Work In

Vol. 124 WORK IN PROGRESS Progress

The Double Contrast Shoulder Arthrogram: MATERIAL AND METHODS

Evaluation of Rotary Cuff Tears 1
Bernard Ghelman, M.D., and Amy Beth Goldman, M.D.
Double contrast shoulder arthrograms revealed rotator cuff abnormalities in 14
of 31 cases. Although both the single and double contrast methods provide a
means of diagnosing complete tears of the cuff, or partial tears of its inferior
surface, the double contrast study provides additional information regarding the
width of the tear, the presence of degenerative changes in the cuff, and the
condition of the articular cartilages.
INDEX TERMS: Shoulder, arthrography, 4(1).122. Shoulder, wounds and in-
juries
Radiology 124:251-254, July 1977
The earliest studies of shoulder arthrography (reported by
Oberholzer in 1938 and Frostad in 1942) utilized air as the only
contrast medium (1). Several examinations were done with a
combination of air and Abrodil to achieve double contrast (1).
Later investigators (2-5) chose to perform their shoulder studies
with iodinated material alone. This method provided an accurate
and reproducable means of diagnosing complete tears of the
rotator cuff, incomplete tears of the inferior surface of the rotator
cuff, and frozen shoulders. The double contrast arthrogram re-
mained the procedure of choice at the Royal National Ortho-
paedic Hospital (6).
Thirty patients (one with bilateral complaints) were referred
to the Hospital for Special Surgery for pain, limitation of motion,
or weakness of the shoulder. They were studied by double
contrast arthrograms and radiographs obtained under fluo-
roscopic control with the patients in the upright position.
Injections were done with the patient in the supine position
and the shoulder held in minimal external rotation and abduction.
Under fluoroscopic control, a lead marker was placed over the
center of the glenohumeral joint, and this point was then marked
on the skin. Following the administration of local anesthesia, a
22-gauge spinal needle was directed straight downward into the
joint space. When the space was entered, 4 ml of 60% Reno-
grafin and then 10 ml of air were injected, and the needle re-
moved. The amount of contrast material is critical to the success
of this study, since too much positive contrast agent will obscure
the articular cartilages, while too much air will produce extrav-
asation from the subscapularis bursa.
The patient is placed in an upright position after the injections,
so that air rises to the superior portion of the joint and outlines
the contrast-coated inferior surface of the rotator cuff (Fig. 1).
The patient is also asked to hold a 5-lb. sand bag to produce
distraction of the joint space. Serial radiographs are then ob-
tained with the shoulder in both internal and external rotation.

Fig. 1. Upright internal (A) and external (B) rotation views of a normal double contrast shoulder arthrogram. The white arrowheads indicate
the contrast-coated inferior surface of the rotator cuff, which is outlined by air. The latter surface should be perfectly smooth and without
extension of air or positive contrast above it. The black arrowhead on the internal rotation view (A) marks the cartilaginous limbus of
the glenoid. The black arrow indicates the sheath of the biceps tendon, which on external rotation of the shoulder (B) is partially superimposed
on the inferior surface of the rotator cuff.

251
252 WORK IN PROGRESS July 1977

Fig. 2. Upright internal (A) and external (8) rotation views of a double contrast shoulder arthrogram demonstrating a complete tear
of the rotator cuff. The white arrowhead indicates the edges of the torn tendons. The superior and inferior surfaces of the fragments are
outlined by the double contrast method, and in this case show that they are smooth and of normal width, indicating an absence of degenerative
changes. A portion of intact cuff is visualized between the fragments. On the external rotation view (8), the biceps tendon is marked by
a black arrow.

Fig. 3. A pre-exercise upright internal rotation view (A) of a double contrast shoulder arthrogram demonstrates a complete tear of
the rotator cuff, with air extending into the subacromial and subdeltoid bursae; irregularity of the tendon fragments consistent with de-
generative changes (white arrowheads); and blunting of the cartilaginous limbus, indicating secondary degenerative joint disease (black
arrowhead). The post-exercise upright external rotation view (8) shows the full width of the tear.

Vol. 124 WORK IN PROGRESS
The spot film technique using a General Electric Telegem is
useful, because varying the angle of the beam and directing it
downward towards the feet will project the area of the rotator
cuff away from the osseous acromion process.
Following the upright studies, the patient is returned to the
supine position, and further radiographs are obtained with the
shoulder in internal and external rotation; axillary and bicipital
groove views are obtained as well.
If a complete rotator cuff tear is not revealed by the initial
studies, the patient is asked to exercise the shoulder and the
upright spot studies are repeated.
RESULTS
Fourteen of the 31 shoulders studied by the double contrast
method had abnormalities of the rotator cuff. Twelve had com-
plete tears (Figs. 2 and 3), 1 had a partial tear associated with
a fracture of the greater tuberosity (Fig. 4), and 1 patient with
rheumatoid arthritis had early erosive changes along the inferior
surface of the tendons (Fig. 5).
The remaining portions of the cuff were visualized in 9 of the
12 patients with complete tears, permitting evaluation of the size
of the tear and the state of the remaining rotator cuff. In the 3
cases in which the rotator cuff was not visualized on the contrast
study, there were plain radiographic findings of chronic severe
rotator cuff disease.
DISCUSSION
Once the diagnosis of a rotator cuff tear is established, two
difficulties in patient management remain. First is the choice of
Fig. 4. A double contrast shoulder arthrogram performed on a
patient with persistent pain six months following a fracture of the
humeral head demonstrates a partial tear of the inferior surface of the
rotator cuff (white arrowheads) and post-traumatic degenerative joint
disease, with marked irregularity of the articular cartilage of the glenoid
(black arrowhead).
Work In
253 Progress
surgical candidates and second (in operative cases) is the choice
of the optimal incision to achieve a tension-free repair (7).
The indications for surgery include: (a) a wide acute purely
traumatic tear, with or without a displaced fracture of the greater
tuberosity (7,8); and (b) chronic tears which, following a course
of conservative therapy, still produce pain and weakness (7, 9).
A major contraindication is the presence of severe preexisting
degenerative changes in the remaining tendons (7-9), leaving
the surgeon "only rotten cloth to sew" (8). The double contrast
method of shoulder arthrography has the advantage of demon-
strating the width of the tear and the quality of the remaining
tissues (Figs. 2 and 3). The evaluation of the articular cartilages
is also of use, since co-existing degenerative joint disease would
decrease the probability of a pain-free repair. Information con-
cerning the remaining tendons and articular cartilages is
therefore important for an appropriate choice of therapy.
The evaluation of the width of the tear is also important in the
selection of the surgical incision. A good surgical result requires
complete resection of the dead tissue at the edges of the tear;
a vascular bone bed; close apposition of the remaining frag-
ments; and a tension free suture line (7-9). In patients with large
gaps, the frequently used anterior incision (9) may result in an
inadequate exposure. In one series of 55 cases, operative repair
by this method was unsuccessful in 4 patients with extensive
tears (9). The posterosuperior approach suggested by Debeyre
(7) requires an osteotomy of the acromion, but provides exposure
of the entire supraspinatus muscle, from its origin to its insertion;
this exposure allows for the closure of larger tears.
The double contrast shoulder arthrogram provides diagnostic
accuracy equal to that of the single contrast study, and has the
added advantage of demonstrating the width of the tear and the
quality of the injured tendons in many cases. The visualization
Fig. 5. A double contrast shoulder arthrogram, performed on a
patient with known rheumatoid arthritis, demonstrates irregularity of
the inferior surface at the rotator cuff (white arrowhead) and complete
loss of the articular cartilages (black arrowheads).
254 WORK IN PROGRESS
of air and contrast extending into the subdeltoid and subacromial
bursas, while failing to demonstrate any portion of the rotator
cuff, probably indicates severe degenerative disease of the
tendons. Future surgical correlation will determine if this added
information provides useful criteria for the selection of operative
candidates.
REFERENCES
1. Fischedick 0, Haage H: Die kontrastdarstellung der schulter-
gelenke. [In]: Encyclopedia of Medical Radiology. Berlin, Springer-
Verlag, 1973, pp 295-304
2. Lindblom K, Palmer J: Ruptures of the tendon aponeurosis of
the shoulder joint-the so-called supraspinatus ruptures. Acta Chir
Scand 82:133-142, Oct 1939
3. Nevaiser JS: Ruptures of the rotator cuff. Clin Orthop 3:92-98,
Jan-Jun 1954
July 1977
4. Andren L, Lundberg BJ: Treatment of rigid shoulders by joint
distension during arthrography. Acta Orthop Scand 36:45-53, 1965
5. Killoran PJ,Marcove RC, FreibergerRH: Shoulderarthrography.
Am J RoentgenoI103:658-668, Jul 1968
6. Stoker D: Personal communication
7. Debeyre 0, Patie 0, Elmelik E: Repair of ruptures of the rotator
cuff of the shoulder with a note on advancement of the supraspinatus
muscle. J Bone Joint Surg 47(8):36-42, Feb 1965
8. McLauglin HL: Rupture of the rotator cuff. J Bone Joint Surg
41(A):978-983, Jul 1963
9. Wolfgang GI: Surgical repair of tears of the rotator cuff of the
shoulder. Factors influencingthe result. J Bone Joint Surg 56(A): 14-26,
Jan 1974
1 From the Department of Radiology, Hospital for Special Surgery,
New York Hospital-Cornell University Medical College, New York, N.Y.
Accepted for publication in February, 1977. 55