Four-strand hamstring tendon autograft for ACL reconstruction in patients aged 50 years or older.

INTRODUCTION: Reconstruction of the anterior cruciate ligament using a four-strand hamstring tendon autograft in symptomatic patients aged 50 years or older is an accepted treatment option. HYPOTHESIS: Four-strand hamstring tendon autograft although not universally utilized in patients who are at least 50 years old is an efficient procedure to control knee instability. MATERIAL AND METHODS: In this retrospective, we analyzed the clinical outcomes of 18 patients treated from September 1998 to September 2003. Criteria for inclusion were the following: age above 50 years at surgery, chronic anterior laxity associated or not with meniscal damage; one or more episodes of knee instability and no prior ligament surgery on the involved knee. A same operative technique (arthroscopic single-bundle four-strand hamstring reconstruction, blind femoral tunnel, through anteromedial portals), a same fixation type (absorbable interference screws in femur and tibia) and a same rehabilitation protocol were used for all these knees. The IKDC 93 scores were determined pre- and postoperatively combined with anteroposterior and lateral views, single leg stance, 30 degrees flexion stance, and passive Lachman test (Telos) postoperatively. RESULTS: At mean 30 month-follow-up (range 12-59 months), there were no graft failure and no loss of extension for any of these knees. Three patients complained of hypoesthesia in the medial saphenous nerve territory and one patient experienced posterior knee pain. All patients graded their knee as normal or nearly normal, all were satisfied or very satisfied with their operation. None of the patients reported instability. The Lachman-Trillat test was noted "firm end point" in 14 knees and "delayed firm end point" in four. The pivot-shift test was negative in 16 knees and mild positive in two. The mean residual differential laxity was 3.1 mm (0 to +6 mm) for the passive Lachman test. At last follow-up, the overall IKDC score was 7A, 7B, 3C, and 1 D. Patients with preserved meniscus (nine patients) reported a lesser degree of pain and a better residual laxity control compared with patients who had undergone a meniscectomy. CONCLUSION: Age over 50 years is not a contraindication to select a hamstring tendon autograft for ACL reconstruction. This surgery can restore knee stability but does not modify the pain pattern in patients, who had a medial meniscectomy prior to the ACL reconstruction.

The management of infection in arthroplasty of the shoulder.

The management and outcome of treatment in 42 patients (49 shoulders) with an infected shoulder prosthesis was reviewed in a retrospective multicentre study of 2343 prostheses. The factors which were analysed included the primary diagnosis, the delay between the diagnosis of infection and treatment and the type of treatment. Treatment was considered to be successful in 30 patients (71%). Previous surgery and radiotherapy were identified as risk factors for the development of infection. All patients with an infected prosthesis had pain and limitation of movement and 88% showed radiological loosening. In 50% of the shoulders, the antibiotics chosen and the length of treatment were considered not to be optimal. The mean follow-up was 34 months. Antibiotics or debridement alone were ineffective. In acute infection, immediate revision with excision of all infected tissue and exchange of the prosthesis with appropriate antibiotic therapy gave the best results. Multidisciplinary collaboration is recommended.

[Entrapment of the long head of the biceps: the "hourglass biceps". Another cause of pain and locking of the shoulder]. / Le long biceps en sablier ou long biceps piégé: une autre cause de douleur et de blocage de l'épaule.

PURPOSE OF THE STUDY: We describe a mechanical condition affecting the long head of the biceps tendon (LHBT) causing potentially unrecognized entrapment within the joint and subsequent pain and locking. This is caused by a hypertrophic intra-articular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. MATERIALS AND METHODS: Twenty one patients were identified, during open (14 cases) or arthroscopic (7 cases) surgery, with a so called "hourglass biceps" i.e., hypertrophic intraarticular portion of the LHBT and incarceration of the tendon during elevation. All cases occurred in conjunction with a rotator cuff rupture except one who had a partial deep tear. All patients were treated by excision of the biceps, after tenodesis or bipolar tenotomy, and appropriate treatment of the concomitant lesions. RESULTS: All patients presented with anterior shoulder pain and loss of passive elevation averaging 10-20 degrees. A dynamic intraoperative test involving forward elevation with the elbow extended demonstrated entrapment of the tendon within the joint in each case. This test creates a characteristic "buckling" of the tendon and "squeezing" of the tendon between the humeral head and the glenoid ("hourglass test"). Excision of the tendon allowed immediate restoration of complete elevation. Mean Constant score increased from 38 points to 76 points postoperatively. DISCUSSION: The "hourglass biceps" is caused by a hypertrophic intraarticular portion of the tendon that is unable to slide into the bicipital groove during elevation of the arm. Loss of 10-20 degrees of passive elevation, bicipital groove tenderness, and radiographic findings of a hypertrophied tendon can aid in diagnosis. The "hourglass biceps" should not be misdiagnosed for a frozen shoulder. Definitive diagnosis is made at surgery with the "hourglass test": incarceration and squeezing of the tendon within the joint during forward elevation of the arm with the elbow extended. Simple tenotomy cannot resolve this mechanical block. Either tenotomy with excision of the intraarticular portion of the LHBT or tenodesis must be performed. The "Hourglass" biceps is an addition to the familiar pathologies of the long head of the biceps tendon (tenosynovitis, prerupture, rupture, instability), and should be considered in any case of chronic anterior shoulder pain associated with a loss of shoulder elevation.

Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus.

The purpose of this study was to evaluate the results of hemiarthroplasty for displaced proximal humeral fractures and to assess clinical and radiologic parameters that could explain unsatisfactory results. Sixty-six consecutive patients (45 women and 21 men) with a mean age of 66 years (range, 31-85 years) were followed up postoperatively for a mean of 27 months (range, 18-59 months), both clinically and radiologically. Subjectively, 29 patients were very satisfied, 9 were satisfied, and 28 were unsatisfied. Postoperative active elevation averaged 101 degrees +/- 33 degrees, external rotation averaged 18 degrees +/- 15 degrees, and internal rotation averaged the L3 level (+/-3 vertebrae). The absolute Constant score averaged 56 of 100 points (range, 20-95 points). Initial tuberosity malposition was present in 18 patients (27%). Tuberosity detachment and migration were noted in 15 patients (23%). Tuberosity migration could be observed after initial tuberosity malpositioning, as well as after initial correct positioning. Final tuberosity malposition occurred in 33 patients (50%) and correlated with an unsatisfactory result, superior migration of the prosthesis, stiffness or weakness, and persistent pain. Factors associated with failure of tuberosity osteosynthesis were poor initial position of the prosthesis (specifically, excessive height and/or retroversion), poor position of the greater tuberosity, and women over age 75 years (likely with osteopenic bone). Techniques to improve tuberosity osteosynthesis, including modifications to current prosthetic design and instrumentation to allow for a more anatomic reconstruction, should lead to more predictable and satisfactory results.