H. Thomazeau

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.

Total shoulder arthroplasty - arthroplasty for glenohumeral arthropathies: results and complications after a minimum follow-up of 8 years according to the type of arthroplasty and etiology.

INTRODUCTION Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology. The aim of our study was to evaluate the rate of complications and the functional improvement with different types of shoulder arthroplasties after a minimum follow-up of 8 years. MATERIALS AND METHODS This was a multicenter retrospective study of 198 shoulders including 85 primary osteoarthritis of the shoulder, 76 cuff tear arthropathies, 19 avascular necrosis and 18 rheumatoid arthritis. Arthroplasties included 104 anatomic total shoulder arthroplasties (TSA), 77 reverse arthroplasties and 17 hemiarthroplasties. Ten patients had their arthroplasty revised, and 134 patients with TSA were able to be present at the final follow-up or provide information on their case. Function was evaluated by the Constant-Murley score and loosening by standard radiographs. RESULTS In the group with primary osteoarthritis of the shoulder, there were eight complications (11%) including six (8.3%) requiring implant revision. In the group of rotator cuff arthropathies, there were nine (14.7%) complications including four (6.5%) requiring implant revision. In the group with rheumatoid arthritis, there was one complication, and no surgical revision was necessary. There were no complications in the group with avascular necrosis. Glenoid migration occurred in 28.5% of anatomic TSA, and 3.4% of reverse arthroplasties. This difference was significant (P<0.001). The Constant-Murley score was significantly improved in all etiologies. CONCLUSIONS Glenohumeral arthropathies can be successfully treated by arthroplasty. Anatomic TSA was shown to be associated with a high risk of glenoid loosening at radiographic follow-up, which makes us hesitate to use the cemented polyethylene implant, especially in young patients. LEVEL OF EVIDENCE IV - Retrospective study.

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.

Is MRI useful to assess labral reduction following acute anterior shoulder dislocation

INTRODUCTION Better knowledge of the anatomical lesions following primary anterior dislocation of the shoulder could help to resolve the issue of the recommended position of immobilization. The aim of this study was to describe such early lesions and to evaluate labral reducibility in both external and internal rotation of the arm. PATIENTS AND METHODS Fifteen shoulders were investigated by MRI without intra-articular injection. The 15 patients (14 men and one woman) had a mean age of 28 years (range: 17-42 years). Labral lesions were classified on a system based on Gleyze and Habermeyers endoscopic assessment and reducibility was assessed on Itois criteria. RESULTS Constant hemarthrosis allowed an arthrogram type effect. The Hill-Sachs lesion was small in five cases, medium in eight cases and large in two. There were seven labral lesions of type I, seven of type II and one of type III. External rotation (mean: 30.6 degrees; range: 15 degrees-65 degrees), reduced the labrum in six cases (40%). DISCUSSION The present study failed to confirm the constant reduction of the labrum reported by Itoi, perhaps because external rotation was less than that obtained in his study (m=52 degrees; range: 35 degrees-81 degrees). Reduction was partly due to posterior migration of the hemarthrosis obtained by external rotation. CONCLUSION MRI assessment of labral reducibility after primary anterior shoulder dislocation may be considered for patients at high risk of recurrence, in order to decide the ideal position of immobilization. LEVEL OF EVIDENCE Level IV. Retrospective diagnostic study.

The human acromion viewed from an evolutionary perspective

The high prevalence of rotator cuff tendinopathy in modern humans may be partly related to the shape acquired by the scapula as species changed throughout evolution. Here, we compared the anatomic features of the scapula across members of the Hominoid group. The results support the hypothesis that the scapula of Homo sapiens sapiens exhibits distinctive anatomic characteristics compared to that of other Hominoids. We studied 89 scapulae from five species. For each scapula, we measured eight parameters and determined six index. We then compared the results across species. We identified two distinctive characteristics of the lateral aspect of the human scapula, namely, a lateral orientation of the glenoid cavity and a narrow coraco-acromial arch. Similar to the gorilla acromion, the human one is steeply sloped and, above all, larger and squarer than the acromion of other Hominoids. These features may explain, in part at least, the pathogenesis of rotator cuff tendinopathy in modern man.

Volumetric definition of shoulder range of motion and its correlation with clinical signs of shoulder hyperlaxity. A motion capture study

BACKGROUND Shoulder hyperlaxity (SHL) is assessed with clinical signs. Quantification of SHL remains difficult, however, because no quantitative definition has yet been described. With use of a motion capture system (MCS), the aim of this study was to categorize SHL through a volumetric MCS-based definition and to compare this volume with clinical signs used for SHL diagnosis. METHOD Twenty-three subjects were examined with passive and active measurement of their shoulder range of motion (SROM) and then with an MCS protocol, allowing computation of the shoulder configuration space volume (SCSV). Clinical data of SHL were assessed by the sulcus sign, external rotation with the arm at the side (ER1) >85° in a standing position, external rotation >90° in a lying position, and Beighton score for general joint laxity. Active and passive ER1, EIR2 (sum of external and internal rotation at 90° of abduction), flexion-extension, and abduction were also measured and correlated to SCSV. RESULTS Except for the sulcus sign, SCSV was significantly correlated with all clinical signs used for SHL. Passive examination of the different SROMs was better correlated to SCSV than active examination. In passive examination, the worst SROM was ER1 (R = 0.36; P = .09), whereas EIR2, flexion, and abduction were highly correlated to SCSV (P < .01). CONCLUSION SCSV appears to be an appealing tool for evaluation of SHL regarding its correlation with clinical signs used for SHL diagnosis. The sulcus sign and ER1 >85° in a standing position appear less discriminating and should be replaced by EIR2 measurement for SHL diagnosis.

Résultat de la butée coracoïdienne type Latarjet pour instabilité antérieure chronique de l'épaule : À propos de 74 cas

PURPOSE OF THE STUDY Results of the Latarjet procedure for chronic anterior shoulder instability using a coracoid block are known in terms of recurrence, but not in terms of apprehension. We studied a prospective consecutive series of shoulders treated with the Latarjet method in order to determine whether patients forget their shoulder or whether they are still bothered, particularly during sports activities. MATERIAL AND METHODS The series included 74 patients with chronic anterior shoulder instability treated with a coracoid block according to the Latarjet procedure. Sixty-nine were available for review and 66 had complete radiographic explorations (93.2%). The Duplay score was used to classify sports activities. Mean age was 26.5 years; 90% of the patients practiced sports. The surgical procedure was performed by the same operator for 78% of patients. The Duplay score and the Constant score were determined and standard x-rays (four views) were obtained. Statistical analysis was performed with the chi-square test. Multivariate analysis was then applied to the subpopulation presenting persistent apprehension. RESULTS Follow-up was at least 24 months, average follow-up 50 months. Four patients presented secondary dislocation and two subluxation; 85% of patients were satisfied, 6% were hesitant and 9% were dissatisfied. The Duplay score was: excellent (18.8%), good (49.9%), fair (20.2%) and poor (10.1%). External elbow rotation (RE1) was limited by 17.69 degrees compared with the other side. Eighty-seven percent of patients resumed their sports activity five months postoperatively on average; 34% presented persistent apprehension. This subpopulation was examined separately. Multivariate analysis demonstrated two significantly independent factors of persistent apprehension: recovery of RE1 at 30 days postop, and total recovery of R1 at last follow-up. The radiographies demonstrated degenerative lesions in 10.6% of patients. DISCUSSION The satisfaction rate of 85% and the 9% failure rate are similar to earlier reports. Our series was however exceptional in terms of an unusually high rate of persistent apprehension. Statistical analysis did not demonstrate a significant link between the presence of hyperlaxity and persistent apprehension. Nevertheless, in patients with hyperlaxity associated with chronic anterior shoulder instability, we associate Latarjet coracoid block with Neer capsuloplasty.Resume L’objectif du travail etait d’apprecier les resultats de l’intervention de Latarjet dans le traitement de l’instabilite anterieure chronique d’epaule. Il s’agit d’une etude retrospective et continue. Soixante-quatorze butees coracoidiennes ont ete realisees, 69 ont ete revues (92,2 %). Le recul minimum etait de 24 mois avec une moyenne de 50 mois. Quatre-vingt-dix patients etaient sportifs. L’intervention a ete realisee par le meme operateur dans 78 % des cas. Les scores de Duplay et Constant ont ete utilises. Quatre-vingt-cinq pour cent des patients etaient satisfaits, 6 % etaient hesitants, et 9 % mecontents. Six patients ont recidive. Selon le score de Duplay, on retrouvait 18,8 % d’excellents resultats, 49.2 % de bons resultats, 20,2 % de resultats moyens et 10,11 % de mauvais resultats. La rotation externe coude au corps (RE 1) a perdu 17,69 en moyenne. Le score de Constant moyen etait de 91,6 points. Trente-quatre pour cent des patients presentaient une apprehension persistante. La recuperation trop rapide de la RE 1 au 45 e jour post-operatoire (p = 0.03) et la recuperation totale de la rotation interne (p = 0.02) se sont averees statistiquement significatives d’apprehension persistante residuelle. Aucun critere d’hyperlaxite n’etait statistiquement lie. Radiographiquement, la butee etait normale dans 79 % des cas, avec 10,6 cas d’arthrose. Avec quatre-vingt-cinq pour cent de patients satisfaits et 9 % d’echecs, cette serie est comparable aux autres. Neanmoins, elle se demarque avec un taux d’apprehension persistante inhabituel.

How long should arthroscopic clavicular resection be in acromioclavicular arthropathy? A radiological-clinical study (with computed tomography) of 18 cases at a mean 4 years' follow-up.

INTRODUCTION Endoscopic clavicular resection is a common procedure, but few studies have analyzed predictive factors for outcome. HYPOTHESES 1) Computed tomography (CT) of clavicular resection is reproductible; 2) Functional outcome correlates with resection length; 3) Other factors also influence outcome. MATERIAL AND METHODS Patients operated on between 2005 and 2010 were called back to establish functional scores (Constant, Simple Shoulder Test [SST], satisfaction) and undergo low-dose bilateral comparative computed tomography (CT) centered on the acromioclavicular joints. The assessment criteria were resection edge parallelism and resection length, measured using OsiriX software. Radiological and clinical data were correlated. RESULTS 18 out of 21 patients (85%: 3 female, 15 male) were assessed. Mean age at surgery was 49 years (range, 40-62 yrs); mean follow-up was 4.2 years (1.6-7.2 yrs). Mean Constant score rose from 57.7 (25-85) to 70.2 (30-96); mean postoperative SST was 9.3 (3-12). 11 patients had very good and 4 poor results. CT resection length was reproducible, with intraclass, intra- and interobserver correlation coefficients >95%. There was no significant correlation between articular resection length on CT and functional scores (P=0.2). Functional scores were negatively influenced by an occupational pathologic context (P<0.01) and by associated tendinopathy. DISCUSSION AND CONCLUSION Low-dose CT enabled reproducible analysis of clavicular resection. The hypothesized correlation between resection length and functional result was not confirmed. Work accidents and occupational disease emerged as risk factors. LEVEL OF EVIDENCE Single-center retrospective analytic cohort study. Level 4, guideline grade C.