Clinical Results and CT Analysis of ISA Stemless at a Minimum Follow-up of 2 Years.

INTRODUCTION: The utilization of stemless anatomic total shoulder arthroplasty is on the rise. Epiphyseal fixation leads to radiological bone remodeling, which has been reported to exceed 40% in certain studies series. The aim of this study was to present the clinical and radiological outcomes of a stemless implant with asymmetric central epiphyseal fixation at an average follow-up of 31 months. MATERIALS: This retrospective multicenter study examined prospective data of patients undergoing total anatomic arthroplasty with ISA Stemless implant and followed up at least 2 years. Clinical assessment included preoperative and final follow-up measurements of active range of motion (ROM), Constant score, and Subjective Shoulder Value (SSV). Anatomical epiphyseal reconstruction and bone remodeling at the 2-year follow-up were assessed by standardized Computed Tomography Scanner (CT scan). Statistical analysis employed unpaired Student's t-test or chi-squared test depending on the variable type, conducted using EasyMedStat software (version 3.22; www.easymedstat.com). RESULTS: Fifty patients (mean age 68 years, 62% females) were enrolled, with an average follow-up of 31 months (24-44). Primary osteoarthritis (68%) with type A glenoid (78%) was the prevailing indication. The mean Constant score and SSV improved significantly from 38 ± 11 to 76 ± 11 (p<0.001) and from 31% ± 16 to 88% ± 15 (p<0.001) respectively at the last follow-up. Forward elevation, external rotation and internal rotation ROM increased by 39° ± 42, 28° ± 21 and 3,2 ± 2,5 points respectively, surpassing the Minimally Clinically Important Difference (MCID) after total shoulder arthroplasty. No revisions were necessary. CT scans identified 30% osteolysis in the posterior-medial calcar region, devoid of clinical repercussions. No risk factors were associated with bone osteolysis. CONCLUSION: At an average follow-up of 31 months, ISA Stemless implant provided favorable clinical results. CT analysis revealed osteolysis-like remodeling in the posterior-medial zone of the calcar (30%), without decline in clinical outcomes and revisions. Long-term follow-up studies are mandated to evaluate whether osteolysis is associated with negative consequences.

Prevalence of metal hypersensitivity in patients with shoulder pathologies.

BACKGROUND: To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire. METHODS: The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was "reported hypersensitivity to metals," comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips. RESULTS: A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals. CONCLUSIONS: This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.

Internal impingement of the shoulder in overhead athletes: Retrospective multicentre study in 135 arthroscopically-treated patients.

BACKGROUND: Internal impingement of the shoulder (IIS) is the leading cause of chronic shoulder pain in overhead throwing athletes. No consensus exists about which techniques are optimal when surgery is in order. The available studies are limited by small sample sizes and short follow-ups. The primary objective of this study was to assess return-to-sports (RtS) outcomes after surgical treatment for IIS. A favourable RtS outcome (RtS+) was defined as returning to the previous sport at the same or a higher level. HYPOTHESIS: The main hypothesis was that surgical treatment resulted in an RtS+ outcome. The secondary hypothesis was that epidemiological factors, pre- and intra-operative anatomical factors, and specific surgical procedures were associated with higher RtS+ rates. MATERIAL AND METHODS: A retrospective multicentre design was used. We included 135 patients with IIS managed arthroscopically using any of the following procedures: anterior capsulorrhaphy, posterior capsulotomy/capsulectomy, postero-superior labral debridement, posterior glenoidplasty, and rotator cuff tear debridement or repair. Follow-up was at least 1 year. The patients were divided into two groups based on whether they had an RtS+ outcome as defined above or an RtS- outcome defined as a return to the previous sport at a lower level, a switch to another sport, or an inability to engage in any sport. The Kerlan-Jobe Orthopaedic Clinic (KJOC) and Constant's score were used to evaluate subjective and objective shoulder function. RESULTS: Mean follow-up was 7.9 years. Of the 135 patients, 120 (90%) returned to sports after surgery including 70 (52%) to the previous sport at the same level (RtS+ outcome). By univariate analysis, the following factors were associated with an RtS+ outcome: male sex, rotator cuff tear documented intra-operatively, absence of a greater tuberosity cyst on pre-operative imaging studies, and cuff tear debridement. Anterior capsulorrhaphy was associated with worse post-operative pain. DISCUSSION: The RtS+ rate in this study differed from previously reported values, due to differences in the sports practiced by the patients and to considerable variability in the surgical techniques used. The positive association between presence of a rotator cuff tear and an RtS+ outcome is at variance with most of the previously published data. Some of the apparent discrepancies between our results and those from other countries may be ascribable to differences in the most popular sports. LEVEL OF EVIDENCE: IV.

Internal impingement of the shoulder: An international survey of 261 orthopaedic surgeons.

BACKGROUND: Internal impingement of the shoulder (IIS) is a specific disorder of young overhead-throwing athletes that was first described in 1991. The many non-operative and surgical treatments suggested to date have produced mixed outcomes. The objective of this study was to compare the practices of surgeons in France versus other countries regarding the diagnosis and treatment of IIS. HYPOTHESIS: Diagnostic and therapeutic practices regarding IIS differ between surgeons in France and in other countries. MATERIAL AND METHODS: A 21-item questionnaire in French and English was emailed to the 1300 members of the French Arthroscopy Society and to surgeons from countries other than France. The questionnaire collected information on knowledge about IIS (2 items), the frequency of IIS in clinical practice (2 items), the diagnosis of IIS (6 items), the non-operative and surgical treatment of IIS (3 and 5 items, respectively), and return-to-sports rates after treatment for IIS (3 items). RESULTS: The completed questionnaire was sent back by 261 surgeons, 206 in France and 55 in other countries, including 42 in Japan. Among the respondents, 90% knew about IIS. Experience with IIS in terms of number of patients seen or surgical treatments performed was greater in the international group (45% vs. 19% in France, p<0.001). Posterior shoulder pain in the arm cocking position was the most widely recognised symptom (99% in France, 74% internationally, p<0.001), followed by excessive external rotation during arm abduction (55% vs. 65%, p=0.23). The most commonly sought lesions were those of the postero-superior labrum and articular surface of the rotator cuff. Rotator cuff debridement was among the surgical options according to most respondents (74% vs. 70%). In contrast, postero-superior glenoidplasty was cited almost only by surgeons in France (67% vs. 4%, p<0.001). The proportion of patients who are able to return to sports was estimated at 50% to 75% by most respondents. DISCUSSION: Most respondents had theoretical knowledge about IIS, but surgery was rarely performed in France. Only very few athletes in France play baseball, which is responsible for most sports injuries of the shoulder seen in Japan. This fact, combined with differences in the lesions or even the diagnoses, may have contributed to the differences in the responses to the survey items between the French and international groups.

Is posterosuperior contact a normal occurrence in the shoulder?

Posterosuperior (or internal) impingement at the shoulder is defined as contact between the underside of the supraspinatus or infraspinatus tendons with the posterosuperior labrum during extreme external rotation and abduction. In many cases, this contact damages the tendon and causes mirror posterosuperior labrum deterioration. The primary aim of this study was to define whether this contact occurs normally in patients who do not have a rotator cuff tear. METHODS: We evaluated 100 shoulders in 100 patients. All patients were operated on in the beach chair position. After introducing the scope through the posterior portal, contact between the articular side of the rotator cuff and the posterosuperior labrum was noted as being present or absent when the arm was cocked in 90° abduction and 90° external rotation (90/90) then the arm was cocked in 140° abduction and maximum external rotation (140/Max). RESULTS: Contact was observed in 69% of patients in the 90/90 cocked position and in 94% of patients in the 140/Max cocked position. We found a correlation between the presence of rotator cuff and/or labrum lesions and the patient regularly performing arm-cock movements (p=0.035). DISCUSSION: Contact between the underside of the supraspinatus tendon and the posterosuperior labrum occurs physiologically. Repetitive arm-cock movements may contribute to macroscopic lesions of the underside of the rotator cuff and posterosuperior labrum. LEVEL OF EVIDENCE: IV, basic science study.

Management of Massive Rotator Cuff Tears: Prospective study in 218 patients.

BACKGROUND: No consensus exists about the management of massive and symptomatic rotator cuff tears (RCTs). The objective of this study was to compare the 12-month clinical outcomes of various treatment options for massive RCTs. HYPOTHESIS: Arthroscopic surgery has a role to play in the treatment of massive and apparently irreparable RCTs. MATERIAL AND METHODS: A prospective multicentre non-randomised study was performed in patients with massive RCTs managed non-operatively (NONOP) or by arthroscopic tenotomy/tenodesis of the long head of biceps (aTLB), arthroscopic partial tendon repair (aPTR), arthroscopic latissimus dorsi transfer (aLDT), or reverse shoulder arthroplasty (RSA). Clinical outcomes were evaluated based on the Constant score, Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) score after 3, 6, and 12 months. RESULTS: The 218 included patients (mean age, 69 years) were distributed as follows: NONOP, n=71; aTLB, n=26; aPTR, n=61; aLDT, n=25; and RSA, n=35. After 12 months, the mean Constant score, SSV, and ASES score values were 70, 68%, and 73, respectively, and had improved significantly versus the preoperative values in all treatment groups. RSA was the only treatment followed by improvements in all Constant score items. Active forwards elevation improved significantly in the NONOP (+25°), aPTR (+26°), and RSA (+66°) groups. An improvement in active external rotation was seen only in the RSA group, where it was small (+10°, p=0.046). Significant increases in internal rotation were seen in the NONOP (+1.6 points) and aPTR (+1.7 points) groups. CONCLUSION: Arthroscopic techniques (aTLB, aPTR, and aLDT) for managing massive irreparable RCTs produce significant functional gains. Partial tendon repair (aPTR) and RSA may provide better outcomes than isolated aTLB or aLDT. LEVEL OF EVIDENCE: III, non-randomised prospective study.

Arthroscopic treatment of anterosuperior rotator cuff tears.

This study evaluated pre- and postoperative clinical and structural outcome data on anterosuperior rotator cuff tears involving the supraspinatus and subscapularis treated by arthroscopic methods. Between June 2006 and October 2007, a total of 155 consecutive patients underwent an arthroscopic repair for a supraspinatus or supraspinatus and infraspinatus (superior) rotator cuff tear. Of these, 44 (28%) were identified on preoperative imaging to have involvement of the subscapularis. Confirmation of subscapularis tears occurred during arthroscopic repair of the superior rotator cuff. If the subscapularis was found to be torn, it was documented, and an arthroscopic repair was performed. Postoperative clinical and radiographic outcomes were assessed with the belly press and lift-off tests, range of motion, strength, pain score, Constant score, and either a magnetic resonance imaging arthrogram or a computed tomography arthrogram at an average of 15 months postoperatively. Failure was determined based on rotator cuff integrity on radiologic studies. Sixteen of the 44 anterosuperior rotator cuff tears identified on preoperative imaging were found to have a full-thickness subscapularis tear requiring repair on arthroscopic examination. On preoperative imaging, subscapularis tears were all either grade 1 or grade 2 (no complete grade 3 tears). Mean follow-up was 16.9 months (range, 13-24 months). Compared with preoperative values, significant postoperative improvements occurred in Constant scores, forward flexion, strength, and pain scores (P<.01). Patients also showed significant improvements in both the lift-off and belly press tests (P<.001). Mean postoperative patient satisfaction was 7.9 (range, 5-10) with 10 (59%) of 17 patients being extremely satisfied. Two of the 17 patients with an anterosuperior rotator cuff tear had confirmed retears of the supraspinatus (1 partial and 1 full-thickness) with no radiographic evidence of retear of any of the subscapularis repairs at most recent follow-up.

Early structural and functional outcomes for arthroscopic double-row transosseous-equivalent rotator cuff repair.

BACKGROUND: The arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair is growing in popularity. The current body of literature supports this technique; however, the number of patients in these studies is relatively small. The authors conducted this study to learn more about the natural history of this construct in a large sample of patients. HYPOTHESIS: The double-row TOE rotator cuff repair will have an acceptable structural failure rate with improved clinical outcomes at 1-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between June 2006 and October 2007, 225 patients underwent an all-arthroscopic rotator cuff repair at 2 surgical centers. A total of 155 TOE primary rotator cuff repairs were performed, and 154 of these patients met the inclusion criteria. Assessment of structural integrity was based on evaluation of postoperative magnetic resonance imaging or computed tomography arthrogram at a minimum of 12 months after surgery. The Constant scores, visual analog pain scale, range of motion, strength, and complications were the clinical outcomes analyzed for the study. Seventeen patients (of 154) had postoperative shoulder stiffness at follow-up. RESULTS: The 154 patients were clinically and radiologically evaluated at a mean of 15 months postoperatively (range, 12-26.1 months). The study included 47 small (30.5%), 89 large (57.1%), and 19 massive (12.3%) rotator cuff tears. Analysis of postoperative imaging demonstrated that 92%, 83%, and 84% of the small, large, and massive rotator cuff tears, respectively, were intact. The mean Constant score improved from 44.42 points preoperatively to 80.47 points postoperatively (P < .001). The mean preoperative pain score improved from 3.83 to 12.77 (P < .001) postoperatively. The mean forward flexion improved from 123.06° preoperatively to 162.39° postoperatively (P < .001). Seventeen patients (of 154) had postoperative shoulder stiffness at follow-up. CONCLUSION: The short-term results of this study indicate that the clinical outcomes and structural integrity of TOE double-row rotator cuff repair (the suture-bridge technique) have results that compare favorably with those reported for other double-row suture anchor techniques employed in rotator cuff repairs. Long-term follow-up will be necessary to determine if the durability of these repairs and the structural integrity of these constructs maintain their performance over time.

[Urachal adenocarcinoma: analysis of 3 cases]. / L'adénocarcinome de l'ouraque: analyse de 3 cas.

Adenocarcinoma of the urachus is a very rare disease. It often remains undiagnosed for a long time and has an aggressive course. Surgery, the only potentially curative treatment, was initially very extensive, but this attitude has been revised more recently. The authors present three clinical cases, and discuss the treatment options. The first two cases were treated by one-stage resection and the third case, which presented with a mucus collection in the abdomen with "signet ring" cells, was treated by Intraperitoneal ChemoHyperthermia (IPCH) during second-look laparotomy. A review of the literature shows that the current tendency is towards less mutilating surgery. Diagnostic examinations, allowing earlier detection of this disease, may possibly alter its prognosis, which was considered to be very poor up until recently.