Comparison of functional gains after arthroscopic rotator cuff repair in patients over 70 years of age versus patients under 50 years of age: a prospective multicenter study.

PURPOSE: To assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic repair in patients older than 70 years versus patients younger than 50 years. METHODS: We conducted a multicenter, prospective, comparative study of 40 patients younger than 50 years (group A) and 40 patients older than 70 years (group B) treated with arthroscopic rotator cuff repair. Patients older than 70 years were operated on only if symptoms persisted after 6 months of conservative treatment, whereas patients younger than 50 years were operated on regardless of any persistent symptoms. Imaging consisted of preoperative magnetic resonance imaging and postoperative ultrasound. Preoperative and postoperative function was evaluated with Constant and modified Constant scores. Patient satisfaction was also assessed. The evaluations were performed at least 1 year postoperatively. RESULTS: No patient was lost to follow-up. The incidence of both supraspinatus and infraspinatus tears was greater in group B. Greater retraction in the frontal plane and greater fatty infiltration were observed in group B. The Constant score was significantly improved in both groups (51 ± 12.32 preoperatively v 77.18 ± 11.02 postoperatively in group A and 48.8 ± 10.97 preoperatively v 74.6 ± 12.02 postoperatively in group B, P < .05). The improvement was similar in both groups. The modified Constant score was also significantly improved in both groups (57.48 ± 18.23 preoperatively v 81.35 ± 19.75 postoperatively in group A and 63.09 ± 14.96 preoperatively v 95.62 ± 17.61 postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). Partial rerupture of the rotator cuff occurred in 2 cases in group A and 5 cases in group B. Complete rerupture was observed in 2 patients in group B. In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. CONCLUSIONS: Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results.

PURPOSE: The transfer of the pectoralis major in cases of irreparable rupture of the subscapularis has been described through different techniques. The aim of this prospective study was to compare the clinical results of transferring the clavicular or the sternal head of the pectoralis major tendon underneath the conjoint tendon. METHODS: Fifteen patients underwent the procedure, including eight clavicular head of the pectoralis major tendon transfers and seven sternal head transfers. The mean age at the time of surgery was 57 years (range, 37-66). Each patient had pre-operative MRI and CT scan. The criteria for an irreparable subscapularis tear were retraction at the level of the glenoid and fatty infiltration of the muscle graded III or IV. Pre-operative and postoperative functions were assessed by the Constant score. Patients were finally asked if they were very satisfied, satisfied or unhappy with the functional outcome. RESULTS: The average follow-up was 24 months (range, 12-50). The mean absolute Constant score of the entire series increased significantly from 36 preoperatively to 69 at the latest follow up (p < 0.01); it improved significantly and similarly in both types of tendon harvested. Nine patients were very satisfied, three were satisfied and three were dissatisfied with the clinical outcome. CONCLUSION: A clavicular or a sternocostal head transfer of the pectoralis major under the coracoid process reduced pain, and improved the strength and function of the shoulder.

Results of 45 arthroscopic Bankart procedures: Does the ISIS remain a reliable prognostic assessment after 5 years?

PURPOSE: The Instability Severity Index Score (ISIS) includes preoperative clinical and radiological risk factors to select patients who can benefit from an arthroscopic Bankart procedure with a low rate of recurrence. Patients who underwent an arthroscopic Bankart for anterior shoulder instability with an ISIS lower than or equal to four were assessed after a minimum of 5-year follow-up. METHODS: Forty-five shoulders were assessed at a mean of 79 months (range 60-118 months). Average age was 29.4 years (range 17-58 years) at the time of surgery. Postoperative functions were assessed by the Walch and Duplay and the Rowe scores for 26 patients; an adapted telephonic interview was performed for the 19 remaining patients who could not be reassessed clinically. A failure was defined by the recurrence of an anterior dislocation or subluxation. Patients were asked whether they were finally very satisfied, satisfied or unhappy. RESULTS: The mean Walch and Duplay score at last follow-up was 84.3 (range 35-100). The final result for these patients was excellent in 14 patients (53.8 %), good in seven cases (26.9 %), poor in three patients (11.5 %) and bad in two patients (7.7 %). The mean Rowe score was 82.6 (range 35-100). Thirty-nine patients (86.7 %) were subjectively very satisfied or satisfied, and six (13.3 %) were unhappy. Four patients (8.9 %) had a recurrence of frank dislocation with a mean delay of 34 months (range 12-72 months). Three of them had a Hill-Sachs lesion preoperatively. Two patients had a preoperative ISIS at 4 points and two patients at 3 points. CONCLUSION: The selection based on the ISIS allows a low rate of failure after an average term of 5 years. Lowering the limit for indication to 3 points allows to avoid the association between two major risk factors for recurrence, which are valued at 2 points. The existence of a Hill-Sachs lesion is a stronger indicator for the outcome of instability repair. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series, Treatment Study.

Uncemented metal-back glenoid component in revision of aseptic glenoid loosening: a prospective study of 10 cases with a minimum follow-up of 2 years.

INTRODUCTION: Glenoid component loosening comprises 25 % of all complications related to total shoulder arthroplasties (TSA). This prospective study was undertaken to assess the accuracy of an uncemented metal-back glenoid component in cases of revision of aseptic glenoid loosening. MATERIALS AND METHODS: Between September 2007 and January 2010, a total of ten patients with symptomatic glenoid loosening after TSA (7 cemented and 3 non-cemented) underwent revision surgery with an uncemented metal-back glenoid component (MB). The rotator cuff was functional in all cases. The reconstruction of the glenoid was obtained using an iliac crest graft (8 patients) or synthetic bone substitute (2 patients). The non-cemented glenoid component was fixed into the glenoid native bone, thus stabilizing the graft reconstruction. A clinical and radiological checkup was performed at the long-term follow-up and compared with the preoperative values. The patients were also asked to quantify their pain and satisfaction. RESULTS: There were no intraoperative complications. In all cases, the radiological evaluation showed a good integration of the bone graft with no radiolucency or new glenoid loosening. In one patient, the revision surgery was indicated for the dissociation between MB and polyethylene. After more than 2 years of follow-up, all patients were satisfied or highly satisfied with the outcomes. The pain VAS score (0-10) decreased from 5.1 to 0.6 (p < 0.001). The simple shoulder test increased from 3.4 to 7.9 points (gain 4.5; p < 0.001). The Constant and Murley score increased from 39.4 to 71 points (gain 31.6; p < 0.001). The gain in anterior elevation was 31°, from 118° to 149° (p < 0.001). External rotation elbow to the body (ER1) increased from an average of 34° preoperatively to 47° after surgery (p < 0.001) and external rotation at 90° of abduction from 43° to 66° (p < 0.001). CONCLUSION: This study suggests that revision with a non-cemented glenoid component associated with a bone graft can solve the difficult challenge of glenoid loosening, provided that the rotator cuff is functional and the glenoid is reconstructable. LEVEL OF EVIDENCE AND STUDY TYPE: Cohort studies (prospective) without controls, Level IV.

Small supraspinatus tears repaired by arthroscopy: are clinical results influenced by the integrity of the cuff after two years? Functional and anatomic results of forty-six consecutive cases.

PURPOSE: We assessed cuff integrity after arthroscopic repair of small full-thickness supraspinatus tears (<2 cm) and the correlation with clinical results and predisposing factors for recurrence. We hypothesized that clinical results depend on tendon healing, which is obtained in almost all cases. METHODS: The study included 46 small supraspinatus tears in 46 patients. Mean age was 56.8 years (range, 39-75 years). Preoperative and postoperative functions were assessed by the Constant-Murley (CM) score. The integrity of the repair was evaluated by ultrasonography. The average follow-up was 35 months (range, 24-60 months). RESULTS: The mean absolute CM score improved significantly (P < .001) from 46.8 points (range, 34-62 points) preoperatively to 76 (range, 51-98) at the last follow-up. The result was excellent or good in 76.1%, and 42 (91.3%) were subjectively very satisfied or satisfied with the final result. The supraspinatus was completely healed on imaging studies in 33 patients (71.8%). The presence of an intratendinous cleavage of the supraspinatus was the only factor associated with a postoperative rerupture (P = .044). There was no association between functional and anatomic results. CONCLUSION: Arthroscopic repair of small supraspinatus tears yields favorable clinical and anatomic results at a mean of 35 months after surgery. Retearing is relatively common, but has no effect on the clinical result except that patients with radiographic signs of tendon healing appear to have increased postoperative ability to perform activities of daily living (P = .022). An intratendinous cleavage is the only significant predisposing factor for recurrence.