Daniel Goutallier

Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.

A preoperative computed tomography (CT) scan grading muscular fatty degeneration in five stages was done in 63 patients scheduled for repair of a torn rotator cuff. The results were compared with postoperative evaluation done after a mean of 17.7 months in 57 patients. Postoperative arthrographies were also performed in 56 patients. Preoperative CT scans demonstrated that infraspinatus fatty degeneration can occur in the presence of large anterosuperior tears even when the infraspinatus tendon is not torn; it worsens with time. The subscapularis rarely degenerates, and when it does it degenerates moderately, even when its tendon is not torn. After an effective surgical repair, moderate supraspinatus degeneration regressed in six of 14 patients; that of the infraspinatus never regressed but rather, increased, in three patients. One of these deteriorations, involving both supra- and infraspinatus, could probably be attributed to a partial subscapular nerve injury. Infraspinatus degeneration was correlated with functional pre- and postoperative impairment of active external rotation. Recurrence of infraspinatus tear was never observed, but recurrence occurred in 25% of supraspinatus repairs. Infraspinatus degeneration had a highly negative influence on the outcome of supraspinatus repairs. It seems preferable to operate on wide tears before irreversible muscular damage takes place.

Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears.

Two hundred twenty shoulders with a rotator cuff tear repaired by simple tendon-to-bone suture were analyzed to determine whether the severity of presurgical fatty degeneration had an influence on their anatomic and functional outcome. Fatty degeneration was evaluated for each muscle with the 5-stage grading system developed by Goutallier et al. A global fatty degeneration index (GFDI), the mean value of the 3 muscles, was calculated for each shoulder. Cuff integrity was evaluated by magnetic resonance imaging (116 cases) or computed arthrotomography scan (104 cases) at a mean 37 months follow-up, and functional outcomes were evaluated with the Constant score. A recurrent tear was found in 79 cases (36%) and was more frequently encountered in posterosuperior tears. The likelihood of a recurrent tear was greater for tendons whose muscle showed fatty degeneration greater than grade 1. Fatty degeneration of the infraspinatus or subscapularis muscles had an influence on supraspinatus tendon outcome. A GFDI lower than 0.5 was necessary to yield less than 25% retears. The mean global Constant score was 75 at revision, significantly lower when a retear was present (70.5 versus 77.5). In the subgroup of watertight cuffs, it was lower when GFDI was higher. Fatty degeneration is an important prognostic factor in rotator cuff surgery.

Revision total hip arthroplasty performed after fracture of a ceramic femoral head. A multicenter survivorship study.

Background: The alumina ceramic femoral head was introduced for total hip arthroplasty approximately thirty years ago. One of its main drawbacks was the risk of implant fracture. The aim of this study was to examine the results of revision total hip replacement performed specifically to treat a fracture of a ceramic femoral head and to identify technical factors that affected the outcomes. Methods: One hundred and five surgical revisions to treat a fracture of a ceramic femoral head, performed at thirty-five institutions, were studied. The patients were examined clinically by the operating surgeon at the time of the last follow-up. The surgeon provided the latest follow-up radiographs, which were compared with the immediate postoperative radiographs. The success of the revisions was assessed with Kaplan-Meier survivorship analysis, with the need for repeat revision as the end point. We evaluated the complication rate and radiographic changes indicative of implant loosening. The average duration of follow-up between the index revision and the last clinical and radiographic review was 3.5 years (range, six months to twenty years). Results: Following the revisions, radiographic evidence of cup loosening was seen in twenty-two hips (21%) and radiographic evidence of femoral loosening was seen in twenty-two (21%). One or several repeat revisions were necessary in thirty-three patients (31%) because of infection (four patients), implant loosening (twenty), osteolysis (eight), or fracture of the revision femoral head component (one). The survival rate at five years was 63% (95% confidence interval, 51% to 75%). The survival rate was significantly worse when the cup had not been changed, when the new femoral head was made of stainless steel, when a total synovectomy had not been done, and when the patient was less than fifty years old. Conclusions: Fracture of a ceramic femoral head component is a rare but potentially serious event. A suitable surgical approach, including total synovectomy, cup exchange, and insertion of a cobalt-chromium or new ceramic femoral ball minimizes the chance of early loosening of the implants and the need for one or more repeat revisions. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Long-term functional and structural outcome in patients with intact repairs 1 year after open transosseous rotator cuff repair

HYPOTHESISnTendon-to-bone suture and a fatty degeneration index (FDI) <or= 2 are required to achieve an intact cuff in the mid-term. Our primary objective was to determine the structural and functional long-term outcomes of repaired cuffs that were intact after one year.nnnMATERIALS AND METHODSnWe studied 30 cuffs with FDI <or= 2 at surgery and no tear one year after tension-free tendon-to-bone suture. Mean follow-up was 9 +/- 0.8 years. Gross tendon-stump lesions were excised prior to repair.nnnRESULTSnRe-tear after one year was rare: only one cuff showed a recurrent tear. In the 29 intact cuffs, mean un-weighted Constant score and sub-scores improved significantly (P values, < .0001- .0002; final Constant score = 77) for two years then remained stable. FDI values increased during the first year and then remained stable. Mild osteoarthritis was noted in one shoulder at last follow-up.nnnCONCLUSIONnFinal functional outcomes correlated significantly to FDI at baseline and last follow-up. Tension free tendon-to-bone suture is effective functionally and structurally at nine years follow-up provided the FDI at surgery is <or= 2 and the repair is intact after one year.nnnLEVEL OF EVIDENCEnLevel 3; Retrospective cohort therapeutic study.

Macroscopic and histological assessments of the cruciate ligaments in arthrosis of the knee

We examined the macroscopic appearance of both cruciate ligaments in 52 knees during knee replacement. It was classsified as normal, abnormal or ruptured. The ligaments were also evaluated histologically: stage 0 (normal), stage 1 (degeneration of < 1/3 of the collagen fibers), stage 2 (degeneration of 1/3-2/3) and stage 3 (> 2/3). 17 anterior cruciate ligaments (ACL) were normal, 14 were abnormal and 21 ruptured. All the posterior cruciate ligaments (PCL) were normal. 14 ACL were stage 0, 6 stage 1, 8 stage 2 and 24 were stage 3. 22 PCL were stage 0, 14 stage 1, 13 stage 2 and 3 were stage 3. When the ACL was abnormal or ruptured, the PCL was stage 0 only in one fourth of the cases. The long-term results of TKR retaining the PCL should be better if the ligament is strong. The intraoperative assessment of the macroscopic appearance of the ACL reflects the histological state of the PCL.

Influence of Lower-Limb Torsion on Long-Term Outcomes of Tibial Valgus Osteotomy for Medial Compartment Knee Osteoarthritis

BACKGROUNDnThe results of tibial osteotomy used to treat osteoarthritis of the medial compartment of the knee deteriorate over time even when the initial correction is optimal. Studies have shown that tibial and femoral torsion and the femorotibial index (tibial torsion minus femoral torsion) contribute, together with coronal malalignment, to the development of single-compartment knee osteoarthritis. The objective of our study was to evaluate the impact of femoral and tibial torsion and of coronal realignment on the long-term clinical and radiographic outcomes of valgus tibial osteotomy.nnnMETHODSnA function score was calculated for sixty-eight patients at a mean of thirteen years after the osteotomy. Anteroposterior single-leg-stance radiographs were used to evaluate loss of the femorotibial joint space. Goniometry was used to measure coronal malalignment preoperatively, at one year, and at the time of the last follow-up, and postoperative computed tomography was performed to measure femoral anteversion and tibial torsion and to calculate the femorotibial index. We looked for associations linking body mass index, initial loss of joint space, coronal malalignment, femoral and tibial torsion, the femorotibial index, and functional outcomes.nnnRESULTSnWorse outcomes were associated with changes in coronal alignment (>/=2 degrees ) over time, which were associated with deterioration of the femorotibial space. Femoral anteversion was significantly greater in patients in whom valgus increased over time than in those in whom valgus decreased over time. Stability of coronal alignment seemed to be dependent on a linear relationship between the femorotibial index and the degree of postoperative realignment. A body mass index of >25 kg/m(2) was associated with a long-term loss of coronal realignment. Preoperative loss of the medial femorotibial joint space, coronal alignment at one year, and age were not associated with secondary malalignment or functional outcomes.nnnCONCLUSIONSnLong-term success of a valgus tibial osteotomy is related to the stability over time of the postoperative coronal realignment. Therefore, the results of our study suggest that modifying the realignment according to the extent of femoral anteversion may improve long-term outcomes.

Surgical Treatment of Destructive Cervical Spondyloarthropathy With Neurologic Impairment in Hemodialysis Patients

Study Design. We have retrospectively reviewed 11 chronic hemodialysis patients with cervical destructive spondyloarthropathy responsible for neural impairment 1 year after surgery and at last follow-up. Objective. To evaluate clinical and radiologic outcomes, and necessity of vertebral block excision. Summary of Background Data. Destructive spondyloarthropathy of the cervical spine is associated with long-term hemodialysis for chronic kidney failure. Spinal cord compression and neurologic troubles occur in a few cases. Surgical treatment remains controversial because these are debilitated patients with multiple organ failures. Methods. All 11 patients had unstable cervical spondylolisthesis, and 10 had kyphotic vertebral fusion involving at least 2 vertebrae. We performed interbody bone grafting (cement in 1 case) and stabilized with a plate. In 6 of the 10 patients with vertebral block, excision of the block was performed. Results. No patients were lost to follow-up. One patient died 2 days after the operation. There were 2 other patients who required early surgical revision (i.e., a corporectomy followed by early graft expulsion). Bone healing settled in all patients. One year after surgery, patients had almost complete resolution of the pain and satisfactory neurologic recovery. Improvement was evaluated according to the Nurick classification. Conclusion. Functional and neurologic results were similar whether the patients did or did not undergo vertebral block excision, suggesting that stabilizing the unstable level may be sufficient in patients with neurologic impairment. Excision of spontaneous vertebral blocks should be avoided to minimize the morbidity of surgery in these debilitated patients with a limited life expectancy.

Total shoulder arthroplasty using the superior approach: influence on glenoid loosening and superior migration in the long-term follow-up after Neer II prosthesis installation.

Glenoid component loosening and superior humeral translation are common after Neer II total shoulder arthroplasty using the anterior approach. To determine whether the superior approach reduced these complications, we retrospectively reviewed 20 shoulders in 16 patients. Both components were cemented. Patient satisfaction, unweighted Constant score, and imaging studies were evaluated at a mean of 3.5 years and at a mean of 11.1 years. Fourteen patients were satisfied or very satisfied. The mean unweighted Constant score improved from 25/100 preoperatively to 57/100 after 3.5 years and to 51/100 after 11.1 years. Pain relief contrasted with low strength. Radiolucent lines appeared around 95% of glenoid components and 20% of humeral stems. Computed tomography showed severe glenoid osteolysis in 3 of 13 shoulders. Humeral superior translation did not occur. This study confirms the glenoid component fixation issue. The superior approach may reduce the risk of humeral superior translation and radiologic glenoid component loosening.

Coracoid process x-ray investigation before Latarjet procedure: a radioanatomic study.

BACKGROUNDnThe purpose of this study was to determine whether a preoperative radiologic assessment of the coracoid process is predictive of the amount of bone available for coracoid transfer by the Latarjet procedure.nnnMATERIALnThirty-five patients with anterior instability undergoing a Latarjet procedure were included. A preoperative radiologic assessment was performed with the Bernageau and true anteroposterior (true AP) views.nnnMETHODSnThe length of the coracoid process was measured on both radiographic views and the values were compared with the length of the bone block during surgery. Statistical analysis was carried out by ANOVA and Wilcoxon tests (P < .05).nnnRESULTSnOn radiologic examination, the mean coracoid process length was 29 ± 4 and 33 ± 4 mm on the Bernageau and true AP views, respectively. The mean bone block length during surgery was 21.6 ± 2.7 mm. A significant correlation was found (P = .032) between the coracoid process length on the true AP view and the intraoperative bone block length.nnnDISCUSSIONnPreoperative planning for the Latarjet procedure, including graft orientation and screw placement, requires knowledge of the length of coracoid bone available for transfer. This can be facilitated with the use of preoperative standard radiographs, thus avoiding computed tomography. This planning allows the detection of coracoid process anatomic variations or the analysis of the remaining part of the coracoid process after failure of a first Latarjet procedure to avoid an iliac bone graft.nnnCONCLUSIONnRadiologic preoperative coracoid process measurement is an easy, reliable method to aid preoperative planning of the Latarjet procedure in primary surgery and reoperations.

Magnetic resonance imaging findings in shoulders of hemodialyzed patients.

Twenty two patients (24 shoulders) who had undergone hemodialysis for a mean of 13.4 years, and who had reported chronic shoulder pain for > 6 months, were examined by magnetic resonance imaging (MRI), including T1 and T2 echo gradient images in the frontal plane and T1 images after gadolinium. An increase in thickness of the rotator cuff as well as synovitis and bursitis were documented. Twenty shoulders demonstrated a mean thickness of 8.05 mm. Most often, the signal intensity of T2 and T1 weighted images was intermediate, and T1 images failed to show an uptake of gadolinium. Of the 24 shoulders, 20 had subacromial subdeltoid bursitis and 21 had glenohumeral synovitis. These results indicate that MRI is of help in the early diagnosis of arthropathy in long term hemodialyzed patients. Magnetic resonance imaging findings are more precise than those of ultrasound, particularly for thickness measurements. Moreover, MRI films are easier to read and permit the detection of synovial involvements. The therapeutic value of MRI lies in the fact that it can isolate the two principal causes of shoulder pain in hemodialyzed patients. The increase in cuff thickness leading to impingement syndrome can be treated by surgical decompression; the synovitis can be treated by radioisotope synovectomy.