Philippe Clavert

Open operative treatment for anterior shoulder instability: When and why?

The treatment of anterior glenohumeral instability continues to evolve. Open capsulolabral repairs are time-tested and reliable. In an era in which arthroscopic techniques continue to improve, open surgery remains an acceptable option, and there are still certain injury patterns that cannot be adequately addressed arthroscopically. Decision-making regarding surgery for instability is influenced by the surgeons experience and the relevant pathological findings. Open operative treatment is the preferred approach in many instances of recurrent anterior instability, particularly when there is bone and soft-tissue loss and in revision settings.

Recurrent posterior shoulder instability.

Abstract Recurrent posterior shoulder instability is an uncommon condition. It is often unrecognized, leading to incorrect diagnoses, delays in diagnosis, and even missed diagnoses. Posterior instability encompasses a wide spectrum of pathology, ranging from unidirectional posterior subluxation to multidirectional instability to locked posterior dislocations. Nonsurgical treatment of posterior shoulder instability is successful in most cases; however, surgical intervention is indicated when conservative treatment fails. For optimal results, the surgeon must accurately define the pattern of instability and address all soft‐tissue and bony injuries present at the time of surgery. Arthroscopic treatment of posterior shoulder instability has increased application, and a variety of techniques has been described to manage posterior glenohumeral instability related to posterior capsulolabral injury.

Surgical management of the infected reversed shoulder arthroplasty: a French multicenter study of reoperation in 32 patients

BACKGROUND In a retrospective multicenter study, we evaluated the efficiency and outcomes of the different therapeutic options for infection after reversed shoulder arthroplasty. METHODS Thirty-two patients were reoperated on for infection after reversed shoulder arthroplasty between 1996 and 2011. The mean age was 71 (55-83) years. The involved implants were primary prostheses in 23 cases and revision prostheses in 9 cases. The average preoperative Constant score was 34 (11-69). Six of these patients needed 2 successive procedures. A total of 38 procedures were performed: débridement (13), 1-stage (5) or 2-stage revision (14), or implant removal (6). At last follow-up (mean, 36 months; range, 12-137 months), every patient had clinical, biologic, and radiographic evaluation. RESULTS Infections were largely caused by coagulase-negative staphylococci (56%) and Propionibacterium acnes (59%). The complication rate was 26%. At last follow-up, 26 patients were free of infection (81%). The final Constant score was 46 (12-75). After débridement with implant retention, the mean Constant score was 51 (29-75), but the healing rate was only 54%. Implant revision (1 or 2 stage) led to better functional results than implant removal (46 vs. 25; P = .001), with similar healing rates (73% and 67%, respectively). Patients with low initial impairment (Constant score > 30) were not significantly improved by surgical treatment. CONCLUSION Débridement is the less aggressive option but exposes patients to healing failure. It should be proposed as a first treatment attempt. Revision of the implant is technically challenging but preserves shoulder function, with no higher rate of residual infection compared with implant removal.

A plea for the use of drawing in human anatomy teaching

Descriptive human anatomy constitutes one of the main parts of the educational program of the first part of the medical studies. Professors of anatomy have to take into account the exponential evolution of the techniques of morphological and functional exploration of the patients, and the trend to open more and more the contents of the lectures of anatomy to clinical considerations. Basically, teaching requires a series of descriptive and educational media to set up, in front of the student, the studied structures and so to build the human body. More generally, lectures in morphological sciences try to develop three types of knowledge: declarative, procedural, and conditional. Traditionally in France “basic or first” anatomy is taught in amphitheater and in big groups by building each structure or region on a blackboard with colored chalk that allows a relief stake of certain structures and builds in two dimensions a three-dimensional organization. Actually, the blackboard is and stays for us an excellent media of non-verbal expression.

Split Pectoralis Major and Teres Major Tendon Transfers for Reconstruction of Irreparable Tears of the Subscapularis

Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. In certain circumstances, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. A pectoralis major tendon transfer is an acceptable salvage option for irreparable subscapularis tendon ruptures. Although limited functional goals may be expected in most cases, the majority of patients obtain a good pain relief, which improves their function below chest level. Addition of the teres major component to the transfer may be beneficial in cases where both the upper and lower portion of the subscapularis muscle is irreparable. Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears.1 Because unspecific complaints like pain and weakness without loss of function are in most cases the only subjective signs associated with subscapularis tears, diagnosis and treatment occurred often with delay (Fig. 1). In certain instances, such as chronic tears or subscapularis insufficiency after previous surgery, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. FIGURE 1. Unspecific subjective complaints and compensated shoulder function usually lead to a delay in diagnosis of a subscapularis tear.

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.

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.

Arthroscopie complémentaire de l’ostéosynthèse du radius distal par abord antérieur

Resume A partir de 25 dissections de pieces anatomiques, nous avons analyse l’anatomie morphologique du systeme capsulo-ligamentaire de la face anterieure du poignet et mis en place deux nouvelles voies d’abord arthroscopiques radio-carpienne et radio-ulnaire. Les ligaments intrinseques et extrinseques du poignet ont ete reperes, et les soft-points ont ete repertories. Deux points d’introduction potentiellement utilisable en cas d’abord de la face anterieure du radius selon la voie de Henry ont ete systematiquement trouves : entre le ligament radio-lunaire et le ligament radio-scapho-capitatum sur le versant radial et entre le ligament radio-lunaire et le ligament ulno-lunaire. L’exploration arthroscopique a permis d’observer les ligaments scapho-lunaire, luno-triquetral, le complexe triangulaire, et l’ensemble de la surface articulaire radiale inferieure. A notre connaissance, aucune voie d’abord anterieure radiale n’a ete decrite pour l’arthroscopie. Cette voie d’abord nous semble interessante dans le cadre des fractures articulaires du radius distal necessitant une osteosynthese anterieure.PURPOSE OF THE STUDY Morphological and morphometric studies of the wrist ligaments are scarce. The radiocapitatum and scapholunate ligaments play a pivotal role in wrist stability. Classically, a posterior approach is used for arthroscopic procedures, but an anterior approach should be possible. We conducted a cadaver study to search for new anterior portals for wrist arthroscopy. MATERIAL AND METHODS Twenty-five formol-treated upper limbs were dissected. The classical anterior approach for open wrist surgery was executed. The different elements of the capsule-ligament system of the anterior aspect of the wrist were identified and labeled. The dissection was then extended to the ulna in search of soft points which were identified and evaluated. The different structures generally identified during wrist arthroscopy were noted. RESULTS Two potential portals were identified in all wrists: one between the radiolunate ligament and the radio-scapho-capitatum ligament on the radial aspect and one between the radio-lunate ligament and the ulno-lunate ligament. Arthroscopic exploration enabled observation of the scapho-lunate ligament, the luno-triquetral ligament, the triangular complex of the carpus, and the entire inferior aspect of the radial joint surface, with no risk of vessel or nerve injury because of the exposure allowed by the osteosynthesis approach. DISCUSSION Wrist arthroscopy is now accepted as a reliable technique not only for diagnostic purposes but also for therapeutic interventions for the treatment of fractures of the lower radius. Most of the arthroscopic portals described in the literature are posterior. The anterior portals described here do not involve any vascular or neurological risk since the radial approach is made under visual control by extension of the open anterior approach and on the ulnar side the noble structures are positioned medially to the ulnar flexor tendon of the carpus. This enables good triangulation necessary for the usual arthroscopic procedures. Finally, these portals have no supplementary morbidity which would be the case with percutaneous portals (injury to the medial nerve, the radial vasculonervous bundle, the radial flexor tendon). CONCLUSION These new arthroscopic portals are complementary to the anterior approach for open wrist surgery and enable a natural extension of joint exploration via both the radial and ulnar approaches described in this study.