J.-M. Postel

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.

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

HYPOTHESIS Tendon-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. MATERIALS AND METHODS We 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. RESULTS Re-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. CONCLUSION Final 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. LEVEL OF EVIDENCE Level 3; Retrospective cohort therapeutic study.

Acromio humeral distance less than six millimeter: Its meaning in full-thickness rotator cuff tear

UNLABELLED The present study sought to identify full-thickness rotator cuff tears liable to induce an acromiohumeral distance (AHD) of less than 6 mm. The hypothesis was that, less than 6mm AHD is found exclusively in association with total full-thickness infraspinatus tear. MATERIALS A continuous single-center series recruited 109 shoulders, free of glenohumeral osteoarthritis, presenting with full-thickness tear requiring surgery. Preoperative acromiohumeral distance, rupture location and extension on the various tendons and muscular fatty degeneration (FD) were known. METHODS Full-thickness tears were categorized by location and extension on the various tendons. For each group, the number of shoulders showing AHD<6 mm was determined. RESULTS Total full-thickness infraspinatus tears were almost the only tendon lesions able to induce AHD<6 mm, but this only when the infraspinatus muscle showed FD equal to or greater than 2.25: i.e., when the tear was longstanding. DISCUSSION Unlike previous reports, the present study took account of the total or partial nature of infraspinatus and subscapularis tendon tear. The findings may suggest that AHD<6 mm is induced by posterior migration of the humeral head secondary to longstanding total infraspinatus tear, reducing AHD projection height on X-ray. CONCLUSION AHD<6 mm is a sign of rotator-cuff rupture almost systematically involving longstanding total infraspinatus tear, not always amenable to suture repair due to advanced fatty degeneration. AHD equal to or greater than 6mm is of no diagnostic relevance and in no way indicates whether there is subscapularis tear and, if so, whether suture repair is feasible.

Les lésions histologiques des tendons des supraspinatus dans les ruptures transfixiantes de la coiffe des rotateurs

Resume Les auteurs ont essaye de savoir si les ruptures iteratives apres simple suture tendon-os des coiffes des rotateurs rompues pourraient etre expliquees par la presence, sur les moignons tendineux repares, de lesions histologiques qui, ont le sait, diminuent leur qualite mecanique. Trente-deux moignons de supraspinatus rompus, reseques sur plus d’1 cm pour eliminer les lesions tendineuses macroscopiques (tendons fins, dilaceres, clives ou indurees et blanchâtres) et pour retrouver un moignon tendineux suffisamment epais et legerement saignant ont ete etudies sur des coupes histologiques longitudinales. Tous les moignons tendineux reseques etaient histologiquement anormaux. L’etendue des lesions histologiques etait en moyenne de 4 mm inferieure a celle de la resection tendineuse. Dix-huit fois cependant tout le tendon reseque etait histologiquement anormal. Les lesions histologiques des moignons tendineux des ruptures de coiffe pourrait etre au moins en partie a l’origine des ruptures iteratives apres simple suture tendon-os. La resection des moignons tendineux macroscopiquement anormaux apparait logique mais elle expose, en dehors d’artifice technique, a des sutures sous tension elles memes generatrices de rupture iterative.

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.

Reparación de las roturas trasnfixiantes del manguito de los rotadores

El manguito es una envoltura musculotendinosa escapulohumeral que rodea la articulacion glenohumeral. Esta constituido, en sentido anteroposterior, por tres musculos principales, el subescapular, el supraespinoso y el infraespinoso, a los que debe anadirse el redondo menor. El espacio situado entre el subescapular y el supraespinoso esta ocupado por el ligamento coracohumeral, del que una expansion que se inserta en el troquiter constituye una polea de reflexion que centra la porcion larga del biceps a su entrada en la corredera bicipital del humero. Los tendones del supraespinoso, del infraespinoso y del redondo menor forman una capa tendinosa continua. Los limites entre cada uno de los tendones no pueden distinguirse. Solo pueden apreciarse si se prolongan los limites de los cuerpos musculares correspondientes. Los tendones, sobre todo el del supraespinoso, se adhieren a la capsula. Los tendones del supraespinoso y del infraespinoso, pero no siempre el del subescapular, estan recubiertos por la bolsa serosa subdeltoidea. Se adhieren a su capa profunda. Esto explica que, en las roturas de los tendones del supra e infraespinoso, la bolsa subdeltoidea aparezca inyectada con material de contraste en las artrografias, mientras que puede que no sea asi en las roturas aisladas del subescapular.