This female patient presented to my clinic in mid-2013 for care of her shoulder pain. Due to her low insurance reimbursement level, she was not provided imaging by her referring physician and was directed to Physical Therapy for shoulder pain management. As I MSKUS all of my shoulder patients, I performed a screening exam and found a rotator cuff tear that involved < 50% of the CSA of the supraspinatus tendon. The patient was informed of these findings and was assured that we would teach her rehbailitate her shoulder to reduce her pain and improve her function. She attended 2 of her allowed 6 visits before failing to return for further care.
She subsequently had a rotator cuff repair, and then returned to see me post-operatively in 2014. Sadly this appointment was then cancelled on the day of care, stating that she had fallen and feared that she had re-torn her shoulder. It appears that she did re-injure the shoulder and had further surgery.
The second rotator cuff repair was in the start of 2014 and she subsequently returned to me later that year. On assessment, my shoulder ultrasound started as usual and I found minimal long head of biceps tendon haloing above the pectoral hooding and showing the tendon intact and well reflected. I had placed the patient in the modified crass position and was beginning to do a long axis scan of the supraspinatus when this flash of reflective material showed up boldly (Figure 1), I then went orthogonal/transverse on the foreign body (Figure 2) and found that it was long and narrow. It was clearly located under the deltoid muscle and above the supraspinatus tendon but had no “signature” echo that I had ever seen. Finishing my exam with some dynamic images and watching this object impact upon the acromion causing pain.
After the MSKUS scan I informed the patient that I would be calling her surgeon with the findings. I informed my receptionist that I wanted the surgical narrative from the second RCR surgery and she had it faxed. In it there is documented that a SwiveLock Anchor appeared to have some movement,but it could be seen firmly within the bone and it was not removed.
I then looked up SwiveLock in Google and found the image (Figure 3). This as you can see in the study fits exactly and I was convinced that the referenced SwiveLock had come loose from the humeral fixation. A useful video of the action of the suture can be found here.
The next encounter I had with this patient was in February 2015 when she was re-referred. I again imaged the shoulder and found that the hardware remained and had even more effusion surrounding it.
She offered that she had an MRI, we have access to the PACS online image review link and I was eager to see whether there was hardware visible. I then reviewed the images slice by slice and clearly could see the hardware (See).
Having reviewed the MRI slices, I contacted the surgeon and showed them the MRI slices and the ultrasound images correlating with it. He was in agreement and felt there was a loose suture and the patient was scheduled for removal of it.
Access to MSKUS imaging in clinic allowed for this patients progress to be reviewed and also for direct correlation with her MRI scan to be performed. This ultimately changed this patients management as a result.
Articles of interest:
Greg Fritz works at Anacortes Physical Therapy Clinic, near Seattle.
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