Superior glenoid inclination and glenoid bone loss : Definition, assessment, biomechanical consequences, and surgical options.

Correct anatomical alignment of the glenoid component is of central importance for wear and loosening in shoulder endoprostheses. The aim of this article is to review and clarify the biomechanical and clinical effects of incorrect glenoid inclination in reverse and anatomical joint replacements. Based on the literature and on our own work, statements are made about the following: (1) the glenoid inclination of a normal glenoid, a degenerative glenoid and a glenoid implant, and the consequences if superior inclination is too large, and (2) the surgical technique as well as tips and tricks for correct adjustment of the inclination. The inclination of the glenoid plane is a morphological parameter of the scapula with high individual variation and is best measured using reformatted computed tomography using three-dimensional software for reconstruction and evaluation. The standard value is between 0 and 10°. Excessive superior inclination promotes translation of the humeral head and the formation of rotator cuff tears-in a degenerative glenoid, to superior wear. The correct amount of superior inclination of the glenoid component is essential for the survival of the implant. Positioning without excessive superior inclination is therefore mandatory. Precise preoperative determination of glenoid inclination and wear is important in order to correctly plan the positioning of an implant. This serves as the basis for deciding whether a bone graft or patient-specific instrumentation is necessary. Thus, the surgeon also has prognostic parameters for the anticipation of possible complications as a result of the bone defect and abnormal orientation. However, the evaluation must always include the position of the scapula in these considerations.

Three-dimensional assessment of the dimensions of the osteoarthritic glenoid.

Osteoarthritis results in changes in the dimensions of the glenoid. This study aimed to assess the size and radius of curvature of arthritic glenoids. A total of 145 CT scans were analysed, performed as part of routine pre-operative assessment before total shoulder replacement in 91 women and 54 men. Only patients with primary osteoarthritis and a concentric glenoid were included in the study. The CT scans underwent three-dimensional (3D) reconstruction and were analysed using dedicated computer software. The measurements consisted of maximum superoinferior height, anteroposterior width and a best-fit sphere radius of curvature of the glenoid. The mean height was 40.2 mm (SD 4.9), the mean width was 29 mm (SD 4.3) and the mean radius of curvature was 35.4 mm (SD 7.8). The measurements were statistically different in men and women and had a Gaussian distribution with marked variation. All measurements were greater than the known values in normal subjects. With current shoulder replacement systems using a unique backside radius of curvature for the glenoid component, there is a risk of undertaking excessive reaming to adapt the bone to the component resulting in sacrifice of subchondral bone or under-reaming and instability of the component due to a 'rocking horse' phenomenon.

Three-dimensional measurement method of arthritic glenoid cavity morphology: feasibility and reproducibility.

INTRODUCTION: Glenoid component loosening is the main complication of total shoulder arthroplasty. Better knowledge of the arthritic glenoid cavity anatomy can help in developing new implants and techniques. The goal of this study was to describe and validate the reproducibility of a CT scan-based, 3D measurement method used to describe various parameters characterizing arthritic glenoid cavity morphology. MATERIALS AND METHODS: Twelve CT scans and 29 CT arthrogram were evaluated. These scans were taken from 41 patients with glenohumeral osteoarthritis who received an anatomical shoulder prosthesis. A 3D reconstruction of the scapula was performed based on the DICOM files. Following the 3D volume acquisition, points on the glenoid articular surface were manually extracted by three observers, each one three times, allowing one week between readings, to determine the inter- and intra-observer reproducibility. The intraclass correlation coefficient (ICC) was calculated on five 3D parameters that were automatically calculated: glenoïd height, glenoid width, height at maximum width glenoid version and radius of the articular surface best-fit sphere. RESULTS: The intra-observer and inter-observer ICC were 0.91 to 0.99, and 0.95 to 0.99, respectively. DISCUSSION: This study is the first to report on a reproducible 3D measurement method, based on CT scans, for the arthritic glenoid cavity, which derives the joint radius of curvature among other morphology parameters. These 3D measurements are advantageous because they are free of problems related to patient positioning in the CT scanner and to the choice of slices, which limits the accuracy of measurements made on slices from 2D CT scans. Three-dimensional methodology similar to ours has been validated on healthy glenoids. CONCLUSION: This study confirms the reliability and good reproducibility of our method, which allows us to extend this method to a larger patient cohort and adapt this automated technology to preoperative planning software.

Comparison and critical evaluation of rehabilitation and home-based exercises for treating shoulder stiffness: prospective, multicenter study with 148 cases.

INTRODUCTION: The goal of this study was to evaluate the effectiveness of individual exercises performed as classic rehabilitation or a home program on the clinical progression of patients with shoulder stiffness. Based on this information, the secondary goal was to develop a new rehabilitation protocol. PATIENTS AND METHODS: This prospective, comparative series included 148 cases of shoulder stiffness. There were three treatment groups: T1: classic rehabilitation performed below the pain threshold (58 cases); T2: home program with provocation above the pain threshold (59 cases); T3: home program supervised by a physical therapist (31 cases). The execution, pain level and time spent doing each exercise were compiled for each work session - every day for the first 6 weeks, then every week up to 3 months. Clinical (Constant score) and range of motion evaluations were performed at enrollment, week 6 and month 3.Changes were compared between groups; correlation tests were used to analyse the effectiveness of each exercise during each session. RESULTS: Other than physical therapy and balneotherapy, classic rehabilitation exercises had a negative effect on clinical progression during the first 3 to 5 weeks (P<0.05), but this did not hinder the occurrence of a slow, continuous clinical improvement (P<0.05). Home programs led to rapid functional progression with improvement directly related to the number of exercises actually performed (P<0.05), however, pain during the day increased and pain at night decreased. Supervision by a physical therapist helped to optimize the home program, with the same result at week 6, but a better result at month 3 (P<0.05). CONCLUSIONS: Based on the results of this study, a new treatment protocol for shoulder stiffness was proposed that combines an intensive patient home program with a well-informed physical therapist, who progressively adds classic rehabilitation techniques when they provide the best treatment value for each exercise. Patient education is the key to treatment success.

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases.

INTRODUCTION: Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined. PATIENTS AND METHODS: This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements). RESULTS: Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05). DISCUSSION: The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.

Pain management in the rehabilitation of stiff shoulder: prospective multicenter comparative study of 193 cases.

INTRODUCTION: The present study investigated the impact of respecting pain threshold on clinical recovery in stiff shoulder. PATIENTS AND METHODS: A prospective multicenter comparative study followed up 193 cases of shoulder stiffness for a mean 12-month period (range, 8-31 months) after four different treatment protocols: (1) conventional sub-pain-threshold rehabilitation (58 cases); (2) self-rehabilitation exceeding the pain threshold (59 cases); (3) supervised suprathreshold rehabilitation (31 cases); and (4) capsulotomy with sub-threshold rehabilitation (45 cases). Follow-up was daily for the first 6 weeks then weekly for the next 6; each session included assessment of the painfulness, feasibility and duration of each rehabilitation and self-rehabilitation exercise and of pain status, disability and psychological status. The surgeon followed patients up at 6 weeks, 3 months, 6 months, 1 year and at last follow-up. RESULTS: Sub-threshold rehabilitation provided progressive results, limited in time (P<0.05). Suprathreshold self-rehabilitation provided reduced pain (P<0.05) as of the first days, with nocturnal pain ceasing after 7 days' rehabilitation in 43% of cases. Supervision of self-rehabilitation exercises optimized the clinical result (P<0.05). Capsulotomy did not influence pain evolution over the first 8 weeks, but then improved it. Failure (at 1 year, 14-17%; last follow-up, 3.5%) correlated directly with the number of exercises performed by the patient (P<0.05). DISCUSSION: The dogma of respecting the pain threshold is dated: pain inflicted on a passive patient impairs clinical evolution, but pain managed by an informed active patient under experienced supervision provides rapid recovery of function and pain-free status.

Scapular notching in reverse shoulder arthroplasties: the influence of glenometaphyseal angle.

UNLABELLED: Solutions described to limit the risk of scapular notching mainly concern the glenoid. Our hypothesis is that this risk also depends upon the glenoid-humeral relationship when the arm is resting along the body. PATIENT AND METHODS: This is a retrospective study of a continuous series of 85 reverse shoulder arthroplasties; 62 of these fulfilled inclusion criteria. The following parameters were studied: body mass index (BMI), inferior overhang of the glenosphere, the angles showing the position of the glenoid (GH) and the humerus (MH) in the scapular plane as well as the glenometaphyseal angle (GM=MH-GH), during an initial postoperative follow-up, at 1 and 2 years, and at a final follow up of a mean 45 months (24-81). The parameters studied were compared in two groups with and without scapular notching. RESULTS: There were 21 instances of notching at the final follow-up. This rate was significantly correlated to the BMI, which was a mean 27.2 in patients without a notch and 22.6 in patients with a notch, while the preoperative inclination of the glenoid in these groups was respectively 92.3° versus 85° respectively, the inferior overhang of the glenosphere was 4mm versus 2.8mm, the GM angle was 36° versus 47°, the MH angle at one year of follow-up was 135° versus 145° and the GH angle at the final follow-up was 103° versus 94° respectively. The BMI was significantly correlated to the GM angle, and a low BMI was associated with high values of this angle. DISCUSSION: The relative position of the glenoid and humeral components, as shown by the GM angle, was an essential factor in the development of a scapular notching. The humeral component of the GM angle evolved in thin patients with progressive adduction of the arm, which is associated with a risk of notching. This should be taken into account when performing reverse shoulder arthroplasties. LEVEL OF EVIDENCE: Level IV retrospective study.

[Arthroscopic debridement of full-thickness tears of the rotator cuff: a retrospective multicenter study of 283 cases with 3-year follow-up]. / Le débridement endoscopique des ruptures transfixiantes de la coiffe des rotateurs: étude rétrospective multicentrique de 283 cas à plus de 3 ans de recul.

PURPOSE OF THE STUDY: The purpose of this study was to assess clinical and radiological course of full-thickness rotator cuff tears treated by arthroscopic debridement and to discuss surgical indications according to patient demands and anatomical lesions. MATERIAL AND METHODS: This retrospective and multicentric study included patients with a minimal 3 years follow-up. The coronal extent of the supraspinatus tear was described as distal, intermediate or retracted. The sagittal extent to the infraspinatus and/or subscapularis and rotator interval was detailed. All patients were evaluated pre and post-operatively using Constant score and radiological A-P view for sub-acromial space measurement. In order to assess the influence of age, anatomical extent of the tear and follow-up, results were analyzed for 4 groups of patients according to their age: group I (19 cases less than 50 years), group II (88 cases from 51 to 60 years), group III (58 cases from 61 to 65 years) and group IV (118 cases over 65 years). Results were finally evaluated according the arthroscopic procedure (isolated acromioplasty and biceps tenotomy, or association of both). RESULTS: 283 patients, aged 63.1 years (range 32 to 82) entered this study. A complete antero-posterior tear of the supra-spinatus tendon was noticed in 93.2 p. 100 of cases. The tear extended to the infraspinatus tendon in 57.3 p. 100, and to the subscapularis tendon in 29 p. 100 of cases. The long head of the biceps was involved in 73 p. 100 of cases. 218 acromioplasties and 116 biceps tenotomies were performed. The 2 procedures were combined in nearly 25 p. 100 of cases. At final revision (mean follow-up of 4.7 years), 98 patients (34.6 p. 100) were very satisfied, 122 (43.1 p. 100) satisfied, 43 (15.2 p. 100) moderatly satisfied and 20 (7.1 p. 100) were disappointed. The average Constant score increased from 42.4 to 67.6 points. The radiological study showed a 1 mm narrowing of the sub-acromial space. Objective results were surprisingly good for group I at a 5.4 years follow-up but dropped from group II to group IV, mainly in relation with the extent of the tear. A deleterious effect of the isolated biceps tenotomy was demonstrated in case of subacromial space superior to 7 mm. Inversely after this procedure patients with a narrowed space improved. DISCUSSION: Even if traditional bias of retrospective and mullticentric study could not be avoided, the large number of patients and long follow-up of this study are superior to most of the published papers. The extent of the supraspinatus tear seems to progress during the 50-60 years decade. Objective results appeared to be much more related to the anatomical lesions than to the arthroscopic procedure. CONCLUSION: This series did not demonstrate a secondary clinical or radiological deterioration after an endoscopic treatment without repair of full-tickness rotator cuff tears. Subacromial decompression and/or biceps tenotomy indications depend on age and extension of the tear.

[Coraco-humeral space and rotator cuff tears]. / Espace coraco-huméral et rupture de la coiffe des rotateurs de l'épaule.

PURPOSE OF THE STUDY: The anterior or subcoracoïd impingement is often mentioned but remains unprecise as far as clinical, radiological or even anatomical lesion are concerned. The purpose of our work was to study the different factors influencing the subcoracoïd space in case of cuff tear. METHODS: Our study was based on 206 shoulders operated for full-thickness rotator cuff tear. The SubCoracoïd Space (SPS), measured in millimeters on pre-operative arthro-CT-scan, was defined by the shortest distance between the coracoïd process and the humeral head. Muscular statement of the rotator cuff componants was graded according to Goutallier's and Bernageau's classification. According to literature data, we chose "6 mm" value as an inferior limit for normality. Shoulders were dispatched into three groups: group 1 was composed of supraspinatus +/- infraspinatus tears (59 cases), group 2 was composed of isolated lesions of the subscapularis (57 cases) and group 3 was composed of large cuff tears (supraspinatus +/- infraspinatus) involving also the subscapularis (90 cases). RESULTS: There was a statistically significant relationship between SCS narrowing, duration of symptoms and the non-traumatic onset. When there was no subscapularis lesion (group 1) the mean SCS was 9 +/- 2 mm, in 3 cases the SCS was inferior to 6 mm. In group 2 (isolated lesion of the subscapularis), the results were similar with 9 mm as an average and 3.5 p. 100 SCS inferior to 6 mm. On the contrary, in group 3 we found the major percentage of SCS inferior to 6 mm (27 p. 100) with an average of 7.7 +/- 3.5 mm. The long head of the biceps had no influence on the SCS. There was a strong statistically significant relationship between SCS size and fatty degeneration of the subscapularis muscle (p < 10-4) and infraspinatus muscle (p = 0.0004). Eventually, there was a statistically significant correlation between the subcoracoïd space and the sub acromial space. DISCUSSION: Measurements of the SCS in isolated lesions of the subscapularis show that the coracoïd process is not the mechanical factor responsible for tendon rupture. SCS narrowing is the consequence of a large cuff tear involving both the subscapularis and the infraspinatus tendon. Subscapularis tear is a necessary but not a sufficient condition by itself for SBS narrowing. Complete tear of the infraspinatus tendon and above all the muscular degeneration of the infraspinatus muscle is the other necessary condition for SCS narrowing. The horizontal control of the humeral head depends on subscapularis-infraspinatus muscular balance control. According to Patte's hypothesis SCS narrowing corresponds to an horizontal anterior translation of the humeral head due to fatty degeneration of subscapularis and infraspinatus muscle.

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.

Results of derotational humeral osteotomy in posterosuperior glenoid impingement.

We identified 20 throwing athletes who continued to have pain after articular debridement for posterosuperior impingement syndrome. These patients were unable to resume sports, and we subsequently performed a derotational humeral osteotomy with a myorraphy of the subscapularis muscle. Patients were observed for an average of 46 months (range, 12 to 69). Eleven patients were able to resume the same sport at the same level, five resumed the same sport at a lower level, three changed sport secondary to persistent pain, and the last patient did not resume any sport and was worse after surgery. Patients returned to sports at an average of 6 months postoperatively (range, 4 to 44) and to their previous level of sports at an average of 12 months (range, 8 to 18). The mean increase in humeral retroversion was 29 degrees (range, 18 degrees to 44 degrees) Three women with preoperative multidirectional hyperlaxity were considered to have failed results. Derotational humeral osteotomy can be considered in the throwing athlete with posterosuperior impingement after failure of all other means of treatment. Careful patient selection and preoperative evaluation of humeral retroversion is important. Best results can be achieved in a motivated patient with low retroversion (< 10 degrees). If retroversion is normal (20 degrees to 30 degrees), the surgical indication is unclear. We do not recommend this surgery for patients with hyperlaxity.

Subluxations and dislocations of the tendon of the long head of the biceps.

Seventy-one cases of subluxation or dislocation of the long head of the biceps tendon (LHB) were retrospectively evaluated. Subluxation was observed in 25 (35%) cases combined with partial tearing of the subscapularis tendon and in 70% with tears of the supraspinatus tendon. Dislocation was defined as a permanent loss of contact between the tendon and the intertubercular groove; it was observed in 46 (65%) cases. Dislocation was associated with complete rupture of the subscapularis tendon in 23 cases, with partial tearing in 21 cases, and with an intact subscapularis tendon in 2 cases. Out of a series of 445 rotator cuff repairs, medial displacement of the LHB was found in 16%. In 70% of all cases dislocation of the long biceps tendon was associated with massive rotator cuff tears including the supraspinatus and infraspinatus tendons. Although "pseudoparalysis" of the shoulder (sudden loss of active elevation) was observed in 46% of all cases, no specific clinical test correlated to the presence of medial displacement of the LHB. Arthrography revealed displacement of the LHB in 28%, whereas arthro-computed tomography demonstrated lesions in 76%. The authors believe that medial displacement of the LHB can easily be overlooked during open surgery, and opening of the rotator interval is an essential part of rotator cuff repair.

Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting.

Twenty patients with pseudarthrosis of the upper humerus underwent surgery with the intramedullary bone peg technique. A 6 to 10 cm corticocancellous autogenous bone graft (11 iliac crest, 6 anterior tibial crest, 3 middle-third of the fibula) was pegged] into the humerus and bridged the pseudarthrosis. Stability of the fracture site was obtained by plate osteosynthesis; an additional peripheral cancellous graft was performed. Our patient series included 15 women and five men with an average age at operation of 58 years; the dominant side was involved in 12 cases. Eleven had undergone 22 previous operations. The average delay between fracture and surgery was 12 months, (range 6 to 72 months). The patients were monitored an average of 42 months (range 12 to 120 months). Union was confirmed in 19 cases; the last case demonstrated no peripheral callus. No necrosis of the humeral head was seen. Active anterior elevation of the shoulder improved from an average of 60 degrees to an average of 131 degrees. According to Constant's scale adjusted according to age and sex, the results obtained averaged 81.2%. Subjectively, 65% of patients were very satisfied, 30% were satisfied, and 5% were disappointed. The rate of union (96%) is in contrast with the results reported in the literature, underlining the importance of an intramedullary bone graft in association with peripheral osteosynthesis in the treatment of pseudarthrosis of the surgical neck of the humerus.

[The acromio-humeral interval. A study of the factors influencing its height]. / L'espace sous-acromial. Etude des facteurs influençant sa hauteur.

PURPOSE OF THE STUDY: The narrowing of the Acromio Humeral Interval (AHI) under 6-7 mm, lower limit reported in normal shoulder, has been considered to be a specific indicator for full-thickness cuff tears. The purpose of this study was to analyse the factors influencing the AHI. METHODS: 264 shoulders were operated on between 1984 and 1994 for full thickness tear of the supraspinatus and infraspinatus associated or not with an anterior cuff lesion. All patients had X-ray with A.P. view of the shoulder in neutral rotation. The AHI was defined as the shortest distance measured between the inferior cortex (dense line) of the acromion and the humerus. CT arthrogram was performed in 84 patients to analyse cuff muscular fatty degeneration. A full thickness tear was confirmed and measured by surgical approach in all cases. RESULTS: There was a moderate significant relationship (p < 0.05) between AHI and symptoms duration. There was a significant relationship between AHI and tear size (p < 0.05). When the supraspinatus tendon was only torn, the mean AHI was 9.5 +/- 0.17 mm (4.5 per cent of narrowing AHI). When supra and infraspinatus tendon were torn, the mean AHI was 7.5 +/- 0.4 mm (28 per cent of narrow AHI) and when an anterior lesion was associated, the mean AHI decreased to 5.4 +/- 0.5 mm and the percentage of narrow AHI increased to 63 per cent. The AHI was not influenced by the biceps rupture: with a similar symptoms duration, the mean AHI was 9 +/- 0.5 mm with biceps tear versus 9.2 +/- 2 mm when the biceps was normal. However, the mean AHI decreased to 5.5 +/- 0.6 mm when the long head of the biceps was dislocated and the AHI was less than 7 mm in 61 per cent of the cases. A highly significant relationship was found between the AHI and the infraspinatus muscle degeneration. We have found 100 per cent incidence of AHI narrowing when the infraspinatus was degenerated (mean AHI 2.2 +/- 1.1 mm). A moderate similar relationship was found concerning the supraspinatus muscle (p < 0.05) and no relationship was found with the subscapularis degeneration. DISCUSSION: The infraspinatus, external rotator of the humerus, seems to be the major active depressor of the humeral head. The biceps tendon, which is a passive depressor of the humerus, has no influence on the AHI whatever it is ruptured or not. However biceps dislocation is associated with significant humeral head superior migration. Symptoms duration and cuff tear size seem to be only secondary factors affecting the AHI. CONCLUSION: AHI narrowing should evocate a severe cuff tear with biceps dislocation or muscular degeneration. In these cases, surgical repair might be questionable. AHI value is more prognostic than diagnostic.

Arthroscopic stabilization for recurrent anterior shoulder dislocation: results of 59 cases.

Fifty-nine patients with recurrent anterior dislocation of the shoulder underwent the Morgan arthroscopic stabilization with transglenoidal suture of the inferior glenohumeral ligament. All patients were followed-up for an average of 49 months (range, 29 to 71 months). Using Rowe's scoring system, the overall objective results were disappointing. There were 33% excellent results, 9% good, 9% fair, and 49% poor. Twenty-six patients had a further dislocation, and 3 others had recurrent subluxation on average 13 months after the operation. The failures were associated with a preoperative clinical finding of inferior hyperlaxity as demonstrated by a positive sulcus sign, a preoperative radiological finding of a bony lesion on the anterior edge of the glenoid, or an arthroscopic finding of extended ligamentous lesions at the time of operation. The results of this study are clearly worse than those reported by other investigators. Direct comparison between the reported studies is problematic and is discussed. It was concluded that arthroscopic stabilization should only be performed by interested specialists as part of controlled clinical trials.

[Recurrent anterior and multidirectional instability of the shoulder]. / Instabilité antérieure récidivante avec hyperlaxité multidirectionnelle de l'épaule.

PURPOSE OF THE STUDY: Surgical treatment for recurrent anterior instability associated to multidirectional shoulder hyperlaxity: results analysis. MATERIAL: Twenty five patients operated for recurrent anterior dislocation or subluxation with multidirectional hyperlaxity. Age at operation was low (22 years old), there were more females than males, instability was bilateral in 52 per cent cases. METHOD: Five patients underwent a capsular shift followed by a four weeks post operative immobilization. Twenty patients underwent a bone block procedure with the coracoid process associated with a modified capsular shift. Inferior half of the subscapularis muscle was left intact under the coraco-biceps tendon. RESULTS: The results were fair with only 52 per cent excellent or good results. Ten patients (40 per cent) presented a recurrence either a dislocation or a subluxation. Hyperlaxity recurred in all but three patients. The procedure didn't influence the results which were related to the antecedent: the patients with a previous history of voluntary recurrent posterior subluxations achieved 33 per cent fair or poor results. Patients with previous history of recurrent anterior subluxation achieved 100 per cent poor results, whereas the patients without antecedent achieved 85 per cent good to excellent results. DISCUSSION: Establishing a difference between laxity and instability helps to analyse the patients with an unstable shoulder rather than considering traumatic or atraumatic onset of the instability. Identification of the hyperlaxity and of the antecedents must influence the therapeutic discussion. CONCLUSION: We recommend to use the term multidirectional hyperlaxity rather than multidirectional instability to characterize these patients.

[Postoperative low patella. Treatment by lengthening of the patellar tendon]. / La rotule basse postopératoire. Traitement par allongement du tendon rotulien.

PURPOSE OF THE STUDY: Patella infera is a post operative complication that can be prevented in most cases. This study was undertaken to determine etiological factors and to determine the means to avoid patella infera following knee surgery. The authors describe a new surgical technic to correct this complication and describe prognostic factors for achieving good results. MATERIAL AND METHODS: From 1985 to 1991, 35 patellar tendon lengthenings were performed in 35 patients. There were 28 female and 7 male patients with an average age of 37 years (21 to 72). Follow-up averaged 27 months and all patients had radiographic follow-ups. All patients had previous knee surgery: 21 for patellar pain (= patellar pain), 9 ACL reconstructions, 5 traumatic lesions. The range of motion of the knee was between 5 and 120 degrees. Patients complained of a burning pain in the patellar region and the sensation that the knee was held in a vice. The average Insall index was 0.55 (0.3 to 0.87). 25 patients had osteoporosis of the patella and 31 patients had a typical "sunrise" aspect on axial radiographs in 30 degrees of flexion. The usual diagnosis was that of algodystrophy. All patients underwent patellar tendon lengthening. RESULTS: Intra operative findings showed transverse retractions leading to resection of the medial and lateral retinaculum. The patellar tendon was short but its histological structure was normal. 15 patients had excellent results with no residual pain and were able to resume sports activities. 11 had good results with residual pain in hyperflexion and 9 had poor functional results, however nocturnal pain disappeared. Range of motion was between 0 and 130 degrees. Radiographic results were excellent since the preoperative average Insall score of 0.55 increased to 1.02 at follow-up. DISCUSSION: Patella infera is caused by combination of two factors: patellar surgery (painful patellar syndrome, patellar instability, ACL reconstruction using the mid third of the patellar tendon) and painful post operative rehabilitation with no active quadriceps contractions. To avoid this complication, the knee should be braced in 20 degrees of flexion to tense the patellar tendon and rehabilitation should be undertaken with active quadriceps contractions. Patellar lengthening is a successful procedure with the results being dependent upon number of previous surgeries, cartilage damage and, most importantly, the patellar index: between 0.8 and 0.65 the results are uncertain, < 0.6, the results are usually good. CONCLUSION: Patella infera is not a frequent complication of knee surgery. It is important to diagnose it early in order to prevent it. For chronic cases, surgical criteria should be strict: sensation of burning pain, lack of motion, unstable flexed monopodal stance, "sunrise" aspect on axial radiographs and a patellar index < 0.6. Patella infera differs from algodystrophy and re operation by retinacular release is indicated if the delay from previous surgery is < 2 months. In older cases, patellar tendon lengthening should be undertaken.