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Fatty degeneration of the rotator cuff muscles on pre- and postoperative CT arthrography (CTA): is the Goutallier grading system reliable?

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To retrospectively evaluate fatty degeneration (FD) of rotator cuff muscles on CTA using Goutallier’s grading system and quantitative measurements with comparison between pre- and postoperative states.

Materials and methods

IRB approval was obtained for this study. Two radiologists independently reviewed pre- and postoperative CTAs of 43 patients (24 males and 19 females, mean age, 58.1 years) with 46 shoulders confirmed as full-thickness tears with random distribution. FD of supraspinatus, infraspinatus/teres minor, and subscapularis was assessed using Goutallier’s system and by quantitative measurements of Hounsfield units (HUs) on sagittal images. Changes in FD grades and HUs were compared between pre- and postoperative CTAs and analyzed with respect to preoperative tear size and postoperative cuff integrity. The correlations between qualitative grades and quantitative measurements and their inter-observer reliabilities were also assessed.


There was statistically significant correlation between FD grades and HU measurements of all muscles on pre- and postoperative CTA (p < 0.05). Inter-observer reliability of fatty degeneration grades were excellent to substantial on both pre- and postoperative CTA in supraspinatus (0.8685 and 0.8535) and subscapularis muscles (0.7777 and 0.7972), but fair in infraspinatus/teres minor muscles (0.5791 and 0.5740); however, quantitative Hounsfield units measurements showed excellent reliability for all muscles (ICC: 0.7950 and 0.9346 for SST, 0.7922 and 0.8492 for SSC, and 0.9254 and 0.9052 for IST/TM). No muscle showed improvement of fatty degeneration after surgical repair on qualitative and quantitative assessments; there was no difference in changes of fatty degeneration after surgical repair according to preoperative tear size and post-operative cuff integrity (p > 0.05). The average dose-length product (DLP, mGy · cm) was 365.2 mGy · cm (range, 323.8-417.2 mGy · cm) and estimated average effective dose was 5.1 mSv.


Goutallier grades correlated well with HUs of rotator cuff muscles. Reliability was excellent for both systems, except for FD grade of IST/TM muscles, which may be more reliably assessed using quantitative measurements.

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  1. Gladstone JN, Bishop JY, Lo IKY, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med. 2007;35:719–28.

    Article  PubMed  Google Scholar 

  2. Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Should Elbow Surg. 2003;12:550–4.

    Article  Google Scholar 

  3. Liem D, Lichtenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging of arthroscopic supraspinatus tendon repair. J Bone Joint Surg. 2007;89:1770–6.

    Article  PubMed  Google Scholar 

  4. Mellado J, Calmet J, Olona M, et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings. AJR. 2005;184:1456–63.

    Article  PubMed  CAS  Google Scholar 

  5. Oh JH, Kim SH, Ji HM, Jo KH, Bin SW, Gong HS. Prognostic factors affecting anatomic outcome of rotator cuff repair and correlation with functional outcome. Arthroscopy. 2009;25:30–9.

    Article  PubMed  Google Scholar 

  6. Uhthoff HK, Matsumoto F, Trudel G, Himori K. Early reattachment does not reverse atrophy and fat accumulation of the supraspinatus—an experimental study in rabbits. J Orthop Res. 2003;21:386–92.

    Article  PubMed  Google Scholar 

  7. Burkhart SS, Barth JRH, Richards DP, Zlatkin MB, Larsen M. Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration. Arthroscopy. 2007;23:347–54.

    Article  PubMed  Google Scholar 

  8. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg. 2008;82:505–15.

    Google Scholar 

  9. Cole BJ, McCarty III LP, Kang RW, Alford W, Lewis PB, Hayden JK. Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up. J Should Elbow Surg. 2007;16:579–85.

    Article  Google Scholar 

  10. DeFranco MJ, Bershadsky B, Ciccone J, Yum JK, Iannotti JP. Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results. J Should Elbow Surg. 2007;16:759–65.

    Article  Google Scholar 

  11. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures: pre-and postoperative evaluation by CT scan. Clin Orthop. 1994;304:78–83.

    PubMed  Google Scholar 

  12. Henn III RF, Kang L, Tashjian RZ, Green A. Patients’ preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg. 2007;89:1913–9.

    Article  PubMed  Google Scholar 

  13. Sherman SL, Lyman S, Koulouvaris P, Willis A, Marx RG. Risk factors for readmission and revision surgery following rotator cuff repair. Clin Orthop. 2008;466:608–13.

    Article  PubMed  Google Scholar 

  14. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg. 2007;89:953–60.

    Article  PubMed  Google Scholar 

  15. Oh JH, Kim SH, Choi JA, Kim Y, Oh CH. Reliability of the grading system for fatty degeneration of rotator cuff muscles. Clin Orthop. 2010;468:1558–64.

    Article  PubMed  Google Scholar 

  16. Pfirrmann CWA, Zanetti M, Weishaupt D, Gerber C, Hodler J. Subscapularis tendon tears: detection and grading at MR arthrography. Radiology. 1999;213:709–14.

    PubMed  CAS  Google Scholar 

  17. Tingart MJ, Apreleva M, Lehtinen JT, Capell B, Palmer WE, Warner JJP. Magnetic resonance imaging in quantitative analysis of rotator cuff muscle volume. Clin Orthop. 2003;415:104–10.

    Article  PubMed  Google Scholar 

  18. van de Sande MAJ, Stoel BC, Obermann WR, Tjong a Lieng JGS, Rozing PM. Quantitative assessment of fatty degeneration in rotator cuff muscles determined with computed tomography. Invest Radiol. 2005;40:313–9.

    Article  PubMed  Google Scholar 

  19. Zanetti M, Gerber C, Hodler J. Quantitative assessment of the muscles of the rotator cuff with magnetic resonance imaging. Invest Radiol. 1998;33:163–70.

    Article  PubMed  CAS  Google Scholar 

  20. Tae SK, Oh JH, Kim SH, Chung SW, Yang JY, Back YW. Evaluation of fatty degeneration of the supraspinatus muscle using a new measuring tool and its correlation between multidetector computed tomography and magnetic resonance imaging. Am J Sports Med. 2011;39:599–606.

    Article  PubMed  Google Scholar 

  21. Oh JH, Kim JY, Choi JA, Kim WS. Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: comparison with magnetic resonance imaging with arthroscopic correlation. J Should Elbow Surg. 2010;19:14–20.

    Article  Google Scholar 

  22. Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Should Elbow Surg. 1998;8:599–605.

    Article  Google Scholar 

  23. Thomazeau H, Rolland Y, Lucas C, Duval JM, Langlais F. Atrophy of the supraspinatus belly assessment by MRI in 55 patients with rotator cuff pathology. Acta Orthop. 1996;67:264–8.

    Article  CAS  Google Scholar 

  24. Kenn W, Bohm D, Gohlke F, Hummer C, Kostler H, Hahn D. 2D SPLASH: a new method to determine the fatty infiltration of the rotator cuff muscles. Eur Radiol. 2004;14:2331–6.

    Article  PubMed  Google Scholar 

  25. Pfirrmann CWA, Schmid MR, Zanetti M, Jost B, Gerber C, Hodler J. Assessment of fat content in supraspinatus muscle with proton MR spectroscopy in asymptomatic volunteers and patients with supraspinatus tendon lesions. Radiology. 2004;232:709–15.

    Article  PubMed  Google Scholar 

  26. Cicchetti DV, Sparrow SA. Developing criteria for establishing interrater reliability of specific items: applications to assessment of adaptive behavior. Am J Ment Defic. 1981;86:127–37.

    PubMed  CAS  Google Scholar 

  27. Nakagaki K, Ozaki J, Tomita Y, Tamai S. Function of supraspinatus muscle with torn cuff evaluated by magnetic resonance imaging. Clin Orthop Relat Res. 1995;318:144–151.

    Google Scholar 

  28. Fuchs B, Gilbart MK, Hodler J, Gerber C. Clinical and structural results of open repair of an isolated onetendon tear of the rotator cuff. J Bone Joint Surg Am. 2006;88:309–16.

    Article  PubMed  Google Scholar 

  29. Matsumoto F, Uhthoff HK, Trudel G, Loehr JF. Delayed tendon reattachment does not reverse atrophy and fat accumulation of the supraspinatus. An experimental study in rabbits. J Orthop Res. 2002;20:357–63.

    Article  PubMed  Google Scholar 

  30. Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop Relat Res. 1997;344:275–283.

    Google Scholar 

  31. Hata Y, Saitoh S, Murakami N, Kobayashi H, Kaito T, Kato H. Volume changes of supraspinatus and infraspinatus muscles after supraspinatus tendon repair: a magnetic resonance imaging study. J Should Elbow Surg. 2005;14:631–5.

    Article  Google Scholar 

  32. Gerber C, Schneeberger AG, Hoppeler H, Meyer DC. Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: a study in thirteen patients. J Should Elbow Surg. 2007;16:691–6.

    Article  Google Scholar 

  33. Rubino LJ, Stills Jr HF, Sprott DC, Crosby LA. Fatty infiltration of the torn rotator cuff worsens over time in a rabbit model. Arthroscopy. 2007;23:717–22.

    Article  PubMed  Google Scholar 

  34. Goodpaster BH, Kelley DE, Thaete FL, He J, Ross R. Skeletal muscle attenuation determined by computed tomography is associated with skeletal muscle lipid content. J Appl Physiol. 2000;89:104–10.

    PubMed  CAS  Google Scholar 

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This paper has been partially supported by the National Research Foundation (NRF) grant funded by the Korean government (MEST) (2010–0027294) and partially by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2012010896).

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The authors declare that they have no conflicts of interest.

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Correspondence to Jung-Ah Choi.

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Lee, E., Choi, JA., Oh, J.H. et al. Fatty degeneration of the rotator cuff muscles on pre- and postoperative CT arthrography (CTA): is the Goutallier grading system reliable?. Skeletal Radiol 42, 1259–1267 (2013).

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