Post-traumatic elbow osteoarthritis after radial head arthroplasty: Prevalence and risk factors

BACKGROUND

One of the treatment options for comminuted radial head fractures is radial head arthroplasty (RHA), especially when the elbow is also dislocated. While the clinical outcomes of RHA have been well documented, the incidence of post-traumatic osteoarthritis after RHA and its risk factors are not well known.

OBJECTIVE

To determine the incidence of post-traumatic elbow osteoarthritis (humeroulnar and humeroradial joints) after RHA and identify its risk factors.

METHODS

All patients who underwent RHA at our hospital between 2008 and 2016 were included retrospectively. The inclusion criteria were primary RHA, recent radial head fracture (isolated or associated with elbow dislocation), minimum 1 year of follow-up, clinical and radiographic examination at final assessment. The exclusion criteria were pre-existing elbow osteoarthritis, RHA revision, multiple fractures of the ipsilateral upper limb or polytrauma. The final assessment consisted of a clinical examination [joint range of motion (ROM) and Mayo Elbow Performance Score (MEPS)] and standard radiographs. The correlation between the incidence and severity of osteoarthritis and various risk factors was determined.

RESULTS

Seventy-three patients were included in the analysis with a mean age of 56 years (21-85). The injuries consisted of 41 terrible triad, 15 isolated radial head fractures, 11 Monteggia fractures and 6 transolecranon fracture-dislocations. The mean follow-up was 3.4 years (1-10.9). At the final assessment, osteoarthritis was visible in the humeroulnar compartment in 56% of cases and in the humeroradial compartment in 72% of cases. There was a statistical correlation between the presence of humeroulnar osteoarthritis at the final assessment and ROM in flexion-extension (p=0.003), MEPS (p<0.001), duration of immobilization (p=0.03) and presence of posterior subluxation on immediate postoperative radiographs (p=0.012). The correlation between humeroradial osteoarthritis at the final assessment and ROM in flexion-extension (p=0.0054), RHA implant position (p<0.01), and unipolar configuration (p=0.027) was statistically significant.

CONCLUSION

In our study, elbow osteoarthritis incidence after RHA was 56% in the humeroulnar joint and 72% in the humeroradial joint. RHA implant placement, posterior subluxation immediately postoperative and the duration of immobilization were significantly corelated with osteoarthritis.

LEVEL OF EVIDENCE

IV; case series without control group.

Arthroscopic intramedullary nailing of humeral fractures through the rotator interval

INTRODUCTION

Antegrade nailing of humeral fractures is a proven technique with well-documented results. The standard surgical approach requires incision of the supraspinatus tendon to insert a nail, which comes with the risk of damaging the rotator cuff. The aims of this study were to describe a new surgical technique for arthroscopic humeral nailing that does not require opening the rotator cuff and to report the clinical and radiological outcomes of this technique.

MATERIALS AND METHODS

This was a single center, retrospective study of patients who had a humeral shaft or surgical neck fracture at our hospital in 2017 and underwent antegrade intramedullary nailing by arthroscopy. The nail was introduced through the rotator interval without opening the rotator cuff. All were reviewed at 1-year postoperative: clinical examination (joint range of motion and Constant score) plus AP and lateral radiographs of the shoulder.

RESULTS

Eighteen patients (12 women, 6 men) with a mean age of 65.4 years (37-84) were included retrospectively. One patient died during the follow-up period thus 17 patients were available for analysis. At the 1-year follow-up, the mean forward flexion was 152.1° (90-180), the mean external rotation was 56.1° (30-80), the mean absolute Constant score was 73.9 (54-88) points and the mean adjusted Constant score was 93.5 (67-100) points. Bone union was achieved in 16/17 patients (94%) with 1 patient experiencing a nonunion. There were no complications.

CONCLUSION

Arthroscopic antegrade nailing of humeral shaft and surgical neck fractures through the rotator interval yields good clinical and radiological results in our hands. This new, rotator cuff-sparing technique is a viable option for treating humeral fractures by arthroscopy.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Biomechanical model of distal articular humeral fractures-influence of bone density on the fracture threshold

INTRODUCTION

Working hypothesis: The distal humeral bone density influences supracondylar fracture threshold. The aim of this study was first to develop a reproducible model of intra-articular distal humeral fractures and second to establish a relationship between bone mineral density (BMD) and the fracture threshold of the humerus.

MATERIALS AND METHODS

An original model of the fracture was developed using ten sawbones. After obtaining a reproducible and clinically relevant fracture model, we tested 21 cadaveric distal humeri for which the BMD was known with a stainless-steel custom-made proximal ulna jig. Fractures were created using a servo hydraulic-testing machine in axial compression to simulate a fall onto an outstretched hand. Fracture lines, load to failure, and rigidity of the bone were recorded based on the stress-strain curves.

RESULTS

The fracture generation was reliable, reproducible, and clinically relevant (type B2). A significant correlation between the BMD and the fracture threshold was found. Mean threshold was 901.86 N/m². Mean distal humerus BMD was 0.9097 g/cm² (r = 0.7321).

CONCLUSIONS

We developed a reproducible articular fracture of the distal humerus model and found a correlation between the fracture threshold and bone mineral density.

Comparison of bipolar and monopolar radial head prostheses in elbow fracture-dislocation

INTRODUCTION

The role of bipolar radial head prostheses (RHP) in elbow fracture-dislocation is controversial, with some reports of poorer stabilization than with monopolar designs. The aim of the present study was to compare mono- versus bi-polar RHPs in elbow fracture-dislocation. The study hypothesis was that mono- and bi-polar RHPs do not differ in clinical and radiological results, complications or revision rates.

MATERIAL AND METHODS

A single-center retrospective study included 58 patients, with a mean age of 55 years (range, 21-84 years). All received RHP for elbow dislocation with association: terrible triad, Monteggia fracture-dislocation, transolecranal dislocation or divergent dislocation. Two groups were compared: Mono-RHP, with monopolar prosthesis (n=40), and Bi-RHP, with bipolar prosthesis (n=18). All patients underwent clinical and radiological examination at last follow-up.

RESULTS

Mean follow-up was 42.7 months (range, 12-131 months). There were no significant (p>0.05) inter-group differences in range of motion or Mayo Elbow Performance Score. Mono- versus bi-polar design did not correlate with onset of complications (p=0.89), surgical revision (p=0.71), persistent or recurrent instability (p=0.59), or ulnohumeral (p=0.62) or capitulum (p=0.159) osteoarthritis at last follow-up.

DISCUSSION AND CONCLUSION

No differences were found between mono- and bi-polar RHPs in the treatment of elbow fracture-dislocation. Clinical and radiographic results were similar, as were complications and revision rates. The literature is inconclusive, reporting contradictory conclusions. We see no contraindications to bipolar RHPs in elbow dislocation with association, notably terrible triad injury.

LEVEL OF EVIDENCE

III, Retrospective case-control study.

Anterior capsule re-attachment in terrible triad elbow injury with coronoid tip fracture

BACKGROUND

During the surgical treatment of terrible triad elbow injury (TTEI), the usefulness of re-attaching the anterior joint capsule when the coronoid tip is fractured remains unclear. The primary objective of this study was to assess potential benefits during surgery for TTEI of re-attaching the joint capsule when the coronoid tip is fractured.

HYPOTHESIS

Re-attaching the anterior joint capsule in TTEI with a fractured coronoid tip improves clinical and radiological outcomes and decreases the complication and revision rates.

MATERIALS AND METHODS

This single-centre retrospective study included patients who underwent surgery at the acute phase of TTEI with a fractured coronoid tip. In all patients, a physical examination and elbow radiographs were performed at least 1year after surgery. A statistical analysis was done to compare the groups with vs. without re-attachment of the anterior capsule and coronoid tip.

RESULTS

The study included 30 patients, 16 females and 14 males, with a mean age of 51years (range: 21-84years). Among them, 11 did and 19 did not undergo re-attachment. The two groups were comparable regarding demographic features and follow-up duration. No significant differences were found at last follow-up for flexion-extension motion arc (p=0.75), pronation-supination motion arc (p=0.3051), or the Mayo Elbow Performance Score (p=0.19). Radiographic evidence of humero-radial osteoarthritis was significantly more common in the absence of re-attachment (p=0.04), whereas no differences were evidenced regarding humero-ulnar osteoarthritis (p=0.73), the occurrence of subluxation or dislocation (p=0.43), or loosening of the radial head implant (p=0.47). The complication and revision rates were similar in the two groups.

CONCLUSION

In our experience, re-attaching the anterior capsule during the surgical treatment of TTEI with a coronoid tip fracture did not improve the clinical or radiographic outcomes after a mean follow-up of 54months.

LEVEL OF EVIDENCE

IV, retrospective study.

Clinical and radiological outcomes of osteoarthritis twenty years after rotator cuff repair

PURPOSE

Outcomes of open or arthroscopic rotator cuff repairs are well reported in the literature. The purpose of the study was to evaluate the prevalence and clinical impact of osteoarthritis 20 years following rotator cuff repair. The hypothesis was that, at long follow-up, most shoulders would have developed gleno-humeral osteoarthritis.

METHODS

The authors retrospectively recalled all 322 patients, operated for rotator cuff tears in 1994 at 6 different centres, for clinical and radiographic assessment. At 20 years of follow-up, 24 were re-operated (5 arthroplasty) and 53.4% were lost to follow-up. This left 126 patients, had been clinically assessed, had Magnetic Resonance Images (MRI) that allowed anatomic assessment of tendon healing (Sugaya), fatty infiltration (Goutallier), and X rays in order to analyse arthritis without head migration (Samilson) and with head migration (Hamada and Fukuda). Only patients with complete data were selected.

RESULTS

Mean aged was 52.3 years (25.3-68.6) at index operation. The Constant score was 45.3±19.6 preoperatively to 67.4±18.7 points at 20 years. The SSV was 73.5±21 postoperatively. The rate of osteoarthritis was 29%. Osteoarthritis was associated with a significant inferior Constant score compared to the non-arthritic group (61 versus 71 points, p=0.02), mainly due to a significant lower strength (5.4 versus 8.7 points, p=0.007). Massive rotator cuff tears were significantly associated with a higher rate of osteoarthritis. Only 4,8% patients after cuff repear needed a reverse shoulder arthroplasty. Significantly less osteoarthritis was observed when the rotator cuff repair remained intact. Suprasupinatus retear had a significant influence on fatty infiltration of the infrasupinatus muscle and on the progression towards osteoarthritis.

CONCLUSION

Twenty years after open rotator cuff repair, the rate of osteoarthritis was 29%. Massive rotator cuff tears were significantly associated with a higher rate of osteoarthritis. Less osteoarthritis was observed when suprasupinatus healed.

LEVEL OF EVIDENCE

IV.

Does the cement mantle thickness influence the glenoid loosening in anatomic total shoulder arthroplasty? An experimental study

BACKGROUND

Glenoid component loosening is the most frequent failure mode. Few data are available on the effect of thickness of cement on glenoid loosening. The purpose of this study is to determine if the cement mantle thickness influences the mode and localization of loosening. Our hypotheses are: 1) failure is caused by traction stresses generated within the cement mantle and 2) a thicker cement mantle amplifies the rocking horse effect.

METHODS

Using bone substitute, an experimental protocol was designed to compare loosening of a keeled glenoid prosthesis in axial traction and off-centered-load, to recreate the rocking-horse effect (1.000.000 cycles). Different standardized mantle of cement between the back of the glenoid and the foam were tested (0-1 - 2-3 mm). The displacement of the polyethylene was assessed with an LVDT (Linear Variable Differential Transformer) gauge when the prosthetic humeral head loaded the opposite part of the implant.

RESULTS

The loosening took place within the keel of the implant, and at the polyethylene-cement interface in traction if there was cement at the back of the polyethylene. For cycling loading, we observed a loosening at this interface, with associated fracture of the cement, only for cement 2 and 3 mm thick.

CONCLUSION

This experimental study suggests that the cement mantle should be as thin as possible between the back of the implant and the sub-chondral bone but should be optimized around the keel of the implant.

LEVEL OF EVIDENCE

Basic Science Study.

Clinical and MRI Outcomes 10 Years After Repair of Massive Posterosuperior Rotator Cuff Tears

BACKGROUND

Massive rotator cuff tears are challenging to treat, with few or no studies on long-term outcomes of repair. The purpose of this study was to report 10-year outcomes following repair of massive posterosuperior rotator cuff tears, with and without extension into the subscapularis, and to determine prognostic factors that could influence clinical scores and retear rates.

METHODS

The records of 234 patients who underwent repair of a massive posterosuperior rotator cuff tear at a total of 15 centers were retrieved. Patients were asked to return for evaluation at 10 years; 78 patients could not be contacted, 7 had died, and 19 had undergone a reoperation. A total of 130 patients (68% men) with a mean age (and standard deviation) of 56.1 ± 7.7 years (range, 26 to 79 years) were evaluated clinically, and 102 of them were also evaluated using magnetic resonance imaging (MRI). The tear was confined to the supraspinatus and infraspinatus tendons in 94 shoulders and also involved the superior portion of the subscapularis in 36 shoulders. Univariable and multivariable regressions were performed to determine whether 10-year total Constant-Murley scores and repair integrity were associated with patient characteristics, tear patterns, or repair techniques.

RESULTS

In the study cohort, complications were noted in 14 shoulders (11%) (stiffness in 10 and infection in 4). For the 130 shoulders evaluated clinically, the mean total Constant-Murley score improved from 53.1 ± 15.9 (range, 14 to 83) preoperatively to 78.5 ± 11.3 (range, 36 to 98) at 10 years. Of the 102 shoulders evaluated using MRI, 32 had a retear (Sugaya type IV or V). Of the 19 shoulders that underwent a reoperation (excluded from the study cohort), 9 had a retear. The overall prevalence of retears was 34%. Multivariable regression analysis revealed a significant association between the 10-year Constant-Murley score and preoperative retraction of the infraspinatus tendon, but no association between retears and any of the variables. Involvement of the subscapularis had no significant effect on preoperative or postoperative Constant-Murley scores or retear rates.

CONCLUSIONS

Patients who had repair of a massive posterosuperior rotator cuff tear maintained considerable improvements in clinical and radiographic outcomes at 10 years. Partial concomitant tears of the subscapularis did not affect the total postoperative Constant-Murley scores or retear rates.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Tenodesis renders better results than tenotomy in repairs of isolated supraspinatus tears with pathologic biceps

BACKGROUND

Many authors recommend systematic biceps tenotomy or tenodesis when repairing rotator cuff tears, regardless of whether the biceps is normal or pathologic. The purpose of this study was to determine whether 10-year outcomes of repairs of isolated supraspinatus tears are influenced by adjuvant biceps tenodesis or tenotomy.

METHODS

Patients who underwent repair of isolated supraspinatus tears were recalled for evaluation at a minimum follow-up of 10 years. A total of 249 patients (51% men) aged 56.7 ± 6.3 years were evaluated clinically (Constant score), of whom 182 were also evaluated using magnetic resonance imaging (Sugaya classification). The biceps was intraoperatively found to be pathologic in 52% of shoulders, of which 39% had a tenotomy and 54% had a tenodesis; it was found to be normal in 48% of shoulders, of which 88% were left intact.

RESULTS

There were no significant differences in Constant scores for patients who had normal biceps without adjuvant procedures (77.1 ± 11.7) compared with patients who had pathologic biceps with either tenodesis (79.8 ± 11.5, P = .104) or tenotomy (75.3 ± 10.7, P = .420). However, for patients who had pathologic biceps, Constant scores were significantly better for those with tenodesis compared with those with tenotomy (P = .025). Multivariable regression revealed Constant scores to be significantly lower for women, as well as patients with fatty infiltration of stages 1 and 2, but significantly higher for patients who underwent tenodesis.

CONCLUSION

Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears, unless biceps pathology is observed intraoperatively, for which tenodesis grants better function and strength than tenotomy.

Clinical and anatomic results of rotator cuff repair at 10 years depend on tear type

PURPOSE

Although good short-term and mid-term outcomes are reported for rotator cuff repair, few studies have investigated long-term outcome with clinical and MRI evaluation. The hypothesis was that 10 years following repair of rotator cuff tear, the clinical and anatomic results depend on the extension of the tear.

METHODS

The records of all 965 patients who underwent repair of rotator cuff tears in 2003 were retrieved. The patients were reviewed in 2014 for evaluation at a minimum follow-up of 10 years. A total of 511 patients were evaluated clinically, of whom 397 were also evaluated using MRI. There were 289 isolated supraspinatus tears (SS), 94 tears with posterior extension (P), 92 with anterior extension (A) and 36 with anteroposterior (AP) extension.

RESULTS

The Constant score had significantly improved from 53.8 ± 14.7 preoperatively to 77.7 ± 12.1 (P < 0.0001) at 10 years, with no significant difference between the four groups. The rate of retear (Sugaya IV, V) was lower in the SS group (19%) and higher in the P (32%) and AP groups (31%). At review, infraspinatus fatty degeneration was significantly greater (Fuchs > 2) in the P (P < 0.001) and AP (P < 0.001) groups and subscapularis fatty degeneration was significantly greater (Fuchs > 2) in the A (P < 0.001) and AP (P < 0.001) groups. The rate of osteoarthritis (Samilson > 2) was significantly higher at 11% (P = 0.001) in the A group. The failure rate was significantly lower (P = 0.044) in the SS group (25%) than the massive rotator cuff tear groups (A, P and AP groups) (35%). Complications occurred in 51 shoulders (10%) and repeat surgery was required in 62 shoulders (12%), with no difference between the four groups.

CONCLUSIONS

The long follow-up period of this study, large series of patients and MRI evaluation of tendon repair allowed us to demonstrate that 10 years following rotator cuff tear repair, between 68 and 81% of tendons had healed. These findings are of value in predicting response to surgical treatment. Tears with posterior extension had a higher risk of retear. However, surgical repair appeared to give a good functional outcome whatever the type of tear, despite the overall rate of complications and repeat surgery.

LEVEL OF EVIDENCE

IV.

Fatty infiltration of stage 1 or higher significantly compromises long-term healing of supraspinatus repairs

BACKGROUND

Fatty infiltration (FI) compromises outcomes of rotator cuff repairs. Most clinicians consider FI of the infraspinatus, whether it is torn or intact, because it is most rapidly affected. The purpose of this study was to report long-term outcomes of isolated supraspinatus repairs and to determine their associations with FI of the infraspinatus and supraspinatus.

METHODS

The records of 182 patients who underwent repair of isolated supraspinatus tears and had preoperative magnetic resonance imaging were retrieved. Of these, 147 patients were evaluated at 10 years' follow-up using the Constant score and magnetic resonance imaging scans.

RESULTS

Preoperative FI was greater in the supraspinatus (52% stage ≥1) than in the infraspinatus (29% stage ≥1). The 10-year Constant scores were influenced by FI of the supraspinatus (P = .006) but not of the infraspinatus (P = .422). Multivariable regression confirmed that Constant scores were significantly lower for female patients, repetitive work, and stage 1 and stage 2 FI of the supraspinatus in addition to open surgery. Retear rates (Sugaya types IV-V) were also influenced by FI of the supraspinatus (P = .001) but not of the infraspinatus (P = .979). Shoulders with supraspinatus FI at stages 0, 1, and 2 had retear rates of 10%, 22%, and 31%, respectively. Multivariable regression affirmed that the odds of retears are significantly increased by both stage 1 and stage 2 FI of the supraspinatus.

CONCLUSIONS

The Constant scores and retear rates were significantly associated with FI of the torn supraspinatus (stage ≥1) but not of the intact infraspinatus. The authors recommend that rapid surgical intervention be considered, before accumulation of fat, especially for young, active patients.

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.

Revisions of total shoulder arthroplasty: Clinical results and complications of various modalities

INTRODUCTION

The number of primary total shoulder arthroplasties has increased exponentially in recent years, with a corresponding increase in the number of revision procedures.

OBJECTIVE

To assess clinical results and complications in a series of shoulder implant replacement, of whatever etiology.

MATERIALS AND METHODS

Thirty-seven patients, with a mean age of 68.3±11.8 years at time of implant replacement, were included in a retrospective study. Mean interval between primary arthroplasty and revision was 78.4±59.7 months (range, 1-200 months). The main assessment criterion was changed in Constant score between preoperative value and follow-up. Secondary criteria were: onset of intra- and postoperative complications, and reoperation related to a complication.

RESULTS

Mean follow-up was 41.5±32.0 months (range, 12-105 months). Absolute Constant score increased by a mean 17.5±15.1 points (P<0.001) and weighted Constant score by 26.3±23.6 points (P<0.001). Intraoperative complications occurred in 24.3% of patients (9/37) and postoperative complications in 29.7% (11/37). Among the patients, 21.6% (8/37) required reoperation for postoperative complications. Overall, 54% of patients (20/37) suffered from intra- or postoperative complications.

CONCLUSION

Shoulder implant replacement improved function in the present series, but with a high rate of complications and reoperations.

LEVEL OF EVIDENCE

IV, retrospective case-control study without control group.

Intratendinous rupture of the supraspinatus: anatomical and functional results of 24 operative cases

INTRODUCTION

The aim was to describe the natural history of intratendinous partial rotator cuff tears as well as the anatomical and clinical results of surgical treatment of a cohort of 24 patients.

PATIENTS AND METHODS

There were 14 men and 10 women with a mean age of 50 years. The right shoulder was involved in 17 cases. For 16 cases, a progressive history of shoulder pain was reported. Pre-operatively, a painful and positive Jobe's sign was observed in only 13 cases. Pre-operative mean absolute constant score was 63.52 points. Based on standard MRI, intratendinous lesions were diagnosed on the coronal view with hyper-signal within the tendon in the T2 FatSat sequence. No fatty infiltration was noted. Fourteen open and 10 arthroscopic repairs were performed.

RESULTS

Patients were reviewed with clinical assessment and MRI. The final Constant score was 81.3 points with a mean gain of 18.5 points. Patients were back to work after a mean of 5.8 months and to sports after 6 months. The mean subjective result was of 8.9/10. Three cases of reflex sympathetic dystrophy were observed.

DISCUSSION

Intratendinous tears of the supraspinatus tendon are rare and difficult to diagnose. Diagnosis relies on MRI (T2 FatSat). Trauma is not usually described. Chronic calcifying tendonitis may also contribute to the development of such tears. There is no associated fatty infiltration of the muscle. The Jobe's test is frequently painful or positive. Arthroscopic resection of the tendon insertion with reinsertion to the greater tuberosity seems to be the optimal treatment.

LEVEL OF EVIDENCE

Retrospective study, IV.

Arthroscopic elbow joint release with radial head resection arthroplasty: 12 cases

BACKGROUND

Elbow arthritis typically affects manual labourers aged 40 to 50 years and usually starts in the lateral compartment. The objective of this study was to evaluate the medium-term clinical, functional, and radiological outcomes in 12 patients after arthroscopic elbow joint release and radial head resection arthroplasty.

HYPOTHESIS

Our main hypothesis was that pre-operative damage to the radio-capitellar joint was associated with poorer clinical outcomes after elbow joint release.

MATERIAL AND METHOD

Consecutive patients treated by a single surgeon at a single centre between July 2006 and May 2014 were studied retrospectively. The 12 patients - 10 males and 2 females with a mean age of 54.5±9.3 years (33-69 years) - had osteoarthritis confined to the radio-capitellar compartment with elbow stiffness and pain and underwent arthroscopic elbow joint release with radial head resection arthroplasty. Among them, 9 had a history of trauma or micro-trauma and 3 had rheumatoid arthritis. The Broberg and Morrey osteoarthritis grade on the pre-operative radiographs was 1 in 4 patients, 2 in 6 patients, and 3 in 2 patients.

RESULTS

Mean follow-up was 38.1±33.7 months (5-97). One patient required total elbow arthroplasty. Mean arc of motion was 79.6°±20.5° (30-110) pre-operatively, 123.6±18° (90-140) immediately after surgery, and 109°±11.7° (90-120) at last follow-up. At last follow-up, mean values were 81.4±12.5 (65-100) for the Mayo Elbow Score, 11.1±11.1 (2.3-31.8) for the Quick DASH score, and 1.1±1.6 (0-4) for the visual analogue scale pain score. The radiological assessment at last follow-up showed no evidence of osteoarthritis progression.

CONCLUSION

In our case-series, arthroscopic elbow joint release with radial head resection arthroplasty produced good outcomes with a motion arc greater than 100° and little or no pain after a mean follow-up of 3.1 years.

LEVEL OF EVIDENCE

IV, retrospective study.

Recurrence after arthroscopic Bankart repair: Is quantitative radiological analysis of bone loss of any predictive value?

INTRODUCTION

Bone defects in the humeral head or antero-inferior edge of the glenoid cavity increase recurrence risk following arthroscopic Bankart repair. The present study sought to quantify such preoperative defects using a simple radiological technique and to determine a threshold for elevated risk of recurrence.

MATERIALS AND METHODS

A retrospective study conducted in two centers enrolled patients undergoing primary arthroscopic Bankart repair for isolated anterior shoulder instability in 2005. The principle assessment criterion was revision for recurrent instability. Quantitative radiology comprised: the ratio of notch depth to humeral head radius (D/R) on AP view in internal rotation; Gerber's X ratio between antero-inferior glenoid cavity edge defect length and maximum anteroposterior glenoid cavity diameter on arthro-CT scan; and the D1/D2 ratio between the glenoid joint surface diameters of the pathologic (D1) and healthy (D2) shoulders on Bernageau glenoid profile views. Seventy-seven patients were included, with a mean follow-up of 44 months (range, 36-54).

RESULTS

Overall recurrence rate was 15.6%. Recurrence risk was significantly greater when the humeral notch length was more or equal to 20% of the humeral head diameter and the Gerber ratio more or equal to 40%. On Bernageau views, mean D1/D2 ratio was 4.2% (range, 0-23%) in patients without recurrence, versus 5.1% (range, 0-19) in those with recurrence (P=0.003).

DISCUSSION

Beyond the above thresholds, bone defect as such contraindicates isolated arthroscopic stabilization. The D/R and Gerber ratios are simple and reproducible quantitative measurements can be taken in routine practice, enabling preoperative planning of complementary bone surgery as needed.

LEVEL OF EVIDENCE

Level IV; retrospective cohort study.

Pitfalls and complications with locking plate for proximal humerus fracture

PURPOSE

The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures.

PATIENTS AND METHODS

Seventy-three adult patients with a displaced 3- (24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months.

RESULTS

Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score (P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score (P = .029). Quality of the reduction of the greater tuberosity influenced final results (P = .037). Screw cutout rate was 13.7%, with an influence to the constant score (P = .001). A too high plate positioning influenced the constant score (P = .002).

CONCLUSION

Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.

Relationships of the musculocutaneous nerve and the coracobrachialis during coracoid abutment procedure (Latarjet procedure)

PURPOSE

The aim of this study was first to define first the anatomical relationships between the musculocutaneous nerve and the coracobrachialis, and then the induced modifications of these relationships by a preglenoid transposition of the vertical part of the coracoid process.

MATERIALS AND METHODS

Twenty-one embalmed adult trunks and upper limb were dissected. First the coracobrachialis and the musculocutaneous nerve were identified through a deltopectoral approach. We measured the distances between the lateral cord of the brachial plexus and the entry point of the nerve, between the inferior tip of the tip of the coracoid process and the penetration of the nerve or its twigs, and finally the angle between the general axis of the coracobrachialis and the axis of the musculocutaneous nerve. The same measures were performed after the coracoid bone block abutment.

RESULTS

Proximal motor branches destined to the coracobrachialis varied from 0 to 3. Mean distance between the lateral cord of the brachial plexus and entry point of the nerve into the muscle was 47.2 mm before and 48.43 mm after the coracoid transfer. Mean angulations between the nerve and the muscle was 121 degrees before and 136 degrees after the transfer of the coracoid process. Mean distance between the inferior tip of the coracoid process and entry point of the nerve into the muscle was 55.7 mm, reduced to 48.6 mm after the coracoid transposition. Finally, the distance between the tip of the coracoid and the first motor twig entering the coracobrachialis was less than 50 mm in 75% of the cases with a mean value of 40.6 mm.

CONCLUSIONS

Lesion of the musculocutaneous nerve is a known complication of the coracoid bone block abutment procedure (Latarjet-Bristow). From this study we know that they are due to lengthening of the nerve and modification of the penetration angle of the nerve into the coracobrachialis. We also infer that some motor nerve destined to the coracobrachialis might be damaged during the proximal medial release of the muscle after the detachment of the pectoralis minor muscle.

Arthroskopische Rekonstruktion der Rotatorenmanschette

OBJECTIVE

Regain of shoulder function and freedom of pain through arthroscopic fixation of the torn rotator cuff using anchors and tension bands.

INDICATIONS

Isolated 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.

CONTRAINDICATIONS

Fatty 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 >or=65 years.

SURGICAL TECHNIQUE

Subacromial 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.

RESULTS

50 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 surgery of the acromioclavicular joint]

Lesion of the acromioclavicular joint is a usual clinical condition because of it superficial situation. It is often involved in trauma of the shoulder girdle. Moreover, degenerative changes are quite always observed for patients over 40. Distal clavicle resection as a treatment of acromioclavicular joint disease had been first described in 1941. Clinical results in term of mobility and shoulder pain are good and durable in time. Referring to the expansion arthroscopic techniques, distal clavicle resection lead to same middle and long term results as open surgery. Arthroscopic procedures have the theoretical advantages of no deltoid disruption and may help the surgeon to diagnose and treat associated lesions such as rotator cuff ruptures. More recently, arthroscopic surgeries for fresh and/or chronic acromioclavicular disjunctions were proposed. These procedures remain in development and need further evaluations.

Finite element analysis of the strain distribution in the humeral head tubercles during abduction: comparison of young and osteoporotic bone

AIM

The aim of this work was to design an accurate 3D digital model of the humerus and rotator cuff muscles. This model was then used to study strain distribution in humeral tubercles according to bone density.

MATERIALS AND METHODS

The geometry of bone and muscle structures was reproduced using SURFDRIVER software, based on anatomical sections, CT scans and MRI images from the Visible Human Project image library. The contours were transferred to PATRAN software to rebuild volumes and mesh them. Calculations of strains and their distribution were performed using NASTRAN software. All the elements were considered to be isotropes.

RESULTS

The study of the distribution of stress magnitude according to the type of bone modeled, shows that some stresses in cortical bone are greater than those in cancellous bone and are also greater in old bone, implying more deformation in old bone at constant force. This study also shows that stresses do not penetrate deeply into cancellous tissue.

CONCLUSION

Observing the simulation results led understanding of the pathology of certain fractures of the proximal end of the humerus. This study also helped explain why certain types of osteosynthesis fail due to tubercles reconstruction failures.

Exérèse arthroscopique d’une forme pseudo-tumorale de synovite villonodulaire pigmentée de l’épaule

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.

Are there age induced morphologic variations of the superior glenoid labrum? About 100 shoulder arthroscopies

Different anterosuperior aspects of the glenoid labrum have already been described and are thought to be normal anatomical variations. The goals of this study were first to characterize these anterosuperior labral morphologies and then to analyze their variations in function of the patients' age. One hundred shoulder arthroscopies were recorded to study the macroscopic characteristics of the anterosuperior labrum of the glenohumeral joint and its relationships with the proximal insertion of the tendon of the long head of the biceps. Then, patients were divided into two groups in function of their age (below and over 30 years old). Morphological modifications of the labrum were found in function of the age of the patient with an increase of the nonpathologic "mobile labrum" type after 30 years (P=0.0423). Therefore a mobile and loosely attached superior labrum should not always be considered as abnormal, especially in case of patient older than 30 years.

The role of concomitant biceps tenodesis in shoulder arthroplasty for primary osteoarthritis: results of a multicentric study

This study evaluated the effects of concomitant biceps tenodesis in patients undergoing shoulder arthroplasty for primary osteoarthritis. Six hundred eighty-eight shoulders that had undergone replacement for primary glenohumeral arthritis were reviewed at a mean 43 months postoperatively. One hundred twenty-one patients had undergone a biceps tenodesis at arthroplasty, while the remaining patients did not. Tenodesis was significantly better than no tenodesis in most outcome parameters. No difference was found between the groups in complication rate. Biceps tenodesis is a useful adjunct to shoulder arthroplasty in the treatment of primary osteoarthritis.

Shoulder arthroplasty in patients with osteoarthritis and dysplastic glenoid morphology

Fifteen shoulders with primary osteoarthritis and dysplastic glenoid morphology underwent shoulder arthroplasty (eleven total shoulder arthroplasties and four hemiarthroplasties). Patients were evaluated at a mean of 37 months after replacement with clinical examination, Constant score, subjective patient opinion, and radiographic examination. One glenoid component was loose, necessitating removal; the remainder of the prostheses were in place at latest follow-up. Significant improvement was observed in Constant score (32 points preoperatively vs 71 points postoperatively) and active mobility (anterior elevation, 89 degrees preoperatively vs 146 degrees postoperatively; external rotation, 7 degrees preoperatively vs 45 degrees postoperatively) after arthroplasty. This study demonstrates that the rare scenario of osteoarthritis coupled with a dysplastic glenoid can be treated successfully with shoulder arthroplasty.

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.

[Computed tomographic analysis of humeral retrotorsion and glenoid retroversion]

PURPOSE OF THE STUDY

Analysis of the anatomic relations of the humeral head and the glenoid cavity is particularly important for clinical study of shoulder arthroplasty and glenohumeral instability. Analysis of humeral retroversion and glenoid retroversion is quite difficult and data in the literature are scarse. We conducted a computed tomography (CT) analysis of stable shoulders to detail retroversion of the entire height of the glenoid cavity and to measure humeral retrotorsion using two comparative methods. We also compared glenoid retroversion and humeral retrotorsion observed in individual subjects.

MATERIAL AND METHODS

This prospective study used a standardized CT analysis method. Both shoulders of 30 persons free of glenohumeral instability were studied. Two methods, described by Dähnert and Bernageau, were used to analyze humeral retrotorsion. The Benageau method was used to analyze glenoid retroversion.

RESULTS

According to the Dähnert method, humeral retrotorsion was 10 degrees +/- 13 degrees; it was 24 degrees +/- 13 degrees with the Bernageau method; data dispersion was 60 degrees and 65 degrees respectively. According to the Dähnert method, retrotorsion was more pronounced on the dominant side compared with the non-dominant side. There was a significant correlation between retrotorsion values for the two sides. For 95% of the shoulders, glenoid retorversion decreased progressively from the superior part of the glenoid cavity (12.8 degrees +/- 6.4 degrees ) to the lower part (3.1 degrees +/- 4.4 degrees ). Glenoid retroversion was greater on the dominant side. For 21 of the 30 persons (70%), there was a significant correlation between retroversion for the two sides. Correlation coefficients between glenoid retroversion and humeral retrotorsion were negative. Greater humeral retrotorsion was thus related with less pronounced glenoid retroversion and vice versa.

DISCUSSION

This study allowed quantification of glenoid retroversion and humeral retrotorsion. There is a spiral twist in the joint surface of the glenoid cavity with progressive decrease in glenoid retorversion from the upper to the lower part of the cavity for 95% of the shoulders. To our knowledge, this spiral twist in the glenoid cavity is not taken into consideration in any of the currently available implants. The correlation for both parameters between the right and left side is probably determined genetically. The influence of dominance could be explained by adaptation to more or less pronounced stress. The negative correlation between humeral retrotorsion and glenoid retroversion would improve glenohumeral stability. A comparative study with unstable shoulders would be required to verify this hypothesis. The validity of the Dähnert method for assessing humeral retorversion is, in our opinion, insufficiently established. The Bernageau method, which provides a direct measurement, appears to be preferable despite the difficulty in identifying anatomic landmarks.

Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study

Thirty-nine patients (forty shoulders) with primary osteoarthritis consented to be randomized to receive either a cemented all-polyethylene glenoid component or a cementless metal-backed component at the time of total shoulder arthroplasty. Their mean age was 69 years. Preoperative and postoperative evaluations were completed at 3, 6, 12, 24, and 36 months by history, physical examination, radiographs, and Constant scoring system. The presence of periprosthetic radiolucent lines was significantly greater with polyethylene than with metal-backed glenoids (85% vs 25%, P <.01). Of 20 radiolucent lines, 12 (60%) around polyethylene glenoids were present on immediate postoperative radiographs and 25% were progressive. No significant correlation was found between the presence of radiolucent lines around polyethylene glenoids and functional results (P =.3). By contrast, periprosthetic radiolucent lines around metal-backed glenoids were rare but progressive when present. The incidence of loosening of metal-backed implants (4 cases, 20%) was significantly higher than that observed with polyethylene glenoids (0%, P <.001) and was associated with component shift and severe osteolysis. Metal-backed glenoid loosening significantly correlated with deteriorating functional results and increasing pain (P <.05). Revision surgery was required for 4 patients in the metal-backed group (P =.02), for a subscapularis tear (1 case) and metal-backed glenoid component loosening (3 cases). Computed tomography scan analysis and revision surgery revealed that preoperative posterior humeral subluxation may recur with time despite glenoid reorientation and may cause asymmetric accelerated polyethylene wear, resulting in metal-on-metal contact and severe osteolysis. Reimplantation of a stable cemented glenoid component was possible in 1 case, whereas the cavitary defect was packed with cancellous bone in the 2 other cases. At a minimum of 3 years' follow-up, the results of this study clearly show that (1) the survival rate of cementless, metal-backed glenoid components is inferior to cemented all-polyethylene components and (2) the incidence of radiolucency at the glenoid-cement interface with all-polyethylene components is high and remains a concern. The high rate of loosening, because of the absence of ingrowth and/or the accelerated polyethylene wear, has led us to abandon the use of metal-backed glenoids. Efforts must continue to improve glenoid component design and fixation.

Effects of freezing/thawing on the biomechanical properties of human tendons

Numerous biomechanical studies using osteoarticular complex need frozen cadaveric specimens. Some of these studies deal with the resistance of the tendinous structures, for example the resistance of some autografts, such as the patellar ligament and the semitendinosus and gracilis tendons for reconstruction of the anterior cruciate ligament. The aim of this study was the in-vitro evaluation of the mechanical modifications induced by freezing/thawing on human tendons. The long head of the biceps brachii tendon was used as the reference. Eight pairs of tendons of the long head of the biceps brachii were taken from eight fresh cadavers. After drawing lots, one was tested immediately, the other was deep-frozen and then thawed. With an Instron material-testing machine, we performed a relaxation test and a uniaxial tensile test, to estimate the ultimate tensile failure and the elastic modulus of each pair of tendons. Freezing had no influence on the tendinous relaxation, but altered significantly the ultimate tensile failure and Young's modulus of the tendons.

Biomechanical analysis of olecranon fracture fixation in children

The authors present an original fixation technique for olecranon fractures in children, achievable without opening the fracture site. The standard method of Kirschner wire fixation with tension band wiring is replaced by a threaded pin stabilization with adjustable lock effect. An olecranon fracture model was used to compare the mechanical properties of this new system with the tension band wiring technique, and with a simple pin fixation. No significant difference was found between the two first techniques, whereas the simple pin fixation had much poorer mechanical properties.

[Straight femoral taper in cementless primary total hip replacement in less than 65 year-old patients: multicenter study of 115 consecutive implantations at mean 8,2 year follow-up]

PURPOSE OF THE STUDY

The Swedish Arthroplasty Registry experience with cemented primary total hip arthroplasty (THA) has pointed out age below 65 and high activity level as 2 major factors impairing THA long-term outcome. The aim of this study was to provide intermediate results of cementless femoral replacement in primary THA with use of the Alloclassic-SL grit-blasted titanium stem in "high risk" groups of patients.

MATERIAL AND METHODS

From June, 1988 to June, 1992, 127 cementless primary THA's were consecutively performed in<65 year old patients in 2 institutions. Acetabular components were all cementless (threaded cup in 74%) and bearing surfaces were all alumina-ceramic 28mm heads on polyethylene (PE). Five patients (6 hips) died and 6 other hips were lost to follow-up before the 5-year minimum follow-up. Thus, 115 hips in 106 patients could be fully reviewed after a 8.2 year average follow-up period (range, 5 to 12 years). Mean age at surgery of the 62 male and 44 female patients was 52 years (range, 27 to 65 years).

RESULTS

Of the index group (127 hips), intra-operative fracture of the greater trochanter and early dislocation were noted in 4.7% and 3.2% of hips, respectively. Of the study group (115 hips), clinical results according to the Merle d'Aubigné and Charnley rating system were graded excellent and good in 94% of hips and fair in 6% (7 hips), with no poor result. Radiologically, early subsidence of more than 2mm could be detected in 8 hips (7%). Calcar atrophy and spot welds were noted in 81% and 89% of hips, respectively. Proximal reactive and lucent lines and mild proximal stress shielding were observed in 10.5% and 4.3% of hips, respectively. Ten-year survivorship with stem revision for any reason as the end point was 99.2% (92.4-99.9) (1 stem exchanged and reoriented for immediate dislocation). One revision is pending for extensive femoral osteolysis due to polyethylene (PE) wear. There was no stem fracture and no ceramic head breakage thus far. Overall PE-wear rate ranging 1-2 mm was detected in 13 hips (9.6%) and femoral osteolysis in 4 hips (3.5%).

DISCUSSION

Mid-term results of this cementless straight taper at 10 year are at least equal to those of well performing cemented components, even in "high risk" groups of patients. Conversely, 28mm alumina-ceramic heads can reduce but not prevent the occurrence of PE-wear in such a healthy and active population.

CONCLUSION

Press-fitting but not filling the femoral canal with rough titanium straight tapers like the Alloclassic-SL femoral component represent a promising alternative to modern femoral cementing technique in primary THA. Improvement is expected through the use of more wear resistant bearing surfaces.

[Role of standard radiography and computed tomography in the assessment of shoulder instability: decision-making value in surgical planning. (Radio-anatomic study of 51 unstable shoulders)]

The therapeutic algorythm for shoulder instability, either arthroscopically, either surgically, should focus on clinical data as well as imaging ones. The latter involve standard X-rays and arthrotomodensitometry (AOTDM). Both of these are crucial for the surgical approach. This paper emphasizes their limits and places. We analysed anatomical and imaging data of 51 unstable shoulders operated on between January 1998 and February 2000. Our purpose was to determine the sensitivity and specificity of imaging techniques for each anatomical structure playing a role in the management. Standard X-rays include comparative AP and Bernageau's views. Based on our results, their efficiency is confirmed for the therapeutic approach of bony lesions. Their sensitivity was respectively 96% and 93% for the reconnaissance of Hill-Sachs lesions and lesions of the anterior glenoïd rim. The sensitivity of AOTDM in identifying labral desinsertions was 91% but their extent was not precisely documented likewise for the labral degeneration and absence. The sensitivity was respectively 69% and 71%. Results were poor for the evaluation of the anterior ligament complex. TDM could not accurately document 90% soft tissues lesions which carry a poor prognosis for arthroscopic reconstructive procedures. There is a good correlation between the aspect of anterior capsular attachment and the sprain lesions (P = 0.003). We could conclude that the AOTDM is not determinant factor for choice of the reconstructive procedure, either arthroscopically, either surgically.

Hip arthroscopy in hereditary multiple exostoses: A new perspective of treatment

The cases of 2 children (9 and 11 years old) with hereditary multiple exostoses disease are presented. The lesions were located primarily in the acetabular fossa of the left hip and caused pain and limitation of range of motion. Hip arthroscopy was performed to remove the exostoses without damaging the articular surfaces and the Y cartilage. After the procedure, the pain disappeared and normal range of motion was recovered for both children. Conventional surgery would have required hip dislocation to access these lesions with an increased risk of femoral head necrosis. These cases constitute a new and interesting application of hip arthroscopy.

[Failure of acetabular cups fixed with cement and thick embedded wire mesh]

PURPOSE OF THE STUDY

We report our experience with the SKH(R) cemented acetabular cup, analyzing the clinical and radiographic consequences of using cement armed with a thick embedded wire mesh.

MATERIAL AND METHODS

Between June 1990 and June 1991, 118 total hip arthroplasties (THAs) were performed in 110 patients (8 bilateral cases) using the SKH(R) cemented acetabular cup, a self-blocking cemented femoral stem with anterograde injection made of a Ti-6Al-7Nb alloy and a 28 mm ceramic polyethylene articulation. Mean follow-up for 97 implants (91 patients) was 7.1 years (3 - 9 years). Mean age at implantation was 65 years (36 - 85 years) (43 men and 48 women). THAs were performed for degenerative joint disease (n=79) including 67 cases of primary disease, necrosis (n=11), rheumatoid disease (n=6), and fracture of the femoral neck (n=1).

RESULTS

For the 118 procedures, there were 4 complications: 2 dislocations (no revision), one failure of the ceramic head and one implant infection (with revision). As assessed by the Postel-Merle-d'Aubigné score as modified by Charnley for the mobility criterion, clinical outcome was excellent or good in 82% of the cases, fair in 11% and poor in 7%. According to the Massin criteria at last follow-up, there were 13 cup loosenings (13.4%, 10 migrations and 3 total lucent lines > 1 mm); revision procedures were performed in 6 cases. A lucent line postoperatively, observed in 51% of the cases (p=0.025) and involving all or part of zone 1 in 44% (p=0.047), was predictive of acetabular failure. Linear polyethylene wear as measured manually was 0.08 mm/year (average) for non-loosened cups and 0.2 mm/year for loosened cups; the difference was significant (p=0.001). On the contrary, the thickness of the cement, measured at the limits of the three De Lee and Charnley zones, cup tilt and size, age, weight and patient activity level had no effect on failure rate. Actuarial survival of the cup at 9 years was 86.3% taking aseptic loosening (with or without revision) as the failure criterion and 93.8% taking revision for aseptic loosening as the failure criterion.

DISCUSSION

These results were rather disappointing. The thick layer of cement reinforced with the wire mesh produces a metal back effect with the known consequences in terms of loosening, cement-bone lucent line, and polyethylene wear. A modification is now undergoing thermal and mechanical assessment. A thinner and tighter mesh would appear to be preferable.

[Bilateral subtotal scapulectomy for chondrosarcoma in Ollier's disease within a 16-year interval]

PURPOSE OF THE STUDY

We report the case of a young man with Ollier's disease who underwent three successive procedures for sarcomatous degeneration of some of his endochondromatous lesions. From the age of twenty, the patient required surgery for resection of a cartilage tumor of the body of L5, amputation of the right index finger, and successive right then left subtotal scapulectomy. At 40 years, the patient presents other stable lesions, mainly located on the right side of the body. We were particularly interested in the functional outcome of the two shoulders in this patient who continues to have normal social and occupational activities.

[Reconstruction by graft and reinforcement device in severe aseptic acetabular loosening: 10 years survivorship analysis]

PURPOSE OF THE STUDY

We report our experience with the treatment of aceptic acetabular loosening with important loss of bone stock using a graft and a metallic reinforcement device.

MATERIAL AND METHOD

We carried out a retrospective study on 56 acetabular revision arthroplasties with severe loss of bone stock performed between November 1980 and June 1992. Mean age of the 35 females and 19 males was 68.5 years. In all cases, there was a combined lesion (cavity + segmentary) of two roofs (type 3 or 4 in the SOFCOT classification). The superior wall was concerned in all cases (80 p. 100 with a combined lesion). Reconstruction was performed using grafts (autograft (n=15), allograft (n=39) or both (n=2)) covering more than 50 p. 100 of the socket. Structural grafts were embedded into the defects in case of superior combined lesion with extension to the anterior and the posterior walls. A morselized graft was used to fill other defects. The reinforcement device was a Müller ring (n=35) or the Burch-Schneider APC (n=21). Mean follow-up was 8.75 years (range 3 - 16 years).

RESULTS

There were 29 iterative aseptic loosenings of acetabular component revised or non-revised (n=11). Twenty-four of these cases had a Müller ring and 5 had a Burch-Schneider APC. The 10-year cumulative survival rate (CSR) was 0.43 +/- 0.16 and the 11-year CSR was 0.350.16 using iterative aseptic loosening as the end point. The lateral position of the hip center (p=0.02), female gender (p=0.03), and the Müller ring (p=0.0054) were statistically negative factors. The 10-year CSR was 0.44 +/- 0.18 for the Müller ring and 0.78 +/- 0.1 for the Burch-Schneider APC, the difference being statistically significant (p=0.007). These two populations were strictly comparable.

CONCLUSIONS

In case of important loss of bone stock, reconstruction by grafts is widely used as reported in the literature. A metallic reinforcement device must be used to protect the graft during incorporation and to prevent late resorption. Compared with the Müller ring, the Burch-Schneider APC is much more adapted to meet these requirements, particularly when the graft covers more than 50 p. 100 of the socket.

Grit-blasted titanium femoral stem in cementless primary total hip arthroplasty: a 5- to 10-year multicenter study

A total of 133 cementless primary total hip arthroplasties using the Zweymuller-Alloclassic grit-blasted titanium tapered stem were performed in 3 institutions. The patient cohort was divided into 2 subgroups, nonselected and selected, on the basis of excellent bone stock and age (<65 years old at surgery). Acetabular components were all cementless, and bearing surfaces were all alumina-ceramic on polyethylene. After a 7.3-year average follow-up period (range, 5-10 years), 118 primary femoral replacements in 109 patients could be reviewed fully. Mean age at surgery was 55.7 years (range, 27-84 years). According to the Merle d'Aubigne and Charnley rating system, clinical results were graded excellent and good in 89% of hips and fair in 11%. Radiologically, early subsidence >2 mm could be detected in 4 hips (3.4%). Calcar atrophy and spot welds were noted in 77% and 82% of hips. Femoral osteolysis granuloma was noted in 4 hips (3.4%). There has been no stem fracture and no ceramic head breakage. The survivorship at 10 years with definite femoral aseptic loosening (radiographic failure) as the endpoint was 100% (95% Wilson confidence interval, 78.4%-100%; worst scenario, 95.4%). A significant difference between the nonselected and selected patient subgroups was observed only for early reoperation (P =.03) and proximal stress shielding (P =.01). Press-fitting but not filling the femoral canal with a rough titanium, straight, tapered femoral component represents, at intermediate follow-up, a promising cementless option in primary total hip arthroplasty.

[Arthroscopic treatment of acetabular labrum lesions: a series of 12 patients with a 4-year follow-up]

PURPOSE OF THE STUDY

The aim of this work was to report our experience with arthroscopy for the treatment of acetabular labral lesions and identify prognostic factors determining mid- and long-term outcome.

MATERIAL AND METHODS

Between August 1991 and December 1997, 12 patients (ten women, two men, mean age 39 years, age range 25-61 years) underwent arthroscopic treatment of an acetabular labrum lesion. All were reviewed at a mean 4 years follow-up (18 months-8 years). Half of the patients (n =6) had a history of hip surgery: two femoral osteotomies and one acetabular bone block for congenital hip dislocation, two high-energy traumas and one traumatic dislocation. Clinical manifestations including pain (n =12), a sensation of a snag (n =10), or blockage (n =8) had developed over a mean 15 months (2-24 months). Standard x-rays evidenced early signs of degenerative disease in four cases and acetabular dysplasia in four (5 degrees <VCE <18 degrees ), and were normal in four. Arthroscanography was performed in all cases and always evidenced a lesion of the anterior or anterosuperior part of the labrum, generally a fissuration (n =7). The surgical procedure performed on an orthopedic table with traction on the limb lasted 45 to 75 min for regularization of the degenerated labrum in three patients, resection of the languette in six, the anse de seau in two or the labral notch in one. A short hospitalization (24 to 48 hours) was sufficient with immediate weight bearing with two canes. One patient developed sciatic paresia which regressed in 72 hours with vulvar edema due to excessive peroperative traction.

RESULTS

Besides the labral lesion, the exploration also identified an associated chondral lesion in seven cases (acetabulum in two, femoral head in three, both in two) which had been suspected in six cases from preoperative imaging (osteoarthrosis in four, dysplasia in two) and which affected the final outcome. Four of these patients (osteoarthritis in two and dysplasia in two) worsened clinically and radiographically to the point where a total hip arthroplasty was required in three. Among the three other patients, two had residual pain (osteoarthritis in one and initial x-ray normal in one) with no radiographic deterioration and only one (osteoarthrtis) was totally relieved without any radiographic deterioration at six years follow-up. Among the five patients with no chondral lesions, three (with normal x-rays initially) were pain free at four years follow-up while the two others (dysplasia) had residual pain at two years follow-up with no sign of osteoarthrtis on the latest x-rays.

DISCUSSION

Lesions of the acetabular labrum are uncommon but can be treated arthroscopically. Resection of the labral lesion is immediately effective but does not prevent long-term degradation of the joint if there is an associated chondral lesion.

Rapid chondrolysis after an intra-articular leak of bone cement in treatment of a benign acetabular subchondral cyst: an unusual complication of percutaneous injection of acrylic cement

Percutaneous injection of methylmethacrylate is now increasingly employed to treat bone lesions, both malignant and benign. However, the risks of this procedure are still to be fully established. In this report, we describe a case of rapid chondrolysis appearing after the intra-articular leakage of cement during injection of an acetabular subchondral cyst, resulting in hip replacement. Although the mechanism of such chondrolysis is unknown, this event suggests a chondrolytic effect of the acrylic cement. Thus, it is essential to systematically search for the presence of an intra-articular passage before injecting bone cement into a peri-articular cyst. This unusual complication highlights the need for rigorous evaluation of the benefits and risks of percutaneous injection of acrylic cement in the treatment of benign lesions, especially close to an articulation.

[Comparative study of fixation mode in total knee arthroplasty with preservation of the posterior cruciate ligament]

PURPOSE OF THE STUDY

We performed a prospective randomized study to compare two fixation modes, with and without cement, for total knee arthroplasty.

MATERIAL AND METHODS

The study series was composed of 96 cemented or noncemented total knee arthroplasties performed between May 1993 and October 1995. The only difference was the diamond interface used for cemented prostheses and the mesh interface used for uncemented prostheses. The operator was unaware of the type of fixation until the bone slices had been obtained. We assessed outcome in 73 cases with a mean follow-up of 27 months. The two populations were comparable for preoperative clinical status, bone tophicity and surgical procedure.

RESULTS

The mean duration of the operation was sgnificantly longer (> 10 min) for the cemented protheses. The complication rates were comparable but we did have two mobilizations of the tibial implant in the noncemented group. The total scores (127 +/- 29 in the cemented group versus 135 +/- 20 in the uncemented group) were significantly different. There were however more cases with degradation of the controlateral knee in the cemented group although the difference was not significant. When these cases were excluded from the analysis, the total scores for two groups were similar (143 and 140 respectively). Radiographic outcome was quite different with mobilization of the tibial implant in 2 cases and the rate of lucent borders was significantly higher in the noncemented group.

DISCUSSION AND CONCLUSION

While the clinical outcome was comparable, the quality of the fixation was significantly better with cemented arthroplasty, which remains the gold standard.

[Experimental comparative study of 3 systems of osteosynthesis for proximal humeral fractures. Preliminary study of the mechanical properties of conserved trabecular bone]

PURPOSE OF THE STUDY

We have compared three systems for osteosynthesis of proximal humeral fractures on a four-fragment fracture model: Plate with tuberosity screwing (P), Kirschner wires with bone sutures (K) and an original implant, the "bilboquet" (Stryker) (B), composed of a hook for the head supported on a diaphyseal stem.

MATERIAL AND METHODS

Because of the unavailability of fresh human material, we have turned to embalmed bones after having shown, on cancellous femoral head bone, the little influence of our method Vs freezing conservation. Settings were tested in compression. We measured their mechanical resistance judged on the ultimate strength and on the slope (displacement/load), to this limit. We similarly analyzed by video recording displacement of the different fragments according to four components (head slipping, its lateral displacement, its see-saw and the separation of tuberosities), to show the weak points of the three systems.

RESULTS AND DISCUSSION

K was more deformable (p < 0.001) that P and B (average slopes in mm/100N to 0.67 for K, 0.42 for P and 0.43 for B). The ultimate strength differed but not significantly (average values in Newton to 1223 for K, 1601 for P and 1721 for B). We also showed for the three techniques, the significant correlation between slopes and bony densities. Video analysis showed that P opposed lateral displacement of the head and separation of tuberosities better, the resistance to slipping and see-saw seems to be improvable by greater divergence of screws or a modification of the plate (mini canon). B opposed slipping and see-saw better but its weak point was the risk of articular break-in of the hook, by defect of resistance to lateral displacement, that for us could be limited by a less peripheral position of teeth or a modification of their form. K is indeed the least effective of the four components but we think that it would be improvable by using, for example, a centro-medullary technique, allowing an internal cortical support.

Primary glenohumeral osteoarthritis: clinical and radiographic classification. The Aequalis Group

One hundred and fifty-one cases of primary glenohumeral osteoarthritis were analyzed both clinically and radiographically with CT scanning. There were 76% females in this series, and the mean age at operation was 66.8 years. The diagnosis was made only with true anteroposterior views of the shoulder which show the narrowing of the glenohumeral joint and the presence of osteophytes. The arthrogram showed a supra-spinatus tear in 10% of the cases that extended to the infra-spinatus in 2.6%. Glenoid retroversion averaged 15.4 degrees. However, measurements of glenoid retroversion with CT-scan do not distinguish posterior wear from glenoid dysplasia. Posterior subluxation of the humeral head was observed in 45% of the cases. We describe a classification of the glenoid morphology in three types: Type A (53.5%) is characterized by an equal balance of forces acting on the glenoid and a centralized humeral head. Type B (39.5%) has asymmetrical posterior force distribution on the glenoid and a posterior subluxation of the humeral head. Type C (5%) is arbitrarily defined as glenoid retroversion greater than 25 degrees. Posterior subluxation of the proximal humeral head did not correlate with either glenoid retroversion or humeral retroversion. However, subluxation of the humeral head may be responsible for the posterior glenoid erosion and possibly for the biconcave appearance of the glenoid observed in primary glenohumeral osteoarthritis. The posterior subluxation of the humeral head may still be present after shoulder arthroplasty and may be responsible for glenoid loosening due to a "horizontal rocking-horse effect".

Arthroscopic release of the glenohumeral joint in shoulder stiffness: a review of 26 cases. French Society for Arthroscopy

The purpose of this multicenter retrospective study of arthroscopic release of the glenohumeral joint was to evaluate the technical feasibility, the results, and the potential correlations between results and cause of the stiffness. Twenty-six shoulders in 25 patients (19 women and six men) were re-evaluated 3 to 72 months (mean, 21 months) after arthroscopic release of the glenohumeral joint. Diagnoses were primary frozen shoulder in 13 cases, bipolar stiffness (rotator cuff tear plus capsular contraction) in 3 cases, and postinjury or postsurgery stiffness in 10 cases. Results were evaluated on passive range of motion, Constant's score, and subjective assessment. Anterior or anterior inferior capsular release was done at the anterior rim of the glenoid fossa. Posterior capsule release was not performed in this series. There were no intraoperative complications. Mean range of motion gains were 86 degrees for forward elevation, 72 degrees for abduction, 34 degrees for external rotation, and 6 spinal processes for internal rotation. Constant's range of motion score increased from 12.9 out of 40 to 32 out of 40 points. Thirteen patients were very satisfied, 5 satisfied, 5 improved, and 3 unchanged. Range of motion gains were independent from the cause of shoulder stiffness, but global results were better in the primary frozen shoulder group in terms of pain and strength. Arthroscopic release of the glenohumeral joint is feasible and safe. For primary frozen shoulders, in case of failure of the functional treatment, arthroscopic release is a less traumatic alternative to manipulation under general anesthesia. For bipolar stiffness, arthroscopy provides the opportunity for treating concomitant lesions. For postsurgical stiffness, arthroscopic release improves range of motion, but the shoulder often remains painful.

A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty

We followed 210 cases of rotator cuff tears treated in four French centers by arthroscopic acromioplasty in 195 cases and by a tenotomy of the Long Head of Biceps (LHB) in 15 cases. All patients were evaluated by means of the Constant score (CS) and radiographic imaging. The mean age was 61 years and the mean follow-up period was 26.6 months (range, 12 to 93 months). The preoperative CS was 38.2 points; 41% were supraspinatus tears, 40.2% were supra and infraspinatus tears, 10.5% were three-tendon tears, and 8.1% were supraspinatus and subscapularis tears. The LHB was altered or disrupted in 77% of cases, dislocated or subluxated in 44% of cases. Acromioplasty was associated to tear debridement in 183 cases (88%) and to a tenotomy of the LHB in 38 cases (19%) of which 15 did not benefit from an associated acromioplasty. Global objective results shown by the corrected CS reached 79.7% and were satisfying in 73% of cases. Poor clinical factors were preoperative shoulder stiffness, postoperative painful crises, worker compensation, a preoperative history longer than 4 years, and young age. The poor anatomic factors were osteoarthritis, a lesion of the acromioclavicular joint or of the LHB tendon. An isolated supraspinatus tear will produce much better results than a triple-tendon tear. The persistence of an aggressive acromion was a prejudicial factor. The benefits of LHB tenotomy were evident and could be isolated in case of massive rotator tears. It seems that LHB tenotomy was particularly effective for massive tears of two or more tendons. Arthroscopic acromioplasty is an excellent indication for elderly patients without professional activity, functionally less demanding that a younger patient.

[Use of centromedullar nailing as treatment in open tibial fractures stage IIIb in the tropics]

The authors report a retrospective study of 7 cases over a three-years-period. This study concerns patients treated in a tropical area in which the cutaneous tolerance of an external fixator is bad.Debridement was performed as an emergency without consideration of possible closure of the wounds. The bone was always covered at the end of the operation by a muscular pedicled flap.The fixation was performed by a reamed nail in 5 of the 7 cases.A primary consolidation was achieved in 58% of the cases.The mean time to consolidation was 7 months.