Rotator cuff repair complicated by infection

Case contributed by Jason Paek
Diagnosis certain

Presentation

Purulent drainage from a posterior left shoulder sinus tract for over 1 year.

Patient Data

Age: 70 years
Gender: Male

Left shoulder

x-ray

Left shoulder radiographs show large erosion/defect in the greater tuberosity with well-defined margins. Additional lucencies in the humeral head and neck with tubular appearance. There is periosteal reaction along the anterior border of the proximal humeral diaphysis on the axillary view. There is a tiny 3 mm linear radiodensity in the soft tissues superior to the greater tuberosity. Glenohumeral joint osteoarthritis is also noted.

Left shoulder

mri

Left shoulder MR images notable for extensive T1 hypointensity and T2 hyperintensity in the proximal humerus. Postsurgical changes of rotator cuff repair with two suture anchors in the greater tuberosity noted. There is fluid signal and bony erosion/defect around the suture anchors in the greater tuberosity, tunneling through the proximal humerus, breaking through the cortex at the anteromedial humeral head-neck junction, and extending in the soft tissues along the inferior glenohumeral joint to the posterior subcutaneous tissues. There is also one suture anchor migrated inferiorly into the humeral neck and another suture anchor displaced further anteromedially into the axillary soft tissues.

There is an interstitial tear of the anterior supraspinatus tendon. Fluid signal also seen along the superior aspect of the supraspinatus muscle.

There is a partial tear of the proximal long head of the biceps tendon.

Case Discussion

The patient is a 70 year old male who presented to the emergency department for purulent drainage from a sinus tract in the posterior shoulder. The patient stated that the drainage had been ongoing for over 1 year. He denied fever or chills. Surgical history was notable for a left rotator cuff repair approximately 8 years prior to presentation. The drainage was initially presumed to be due to hidradenitis suppurativa and the patient underwent surgical excision of the draining left axillary wound sinus. Intraoperatively, the sinus tract was found to follow deep into the axilla toward the rotator cuff.

This is a case of rotator cuff repair with rare complication of infection, not of the joint but of the hardware/bone, with suture anchors migrating inferiorly through the bony defect, including one that has migrated through a cloaca (cortical defect) into the soft tissues. On physical exam, this patient had a visible draining sinus tract in the posterior shoulder. The MRI findings along with the clinical findings are diagnostic of infection. The radiographs are less specific, with malignancy being a differential consideration based on the radiographs. This patient's risk factors included old age and male sex 1

Case courtesy of Dr. Emad Allam - Assistant Professor of Radiology, Loyola University Medical Center.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.