Results of the Latarjet procedure for recurrent anterior dislocation of the shoulder in patients with epilepsy.

A total of 12 epileptic patients (14 shoulders) with recurrent seizures and anterior dislocations of the shoulder underwent a Latarjet procedure and were reviewed at a mean of 8.3 years (1 to 20) post-operatively. Mean forward flexion decreased from 165° (100° to 180°) to 160° (90° to 180°) (p = 0.5) and mean external rotation from 54° (10° to 90°) to 43° (5° to 75°) (p = 0.058). The mean Rowe score was 76 (35 to 100) at the final follow-up. Radiologically, all shoulders showed a glenoid-rim defect and Hill-Sachs lesions pre-operatively. Osteo-arthritic changes of the glenohumeral joint were observed in five shoulders (36%) pre-operatively and in eight shoulders (57%) post-operatively. Re-dislocation during a seizure occurred in six shoulders (43%). Five of these patients underwent revision surgery using a bone buttress from the iliac crest and two of these patients re-dislocated due to a new seizure. Due to the unacceptably high rate of re-dislocation after surgery in these patients, the most important means of reducing the incidence of further dislocation is the medical management of the seizures. The Latarjet procedure should be reserved for the well-controlled patient with epilepsy who has recurrent anterior dislocation of the shoulder during activities of daily living.

An evaluation of the radiological changes around the Grammont reverse geometry shoulder arthroplasty after eight to 12 years.

Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p < 0.001), as was resorption of the greater (p < 0.001) and lesser tuberosities (p = 0.009).

Prevalence of neurologic lesions after total shoulder arthroplasty.

BACKGROUND: Clinically evident neurologic injury of the involved limb after total shoulder arthroplasty is not uncommon, but the subclinical prevalence is unknown. The purposes of this prospective study were to determine the subclinical prevalence of neurologic lesions after reverse shoulder arthroplasty and anatomic shoulder arthroplasty, and to evaluate the correlation of neurologic injury to postoperative lengthening of the arm. METHODS: All patients undergoing either a reverse or an anatomic shoulder arthroplasty were included during the period studied. This study focused on the clinical, radiographic, and preoperative and postoperative electromyographic evaluation, with measurement of arm lengthening in patients who had reverse shoulder arthroplasty according to a previously validated protocol. RESULTS: Between November 2007 and February 2009, forty-one patients (forty-two shoulders) underwent reverse shoulder arthroplasty (nineteen shoulders) or anatomic primary shoulder arthroplasty (twenty-three shoulders). The two groups were similar with respect to sex distribution, preoperative neurologic lesions, and Constant score. Electromyography performed at a mean of 3.6 weeks postoperatively in the reverse shoulder arthroplasty group showed subclinical electromyographic changes in nine shoulders, involving mainly the axillary nerve; eight resolved in less than six months. In the anatomic shoulder arthroplasty group, a brachial plexus lesion was evident in one shoulder. The prevalence of acute postoperative nerve injury was significantly more frequent in the reverse shoulder arthroplasty group (p = 0.002), with a 10.9 times higher risk (95% confidence interval, 1.5 to 78.5). Mean lengthening (and standard deviation) of the arm after reverse shoulder arthroplasty was 2.7 ± 1.8 cm (range, 0 to 5.9 cm) compared with the normal, contralateral side. CONCLUSIONS: The occurrence of peripheral neurologic lesions following reverse shoulder arthroplasty is relatively common, but usually transient. Arm lengthening with a reverse shoulder arthroplasty may be responsible for these nerve injuries.

Muscle fatty infiltration in rotator cuff tears: descriptive analysis of 1688 cases.

INTRODUCTION: Fatty infiltration (FI) is an important prognosis factor in the anatomical and functional outcomes of rotator cuff repairs. The objective of this study was to analyze the natural history of muscle FI and better evaluate its onset and aggravation time frame. MATERIAL AND METHODS: A total of 1688 medical charts of patients operated on for rotator cuff tear and with a preoperative CT arthrogram (82%) or an MRI (18%) were reviewed. Surgery was performed between 1988 and 2005. The FI of each muscle was assessed as minimal (in Goutallier's stages 0 and 1), intermediate (in stage 2), and severe (in stages 3 and 4). Regarding supraspinatus, we retained the mean FI observed in the sagittal, coronal, and axial planes; for the infraspinatus and the subscapularis, we retained the observed mean on two views at the upper and lower levels of the glenoid in the axial plane. RESULTS: We found a statistically significant correlation (p<0.0005) between FI, the type of tendon lesion, and patient age for the supraspinatus, the infraspinatus, and the subscapularis. Statistically, the FI significantly increased (p<0.0005) with time elapsed for the supraspinatus and the infraspinatus but not significantly for the subscapularis. The mean time to tendon rupture observed for intermediate FI was three years for the supraspinatus and 2.5 years for the infraspinatus and the subscapularis when their tendons ruptured. The mean time observed to severe FI was five, four, and three years for the supraspinatus, the infraspinatus, and the subscapularis, respectively. DISCUSSION AND CONCLUSION: The more extensive the lesion, the longer the time following rupture, and the older the patient is, the more severe the FI is. The objective of surgery is to intervene before intermediate FI sets in, which means irreversible functional loss. LEVEL OF EVIDENCE: Level IV. Diagnostic Retrospective Study.

Off-centric rotation axes in natural head movements: implications for vestibular reafference and kinematic redundancy.

Until now, most studies concerning active head movements in three dimensions have used the classical rotation vector description. Although this description yields both the orientation of the head rotation axis and the amount of rotation, it is incomplete because it cannot specify the location of this rotation axis in space. The latter is of importance for a proper picture of the vestibular consequences of active head movements and has relevance for the problem of how the brain deals with the inherent kinematic redundancy of the multijoint head-neck system. With this in mind, we have extended the rotation vector description by applying the helical axes approach, which yields both the classical rotation vector as well as the location of the rotation axis in space. Subjects (n = 7), whose head movements were recorded optically, were instructed to shift gaze naturally to targets in 12 different directions at an eccentricity of 40 degrees. The results demonstrate that the axes for these head movements occupy consistently different spatial locations. For purely horizontal movements, the rotation axis is located near a point midway between the two ear canals. For gaze shifts in other directions, the rotation axes are located below the ear canals along two circles, one for movements with an upward component (up circle), the other (typically larger in size) for movements with a downward component (down circle). Purely vertical movement (up and down) axes were located on the lower pole of the up and down circles, respectively. It was found that both circles, the upper poles of which coincided, became larger in size as movement amplitude increased, which means that the axis location shifts to lower and more eccentric locations with respect to the skull for larger flexion and extension movements. Although this pattern could be recognized in most subjects, there were consistent intersubject differences in the absolute size of the circles, their increase with movement amplitude, and in the relative sizes of the up and down circles. Because multiple vertebrae are involved in head movements, there are theoretically many possibilities to execute a certain head movement. The differences in circle patterns among subjects indicate different strategies in resolving this kinematic redundancy problem, a fact that was not apparent from the classical rotation vector part of our description, which yielded a rather uniform picture. A simple model suggests that the downward shift of the location of the rotation axis requires a modulation in vestibulo-ocular reflex gain of

Listing's plane dependence on alternating fixation in a strabismus patient.

Listing's law of the eye is one of the best studied findings in motor control, but its functional meaning is still incompletely understood and its status in neurological disorders and in strabismus is almost entirely unknown. We investigated the mechanisms underlying Listing's law and its possible clinical relevance. The dual magnetic search coil technique was used to record three-dimensional binocular eye movements in a stereoblind strabismic patient with good visual acuity in both eyes and capable of voluntarily alternating fixation. This technique yielded an accurate, objective and simultaneous measure of ocular misalignment in three dimensions and showed that the squint angle depended on which eye was fixating. Saccadic eye movement data throughout the oculomotor range were used to fit Listing's plane. Listing's primary position and the thickness of the plane for each eye were calculated for three different fixation conditions. For comparison, control measurements were taken from four normals. In the patient, no large deviations from normal values for the thickness of Listing's plane and the confidence limits of the Listing primary position were found. The most remarkable abnormality was that the orientation of Listing's plane depended on which eye was fixating. Both the change in ocular misalignment and the shift of Listing's primary positions observed when changing fixation are probably linked to accommodation-related vergence. Despite repeated surgery at early age, the patient had well-defined Listing planes for both eyes, but their alignment during left-eye fixation was abnormal. The obedience to Listing's law may reflect a strategy which minimizes muscular effort in each eye separately. The abnormal fixation-condition dependence is probably due to an aberrant coupling with vergence.

Short-term adaptation of electrically induced saccades in monkey superior colliculus.

1. This study focuses on the neural mechanisms underlying short-term adaptation of saccadic eye movements in the rhesus monkey. Involuntary saccades of various amplitudes and directions (E-saccades) were elicited in complete darkness by electrical stimulation (< or = 50 microA) in the deeper layers of the superior colliculus (SC) at 30 different sites in two monkeys. E-saccades at a given site could be adapted by presenting a visual target at a small distance from the expected end point immediately after their occurrence. The monkeys were trained to null the ensuing error signal by making the appropriate correction saccade to the visual target in many successive trials (E-adap paradigm). By properly adjusting the location of the visual target relative to the end point of the E-saccade, the latter could be modified in amplitude as well as in direction. 2. E-saccade modifications were highly significant, always in the intended direction, and occurred only if a postsaccadic visual error signal was created. These changes were plastic and required a subsequent E-adap series with an opposite error signal to cancel them. Their time course, both during the adaptation and the readaptation period, indicated that the modification was a slow and gradual process, as has been observed earlier in classical visual adaptation experiments. 3. Postadaptation tests, assessing whether the adaptation of E-saccades was also noticeable in normal visually guided saccades (V-saccades), showed incomplete adaptation transfer that was significant in most cases. A similar result, significant in all cases, was obtained with an extended version of the E-adap paradigm in which movement planning on the basis of target selection was possible. In this case, a presaccadic visual target was presented at the expected end point of the E-saccade, which was evoked just before the monkey would make a voluntary saccade itself (VE-adap). 4. In another series of experiments, V-saccades, which were matched to the optimal saccade vector of the particular collicular site under investigation, were adapted with the classical intrasaccadic target shift paradigm (V-adap). In agreement with earlier findings, this V-adaptation showed no transfer to the E-saccades. This result was obtained even in trials in which movement planning on the basis of target selection was possible (VE-test). 5. Our experiments have shown that saccades of collicular origin can be adapted and that presaccadic target selection is not crucial for this process. Both results are nicely in line with an existing model featuring a downstream adaptive corrector with access to SC inputs. This scheme, however, does not explain why the degree of saccadic adaptation, achieved by applying any of the three adaptation paradigms (E-adap, EV-adap, or V-adap), was never equally expressed in V- and E-saccades. Arguments for extending the model by adding a cortical input from the frontal eye fields to the adaptive corrector are discussed.

Analysis of saccadic short-term plasticity in three dimensions.

The capacity for short-term adaptation is a well-established property of the horizontal (H) and vertical (V) components of saccades. It allows these directional components, which clearly serve the goal of foveation, to maintain their precision even under changing circumstances. Torsional (T) saccade components, on the other hand, which deal with the orientation of the target on the fovea, have hardly been investigated in adaptation experiments. They appear to be severely restricted by Listing's law during fixations and saccades. The main purpose of Listing's law is far from obvious but could be visual or oculomotor. Better knowledge of the adaptive capacity of the saccadic system in the torsional direction could throw new light on the functional significance of this interesting neural strategy. To study short-term plasticity in the torsional components of saccades, binocular 3D-eye positions were measured, using magnetic search coils. Five normal human subjects were instructed to make uni-directional refixation saccades, while they viewed a large visual scene. To induce a change in the torsional component, the complete stimulus was rapidly rotated during these saccades. We thoroughly investigated the torsional responses of the saccadic system, to see if any short-term adaptive response in torsional direction was induced, in which case the notion of a visual purpose for Listing's law would be strengthened. In none of our experiments, however, did we find any clear adaptive response in torsional direction. To further investigate the reliability of this result and to ascertain that our experimental conditions allowed classical gain adaptation, we also did experiments designed to achieve a combination of torsional adaptation and classic gain shortening in one of the directional components. While gain adaptation was very obvious, none of the experiments provided evidence for a short-term effect in torsion. We conclude that our experiments do not support a purely visual basis for Listing's law.