Jean-David Werthel

Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear

BACKGROUND Management of massive irreparable posterior-superior rotator cuff tear can be very challenging. This study reports the outcome of the lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear. METHODS Included were 33 patients with an average age of 53 years (range, 31-66 years). All patients had symptomatic massive irreparable rotator cuff tear that failed conservative or prior surgical treatment and underwent reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft. The tear was considered irreparable based on the magnetic resonance imaging finding of ≥2 full-thickness rotator cuff tears associated with shortening and retraction of the tendon to the level of the glenoid and a high grade of fatty infiltration of the muscles. This was confirmed at the time of the surgery. RESULTS At an average follow-up of 47 months, 32 patients had significant improvement in pain, subjective shoulder value, and Disabilities of the Arm, Shoulder and Hand score and shoulder range of motion, including flexion, 120°; abduction, 90°; and external rotation 50°. One patient, with a body mass index of 36 kg/m(2), required débridement for an infection and then later underwent shoulder fusion. Patients with >60° of preoperative flexion had more significant gains in their range of motion. Shoulder external rotation improved in all patients regardless of the extent of the preoperative loss of motion. CONCLUSIONS Transfer of the lower trapezius prolonged with Achilles tendon allograft to reconstruct massive irreparable posterior-superior rotator cuff tear may lead to good outcome in most patients, specifically for those who have preoperative flexion of >60°.

Effect of smoking on complications following primary shoulder arthroplasty

BACKGROUND The purpose of this study was to examine the effect of smoking on the incidence of complications after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). METHODS All patients who underwent primary TSA or RSA at our institution between 2002 and 2011 and had a minimum 2-year follow-up were included. Smoking status was assessed at the time of surgery. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures (intraoperative and postoperative), and loosening after surgery. RESULTS The cohort included 1834 shoulders in 1614 patients (814 in smokers and 1020 in nonsmokers). Complications occurred in 73 patients (75 shoulders; 44 in smokers and 31 in nonsmokers). There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Smokers had lower periprosthetic infection-free survival rates (95.3%-99.4% at 10 years; P = .001) and overall complication-free survival rates (78.4%-90.2%; P = .012) than nonsmokers. Multivariable analyses showed that both current and former smokers had significantly higher risk of periprosthetic infection in comparison with nonsmokers (hazard ratio [HR], 7.27 and 4.56, respectively). In addition, current smokers showed a higher risk of postoperative fractures than both former smokers (HR, 3.63) and nonsmokers (HR, 6.99). CONCLUSIONS This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. These findings emphasize the need for preoperative collaborative interventions, including smoking cessation programs.

Is previous nonarthroplasty surgery a risk factor for periprosthetic infection in primary shoulder arthroplasty

BACKGROUND The purpose of this study was to determine the risk of periprosthetic infection after primary shoulder arthroplasty (SA) in patients undergoing previous nonarthroplasty shoulder surgery compared with those without previous surgery. MATERIALS AND METHODS All patients undergoing primary SA at our institution between 1970 and 2012 were included in this study. The cohort consisted of 4577 patients treated with 2890 total SAs, 1233 hemiarthroplasties, and 454 reverse SAs; 813 (18%) patients had undergone prior nonarthroplasty shoulder surgery on the operative side. Patients with and without previous surgery were compared for postoperative periprosthetic infection. Univariate and multivariable analyses were used. RESULTS Deep postoperative infection of the shoulder was diagnosed in 68 patients (1.49%). Of the 813 patients who had undergone previous surgery, 20 (2.46%) developed a deep postoperative infection. However, of the 3764 patients who did not have previous shoulder surgery, 48 patients (1.28%) sustained deep shoulder infection. This difference was significant in both the univariate (P = .0094) and multivariate analyses (P = .0390). In addition, older age and female gender were significantly associated with a lower risk of deep postoperative infection (P = .0150 and P = .0074, respectively). A higher number of previous surgeries was also significantly associated with an increased risk of deep postoperative infection (P = .0272). CONCLUSIONS The risk of infection after primary SA is significantly higher in patients with a history of prior non-arthroplasty-related surgery. This finding should be discussed with the patients before their surgery, and potential preoperative and intraoperative workup should be undertaken to identify at-risk patients.

Carpal tunnel syndrome pathophysiology: role of subsynovial connective tissue.

Carpal tunnel syndrome (CTS) is a very common pathology. Its most common diagnosis is idiopathic. Although it is accepted that chronic increase in pressure within the carpal tunnel is responsible for median nerve neuropathy, the exact pathophysiology leading to this pressure increase remains unknown. All the histological studies of the carpal tunnel in the CTS find a noninflammatory thickening of the subsynovial connective tissue (SSCT), which seems to be a characteristic of this pathology. Numerous animal models have been developed to recreate CTS in vivo to develop and improve preventive strategies and effective conservative treatments by a better understanding of its pathophysiology. The creation of a shear injury of the SSCT in a rabbit model induced similar modifications to what is observed in CTS, suggesting that this could be a pathway leading to idiopathic CTS.

Arthroscopic-Assisted Pectoralis Minor Transfer for Irreparable Tears of the Upper Two-thirds of the Subscapularis Tendon: Surgical Technique

Open transfer of the pectoralis minor through a deltopectoral approach has been described to treat irreparable tears of the upper two-thirds of the subscapularis. We present a less invasive arthroscopic-assisted technique for this transfer. Atraumatic dissection of the pectoralis minor and harvesting of the tendon with a bone chip from the coracoid process allow strong fixation with a double-button device on the lesser tuberosity. This arthroscopic technique allows assessment and treatment of associated intra- or extra-articular lesions and represents a promising option for the management of irreparable tears of the subscapularis.

Outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer in patients with deltoid paralysis

BACKGROUND Management of shoulder arthritis associated with deltoid paralysis can be very challenging. The purpose of this study was to report the outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer to reconstruct the anterior deltoid in patients with symptomatic shoulder arthritis and a paralyzed deltoid. METHODS This study included 31 patients with an average age of 51 years (range, 27-73 years). All patients had chronic deltoid paralysis with significant loss of function due to progressive arthritis associated with rotator cuff deficiency. All patients underwent reverse shoulder arthroplasty with pedicled pectoralis muscle transfer. Additional transfers were performed in patients with no preoperative external rotation: 5 underwent latissimus transfer, and 3 underwent direct lower trapezius transfer to the infraspinatus. RESULTS At an average follow-up of 37 months, 29 patients had significant improvements in pain; the shoulder subjective value; the Disabilities of the Arm, Shoulder and Hand score; and shoulder range of motion, mainly flexion of 83° and external rotation of 15°. Two patients sustained postoperative acromial fractures and had persistent pain after surgery with minimal improvement in shoulder flexion and external rotation. One of them had a failed attempt at open reduction-internal fixation of the acromion. CONCLUSION Reverse shoulder arthroplasty with pedicled pectoralis transfer is a promising procedure that may lead to improved pain and function in patients with shoulder arthritis associated with deltoid paralysis.

Glenoid bone grafting in primary reverse total shoulder arthroplasty

BACKGROUND Severe glenoid bone loss remains a challenge in patients requiring shoulder arthroplasty and may necessitate glenoid bone grafting. The purpose of this study was to determine results, complications, and rates of failure of glenoid bone grafting in primary reverse shoulder arthroplasty. METHODS Forty-one shoulders that underwent primary reverse arthroplasty between 2006 and 2013 with a minimum follow-up of 2 years (mean, 2.8 years; range, 2-6 years) were reviewed. Thirty-four (83%) received corticocancellous grafts and 7 (17%) structural grafts. RESULTS Active range of motion and pain levels were significantly improved (P < .001), with mean American Shoulder and Elbow Surgeons score of 77, Simple Shoulder Test score of 9, and patient satisfaction of 93% at the most recent follow-up. Preoperative severe glenoid erosion and increasing body mass index were significantly associated with worse American Shoulder and Elbow Surgeons scores (P = .04). On radiographic evaluation, 7 patients (18%) had grade 1 or grade 2 glenoid lucency. Glenoid bone graft incorporation was observed in 31 patients (78%). Twelve patients (30%) suffered from grade 1 or grade 2 scapular notching. All of the patients with structural grafts showed graft incorporation and no signs of glenoid lucency. CONCLUSION Although glenoid lucency, glenoid graft resorption, and scapular notching were present at short-term to midterm follow-up, none of the patients needed revision surgery. Primary reverse shoulder arthroplasty with glenoid reconstruction using bone graft relieved pain and restored shoulder function and stability.

Is bipolar latissimus dorsi transfer a reliable option to restore elbow flexion in children with arthrogryposis? A review of 13 tendon transfers

BACKGROUND Scant data are published about different available therapeutic options for restoration of active elbow flexion in arthrogryposis with varying degrees of improvement. In this retrospective study we evaluated medium-term effects of bipolar latissimus dorsi transfer in patients with arthrogryposis. METHODS Pedicled latissimus dorsi bipolar muscle transfer was used to restore elbow flexion in 11 patients (13 limbs) with arthrogryposis. Elbow and shoulder range of motions and strength of elbow flexion were measured preoperatively and at the last follow-up. The functional use of the upper limb was examined by observation of activities of daily living and presence of adaptive mechanisms. General satisfaction was assessed at the final follow-up. RESULTS The patients were a mean age of 5.69 ± 2.49 years. The follow-up period was 27.31 ± 17.8 months. At the last examination, according to transferred muscle function and elbow range of motion, function of 12 limbs was graded as excellent and good, and 1 was graded poor. The active postoperative elbow range of motion was 97.7° ± 34.5°. The general satisfaction of the patients with the surgical results was 92.3%. Activities of daily living were improved in 10 of 13 limbs, but adaptive mechanisms were detected in all patients except 2 at the last follow-up. CONCLUSIONS We suggest pedicled bipolar latissimus dorsi transfer as a reliable therapeutic option to restore active elbow flexion in arthrogryposis with acceptable results regarding regaining range of motion and patient satisfaction. Functional passive elbow range of motion and good quality of latissimus dorsi muscle preoperatively is mandatory.

Total elbow arthroplasty for primary osteoarthritis

BACKGROUND Primary osteoarthritis of the elbow is a less common indication for total elbow arthroplasty (TEA). Higher complication rates in younger, active patients may offset short-term improvements in pain and function. The purpose of this study was to determine pain relief, functional outcomes, complications, and survival of TEA in this population. METHODS Between 1984 and 2011, 20 consecutive TEAs were performed for primary elbow osteoarthritis. Two patients died before the 2-year follow-up. Mean age at surgery was 68 years (range, 51-85 years). Outcome measures included pain, motion, Mayo Elbow Performance Score, satisfaction, complications, and reoperations. Mean follow-up was 8.9 years (range, 2-20 years). RESULTS Three elbows sustained mechanical failures. Complications included intraoperative fracture (n = 2), wound irrigation and débridement (n = 1), bony ankylosis (n = 1), humeral loosening (n = 1), humeral component fracture (n = 1), and mechanical failure of a radial head component (n = 1). Fifteen elbows without mechanical failure were examined clinically. Pain improved from 3.6 to 1.5 (P < .001). Range of motion remained clinically unchanged (P > .05), with preoperative flexion contractures not improving. Mayo Elbow Performance Scores were available for 13 elbows without mechanical failure, averaging 81.5 points (range, 60-100 points); these were graded as excellent (n = 5), good (n = 2), and fair (n = 6). Subjectively, all patients without mechanical failure were satisfied. CONCLUSION TEA represents a reliable surgical option for pain relief in patients with primary osteoarthritis. However, restoration of extension is not always obtained, indicating that more aggressive soft tissue releases or bony resection should be considered. Complications occurred in a large number of elbows, but mechanical failure was low considering the nature of this population and the length of follow-up.

Convertible Glenoid Components Facilitate Revisions to Reverse Shoulder Arthroplasty Easier: Retrospective Review of 13 Cases

Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. The purpose of this study was to demonstrate the feasibility of revisions with a completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases. Between 2003 and 2011, 104 primary total shoulder arthroplasties (TSAs) were performed with an uncemented glenoid component in our group. Of these patients, 13 (average age, 64 years) were revised to reverse shoulder arthroplasty (RSA) using a modular convertible platform system and were included in this study. Average follow-up after revision was 22 months. Outcome measures included pain, range of motion, Constant-Murley scores, Simple Shoulder Tests, and subjective shoulder values. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021), and active external rotation increased significantly from 8° (range, -20°-15°) to 25° (range, -10°-60°). Mean pain scores significantly improved from 4.2 to 13.3 points. The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90). Subjectively, 12 patients rated their shoulder as better or much better than preoperatively. This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function.