Philippe Collin

Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion.

BACKGROUND Management of massive chronic rotator cuff tears remains controversial, with no clearly defined clinical presentation as yet. The purpose of the study was to evaluate the effect of tear size and location on active motion in patients with chronic and massive rotator cuff tears with severe muscle degeneration. METHODS One hundred patients with massive rotator cuff tears accompanied by muscle fatty infiltration beyond Goutallier stage 3 were prospectively included in this study. All patients were divided into 5 groups on the basis of tear pattern (supraspinatus, superior subscapularis, inferior subscapularis, infraspinatus, and teres minor). Active range of shoulder motion was assessed in each group and differences were analyzed. RESULTS Active elevation was significantly decreased in patients with 3 tear patterns involved. Pseudoparalysis was found in 80% of the cases with supraspinatus and complete subscapularis tears and in 45% of the cases with tears involving the supraspinatus, infraspinatus, and superior subscapularis. Loss of active external rotation was related to tears involving the infraspinatus and teres minor; loss of active internal rotation was related to tears of the subscapularis. CONCLUSIONS This study revealed that dysfunction of the entire subscapularis and supraspinatus or 3 rotator cuff muscles is a risk factor for pseudoparalysis. For function to be preserved in patients with massive chronic rotator cuff tears, it may be important to avoid fatty infiltration with anterior extension into the lower subscapularis or involvement of more than 2 rotator cuff muscles.

Influence of Arm Lengthening in Reverse Shoulder Arthroplasty

BACKGROUND Reverse shoulder arthroplasty (RSA) can improve anterior active elevation (AAE) by lengthening of the deltoid and hence increasing its lever arm. However, evaluations of functional outcomes of RSA have shown variable improvements in the range of motion. The aim of our study was to correlate humeral and arm lengthening to postoperative AAE. METHODS We reviewed 183 RSAs with a minimum follow-up of 1 year. Lengthening of the humerus and the arm was evaluated in relation to the contralateral side. RESULTS We observed mean humeral lengthening of 0.2 ± 1.4 cm (range, -4.7 to +5.2 cm) and mean arm lengthening of 1.6 ± 1.9 cm (range, -5.1 to +5.4 cm). Postoperative AAE was 140° ± 27° (range, 30° to 180°). We found no significant correlation between lengthening or shortening of the humerus and AAE (P = .169). Shortening of the arm led to a mean AAE value of 122°; lengthening of 0 and 1 cm, mean AAE of 140°; lengthening of greater than 1 cm to 2.5 cm, mean AAE of 144°; and lengthening of greater than 2.5 cm, mean AAE of 147°. When we compared patients with lengthening of the arm and those with shortening, the postoperative AAE was significantly greater after arm lengthening, 145° versus 122°, with a mean difference of 23° (95% confidence interval, 13° to 33°) (P < .001). CONCLUSION This study shows that shortening of the arm reduced AAE. With respect to arm lengthening, a lengthening threshold was not found. An objective assessment of deltoid lengthening is possible preoperatively, intraoperatively, and postoperatively, and this measure seems to correlate with the functional outcome.

A ten-year radiologic comparison of two-all polyethylene glenoid component designs: a prospective trial.

BACKGROUND Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up of 2 cemented all-polyethylene glenoid components with different backside design geometry and the effect on the presence and progression of radiolucent lines (RLLs). MATERIALS AND METHODS Fifty-six TSAs were performed for primary osteoarthritis. Two surgeons used an identical technique to implant 32 flat-back and 24 convex-back glenoids. In particular, the glenoid components were cemented after a minimal reaming and bone compaction. Standardized postoperative radiologic and clinical follow-up was at 2 and 10 years. Three independent observers evaluated the x-ray images for RLLs around the base plate and keel. The results were analyzed for progression and influencing factors. RESULTS At 10 years, progression of RLL was seen in both components, but there was no difference between the 2 glenoid designs (P = .16). Younger patient age (P = .03), hand dominance (P = .017), and presence of early RLLs (P = .018) were significant factors for progression of RLLs. Constant scores deteriorated with progression of RLLs (P = .006). The glenoid revision rate at 10 years was 5%. CONCLUSION At 10 years there was no difference in the presence or progression of RRLs between a flat-back and a convex-back glenoid all-polyethylene design. Young age, hand dominance, and poor implantation technique influence glenoid RLLs and affect the clinical result of TSA.

Neuropathy of the suprascapular nerve and massive rotator cuff tears: a prospective electromyographic study

BACKGROUND An association between massive rotator cuff tear (RCT) and suprascapular nerve neuropathy has previously been suggested. The anatomic course of the suprascapular nerve is relatively fixed along its passage. Thus, injury to the nerve by trauma, compression, and iatrogenic reasons is well documented. However, the association between retraction of the RCT and development of neuropathy of the suprascapular nerve remains unclear. We aimed to prospectively evaluate the suprascapular nerve for preoperative neurodiagnostic abnormalities in shoulders with massive RCT. METHODS AND MATERIALS A prospective study was performed in 2 centers. Fifty patients with retracted tears of both supraspinatus and infraspinatus were evaluated. This was confirmed with preoperative computed tomography arthrography, and the fatty infiltration of the affected muscles was graded. Forty-nine preoperative electromyograms were performed in a standardized fashion and the results analyzed twice. RESULTS Of 49 shoulders, 6 (12%) had neurologic lesions noted on electromyography: 1 suprascapular nerve neuropathy, 1 radicular lesion of the C5 root, 1 affected electromyogram in the context of a previous stroke, and 3 cases of partial axillary nerve palsy with a history of shoulder dislocation. No difference or diminution of the latency or amplitude of the electromyographic curve was found in the cases that presented significant fatty infiltration. CONCLUSION This study did not detect a suprascapular lesion in the majority of cases of massive RCT. With a low association of neuropathy with massive RCT, we find no evidence to support the routine practice of suprascapular nerve release when RCT repair is performed.

Reverse shoulder arthroplasty in patients with pre-operative impairment of the deltoid muscle

The indications for reverse shoulder arthroplasty (RSA) continue to be expanded. Associated impairment of the deltoid muscle has been considered a contraindication to its use, as function of the RSA depends on the deltoid and impairment of the deltoid may increase the risk of dislocation. The aim of this retrospective study was to determine the functional outcome and risk of dislocation following the use of an RSA in patients with impaired deltoid function. Between 1999 and 2010, 49 patients (49 shoulders) with impairment of the deltoid underwent RSA and were reviewed at a mean of 38 months (12 to 142) post-operatively. There were nine post-operative complications (18%), including two dislocations. The mean forward elevation improved from 50° (sd 38; 0° to 150°) pre-operatively to 121° (sd 40; 0° to 170°) at final follow-up (p < 0.001). The mean Constant score improved from 24 (sd 12; 2 to 51) to 58 (sd 17; 16 to 83) (p < 0.001). The mean Single Assessment Numeric Evaluation score was 71 (sd 17; 10 to 95) and the rate of patient satisfaction was 98% (48 of 49) at final follow-up. These results suggest that pre-operative deltoid impairment, in certain circumstances, is not an absolute contraindication to RSA. This form of treatment can yield reliable improvement in function without excessive risk of post-operative dislocation.

Prospective evaluation of clinical and radiologic factors predicting return to activity within 6 months after arthroscopic rotator cuff repair

BACKGROUND This study aimed to report the outcome of patients who underwent arthroscopic rotator cuff repair (ARCR) and to determine the factors associated with return to work and activity. MATERIALS Three hundred sixty-five patients who underwent ARCR were prospectively evaluated. The cohort was divided into 2 groups based on clinical results at 6 months. Group A consisted of patients who were considered to have a satisfactory outcome based on return to their previous professional or spare-time activities. Group B consisted of patients with an unsatisfactory outcome based on a lack of return to normal work or activities. RESULTS Of the patients, 305 had a satisfactory outcome (group A) and 60 were categorized as having an unsatisfactory outcome (group B). On multivariate analysis, preoperative factors associated with group B included female gender and heavy manual labor. Postoperative bursitis on ultrasound at 6 months was associated with being in group B. Lack of tendon healing was not associated with group B. However, if a patient without healing had persistent pain at 6 months, the pain persisted at 9 months. CONCLUSION ARCR is an effective procedure that leads to significant improvement in pain, function, and tendon healing in most cases. However, in 1 of 5 cases, patients were unable to resume normal activity at 6 months postoperatively. Persistent limitation at 6 months was associated with female gender, heavy manual workers, and the presence of postoperative persistent bursitis.

Massive rotator cuff tears: definition and treatment

PurposeThe aim of this review is to summarise tear pattern classification and management options for massive rotator cuff tears (MRCT), as well as to propose a treatment paradigm for patients with a MRCT.MethodData from 70 significant papers were reviewed in order to define the character of reparability and the possibility of alternative techniques in the management of MRCT.ResultsMassive rotator cuff tears (MRCT) include a wide panoply of lesions in terms of tear pattern, functional impairment, and reparability. Pre-operative evaluation is critical to successful treatment. With the advancement of medical technology, arthroscopy has become a frequently used method of treatment, even in cases of pseudoparalytic shoulders. Tendon transfer is limited to young patients with an irreparable MRCT and loss of active rotation. Arthroplasty can be considered for the treatment of a MRCT with associated arthritis.ConclusionThere is insufficient evidence to establish an evidence-based treatment algorithm for MRCTs. Treatment is based on patient factors and associated pathology, and includes personal experience and data from case series.

Influence of surgical approach on functional outcome in reverse shoulder arthroplasty.

INTRODUCTION Reverse shoulder arthroplasties (RSA) can be performed using a Deltopectoral (DP) or alternatively a Transdeltoid (TD) approach. HYPOTHESIS Although the humeral cut is lower by TD approach, this should not affect postoperative functional results. MATERIAL AND METHODS This retrospective multicentric study evaluated the complete medical records of RSA implanted between October 2003 and December 2008. Inclusion criteria were: follow-up of at least 1 year, a complete file including a comparative radiological work-up making it possible to analyze eventual arm and humeral lengthening. Evaluation of postoperative function was based on Active Anterior Elevation (AAE). RESULTS We studied 144 RSA in 142 patients. One hundred and nine RSA were implanted by the DP approach and 35 by the TD approach. Mean lengthening of the humerus compared to the controlateral side by DP approach was 0.5±1.3 cm while there was a mean shortening of -0.5±1.0 cm by TD approach (P<0.001). The difference in cut was partially compensated by using thicker polyethylene inserts with the TD approach. Mean arm lengthening compared to the controlateral side was 1.7±1.7 cm by DP approach and 1.2±1.4 cm by TD approach (mean difference 0.5 cm; (95% CI -0.1; 1.2). AAE for RSA by DP approach was 145±22° and 135±29° by TD approach (mean difference 10°, 95% CI -1; 21). DISCUSSION RSA results in improved AAE because of restored deltoid tension and an increase in the deltoid lever arm. The humeral cut by TD is lower, but this was partially corrected in this study by the use of thicker polyethylene inserts. Nevertheless there is no significant clinical difference in postoperative function between the two approaches.

Arthroscopic repair of the rotator cuff: prospective study of tendon healing after 70 years of age in 145 patients.

INTRODUCTION The level of activity of patients older than 70 years is tending to increase, as are their expectations in terms of joint function recuperation. It has not been proven that rotator cuff repair healing is satisfactory in the elderly. The main hypothesis of this study was: repair of supraspinous lesions in patients older than 70 years is reliable in terms of both clinical results and healing. The secondary hypothesis was: tendon healing is significantly correlated with the Constant, ASES, and SST scores as well as with age, tendon retraction, and fatty infiltration. MATERIAL AND METHODS Multicenter prospective study on 145 patients older than 70 years, with 135 patients reviewed at 1 year (93%). The mean age was 73.9 years. Full-thickness tears of the supraspinatus extended at most to the upper third of the infraspinatus and retraction limited to Patte stages 1 and 2 were included. Clinical assessment was carried out in accordance with the Constant, ASES, and SST scores. Healing was evaluated with ultrasound. RESULTS A significant improvement was noted in the Constant (44/76)+31.5 (P<0.0001), ASES (35/90)+54.4 (P<0.0001), and SST (3.5/10)+6.6 (P>0.0001) scores at 1 year of follow-up. The healing rate was 89% with 15 re-tears, nine of which were stage 1 and six stage 2. The clinical result was not correlated with patient age (Constant, P=0.24; ASES, P=0.38; SST, P=0.83) nor with the retraction stage (Constant, P=0.71; ASES, P=0.35; SST, P=0.69) or the stage of fatty infiltration (P>0.7). Healing was correlated with the quality of the clinical result (Constant, P=0.02; ASES, P=0.03) and age (P=0.01) but was not correlated with retraction or the fatty infiltration stage (P>0.3). DISCUSSION/CONCLUSION Arthroscopic repair significantly improves the clinical results, even in patients older than 70 years. The clinical results are not correlated with age (but deterioration of the result was not noted after 75 years) or frontal retraction (but the study only included retractions limited to stages 1 and 2). The healing rate is satisfactory, but this study is limited to small ruptures of the supraspinatus, and the postoperative ultrasound analysis probably inferior to CT imaging with contrast agent injection, often used as the reference. Healing proves to be correlated with the quality of the clinical result and patient age.

Injury to the axillary nerve after reverse shoulder arthroplasty: An anatomical study

BACKGROUND Subclinical neurological lesions after reverse shoulder arthroplasty are frequent, mainly those involving the axillary nerve. One of the major reported risk factors is postoperative lengthening of the arm. The purpose of this study was to evaluate the anatomical relationship between the axillary nerve and prosthetic components after reverse shoulder arthroplasty. The study hypothesis was that inferior overhang of the glenosphere relative to glenoid could put this nerve at risk. MATERIAL AND METHODS Eleven fresh frozen shoulder specimens were dissected after having undergone reverse shoulder arthroplasty using a classic deltopectoral approach. RESULTS The mean distance from the inferior border of the glenoid to the inferior edge of the glenosphere was 6.0±4.3mm (range, 1.0 to 16.2mm). The axillary nerve was never closer than 15mm to the glenosphere. The main anterior branch of the axillary nerve was in close contact with the posterior metaphysis or humeral prosthetic implant. The mean distance between the nerve and the humeral implants was 5.2±2.1mm (range, 2.0 to 8.1mm). CONCLUSIONS The proximity of the axillary nerve to the posterior metaphysis or humeral implants may be a risk factor for axillary nerve injury after reverse shoulder arthroplasty. CLINICAL RELEVANCE This study quantifies the proximity of the axillary nerve to the implant after reverse shoulder arthroplasty. LEVEL OF EVIDENCE Basic science study, cadaver study.