Frantz Langlais

Prediction of rotator cuff repair results by magnetic resonance imaging.

Thirty chronic rotator cuff tears were repaired consecutively and evaluated prospectively using a precise anatomic description of the tear that included the rotator interval, the Constant functional score, and an assessment of the tendon state and the atrophy of the supraspinatus muscle by preoperative and postoperative magnetic resonance imaging. Early correlations (mean followup, 21.1 months) attempted to define predictive factors of the final outcome of the repair, physical factors indicative of final tendon state, and postoperative evolution of supraspinatus atrophy. Magnetic resonance imaging oblique sagittal views showed that supraspinatus atrophy correlated with the sagittal and coronal extent of the tear and represented a strong predictive factor of postoperative retearing. At followup, 15 (50%) cuffs were continuous and thick, seven (23%) were continuous but thin, and six (20%) were retorn. Two (7%) cuffs had been repaired only partly. In the group with a persistent tear, flexion strength and differential Constant score were correlated with the final tendon state with no excellent or good results, and with less than 4 kg of strength. Supraspinatus atrophy improved in 18 of the 22 postoperative continuous cuffs, but never decreased in persistent tears, although there was pain relief and functional gain.

Atrophy of the supraspinatus belly. Assessment by MRI in 55 patients with rotator cuff pathology.

A study of 5 fresh cadaveric shoulders demonstrated that an oblique-sagittal plane which crosses the scapula through the medial border of the coracoid process offers a view of the supraspinatus fossa mostly limited by bone. This view could easily be reproduced by MRI and we called it the Y-shaped view. It allowed a reliable measurement of supraspinatus muscle atrophy by the calculation of the occupation ratio (R) which is the ratio between the surface of the cross-section of the muscle belly and that of the fossa. This ratio was calculated in a prospective study based on 55 shoulders divided into 3 groups with different rotator cuff status: group I, 15 controls; group II, 10 degenerative cuffs, without tears; group III, 30 operated tears. There was no difference between groups I (mean ratio 0.7) and II (mean ratio 0.62), but the ratio was decreased in group III (mean ratio 0.44), in which the extent of the tear in both the sagittal and coronal planes aggravated the muscle atrophy. We propose a three-stage classification to improve indications for rotator cuff tear treatment.

Long-term results of hemipelvis reconstruction with allografts.

Thirteen patients underwent pelvic reconstruction by massive allografts after resection of a malignant tumor (primary in 10 patients and metastatic in three patients). In 10 patients, the tumor involved the acetabulum and iliac wing and was reconstructed by a hemipelvic allograft; this was accompanied by a hip arthroplasty in nine of the patients. In three patients, a femoral metaphyseal tumor extending to the acetabulum was reconstructed by a total acetabular allograft and a composite proximal femoral allograft prosthesis. Two patients (20%) had a local recurrence, and one patient died of massive pulmonary embolism. Postoperative complications were one infection and two dislocations. At 3 years, one cup loosening and one acetabular fatigue fracture required surgery. The functional result was excellent in two patients whose gluteal muscles could be spared, good (allowing a normal family life) in six patients, fair in two patients, and poor in two patients. Seven patients had a Musculoskeletal Tumor Society rating greater than 60% of normal (the mean rating in 12 patients was 56.4%). No evidence of long-term deterioration was seen in the patients with the longest followups (7, 8, 10, and 14 years). Reconstruction of the hemipelvis with massive allografts and arthroplasty is a rewarding but demanding procedure and should be reserved for physically active patients who are in good general health and are expected to have a response to anticancer therapy. The procedure is particularly suitable for patients with primary tumors.

Long-term results of allograft composite total hip prostheses for tumors

The functional results of standard reconstruction prostheses are impaired by instability because of poor muscular reinsertion, especially of the gluteal muscles. In 21 patients, composite hip prostheses including proximal femoral allografts were used after primary malignant tumor resection. Ten reconstructions used combined bone-tendon allografts that allowed reinsertion of the gluteal muscles to the allograft tendons. None of the 21 patients had dislocation or infection. Ten patients died within 2 years of surgery without complications requiring reoperations. The mean followup in the 11 other patients was 10 years. Eight patients had reoperation: four for loosening (two at 3 years, two at 11 and 12 years), and four had autologous graftings for nonunion of the trochanter or of the distal graft-bone interface. Evaluation of function in the 11 patients with followups ranging from 4 to 15 years showed an average Musculoskeletal Tumor Society score of 77%. Satisfactory strength of the abductor muscles was achieved by reinsertion of the trochanter or by suture of the patients gluteal muscles with the combined tendon–bone allograft. At long-term, radiologically, the bony allograft showed no change in five patients, very mild resorption in five, and severe resorption in one. Stem fixation was excellent in 10 patients and fair in one. Comparison between the functional results of reconstruction prostheses versus composite prostheses showed a significant improvement with the composite prosthesis. In the authors’ institution, at 10 years, the mechanical survival of composite prostheses was 81%, as compared with only 65% for reconstruction prostheses.

Dysplasie et conflits de hanche de 20 à 50 ans

Resume Dans les douleurs anterieures de la hanche de l’adulte jeune (20 a 50 ans), deux pathologies jouent un role essentiel : la coxarthrose secondaire sur maladie luxante de hanche et les conflits femoro-acetabulaires. Ce symposium a d’une part analyse le resultat a long terme de la chirurgie conservatrice (285 osteotomies et butees a 15 ans) ; d’autre part, il a individualise differents syndromes douloureux aigus anterieurs de hanche, notamment par conflit femoro-acetabulaire et par pathologie du labrum. Dans la dysplasie de hanche, 56 butees isolees, 100 osteotomies femorales de varisation +/- butees, et 127 osteotomies de Chiari ont ete revues avec un recul minimum de 10 ans. Seuls 15 % des patients ont ete perdus de vue avant 10 ans, et le recul moyen etait de 15 ans. Ont ete consideres comme bons resultats les hanches avec un score PMA de 15 a 18 a 15 ans. Les 3 facteurs principaux de pronostic favorable sont : une correction complete de la dysplasie femorale et cotyloidienne; un âge a l’operation de moins de 40 ans ; une arthrose stade 1 ou 2 (De Mourgues et Patte). Dans les dysplasies acetabulaires isolees avec 3 facteurs favorables (pas de coxa valga, âge 40 ans ou l’arthrose > 2. Les resultats sont equivalents pour les osteotomies de varisation +/- butees (85 % de bons resultats a 15 ans, avec 3 facteurs de bon pronostic). Ils sont egalement favorables avec le Chiari, mais cette intervention comporte environ 12 % de complications et 25 % de boiteries persistantes. Avec 85 % de bons resultats a 15 ans, se prolongeant bien souvent au-dela de 20 ans, la chirurgie conservatrice vers 30-35 ans a de meilleurs resultats fonctionnels et une meilleure longevite que la PTH, et preserve toutes les possibilites ulterieures de chirurgie prothetique. En ce qui concerne les conflits aigus douloureux de hanche, les aspects cliniques et d’imagerie des differents syndromes de derangement douloureux anterieur ont ete precises : conflit femoro-cotyloidien par came (et par pince), pathologie du labrum dans la dysplasie. Ils ont ete differencies d’autres butoirs secondaires (par malposition en anteflexion du bassin, par differents types de coxopathie – sportif, coxa retrorsa, etc.–). Des exemples cliniques typiques ont permis d’illustrer les differents types d’imagerie recommandes et les orientations therapeutiques. Les resultats des participants ont ete presentes, tant pour la chirurgie a ciel ouvert que dans 60 cas d’arthroscopie.

Functional Results Following Resection of Tumors in the Proximal Humerus

The authors reviewed 46 cases of resection of the upper humerus for tumor. Of the 46 tumors, 90% were malignant. The average follow-up was 5 years and the functional evaluation according to Enneking’s classification was excellent in one good in seven, fair in 15, and poor in 23. Mechanical complications occurred in 11 cases and reoperation was necessary in eight of these cases.

The Use of a Cemented Dual Mobility Socket to Treat Recurrent Dislocation: A Prospective Evaluation

Methods: A prospective series included 51 patients (39 females, 12 males) with a mean age of 71.3 ± 11.5 years presenting with recurrent dislocation (mean 3.3 ± 1.4). The mean number of previous THA was 1.8 ± 1.1 (1-6). A single cup design was used (Medial cup, Aston Medical, France) consisting of a stainless steel outer shell with grooves with a highly polished inner surface articulating with a mobile intermediate polyethylene component with an opening diameter smaller than the 22.2 mm femoral head. No locking ring or other means of constraint was used.