S. Zilber

Long-term functional and structural outcome in patients with intact repairs 1 year after open transosseous rotator cuff repair

HYPOTHESIS Tendon-to-bone suture and a fatty degeneration index (FDI) <or= 2 are required to achieve an intact cuff in the mid-term. Our primary objective was to determine the structural and functional long-term outcomes of repaired cuffs that were intact after one year. MATERIALS AND METHODS We studied 30 cuffs with FDI <or= 2 at surgery and no tear one year after tension-free tendon-to-bone suture. Mean follow-up was 9 +/- 0.8 years. Gross tendon-stump lesions were excised prior to repair. RESULTS Re-tear after one year was rare: only one cuff showed a recurrent tear. In the 29 intact cuffs, mean un-weighted Constant score and sub-scores improved significantly (P values, < .0001- .0002; final Constant score = 77) for two years then remained stable. FDI values increased during the first year and then remained stable. Mild osteoarthritis was noted in one shoulder at last follow-up. CONCLUSION Final functional outcomes correlated significantly to FDI at baseline and last follow-up. Tension free tendon-to-bone suture is effective functionally and structurally at nine years follow-up provided the FDI at surgery is <or= 2 and the repair is intact after one year. LEVEL OF EVIDENCE Level 3; Retrospective cohort therapeutic study.

Acromio humeral distance less than six millimeter: Its meaning in full-thickness rotator cuff tear

UNLABELLED The present study sought to identify full-thickness rotator cuff tears liable to induce an acromiohumeral distance (AHD) of less than 6 mm. The hypothesis was that, less than 6mm AHD is found exclusively in association with total full-thickness infraspinatus tear. MATERIALS A continuous single-center series recruited 109 shoulders, free of glenohumeral osteoarthritis, presenting with full-thickness tear requiring surgery. Preoperative acromiohumeral distance, rupture location and extension on the various tendons and muscular fatty degeneration (FD) were known. METHODS Full-thickness tears were categorized by location and extension on the various tendons. For each group, the number of shoulders showing AHD<6 mm was determined. RESULTS Total full-thickness infraspinatus tears were almost the only tendon lesions able to induce AHD<6 mm, but this only when the infraspinatus muscle showed FD equal to or greater than 2.25: i.e., when the tear was longstanding. DISCUSSION Unlike previous reports, the present study took account of the total or partial nature of infraspinatus and subscapularis tendon tear. The findings may suggest that AHD<6 mm is induced by posterior migration of the humeral head secondary to longstanding total infraspinatus tear, reducing AHD projection height on X-ray. CONCLUSION AHD<6 mm is a sign of rotator-cuff rupture almost systematically involving longstanding total infraspinatus tear, not always amenable to suture repair due to advanced fatty degeneration. AHD equal to or greater than 6mm is of no diagnostic relevance and in no way indicates whether there is subscapularis tear and, if so, whether suture repair is feasible.

Total shoulder arthroplasty using the superior approach: influence on glenoid loosening and superior migration in the long-term follow-up after Neer II prosthesis installation.

Glenoid component loosening and superior humeral translation are common after Neer II total shoulder arthroplasty using the anterior approach. To determine whether the superior approach reduced these complications, we retrospectively reviewed 20 shoulders in 16 patients. Both components were cemented. Patient satisfaction, unweighted Constant score, and imaging studies were evaluated at a mean of 3.5 years and at a mean of 11.1 years. Fourteen patients were satisfied or very satisfied. The mean unweighted Constant score improved from 25/100 preoperatively to 57/100 after 3.5 years and to 51/100 after 11.1 years. Pain relief contrasted with low strength. Radiolucent lines appeared around 95% of glenoid components and 20% of humeral stems. Computed tomography showed severe glenoid osteolysis in 3 of 13 shoulders. Humeral superior translation did not occur. This study confirms the glenoid component fixation issue. The superior approach may reduce the risk of humeral superior translation and radiologic glenoid component loosening.

Non-simultaneous bilateral hip fracture: Epidemiologic study of 241 hip fractures

INTRODUCTION Hip fractures are an important public health problem given their growing incidence as well as their functional and vital repercussions. With longer survival, patients with a contralateral fracture are increasingly numerous. The objective of this study was to investigate the bilateralization of hip fractures in terms of anatomic location and time to the second fracture. HYPOTHESIS Contralateral fractures are of the same anatomical type as the primary fractures. PATIENTS AND METHODS This was a retrospective epidemiological study on all patients managed for hip fractures between January 2007 and May 2008. Each case of bilateralization was studied. RESULTS We included 241 patients in the study. The mean age at occurrence of the primary fracture was 83.3 years (range, 60-99 years). The distribution showed 45.6% true femoral neck fractures and 54.4% trochanteric fractures. Twenty-six of the 241 patients had already suffered from a hip fracture (10.8%). This fracture was the same type as the recent fracture in 80.8% of the cases. The mean time between the two fractures was 5.6 years (range, 1-277 months). DISCUSSION The contralateral fractures were the same anatomical type as the primary fracture in eight out of ten patients and the symmetry remains intact in 64-83% depending on the series. The fracture occurred on average within 5 years of the first hip fracture. In cases of asymmetry, the second fracture was more often a trochanteric fracture. The causes explaining this symmetry are several and are poorly known. The risk factors are numerous and their prevention is essential (acting on the patients environment to prevent falls, rehabilitation to reestablish autonomy after the first fracture, and preventive treatment of osteoporosis), although these notions are often ignored by surgeons. LEVEL OF EVIDENCE IV, retrospective study.

Coracoid process x-ray investigation before Latarjet procedure: a radioanatomic study.

BACKGROUND The purpose of this study was to determine whether a preoperative radiologic assessment of the coracoid process is predictive of the amount of bone available for coracoid transfer by the Latarjet procedure. MATERIAL Thirty-five patients with anterior instability undergoing a Latarjet procedure were included. A preoperative radiologic assessment was performed with the Bernageau and true anteroposterior (true AP) views. METHODS The length of the coracoid process was measured on both radiographic views and the values were compared with the length of the bone block during surgery. Statistical analysis was carried out by ANOVA and Wilcoxon tests (P < .05). RESULTS On radiologic examination, the mean coracoid process length was 29 ± 4 and 33 ± 4 mm on the Bernageau and true AP views, respectively. The mean bone block length during surgery was 21.6 ± 2.7 mm. A significant correlation was found (P = .032) between the coracoid process length on the true AP view and the intraoperative bone block length. DISCUSSION Preoperative planning for the Latarjet procedure, including graft orientation and screw placement, requires knowledge of the length of coracoid bone available for transfer. This can be facilitated with the use of preoperative standard radiographs, thus avoiding computed tomography. This planning allows the detection of coracoid process anatomic variations or the analysis of the remaining part of the coracoid process after failure of a first Latarjet procedure to avoid an iliac bone graft. CONCLUSION Radiologic preoperative coracoid process measurement is an easy, reliable method to aid preoperative planning of the Latarjet procedure in primary surgery and reoperations.

Transsupraspinatus arthrotomy through an enlarged transacromial approach for total shoulder replacement

The authors describe a step-by-step technique for anatomic total shoulder arthroplasty using transsupraspinatus arthrotomy via the enlarged transacromial approach. This technique seems ideal to ensure adequate postoperative tensional balance of the infraspinatus and the subscapularis, which is critical for the rotator cuffs to function properly and to achieve optimal arthroplasty stability. Reviewing these different steps helps understanding each rotator cuff individual components contribution to achieve optimal arthroplasty stability.