 Hello, everyone. I'm Dr. Raj Lakshmi. I'm a final resident from MNR Medical College in Hospital, Sangarethi. My paper topic is comparison of ultrasoundography and MRI in the evaluation of rotator cuff injuries. The background and introduction, rotator cuff disease is one of the most common cause of shoulder pain. With addition of history and physical examination evaluation of the patient with shoulder pain often involves assessment of the rotator cuff with a diagnostic test such as ultrasoundography or MRI. Previously an arthrography was more commonly used but however it is a very invasive procedure. It comes with risk and discomfort and is very insensitive to partial tears, especially involving the superficial surface and the substance of the cuff. Hence the diagnosis of partial tears is important because many orthopedic surgeons will operate to relieve the impingement of the supraspinatus tendon before it progresses to full thickness there. This was possible because of MRI as it has a key role in their diagnosis. Hence it has become a gold standard for detecting both subtle and obvious internal rearrangement and as in the overall joint structures. The aims and objectives of my study was to evaluate the role of MRI in the rotator cuff injuries, the role of high-resolution ultrasoundography in the rotator cuff injuries and the correlation between the clinical and the high-resolution ultrasoundography and MRI findings. Materials and methodology, the sample size was a minimum of 40 patients. Source of data, all the patients referred to MNR Medical College Department of Radiology with the clinically suspected rotator cuff injuries were taken. An informed consent was obtained and a careful examination was done before the procedure. The inclusion criteria was all the patients with clinical suspicion of rotator cuff injuries and case of all age groups with respect to the sex. Exclusion criteria, the patient having history of claustrophobia, any metallic implants cardiac pacemaker or metallic foreign body which were the absolute contraindications of an MRI study and also patients who was unwilling. A study method, it was a cross-sectional study. The technique in equipment, it was a hospital-based imaging done with 1.5 Tesla GEMR SIGNA machine in the Department of Pediatric Diagnosis Seminar Medical College. Using a shoulder coil, the following sequences were obtained. Coronal oblique T1 weighted proton density weighted image was done, which was a fast spin sequence. Coronal oblique fat suppress sequence was done. Sujaital oblique T2 weighted without fat suppression, axial T2 weighted gradient echo sequence, axial PDW without fat suppression and the field of view was 14 to 16 centimeters with slice thickness of 2 to 3 mm and a matrix of 512 into 512. Technique in equipment, for the ultrasonography, we use GE Logic QF6 machine, which was equipped with a linear probe with frequency of 6 to 12 megahertz. The patient position, it varies from institutions to institutions, however, I used a revolving stool and the patient was seated comfortably and the height of the patient's stool was adjusted to be ergonomically comfortable with the scan performance. So, according to the results, my first table shows the age distribution of the studies and we realize that about 52.5% the highest percentage where of the age group less than 40 years. Next, Table 2, it shows us the range of moments in subjects with rhetoric of injuries about 65% of the patients had a decreased range of moments. The average distribution of subjects of the 40 patients studied 26 patients were male and 14 were female. The mean age, the main age among the female was 42 plus or minus 1.98 and the mean age among the meals was 46 plus or minus 2.2 in our study of rhetoric of injuries. That's about 65% of patients with meals. Table 4 it is a patient with history of trauma. In our study about 15% of the patients had history of trauma. That is about six subjects. Next we will see the association between dominant side and the affected side in our study majority were right handed subjects about 82.5% and 17.5% were left handed subjects. The other seven left handers had rhetoric of injuries on the left side and about 80% of the right hander had injuries on the right side. The association was statistically significant. Next we see the ultrasound findings in tendon injuries. In ultrasound it is observed that 15 patients had tendon tear of the supraspinatus muscle, 12 patients had infraspinatus muscle, three patients had sub-scapularis tear and two patients had biceps tendon tear. And there was no tear in teres minor. Two patients had tendinosis of supraspinatus muscle and three patients had tendinosis of the infraspinatus muscle and one patient had tendinosis of the sub-scapularis. This is the same data expressed in percentages and graphical representation. Next we have MRI findings in tendon injuries. It was observed that 23 patients had tendon lesions of supraspinatus muscle, five patients had infraspinatus tear, three patients had sub-scapularis tear, and there was no tear in teres minor, and two patients had biceps tendon tear. Two patients had tendinosis of the supraspinatus muscle and one patient had tendinosis of the sub-scapularis muscle. This table 10 is the same MRI findings expressed in percentages and graphical representation. Next statistical measures of the ultrasonography findings in comparison with the MRI findings in tendon injuries. Ultrason findings in comparison to MRI findings show the sensitivity of the ultrasound was low in detecting the tendon injuries at all sites. High sensitivity was observed for sub-scapularis and biceps tendon injuries. Specificity was 100% at all the sites except infraspinatus which was 69%. Diagnostic accuracy was low in supraspinatus and infraspinatus tear and highest for sub-scapularis and biceps tendon injuries. The agreement between the ultrasound and MRI findings was measured by Kappa and the highest agreement was observed for sub-scapularis teres. Next we the statistical measures of ultrasound findings in comparison in detecting the peri-bicepital tendon fluid. MRI showed 12 patients positive for peritendinous fluid out of the patients whereas ultrasound showed out of 40 and ultrasound detected 9 out of those 40. And the three were non-detected and did not detect three cases. There was a significant association between ultrasound and MRI findings. MRI was better in detecting the peri-bicepital tendon fluid than ultrasonography. Next we see the association between ultrasound findings and MRI findings in detecting the peri-bicepital tendon fluid, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy where the p-value was less than 0.01 according to G-square test. There was 75% sensitivity, 100% specificity, 100% positive predictive value, 90% NPV and the diagnostic accuracy was 0.925. Next we see the association between ultrasound findings and MRI findings in detecting the sub-acromion and sub-deltoid bursal fluid. MRI showed 10 positive for bursal fluid out of 40 whereas ultrasound detected all the cases of sub-acromion and sub-deltoid bursal fluid. There was significant association between ultrasonography and MRI findings that is USG was equivalent to MRI in detecting it. Now we have a diagnostic accuracy of 1% and 100% sensitivity, specificity, positive predictive value and a negative predictive value. Next we see the association between ultrasound findings and MRI findings in detecting the joint effusion. MRI showed 23 positive for joint effusion out of 40 whereas ultrasound, USG detected 18 and did not detect joint effusion in about five cases. There was significant association between USG and MRI findings, however MRI was better. Now we see a 78% sensitivity, 100% specificity, 100% positive predictive value, 77% negative predictive value and a diagnostic accuracy of 0.875. Next we see the acromion type, majority of the type of acromion was 67.5% had type 2 acromion, 50% had type 3, 10% had type 1 and 7.5 had type 4. We also see a graphical representation of the same. Table 18 are MRI findings of a labral tear. In our study about only 12.5% had associated labral tears, that is about five subjects. Now we see a variation between the MRI diagnosis with the ultrasound diagnosis. In our study it was observed that ultrasound had 66.67% sensitivity, 100% specificity, 100% positive predictive value, 42.86% negative predictive value and a 73.33% diagnostic accuracy in diagnosing the rotatory cuff injuries. Now we see a variation between the USG and MRI was 0.44, that is fair agreement. Table 20 we have the statistical measures of the final diagnosis in comparison of ultrasonography in comparison to MRI, 100% specificity and product positive predictive value 75% sensitivity, 50% negative predictive diagnostic accuracy of 0.8. The standard reference for diagnosis was taken as MRI in our study. When USG findings were compared with MRI it was observed the diagnostic accuracy of ultrasonography was significant in comparison to MRI. The sensitivity, specificity, PVV and NPV as I already mentioned and the diagnostic accuracy was 80%. Here we have images of T2 coronal fat suppressed images where you see a full thickness tear of the supraspinate distendant at this insertion with retraction of fibers and you see a hypoechoic area in the ultrasound image which shows the site of supraspinate distendant insertion. Here we have a GRE-Axial MRI image shows an evolution here of the subcapillary standard with the dislocation of the bicep stand on and ultrasound shows full thickness tear of the subcapillary stand on. Next we have T1 coronal oblique MRI and ultrasound images of the tendinosis of the supraspinates muscle here. You can see the altered echogenicity here and the hyperintensity here. Next you see the ultrasound where a hypoechoic area on the articular surface of the supraspinate distendant near its insertion and also a hyperintensity at the articular aspect of the supraspinate distendant near its insertion. My study conclusion in our study most commonly involved tendon was supraspinates followed by subscapularis and then infraspinates with terrace minor and biceps tendon least commonly affected. And among the rotator cuff tears partial tears were about 57.5% and they were more common than a full thickness tear. Among the partial tear most common was where the articular surface tears were about 75% followed by basal tears in 10% and intrasubstant tears in 10%. The age of the patient with rotator cuff disorders range between 23 to 62 years with a mean of 45 plus or minus 2.06 years with males affected more than females. Dominant arm about 97% affected more than the non-dominant arm with all of the cases showing history of trauma with rotator cuff injuries, depicting the fact that increasing age, male gender, dominant arm and history of trauma were predisposing factors for rotator cuff tears. Patients with decreased range of movement had rotator cuff tears in about 65% of all the cases, depending the fact that decreased range of motion is a manifestation of the death. In our study, 57.5% of the patients with joint effusion and 45% of the patients with bursal fluid show tears in the cuff, tendon depicting the fact the presence of joint effusion or bursal fluid is a marker of rotator cuff tears. In our study, most common acromion type was type 2 followed by type 3 combined with 70% of these patients showing rotator cuff tears. Thus in this study, the rotator cuff tears were more common in type 2 and type 3 acromion. The rotator cuff tears were more sensitive than ultrasound protecting the peri bisapital tendon fluid, joint effusion, sub deltoid sub acromial sub curcoid bursal fluid impingement. Labral tears, acromion type and adjacent bone genus were detected only by MRI. In this study, ultrasound had a sensitivity of 75% specificity of 100% positive predictive value of 100% negative predictive value of 50% and diagnostic accuracy of 80% and a copper degree of agreement of 0.37. These results are just that the positive sonographic reading is more reliable than a negative one, and is still less reliable and detecting rotator cuff tears than MRI, which has the highest diagnostic accuracy. That is all the references for my study.