Jean-François Kempf

A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study☆

Six hundred one total shoulder arthroplasties and eighty-nine hemiarthroplasties were performed for primary osteoarthritis of the shoulder. Patients were evaluated with a physical examination, Constant score, and radiographic evaluation. The minimum follow-up was 2 years. At follow-up, the Constant score averaged 64 points, the adjusted Constant score averaged 86%, active anterior elevation averaged 130 degrees, and active external rotation averaged 36 degrees for the hemiarthroplasties. The Constant score averaged 70 points, the adjusted Constant score averaged 96%, active anterior elevation averaged 145 degrees, and active external rotation averaged 42 degrees for the total shoulder arthroplasties. Eighty-six percent of hemiarthroplasties and ninety-four percent of total shoulder arthroplasties had good or excellent results. Differences were statistically significant for all parameters. Total shoulder arthroplasty provided better scores for pain, mobility, and activity than hemiarthroplasty. Fifty-six percent of total shoulder arthroplasties had a radiolucent line around the glenoid component. Total shoulder arthroplasty provides results superior to those of hemiarthroplasty in primary osteoarthritis.

The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: results of a multicenter study.

Background: Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis. Consequently, the prognostic implications of rotator cuff disease in patients undergoing prosthetic replacement for the treatment of primary glenohumeral osteoarthritis are uncertain. The purpose of this study was to report the effects of the condition of the supraspinatus tendon and the rotator cuff musculature on the results of shoulder arthroplasty in the treatment of primary osteoarthritis.Methods: Five hundred and fifty-five shoulders in 514 patients who had an arthroplasty for the treatment of primary glenohumeral osteoarthritis as part of a multicenter study were evaluated. Forty-one shoulders had a partial-thickness tear of the supraspinatus, and forty-two had a full-thickness tear. Ninety shoulders had moderate (stage-2) fatty degeneration of the infraspinatus, and nineteen had severe (stage-3 or 4) degeneration. Eighty-four shoulders had moderate fatty degeneration of the subscapularis, and fifteen had severe degeneration. The influence of the condition of the supraspinatus tendon and the infraspinatus and subscapularis musculature on the postoperative outcome was evaluated with respect to the scores according to the system of Constant and Murley, active mobility, subjective satisfaction, radiographic result, and rate of complications.Results: The shoulders were evaluated at a mean of 43.1 months postoperatively. With the numbers available, supraspinatus tears were not found to influence the postoperative outcome with respect to the total Constant score, active mobility, subjective satisfaction, radiographic result, or rate of complications. Additionally, the treatment of these tears did not markedly influence the outcome parameters. Conversely, both shoulders with moderate fatty degeneration and those with severe degeneration of the infraspinatus were associated with poorer results than those with no degeneration with respect to the total Constant score (p < 0.0005), active external rotation (p < 0.0005), active forward flexion (p = 0.001), and subjective satisfaction (p = 0.031). Similar although less dramatic results were seen with fatty degeneration of the subscapularis.Conclusions: This study demonstrates that minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon do not appreciably affect most shoulder-specific outcome parameters in shoulder arthroplasty performed for the treatment of primary osteoarthritis. Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature adversely affects many of these parameters.

Le rameau transverse de la branche dorsale du nerf ulnaire : anatomie et rapports avec les voies arthroscopiques du poignet: Quarante-cinq dissections

PURPOSE OF THE STUDY We conducted an anatomic study of the transverse branch of the dorsal ulnar nerve to describe its morphology and position in relation to arthroscopic exploration portals. MATERIAL AND METHODS Forty-five non-side-matched anatomic specimens of unknown age and gender were preserved in formol. The dorsal branch of the ulnar nerve was identified and dissected proximally to distally in order to reveal the different terminal branches. The morphometric analysis included measurement of the length and diameter of the transverse branch and measurement of wrist width. We also measured the smallest distance between the transverse branch and the ulnar styloid process, and between the branch and usual arthroscopic portals (4-5, 6R, 6U) in the axis of the forearm. RESULTS The transverse branch was inconstant. It was found in 12 of the 45 dissection specimens (27%). In two-thirds of the specimens, the branch ran over less than 50% of the wrist width, tangentially to the radiocarpal joint. Mean nerve diameter was 1 mm. It was found 5-6 mm from the ulnar styloid process and was distal to it in 83% of the specimens. The dissections demonstrated two anatomic variants. Type A corresponded to a branch running distally to the ulnar styloid process, parallel to the joint line (10/12 specimens). Type B exhibited a trajectory proximal to the ulnar styloid process, crossing the ulnar head (2/12 specimens). The relations with the arthroscopic portals (4-5, 6R, 6U) showed that the mean distance from the branch to the portal was 3.75 mm for the 4-5 portal (distally in 11/12 specimens), 3.68 mm for the 6R portal (distally in 10/12 specimens), and 4.83 mm for the 6U portal (distally in 7 specimens and proximally in 5). DISCUSSION To our knowledge, there has been only one report specifically devoted to this transverse branch. Two other reports simply mention its existence. According to the literature, the transverse branch of the dorsal ulnar nerve occurs in 60-80% of the cases. We found two anatomic variations different than those described in the literature. Based on our findings and data reported previously, we propose a new classification, describing two main types. In Type 1, the transverse branch arises proximally to the ulnar styloid process;type 1A and type IB are described in relation to the direction of the branch. In Type II, the branch arises distally to the ulnar styloid process;type IIA and type IIB again being described in relation to the direction of the branch. On the tangential trajectory over the radiocarpal joint, the morphometric data show a zone of risk described by a rectangle measuring 10 mm wide (6 mm distal and 4 mm proximal to the ulnar styloid process) and covering 50% of the wrist width. The relations with arthroscopic portals describe a zone of risk corresponding to a 5-7 mm radius circle centered on the portals (4-5, 6R, 6U), which includes 83% of the transverse branches.Resume Le but de ce travail etait de definir l’anatomie morphologique du rameau transverse de la branche dorsale du nerf ulnaire, et de definir ses rapports avec les voies d’abord arthroscopiques du poignet (4-5, 6R et 6U), a partir 45 dissections de pieces anatomiques. Le rameau transverse est variable dans son existence oscillant entre 80 % des cas selon la litterature et 27 % pour notre etude (12 fois sur 45). Selon notre etude, il presente un diametre moyen de 1 mm et un trajet tangentiel a l’articulation radio-carpienne. Deux fois sur 3, il parcourt moins de 50 % de la largeur du poignet. Dans 83 % des cas, il est situe a 5-6 mm en distalite du processus styloide ulnaire. Il existe ainsi une zone a risque schematisee par un rectangle de largeur de 10 mm sur 50 % de la largeur du poignet, centre sur le processus styloide ulnaire, en regard de l’interligne articulaire radio-carpien. Deux types de variations anatomiques, differentes de celles deja publiees, ont ete observees. Le rameau transverse est situe a proximite des voies d’abord arthroscopiques 4-5, 6R et 6U. Les resultats de notre etude anatomique soulignent l’existence d’une zone a risque schematisee par un cercle centre sur chaque voie d’abord, de 5 a 7 mm de rayon incluant 83 % des rameaux transverses. Afin d’eviter une complication nerveuse, il faut avoir a l’esprit l’anatomie de la branche dorsale du nerf ulnaire, l’existence de ces zones a risques et une parfaite connaissance des voies d’abord. Ce respect des structures nerveuses est d’autant plus important que cette region anatomique de la face dorsale du poignet peut etre utilisee comme lambeau pedicule pour la chirurgie reconstructrice.

Un nouvel implant pour les fractures de l’humérus proximal : la plaque à corbeille: Étude expérimentale

Resume Nous avons realise une etude comparative de trois systemes d’osteosynthese des fractures de l’humerus proximal dont les conclusions ont permis l’elaboration d’un implant d’osteosynthese rigide extra-medullaire. Cet implant tire son originalite de la fixation specifique des tuberosites par un systeme de griffes organisees en corbeille. Il existe sous deux versions, avec et sans verrouillage de la vis centrale cephalique. Le travail que nous rapportons est l’etude de ce prototype par deux tests mecaniques statiques sur pieces cadaveriques congelees, sur la base d’un modele experimental de fracture a quatre fragments de l’humerus proximal. Les premiers tests ont ete realises en compression axiale permettant d’analyser le comportement mecanique global de l’implant et d’evaluer l’interet du systeme de verrouillage de la vis centrale cephalique. La seconde serie de tests a ete realisee en traction, permettant l’analyse du comportement des tuberosites fixees par le systeme de griffes. Les deux versions de prototypes ont ete comparees a un implant connu. Nous avons evalue les montages par leur tolerance mecanique jugee sur la charge limite notee a l’inflexion de la courbe, et leur rigidite jugee sur la pente de la courbe jusqu’a cette valeur. Il resultait de la premiere etude que l’implant, ameliore du systeme de verrouillage de la vis centrale cephalique, presentait de meilleures caracteristiques mecaniques globales sans pour autant qu’une difference significative ait ete mise en evidence. La notion de meilleure tenue des tuberosites par le systeme de griffes, que laissait presager la premiere partie, etait renforcee par les donnees de l’observation de la seconde etude, sans qu’il apparaisse pour autant de difference statistiquement significative.PURPOSE OF THE STUDY We conducted a comparative study of three ostheosynthesis systems for proximal humeral fractures. The conclusions led to the elaboration of a rigid extramedullary osteosynthesis implant. This novel implant allows specific fixation of the tuberosities via six adjustable and removable hooks organized like a basket. There are two versions, with and without a central cephalic locking screw. We report two static biomechanical studies conducted to analyze this material. MATERIAL AND METHODS The two studies were performed on fresh frozen cadaver specimens with known bone density and with an experimental model of a four-fragment fracture of the proximal humerus. The first tests were designed to measure axial pressure reproducing the physiological movement applying the most stress on the head of the humerus. This allowed a global analysis of the mechanical behavior of the implant and an assessment of the contribution of the central cephalic locking screw. The second series of tests were traction tests used to analyze the behavior of the tuberosities fixed with the hooks. We assess the assemblies by measuring the mechanical resistance: rigidity of the fixation was recorded in mm/100N. Pre- and post-procedure x-rays and photographs were obtained to allow a subjective assessment of fragment displacement. RESULTS The first series of tests demonstrated that the implant, with the central cephalic locking screw, presented good overall mechanical properties. The notion of better stability of the tuberosities obtained with the hooks, as seen during the first tests, was reinforced by the data from the second tests, although no statistically significant difference was demonstrated. We also noted that there was no statistically significant correlation between bone density and the slopes of the force-resistance curves. DISCUSSION This prototype implant has an overall mechanical resistance equivalent to the reference implant, with at least equivalent performance. Proof of the usefulness of the central locking screw was not established, even though improved tolerance to loading by better force distribution seemed apparent. The contribution of the hook basket was not demonstrated. Data from the observations do however suggest the expectations of the implant will be fulfilled. Tests conducted on a larger scale would probably demonstrate a difference. It is clear that the small number of implants used here limited the study. Comparison with data in the literature show that this new prototype is adapted to the mechanics of the proximal humerus. Resistant to physiological stress, the implant allows pendular movement and passive physical therapy during the early post-operative period.

Réparation arthroscopique des ruptures transfixiantes de la coiffe des rotateurs : étude rétrospective multicentrique de 576 cas avec contrôle de la cicatrisation

PURPOSE OF THE STUDY Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy. MATERIAL AND METHODS The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%. RESULTS On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome. CONCLUSION Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.Resume Les reparations entierement arthroscopiques de la coiffe des rotateurs sont actuellement largement pratiquees. Ces techniques ont fait l’objet d’une etude multicentrique retrospective au sein de la Societe Francaise d’Arthroscopie. Il s’agit de reparations arthroscopiques de ruptures transfixiantes limitees au sus et au sous-epineux evaluees par le score de Constant complete par arthro-IRM ou arthroscanner avec 1 an de recul minimum. Les donnees sont analysees sur le plan statistique par le logiciel SPSS 10. La serie comporte 576 patients operes entre janvier 2001 et juin 2003 de 57,7 ans en moyenne dont 52 % d’hommes et 60 % de travailleurs manuels. Le score de Constant preoperatoire moyen etait de 46,4/100 (± 13,4). La rupture etait limitee au sus-epineux dans 69 % des cas, avec extension au tiers superieur du sous-epineux dans 23,5 % et a la totalite dans 7,5 % des cas. La rupture du sus-epineux etait distale dans 41,7 % des cas, intermediaire dans 44 % des cas et retractee dans 14,3 % des cas. La degenerescence graisseuse du sus-epineux etait au stade 0 dans 60 %, au stade 1 dans 27 %, au stade 2 dans 11 % et au stade 3 dans 24 % des cas. La reparation a ete effectuee par arthroscopie dans tous les cas, sous anesthesie loco-regionale dans 60,9 % des cas. Les implants etaient resorbables dans 33 % et metalliques dans 62,1 % des cas. Une acromioplastie a ete effectuee dans 92,7 % des cas. Une capsulotomie a ete effectuee dans 14,9 % des cas. Le resultat subjectif etait en moyenne de 8,89/10. Le score de Constant est passe de 46,3 (± 13,4) a 82,7 (± 10,3) avec 62 % de patients strictement indolores et une force passant de 5,8 (± 3,7) a 13,6 (± 5,4). On retrouvait 94 % d’excellents et de bons resultats a 18,5 mois de recul moyen. Le taux de complications de la serie etait de 6,2 % avec 3,1 % de raideurs prolongees, 2,7 % d’algodystrophies, 0,2 % d’infection et 0,2 % de migration d’ancre. La coiffe etait jugee normale dans 55,7 % avec image d’addition intra-tendineuse dans 19 % des cas, soit 74,7 % de coiffes non rompues. On notait une fuite ponctuelle dans 9,5 % des cas et marquee dans 15,7 % des cas, soit 25,2 % de ruptures iteratives. Le score de Constant etait fortement correle a l’etancheite de la coiffe (p Les resultats fonctionnels obtenus lorsque la coiffe est cicatrisee incitent a la reparation des ruptures. L’arthroscopie tire ses avantages d’un taux faible de complications tout en permettant d’obtenir de bons resultats cliniques et anatomiques. L’âge est correle au resultat fonctionnel et a la cicatrisation, mais ne doit pas etre une contre-indication.

Arthroskopische Rekonstruktion der Rotatorenmanschette

ZusammenfassungOperationszielWiedererlangung eines schmerzfreien Schultergelenks mit uneingeschränkter Funktion durch arthroskopische Refixation der gerissenen Rotatorenmanschette mit Ankern und Zuggurtungsnähten.IndikationenVollständige, isolierte Ruptur der Supraspinatussehne.Vollständige Ruptur der Supraspinatussehne und des oberen Teils der Infraspinatussehne.Inkomplette Risse des oberen Teils der Subskapularissehne, sowohl isoliert als auch in Kombination mit einer Ruptur der Supraspinatussehne.Bei begleitenden Läsionen und degenerativen Veränderungen der langen Bizepssehne Indikation zur Tenodese bei Patienten < 60 Jahre oder bei körperlich tätigen Arbeitern; in allen anderen Fällen Tenotomie.KontraindikationenFettige Infiltration der Musculi infraspinatus und subscapularis Grad 3 und 4.Schmerzhafte Schultersteife in der Akutphase.Verschmälerung des akromiohumeralen Abstands auf < 7 mm.Vollständige Ruptur der Subskapularissehne.Vollständige Risse der posterosuperioren Sehnenkappe, wenn der Riss in die Sehne des Musculus teres minor hineinreicht.Patienten ≥65 Jahre.OperationstechnikArthroskopische Inspektion des Glenohumeralgelenks und des Subakromialraums. Rekonstruktion der gerissenen Sehne über einen dorsalen und einen vorderen Inside-out-Zugang, zusätzlich ein bis zwei anterolaterale Zugänge. Refixation der Sehne mit einer Ein-Reihen-Technik von Fadenankern. Erforderlichenfalls Tenotomie oder Tenodese der langen Bizepssehne.ErgebnisseBei 50 Patienten mit einem durchschnittlichen Nachuntersuchungszeitraum von 24 Monaten konnte in 34 Fällen eine „wasserdichte“ Rekonstruktion erzielt werden. Der Constant-Score betrug bei diesen Patienten 85,2 Punkte, bei den 16 Patienten mit Reruptur nur 77,4 Punkte.AbstractObjectiveRegain of shoulder function and freedom of pain through arthroscopic fixation of the torn rotator cuff using anchors and tension bands.IndicationsIsolated full-substance rupture of the supraspinatus.Full-substance tear of the supraspinatus and the superior part of the infraspinatus.Incomplete tears affecting the superior part of the subscapularis, either isolated or associated with rupture of the supraspinatus.For lesions of the long head of the biceps: tenodesis in patients < 60 years of age or in blue-collar workers; tenotomy in all other instances.ContraindicationsFatty infiltration of infraspinatus and subscapularis of stage 3 and 4.Frozen shoulder in the active phase.Narrowing of the subacromial space (< 7 mm).Complete tear of the subscapularis.Complete tear of the posterosuperior cuff reaching the teres minor.Patients ≥65 years.Surgical TechniqueSubacromial bursoscopy and glenohumeral arthroscopy.Repair of supraspinatus using a posterior portal and an inside-out anterior portal, associated with one or two additional anterolateral portals. Attachment with a single row of anchors.Tenotomy/tenodesis of long head of biceps, if indicated.Results50 patients, follow-up of an average of 24 months. 34 watertight repairs, Constant Score 85.2; complete tear or leakage in 16 patients, Constant Score 77.4 points.

Arthroscopic repair of rotator cuff tears.

ZusammenfassungOperationszielWiedererlangung eines schmerzfreien Schultergelenks mit uneingeschränkter Funktion durch arthroskopische Refixation der gerissenen Rotatorenmanschette mit Ankern und Zuggurtungsnähten.IndikationenVollständige, isolierte Ruptur der Supraspinatussehne.Vollständige Ruptur der Supraspinatussehne und des oberen Teils der Infraspinatussehne.Inkomplette Risse des oberen Teils der Subskapularissehne, sowohl isoliert als auch in Kombination mit einer Ruptur der Supraspinatussehne.Bei begleitenden Läsionen und degenerativen Veränderungen der langen Bizepssehne Indikation zur Tenodese bei Patienten < 60 Jahre oder bei körperlich tätigen Arbeitern; in allen anderen Fällen Tenotomie.KontraindikationenFettige Infiltration der Musculi infraspinatus und subscapularis Grad 3 und 4.Schmerzhafte Schultersteife in der Akutphase.Verschmälerung des akromiohumeralen Abstands auf < 7 mm.Vollständige Ruptur der Subskapularissehne.Vollständige Risse der posterosuperioren Sehnenkappe, wenn der Riss in die Sehne des Musculus teres minor hineinreicht.Patienten ≥65 Jahre.OperationstechnikArthroskopische Inspektion des Glenohumeralgelenks und des Subakromialraums. Rekonstruktion der gerissenen Sehne über einen dorsalen und einen vorderen Inside-out-Zugang, zusätzlich ein bis zwei anterolaterale Zugänge. Refixation der Sehne mit einer Ein-Reihen-Technik von Fadenankern. Erforderlichenfalls Tenotomie oder Tenodese der langen Bizepssehne.ErgebnisseBei 50 Patienten mit einem durchschnittlichen Nachuntersuchungszeitraum von 24 Monaten konnte in 34 Fällen eine „wasserdichte“ Rekonstruktion erzielt werden. Der Constant-Score betrug bei diesen Patienten 85,2 Punkte, bei den 16 Patienten mit Reruptur nur 77,4 Punkte.AbstractObjectiveRegain of shoulder function and freedom of pain through arthroscopic fixation of the torn rotator cuff using anchors and tension bands.IndicationsIsolated full-substance rupture of the supraspinatus.Full-substance tear of the supraspinatus and the superior part of the infraspinatus.Incomplete tears affecting the superior part of the subscapularis, either isolated or associated with rupture of the supraspinatus.For lesions of the long head of the biceps: tenodesis in patients < 60 years of age or in blue-collar workers; tenotomy in all other instances.ContraindicationsFatty infiltration of infraspinatus and subscapularis of stage 3 and 4.Frozen shoulder in the active phase.Narrowing of the subacromial space (< 7 mm).Complete tear of the subscapularis.Complete tear of the posterosuperior cuff reaching the teres minor.Patients ≥65 years.Surgical TechniqueSubacromial bursoscopy and glenohumeral arthroscopy.Repair of supraspinatus using a posterior portal and an inside-out anterior portal, associated with one or two additional anterolateral portals. Attachment with a single row of anchors.Tenotomy/tenodesis of long head of biceps, if indicated.Results50 patients, follow-up of an average of 24 months. 34 watertight repairs, Constant Score 85.2; complete tear or leakage in 16 patients, Constant Score 77.4 points.

Exérèse arthroscopique d'une forme pseudo-tumorale de synovite villonodulaire pigmentée de l'épaule : Á propos d'un cas au recul de 3 ans

Pigmented villonodular synovitis can be localized or diffuse. Lesions predominate in the knee but all of the joints can be involved. Thirty cases in the glenohumeral joint have been reported in the literature. The different reports to date have not identified any specific clinical signs. Our female patient presented non-specific shoulder pain which persisted for three years. The plain x-rays were normal. MRI and arthroscan revealed an intra-articular pseudotumor. Arthroscopy was performed for tumor biopsy which was followed by total resection. The diagnosis of villonodular synovitis pseudotumor suspected at arthroscopy was confirmed at the pathology examination. The functional outcome was excellent and no recurrence has been observed at three years follow-up. Arthroscopy is less aggressive than open surgery for arthrotomy. Arthroscopy must be performed for diagnostic purposes since imaging findings are not specific. Arthroscopic synovectomy is the treatment of choice for pigmented villonodular synovitis in both the diffuse and pseudotumor forms.

Ten-year Multicenter Clinical and Mri Evaluation of Isolated Supraspinatus Repairs

Background: Early repair of isolated supraspinatus tears could prevent further deterioration of the rotator cuff; however, there is no consensus on the management of such tears because of a lack of long-term outcome studies. The purposes of this study were to report the 10-year outcomes of isolated supraspinatus repairs and to investigate the factors that favor healing and recovery. Methods: We retrieved the records of all 511 patients who, in 2003, underwent repair of full-thickness isolated supraspinatus tears, performed by 15 surgeons at 15 centers. In 2014, the patients were asked to return for evaluation at a minimum follow-up of 10 years. One hundred and eighty-eight patients could not be reached, and 35 were excluded because they had a reoperation (17 had a retear, 7 had conversion to an arthroplasty, and 11 had other causes). A total of 288 patients (50% were men) who had a mean age (and standard deviation) at index surgery of 56.5 ± 8.3 years (range, 32 to 77 years) were evaluated clinically, and 210 of them were also evaluated using magnetic resonance imaging (MRI). Results: Thirty shoulders (10.4%) had complications, including stiffness (20 shoulders), infection (1 shoulder), and other complications (9 shoulders). The total Constant score improved from a mean of 51.8 ± 13.6 points (range, 19 to 87 points) preoperatively to 77.7 ± 12.1 points (range, 37 to 100 points) at 10 years. At the 10-year follow-up evaluation, the mean Subjective Shoulder Value (SSV) was 84.9 ± 14.8 (range, 20 to 100), and the mean Simple Shoulder Test (SST) was 10.1 ± 2.2 (range, 3 to 12). Of the 210 shoulders evaluated using MRI, the repair integrity was Sugaya type I in 26 shoulders (12%), type II in 85 (41%), type III in 59 (28%), type IV in 27 (13%), and type V in 13 (6%). The total Constant score at the final follow-up was significantly associated with tendon healing (p < 0.005) and was inversely associated with preoperative fatty infiltration (p < 0.001). Neither the surgical approach nor the preoperative retraction influenced the outcomes. Conclusions: Repairs of isolated supraspinatus tears maintained considerable improvement in clinical and radiographic outcomes at 10 years. Preoperative fatty infiltration and postoperative retear have a significantly detrimental effect on the long-term functional outcome of rotator cuff repair. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ten-year clinical and anatomic follow-up after repair of anterosuperior rotator cuff tears: influence of the subscapularis

BACKGROUND Anterosuperior rotator cuff tears are more frequent than expected. We report the results of a 10-year follow-up study after repair. Our hypothesis was that the extent of the subscapularis tear influenced the prognosis. MATERIALS AND METHODS The study population consisted of all 138 patients who underwent surgery in 14 participating centers in 2003 for full-thickness tears of the rotator cuff with lesions in the subscapularis and supraspinatus tendons. The patients were divided into 2 groups, depending on whether the subscapularis lesion affected only the superior half of the tendon (group A) or extended into the lower half (group B). Ninety-two patients (56 ± 7 years; 71 in group A and 21 in group B) were available for follow-up after 10 years (127 ± 16 months) with magnetic resonance imaging to evaluate tendon healing and muscle condition. RESULTS The mean Constant scores were 59 ± 16 before surgery and 77 ± 14 at follow-up (P = 1.7 × 10-12). The retear rates were 25% for the supraspinatus and 13.5% for the subscapularis tendon. The clinical results for group A patients were better than those for group B. Severe fatty infiltration was observed more frequently in the subscapularis than in the supraspinatus muscle (27% vs. 12% of cases). Supraspinatus healing influenced subscapularis healing and fatty infiltration. CONCLUSIONS Repair of anterosuperior rotator cuff tears is satisfactory at 10 years, particularly if the subscapularis tear is not extensive. An extensive subscapularis tear is a negative prognosis factor. Postoperatively, fatty infiltration of the subscapularis muscle was frequently observed despite tendon healing.