tissue destruction is seen

53:13

as pseudo tumor and imaging.

53:14

Again, one thing to remember is

53:15

that pseudo tumor is misnomer.

53:17

It's not, uh, a pseudo tumor, it's just tissue necrosis

53:21

that looks like a mass on, on on imaging.

53:26

And pathologically these lesions have abundance

53:28

of perivascular lymphocytes, um, leading

53:31

to vessel constriction

53:32

and that's why there is tissue necrosis.

53:34

And this is the path term that is used for

53:37

these complications, which is aseptic lymphocyte dominated,

53:41

vascular associated lesion.

53:43

Okay, so remember we u radiology uses the term A LTR adverse

53:47

local tissue reaction and when is used

53:49

by pathologists for the same thing.

53:52

And A LTR is the umbrella term, uh,

53:55

for local soft tissue complications resulting from post

53:58

reaction to arthroplasty related metal degrade can include

54:03

al, it can include metalosis.

54:04

It can include otium.

54:08

Okay, I can, we can skip these as the classification

54:10

that I was talking about.

54:13

Okay, we can skip all of this.

54:14

I think that's, this is an example of, uh,

54:17

osis is when this thing happened at the trion

54:20

of the implant when, um, so

54:24

we aspirated this joint

54:26

and we got this black colored fluid from that joint

54:28

that was all that tissue necrosis.

54:30

That's what happening around the joint.

54:31

And this is an intra portal where all these,

54:34

this was necrotic tissue and it was stained black

54:36

because of deposition of metal on that necrotic tissue.

54:41

Okay, I think we are done.

54:43

So if you have any other requests, uh,

54:47

or to go over any particular finding

54:49

or any other case, um, I'll be more than happy to take it.

54:52

If not, if you all have any questions later on,

54:55

this is my email address, so feel free to email me.

54:59

Thank you all for your attention.