Occupational outcome after surgery in patients with a rotator cuff tear due to a work-related injury or occupational disease. A series of 262 cases.

UNLABELLED: The goals of this study were to establish the occupational outcome after surgery in patients with a rotator cuff tear from a work-related injury (WRI) or occupational disease (OD) and determine which factors and conditions affected return to work. HYPOTHESIS: return to work was possible for this type of patient. This questionnaire-based study comprised 262 shoulders in 254 patients with a WRI/OD who had surgery performed on their shoulder between 2000 and 2005. The average age was 50.5 ± 6.4 years. The following variables were analysed: employment status (private sector, self-employed, government employee), type of work (non-manual, manual, heavy manual labour), nature of tendon injury and surgical technique (open, mini-open and arthroscopy). Return to work occurred in 59.5% of the cases. Factors that prevented return to work (40.4% of the cases) included retirement (14.1%), an unrelated medical condition (10.3%), and the outcome of the operated shoulder (16.0%). Age had an impact on return to work (P<5 × 10(-4)). The type of work and nature of tendon injury did not affect return to work, but did affect time away from work. Employment status and surgical technique had an effect on return to work, but not on time away from work. Age was a decisive factor for return to work. Retirement seemed to be the most common choice starting at 55 years of age. Arthroscopy seemed to have reduced the impact of the WRI on the results, particularly on the time away from work. A preoperative evaluation of the patient's probability of returning to work should be done based on occupational and injury features. There may be a longer delay in returning to work for certain profiles of work (manual labour) and tendon injury. Patient management can be improved by knowing the factors and conditions that influence return to work. LEVEL OF EVIDENCE: Level IV - Retrospective study.

Musculotendinous infraspinatus ruptures: an overview.

BACKGROUND: Musculotendinous infraspinatus ruptures belong to the category of "muscle strain injuries". They differ from a classic rotator cuff tear by the following features: tendon attachment remains intact and the acute initial stage typically undergoes an intense muscular edema, replaced, 6 to 12 months later, by complete and permanent fatty infiltration of this muscle. METHODS: Between 1993 and 2007, we prospectively identified 59 musculotendinous ruptures of the infraspinatus muscle tendon complex. Fifty-eight percent of these patients were females. The average age at presentation was 50 years old. Onset was non traumatic in 78% of these cases. Twenty-nine patients were seen at the acute lesion stage with pain and, on T2 fat saturated MRI sequences, muscular edema. A second group of 30 patients presented with a stage 4 fatty infiltration of the infraspinatus muscle associated with a musculotendinous disruption. Twenty-three patients underwent EMG testing which was normal in all cases. None of these patients had a full thickness tear of the rotator cuff tendons, 21% of the patients presenting in the acute phase had a partial thickness tear of the supraspinatus, which increased to 70% in patients presenting in the chronic phase suggesting a more degenerative etiology. Calcific tendonitis was seen in 61% of patients. RESULTS: Twenty-four patients underwent surgery, while the remaining 35 were treated conservatively. The average follow-up, for all of them, was 46 months (12-125). The Constant score increased from 51.7 to 69.4 (p<0.001). There was no significant difference between the operated and the non-operated groups (p=0.325). All the patients seen at the acute painful edematous stage progressed to stage 4 complete fatty infiltrations, irrespective of selected treatment. None of the patients who underwent surgery had any regression of their fatty infiltration. CONCLUSIONS: Early diagnosis of this lesion can be made using T2 fat saturated MRI imaging. We hypothesize that early tendon repair which restores muscle tension in the infraspinatus may halt the progression of this entity and prevent complete functional loss of this muscle. LEVEL OF EVIDENCE: Level IV: Therapeutic study.

Results of latissimus dorsi tendon transfer for irreparable cuff tears.

Rupture of the supraspinatus and infraspinatus tendon (and teres minor) can cause loss of active external rotation (ER), entailing severe functional disability in daily activities. Latissimus dorsi tendon transfer (LDTT), proposed by Gerber in 1988, appears to be the best adapted solution in these cases of irreparable posterior and superior cuff tears. Between 2001 and 2004, 30 patients were operated on by the technique described by Gerber, with the transfer fixed anteriorly to the subscapularis tendon and laterally to the greater tuberosity by transosseous suture. One patient, subsequently requiring revision with a reversed prosthesis, was considered as a failure. Twenty-six patients were reviewed with a mean follow-up delay of 34+/-12 months. There were 14 men and 13 women. Mean age was 55.5 years (36 to 71 years). Preoperatively, active ER was symmetric in seven cases, loss of active ER was moderate with positive lag sign in five cases, significant with positive dropping sign in six cases, and severe in nine cases. Fatty muscular degeneration was present and significant in all cases for the infraspinatus muscle and in 14 cases for the teres minor muscle (associated with significant ER loss). Subjectively, 85% of the patients were very satisfied or satisfied and the Subjective Shoulder Value (SSV) was 68+/-17%. The pain score improved from 4.8+/-3 preoperatively to 12.2+/-2 postoperatively, strength from 3.7+/-2 kg to 4.2+/-1.8 kg, mean Constant score from 50+/-12 to 74+/-9, and Constant score adjusted for age and gender from 62+/-15% to 91+/-11%. Mean active ER gain was 7 degrees (-30 degrees to +50 degrees). The loss of active ER was aggravated in one case, unchanged in three, improved in nine and corrected in six. Hornblower sign was corrected in six cases and persisted in nine. Postoperatively, 8% of the patients were unable to eat and drink, compared to 64.7% preoperatively. The results of this series are comparable to those found in the literature for first-intention cases. LDTT restored active ER, but the results were incomplete and variable. Improvement was better in case of severe preoperative active ER deficit and insufficiency of the teres minor muscle. Recovery of strength was not observed in the present series. A narrow subacromial space and grade-3 Hamada classification had negative impact. In spite of an expected tenodesis effect, LDTT did not recenter the humeral head. LDTT compensates the deficient teres minor muscle rather than the infraspinatus muscle. The optimal indication for LDTT is irreparable superior and posterior rotator cuff rupture with loss of active ER associated with a deficient teres minor muscle. It is debatable whether LDTT is indicated in the absence of active motion deficiency: improvement was observed in these cases, but only in terms of subjective criteria.

[Isolated lesion of the infraspinatus at the myotendinous junction: a new lesion]. / Lésion isolée de l'infra-épineux à la jonction myotendineuse: une nouvelle lésion.

PURPOSE: We have identified a previously unpublished lesion of the infraspinatus muscle at the myotendinous junction. We describe its presentation and MRI appearance, notably the absence of other tendinous pathology in the rotator cuff. MATERIALS AND METHODS: We retrospectively reviewed 25 patients with isolated infraspinatus lesions and associated edema identified on the fat-suppressed T2-weighted images of MRI. Imaging exams and medical records collected over a 7-year period were reviewed by a team of radiologists and surgeons specializing in the shoulder. A presentation of the mechanism of injury, radiological analysis of MRI scans and other investigations (arthro-CT and EMG studies) were carried out; all MRI included at least two fat-suppressed T2-weighted (transverse and coronal) sequences and one T1-weighted (transverse) sequence. RESULTS: The lesion was characterized by tearing or delamination at the myotendinous junction, which was accompanied by edema of the infraspinatus muscle in the initial phase. Over time the edema was seen to resolve and muscle atrophy and fatty degeneration became predominant. We identified two groups by the onset of their symptoms. In the "chronic" group (44%), onset was gradual, with these patients frequently having had one or more infiltrations at presentation to us. In the "acute" group (56%), there was an initial traumatic event that was variable in intensity and mechanism. CONCLUSION: This isolated lesion of the infraspinatus at the myotendinous junction has not been previously described. It is recognized by its characteristic MRI appearance and is not generally seen on CT arthrograms as there is no communication with the joint. Its natural history appears to be of a progression from edema to fatty degeneration with or without myotendinous retraction and scarring. Its etiology has not yet been clearly established.

Critical analysis of the supraspinatus outlet view: rationale for a standard scapular Y-view.

The supraspinatus outlet view has been standardized under fluoroscopic control to become reproducible and comparable; it is the normalized scapular Y-view. Four hundred four healthy shoulders from patients 20 to 80 years old and 63 shoulders with rotator cuff tears underwent x-ray evaluation and were compared. A qualitative study was carried out on the shape of the acromion in relation to Bigliani's types (I, II, III and on the presence or absence of a bony spur on the anterior part of the acromion. Quantitative measurements were determined; the subacromial peak and the spinoacromial angle were assessed for a statistical comparison among the various populations. The acromions of healthy shoulders varied with age (8% type III in patients younger than 60 years, 27% in those older than 60 years), although not significantly. The dominant side and sex of the subjects had no effect. With 29% type III acromions the shoulders with cuff tears differed from those of the healthy shoulders (14% type III). No close correlation was seen between type III acromions and cuff ruptures. The quantitative values of the acromions had no predictive value for cuff rupture. Acromion typology failed to confirm that a type III acromion was responsible for rotator cuff rupture. Spurs are found in increasing incidence with age and in the presence of cuff rupture; whether they are caused by subacromial impingement or by natural aging of the acromion is uncertain.

[Neer's shoulder prosthesis: results according to etiology]. / La prothèse d'épaule de Neer: résultats en fonction de l'étiologie.

The outcome of 80 glenohumeral arthroplasties with the Neer prosthesis in 77 patients with degenerative or inflammatory shoulder disease was evaluated after a mean follow-up of three years five months. The arthroplasties were performed because of intractable pain and functional disability due to destruction of the glenohumeral joint. The postoperative rehabilitation program focused on full recovery of joint motion and function in 65 cases and on joint stability with partial recovery of joint motion and function in 15 cases. According to the criteria developed by Neer, the outcome was excellent or satisfactory in 75% of cases and unsatisfactory in 25%. Constant's scores adjusted for age and gender varied widely across diagnostic categories, from a high of 76% in centered glenohumeral osteoarthritis (n = 40) to lows of 59% in rheumatoid arthritis (n = 21) and 45% in posttraumatic osteoarthritis (n = 10) or eccentric osteoarthritis due to cuff disruption (n = 9). At reevaluation, 70% of patients had little or no pain and 90% were satisfied with the outcome. The mean increase in flexion of the arm (39 degrees) was markedly influenced by the diagnosis. The increases in lateral rotation (mean 35 degrees) and medial rotation (four vertebral levels) of the arm were especially appreciated by the patients as having a very beneficial effect on the ability to perform everyday tasks. Complications included instability in three cases (two anterior dislocations and one posterior dislocation), glenoid component loosening in 11 cases (of which only four required reoperation) and rotator cuff tear in eight cases. Our results add to the existing evidence that nonconstrained shoulder implants, such as the Neer prosthesis, are both safe and effective in alleviating pain and improving joint function. They should be used in patients with refractory pain, disability due to restrictions in external and medial rotation of the arm and roentgenographic evidence of glenohumeral joint space loss.

[Postero-superior glenoid impingement. Another impingement of the shoulder]. / Le conflit glénoïdien postéro-supérieur. Un autre conflit de l'épaule.

An impingement occurring between the deep side of the supraspinatus tendon and the postero-superior edge of the glenoid cavity was evidenced in a young sports thrower presenting with a partial tear of the deep side of the tendon. This impingement occurred when the arm was in abduction-retropulsion and in forced lateral rotation. It was visualized on arthroscopy. The semiology was mixed, including signs of anterior instability and cuff impairment. The possible causes of partial tears of the deep side of the supraspinatus are discussed: sub-acromial impingement of NEER, anterior instability with secondary impingement, postero-superior glenoid impingement.

[Radio-cinematographic study of active elevation of the prosthetic shoulder]. / Etude radio-cinématographique de l'élévation active de l'épaule prothésée.

In order to verify whether it is possible to reproduce the physiologic anterior elevation of the shoulder with a non constrained Neer type prosthesis, the authors have examined the dynamic comportement of 21 total shoulder arthroplasties. Recording of anterior active elevation with video-fluoroscopy and evaluation glenohumeral motion and scapulothoracic motion allowed to distinguish 3 types of biomechanics after total shoulder replacement. A first group of prosthesis (4 cases) had normal biomechanics with conservation of a normal scapulohumeral rythm. This concerned arthroplasties performed for necrosis or osteoarthritis with no cuff tear or loose bone stock and no technical error. A second group of prosthesis (10 cases) had an abnormal biomechanics. There was a superior excursion of the humeral head prosthesis without real glenohumeral motion. A more severe pathology (cuff tear arthropathy, rheumatoid arthritis, old traumas) with bone and/or muscular destruction was sufficient to explain this elevation possible only because of the scapulothoracic motion. Finally, there was a third group of prosthesis (7 cases) which had a reversed scapulohumeral rythm: there was less motion between the prosthetic components but the scapulothoracic motion was unchanged. Three factors can be responsible for this reversed scapulohumeral rythm: 1) The initial pathology, because of the difference in the cuff trophicity. 2) The surgical technic because of the difficulties to respect the position of the joint line and the lever arms. 3) The prosthesis itself, because of the higher degree of conformity and stability between the prosthetic components.

[Surgical treatment of rotator cuff rupture. Prognostic factors]. / Traitement chirurgical des ruptures de la coiffe des rotateurs. Facteurs de pronostic.

A retrospective study of 67 total ruptures of the rotator cuff operated on was carried on, with an average follow-up of 25 months. The lesions were characterised by their size (19 tears of less than 2 cm, 30 between 2 and 4 cm, 18 over 4 cm) and location (27 tears of the supraspinatus, 15 tears of the supraspinatus extending to the front (coraco-humeral, long biceps, subscapular), 20 supra and infra-spinatus, 5 "massive" tears). The tendon of the long biceps was pathological in half of the cases. Fourteen patients presented with a subacromial osteoarthritis. All patients benefited from a decompression and repair of the rupture. Whereas the subjective results indicate 92 per cent satisfied patients, from the objective point of view the average score with Constant's rating was 62.5 pts with 53 per cent favorable results. Evaluation of force was a particular subject of attention: the results obtained with three charts were compared; the conclusion was in favour of an objective measurement using a dynamometer but with a weighting according to age and sex. The characteristics of the tear (location especially), the state of the long biceps, the presence of a subacromial osteoarthritis and the pre-operative mobility affected statistically and significantly the final result. The authors reserve reconstructive surgery for tears without osteoarthritis, isolated lesions of the supraspinatus having the best prognosis. The existence of a subacromial osteoarthritis, always a sign of a massive tear, in elderly patients should lead one to choose a procedure a minima under arthroscopy.

[2 roentgen projections for the subacromial space before and following acromioplasty. Results of a study series of 40 patients]. / Zwei Röntgenzielaufnahmen für den Subakromialraum vor und nach Akromioplastik. Ergebnisse einer Untersuchungsserie von 40 Patienten.

It is suggested that two radiological projections of the scapula, an AP view and a lateral (tunnel) view, be obtained in order to estimate the form and size of the acromion before and after acromioplasty. In order to evaluate the standardized films precisely, a film must have been taken for comparison before the surgery. As the method described is easily reproducible, it can be used to evaluate the effect of an acromioplasty irrespective of whether the procedure was an open or an arthroscopic one. The radiological results can be correlated with the functional results at the beginning of rehabilitation and at the end of this period. More sophisticated studies might require a more elaborate X-ray technique than the one proposed in this article.

[Surgical treatment of painful shoulders caused by lesions of the rotator cuff and biceps, treatment as a function of lesions. Reflections on the Neer's concept]. / Traitement chirurgical des épaules douloureuses par lésions de la coiffe et du long biceps en fonction des lésions. Réflexions sur le concept de Neer.

On the basis of their clinical and surgical experience of 480 shoulders operated upon for rotator cuff pathology, together with a review of the literature, the authors undertake a critical analysis of the Neer impingement syndrome. Since this syndrome cannot explain all lesions and above all cover all rotator cuff pathology, they suggest an anatomical classification based upon a description of lesions. They describe their indications for surgery on the basis of their results and of those from the literature.

[Postero-superior glenoid impingement. Another shoulder impingement]. / Le conflit glénoïdien postéro-supérieur. Un autre conflit de l'épaule.

An impingement occurring between the deep side of the supraspinatus tendon and the posterosuperior edge of the glenoid cavity was evidenced in a young sports thrower presenting with a partial tear of the deep side of the tendon. This impingement occurred when the arm was in abduction-retropulsion and in forced lateral rotation. It was visualized on arthroscopy. The semiology was mixed, including signs of anterior instability and cuff impairment. The possible causes of partial tears of the deep side of the supraspinatus are discussed: sub-acromial impingement of NEER, anterior instability with secondary impingement, postero-superior glenoid impingement.