N. Solignac

Arthroscopic repair of subscapularis tears: preliminary data from a prospective multicentre study.

BACKGROUND Until the introduction of arthroscopic-assisted surgery for rotator cuff repair, the frequency of subscapularis tears was underestimated. These tears remain challenging to treat even with arthroscopy. The absence of a specific classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tears. The objective of this prospective multicentre study was to validate the relevance of arthroscopic subscapularis tendon repair based on an assessment of short-term outcomes according to the initial extent of the anatomic lesions. METHODS A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 208 patients with subscapularis lesions that were either isolated or associated with limited anterosuperior tears. The Constant and UCLA scores were used to assess clinical outcomes. Anatomic and prognostic results were evaluated based on the physical examination, preoperative and postoperative imaging study findings, and anatomic lesions. Clinical data were available for 103 patients after at least 1 year of follow-up and radiological data for 129 patients after at least 6 months. RESULTS The preliminary clinical results in 103 patients with at least 1 year of follow-up showed overall statistically significant improvements in the Constant and UCLA scores, with resolution of the clinical manifestations. The degree of improvement seemed to increase over time. The clinical results varied significantly across patient groups based on a classification system distinguishing four lesion types. Postoperative imaging studies to assess the anatomic results in all patients with at least 6 months of follow-up (n=129) showed tendon healing in 92% of cases but also indicated muscle wasting of the upper subscapularis muscle in 18.6% of cases and increased fatty degeneration of the muscle belly. DISCUSSION Our study confirms the good clinical and radiological results reported in the literature. Our classification system distinguishing four lesion patterns was applicable during the imaging workup. The main finding from this classification system was the difference in results between Type 2 and Type 3 lesions. The trend towards improvements over time requires confirmation by longer-term studies, which will also have to establish that the increased wasting of the upper subscapularis muscle and fatty degeneration of the muscle belly have no adverse effects.

New endoscopic classification for subscapularis lesions.

BACKGROUND The absence of a coherent classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tendon lesions. In addition, a reliable classification system allows comparisons of epidemiological and therapeutic data. The classification systems used until now fail to incorporate the radiological and intraoperative abnormalities of the bicipital sling, and they do not consider the degree of subscapularis tendon cleavage. Here, we describe a new arthroscopy-based classification system intended for therapeutic and prognostic purposes. METHODS A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 150 isolated subscapularis lesions with or without limited anterosuperior involvement. The bicipital sling and insertion of the deep subscapularis layer were routinely investigated by arthroscopy with video recording. Each lesion was classified after a consensus was reached among four surgeons. RESULTS We identified four lesion types based on the bicipital sling findings. Type I was defined as partial separation of the subscapularis tendon fibres from the lesser tuberosity with a normal bicipital sling. Type II consisted of a partial subscapularis tear at the lesser tuberosity attachment combined with partial injury to the anterior wall of the bicipital sling, without injury to the superior glenohumeral ligament. Type III was complete separation of the subscapularis fibres from the lesser tuberosity with extensive cleavage of the bicipital sling. Finally, in Type IV, all the subscapularis fibres were detached and, in some cases, conjunction of the subscapularis and supraspinatus fibres produced the comma sign. Nearly all the lesions identified intraoperatively during the study fit one of these four types. DISCUSSION A reproducible classification system that allows different surgeons to establish comparable homogeneous patient groups is useful for both therapeutic and prognostic purposes. We defined four types of subscapularis lesions that are easy to identify as either isolated lesions or combined with anterosuperior rotator cuff tears. Long head of biceps tendon abnormalities and fatty degeneration of the shoulder muscles can be added to our classification system. Studies of intraobserver and interobserver reproducibility are needed to complete the process of validating the diagnostic and/or prognostic usefulness of this new classification scheme.

Diagnosis of subscapularis tendon tears: Are available diagnostic tests pertinent for a positive diagnosis?

HYPOTHESIS Clinically, subscapularis tendon tears are suggested by the presence of increased passive external rotation compared to the opposite side, resisted internal rotation manoeuvres (Lift-Off test [LOT], Belly-Press test [BPT], Napoleon test and Bear-Hug test [BHT] and positive Internal Rotation Lag Sign and/or Belly-Off Signs). Associated bicipital involvement is frequent with subscapularis tendon tears, because it participates in the formation of the biceps pulley. The Palm-Up test (PUT) is used for the biceps, and the Jobe test for the supraspinatus. MATERIAL AND METHODS In this multicenter study, we evaluated the positive diagnostic value of the clinical tests, LOT, BPT, BHT, PUT, and the Jobe test for subscapularis tears as well as their anatomical value. The relationships of the different parameters studied were compared statistically by analysis of variance (ANOVA). This prospective multicenter study was performed from January 2009 to February 2010 and included 208 cases of subscapularis tendon tears, isolated or associated with partial (Ellman 1, 2 or 3) or full thickness (SFA stage 1) supraspinatus tears. RESULTS The severity of the subscapularis tear was quantified according to the SFA classification into four stages and according to the level of injury (the lower 1/3 and upper 2/3). The three tests LOT, BPT and BHT were correlated to the severity of observed tears (P<0.05). The more deficient the test results were, the more severe the anatomical damage. The LOT is the test that cannot be performed most often (18%) but when it is positive, it is predictive of very severe tears. The BHT is the most sensitive of all tests (82%). The frequency of biceps involvement was correlated to the severity of subscapularis damage. There was no significant correlation between biceps involvement and subscapularis tests, or between supraspinatus involvement and subscapularis tests. There was no correlation between the Palm-Up test and subscapularis tears with associated supraspinatus involvement however, it was significantly correlated to biceps involvement (P<0.05). The Jobe test was disappointing because it was often positive even for isolated subscapularis tears. CONCLUSION Even though all three tests were performed (LOT, BPT, BHT), 24% of the subscapularis tears were only diagnosed during surgery. The role of the Internal Rotation Lag Sign and Belly-Off Sign in improving the diagnosis of tears was not studied in this work.

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases

INTRODUCTION Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined. PATIENTS AND METHODS This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements). RESULTS Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05). DISCUSSION The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.

Arthroscopic treatment in split depression-type tibial pilon fracture

Abstract Treatment of tibial pilon fractures is complicated and often very invasive. Partial fractures with a depressed component raise the question of the choice of surgical technique. Minimally invasive surgical reduction under arthroscopic guidance appears to be a promising alternative in this type of fracture. We describe a technique for arthroscopically assisted treatment of a split depression tibial pilon fracture.