Defining surgical indications in subcoracoid cysts: 3D volumetric analysis and elastography guide tendon-preserving arthroscopic decompression

This prospective cohort study evaluates the impact of arthroscopic subcoracoid cyst decompression on subscapularis tendon elasticity and functional outcomes, while defining prognostic thresholds for surgical decision-making. This prospective cohort study evaluated 46 patients (45-80 years) undergoing arthroscopic decompression for symptomatic subcoracoid cyst. Inclusion criteria required MRI-confirmed subcoracoid cysts and failure of ≥ 6 months of non-operative therapy, while exclusion criteria encompassed prior ipsilateral shoulder surgery, advanced osteoarthritis (Samilson-Prieto grade ≥ 2), irreparable rotator cuff tears, and subscapularis-repaired patients. Pre- and postoperative assessments included 3D MRI cyst volumetry using 3D Slicer 5.6.2, shear-wave elastography (SWE) for tendon stiffness (kPa/m/s) at five anatomical landmarks, coracohumeral distance (CHD) and patient-reported outcomes (QuickDASH, ASES scores). Statistical analyses utilized paired/independent t-tests, non-parametric equivalents, Spearman correlations, and multivariate regression (SPSS 25.0, Python 3.9), with significance set at p < 0.05. The cohort (mean age: 59.2 ± 7.5 years; 67.4% female) exhibited significant postoperative improvements. Cyst volume decreased by 72%, from 2.2 ± 1.5 cm³ to 0.62 ± 0.63 cm³ (p < 0.001), with residual cysts (> 0.5 cm³) correlating with persistent coracohumeral distance narrowing (p < 0.05). Subscapularis tendon stiffness, quantified via SWE, declined by 31% (38.6 ± 8.2 kPa to 26.6 ± 5.4 kPa, p < 0.001), with greater elasticity gains observed in patients with larger baseline cysts (> 2.2 cm³; p < 0.05). Functional outcomes improved markedly: QuickDASH scores decreased by 53% (64.16 ± 20.42 to 30.06 ± 17.77) and ASES scores increased by 109% (38.06 ± 19.72 to 79.59 ± 12.08; p < 0.001). A preoperative cyst volume threshold of 2.2 cm³ predicted advanced intraoperative pathology (Lafosse Stage I/II tears in 78.2% of cases; p < 0.05), while postoperative Lafosse stage downgrading (78% to Stage 0; p < 0.001) correlated with coracohumeral distance expansion (p < 0.05). Multivariate regression identified cyst volume (p < 0.05) and surgical decompression (p < 0.05) as independent predictors of elastographic recovery. Residual cyst volumes (> 0.5 cm³) attenuated both biomechanical (p < 0.05) and functional improvements (p < 0.05), underscoring the imperative for complete intraoperative excision. Arthroscopic subcoracoid cyst decompression restores subscapularis tendon elasticity and shoulder function, with larger cysts (> 2.2 cm³) signaling advanced pathology. Complete cyst excision is critical, as residual volumes impair recovery. SWE emerges as a vital biomarker for postoperative monitoring.