Does partial tear repair of adjacent tendons improve the outcome of supraspinatus tendonfull-thickness tear reinsertion?

BACKGROUND: Partial tearing of the infraspinatus and/or subscapularis tendon(s) is frequently associated with supraspinatus full-thickness tears. However, limited data regarding its influence on supraspinatus surgical repair is available. PURPOSE: Our aim was to assess the functional and anatomical outcomes of open repair of supraspinatus full-thickness tears combined with adjacent partial tearing, comparatively to a control. METHODS: We retrospectively identified 22 patients (22 shoulders) with a partial tear, most of them being a delamination tear, of the infraspinatus and/or subscapularis tendons associated with a complete detachment of the supraspinatus tendon. Twenty-seven patients (27 shoulders) treated for an isolated complete detachment of the supraspinatus tendon by open repair served as controls. The mean age was 58 years. A proximalized trans-osseous reinsertion of the supraspinatus tendon was combined with a curettage-closure of the delamination tear. Patients were evaluated with standardized MRI at last follow-up. RESULTS: At a mean of 75-month follow-up, the presence of a partial tear of either infraspinatus or subscapularis, or both, did not influence function and healing rates of supraspinatus tendon repair. Conversely to the control, when a retear occurred, the functional score tended to worsen. Preoperatively, fatty muscular degeneration was more pronounced when a partial tear was present. Fatty degeneration worsened regardless of repair healing. CONCLUSION: Open reinsertion of a supraspinatus full-thickness tear associated with a thorough treatment of partial tear of adjacent tendons led to optimal functional and anatomical mid term outcomes. Our results suggest the presence of a partial tear of adjacent tendons could be associated with poorer function in case of supraspinatus tendon re-rupture. LEVEL OF EVIDENCE: Level III case-control study.

Surgical treatment of three and four-part proximal humeral fractures.

Three- and four-part fractures of the proximal humerus are usually treated surgically. Open reduction with internal fixation (ORIF) is the method of choice in younger patients. Anatomic reduction of the tuberosities is crucial to ensure that, in the event of poorly tolerated avascular necrosis of the humeral head, hemiarthroplasty can be performed under optimal conditions. Suboptimal outcomes may occur after ORIF, as less-than-perfect reduction and fixation is poorly tolerated at the shoulder. Preoperative computed tomography must be performed routinely to analyse fragment displacement and comminution, classify the fracture, assess humeral head vitality, and evaluate the mechanical properties of the underlying bone. Fracture reduction relies on principles that are shared by the various available techniques. Reduction of each fragment should be assessed separately. Reduction of the humeral head to the shaft should be performed before reduction of the tuberosities. The fixation technique should ensure stability of the anatomic reduction, with secure fixation of the tuberosities and a minimal risk of material migration into the joint. Here, we provide a detailed discussion of the various techniques, with their advantages and drawbacks, to help surgeons select the method that is most appropriate to each individual patient.

Fibular nonunion after closed-wedge high tibial osteotomy.

UNLABELLED: Closed-wedge valgus high tibial osteotomy (HTO) has been reported to be an effective procedure for the treatment of medial compartment osteoarthritis of the knee. It requires shortening the fibula, for which many techniques have been described. Dislocation of the proximal tibiofibular joint limits the correction angle of the procedure and the osteotomy of the fibular head runs the rare but dramatic risk of common fibular nerve palsy, which is why many surgeons perform the osteotomy more distally at the shaft. However, the potential complications of fibula shaft osteotomy in closed-wedge proximal tibial osteotomy have been poorly reported. The purpose of this study is to accurately define the incidence and risk of fibular complications. MATERIALS AND METHODS: One hundred and eight patients (59 men, 49 women, 53±10years old, preoperative varus: 6.7°±4°) underwent a closed-wedge HTO with fibular shaft osteotomy between 1999 and 2004. They were followed up prospectively for clinical and radiological evaluation (2years of follow-up). The main evaluation criterion was the presence of fibular nonunion. RESULTS: Eighteen knees (16.6%) underwent fibular complications: 15 nonunions were indexed (13.9%); 11 of them (10.1%) required surgical revision. Three knees had nerve injury, with spontaneous recovery for two of them. DISCUSSION: Fibular nonunion is the most frequent complication, which often leads to revision procedures. Nonunion was correlated to the preoperative body mass index, the obliquity of the osteotomy plane, and the fragmentary contact. No nonunion was reported when the obliquity of the osteotomy plane was above 50° or the fragment contact greater than 50%. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Posttraumatic dislodgement of the infrapatellar fat pad: an unusual type of superolateral impingement.

The authors report a rare case of dislodgement of the infrapatellar fat pad induced by traumatic hyperflexion. Because of the unusual clinical presentation, open excision was performed to exclude a possible tumoral etiology. This entity seems to be an acute form of superolateral fat pad impingement.

Results of open reduction and cortico-cancellous autograft of intra-articular calcaneal fractures according to Palmer.

OBJECTIVE: To assess the mid term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture using the modified Palmer technique. MATERIALS AND METHODS: Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. The mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. Following Utheza, five fractures (28%) were classified as vertical, three as horizontal (17%) and 10 (55%) as combined. Mean preoperative Böhler angle was -4 degrees (range, -42 to 26 degrees ). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the subthalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screws inserted in a transverse position. Patients were evaluated at the last follow-up by physical examination and by the functional score described by Kitaoka. Böhler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side. RESULTS: Follow-up ranged from 12 to 38 months (mean, 23 months). One patient required a subtalar arthrodesis for advanced osteoarthritis. One patient experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, the mean Kitaoka score was 74 (range, 34-98). The functional score was considered good or excellent in 11 cases (64.7%), fair in three (17.6%), and poor in three (17.6%). The mean Böhler angle was 23.4 degrees (range, 5-40 degrees ) postoperatively and 22.7 degrees (range, 0-38 degrees ) at the last follow-up. A modest loss of correction was observed in four cases. The final Böhler angle was at least 85% compared to the healthy side in 10 cases out of 14 unilateral fractures. The functional score correlated well with restoration of Böhler's angle. DISCUSSION AND CONCLUSION: Operative treatment of intra-articular calcaneal fractures following a modified Palmer technique provided encouraging results, since restoration of Böhler's angle was obtained. The main advantages include an absence of hardware prominence, resulting in an absence of skin complications, and a stable fixation.

[Results of open reduction and cortico-cancellous autograft of intra-articular calcaneal fractures according to Palmer]. / Résultats du traitement des fractures articulaires du calcaneus par relèvement à foyer ouvert et greffe systématique selon la méthode de Palmer. A propos de 18 cas.

OBJECTIVE: To assess the mid-term patient outcome after operative treatment of a displaced intra-articular calcaneal fracture according to Palmer. MATERIALS AND METHODS: Eighteen operatively treated intra-articular fractures of the calcaneus in 16 patients (nine males, seven females) were retrospectively reviewed. Mean age at surgery was 35 years (range, 17-61 years). Two patients had a bilateral fracture. According to Rev Chir Orthop 79 (1993) 49-57, five fractures (28 percent) were classified as vertical, three as horizontal (17 percent), and 10 (55 percent) as combined. Mean preoperative Böhler angle was -4 degrees (range, -42-26 degrees ). An extended lateral approach to the calcaneus was used in each case. A cortical bone autograft was firmly impacted in the sub thalamic void after reduction. Stabilization was achieved by two or three axial Kirschner wires and one or two screw(s) inserted in a transverse position. Patients were evaluated at the last follow-up by physical examination and by the functional score described by Foot Ankle Int 15 (1994) 349-353. Böhler's angle was measured on the immediate postoperative radiographs and at the last follow-up, and compared when possible with the noninjured side. RESULTS: Follow-up ranged from 12 to 38 months (average, 23 months). One patient (one calcaneus) required a subtalar arthrodesis for advanced osteoarthritis. One patient (one calcaneus) experienced reflex sympathetic dystrophy. No skin complication was noted. At the last follow-up evaluation, mean Kitaoka score was 74 (range, 34-98). Functional score was considered good or excellent in 11 cases (64.7 percent), fair in three (17.6 percent) and poor in three (17.6 percent). Mean Böhler angle was 23.4 degrees (range, 5-40 degrees ) postoperatively and 22.7 degrees (range, 0-38 degrees ) at the last follow-up. A modest loss of correction was observed in four cases. Final Böhler angle was at least 85 percent comparatively to the healthy side in 10 cases among 14 unilateral fractures. Functional score correlated well with restoration of Böhler's angle. DISCUSSION AND CONCLUSION: Operative treatment of intra-articular calcaneal fractures according to Palmer provided encouraging results, since restoration of Böhler's angle was obtained. Main advantages include an absence of hardware prominence, resulting in an absence of skin complication, and a stable fixation.

Algorithms for the extraction of various diameter vessels.

In this communication we propose a new and automatic strategy for the multi-scale extraction of vessels. The objective is to obtain a good representation of the vessels. That is to say a precise characterization of their centerlines and diameters. The adopted solution requires the generation of an image scale-space in which the various levels of details allow to process arteries of any diameter. The proposed method is implemented using the Partial Differential Equations (PDE) and differential geometry formalisms. The differential geometry allows, by the computation of a new valley response, to characterize the centerlines of vessels as well as the bottom lines of the valleys of the image surface. The information given by the centerlines and valley response at different scales are used to obtain the 2D multi-scale centerlines of the arteries. To that purpose, we construct a multi-scale adjacency graph which permits to keep the K strongest detections. Then, the detection we obtain is coded as an attributed graph. The suggested algorithm is applied in the scope of two kinds of angiograms: coronaries and retinal angiograms.

Developments in shoulder arthroplasty.

Indications for shoulder arthroplasty are numerous, mainly owing to glenohumeral osteoarthritis, rheumatoid arthritis, or fracture of the proximal humerus. However, the anatomy and the biomechanics of the shoulder are complex and shoulder arthroplasty has evolved significantly over the past 30 years. This paper presents the main recent evolutions in shoulder replacement, the questions not answered yet, and the main future areas of research. The review focuses firstly on the design, positioning, and fixation of the humeral component, secondly on the design, positioning, and fixation of the glenoid implant, and thirdly on other concepts of shoulder arthroplasty such as the reversed prosthesis, the cementless surface replacement arthroplasty, and the bipolar arthroplasty. This review demonstrates that more research is needed. Although, in the long term, large randomized trials are needed to settle the fundamental questions of what type of replacement and which kind of fixation should be used, biomechanical research in the laboratory should be focused primarily on the comprehension of glenoid loosening, which is a major cause of total shoulder arthroplasty failure, and the significance of radiolucent lines which are often seen but with no clear understanding about their relation with failure.

[Metal-metal-backed polyethylene cemented hip arthroplasty: mid-term results]. / Arthroplastie de hanche a couple métal-metal sur polyéthylène cimenté: Résultats a moyen terme.

PURPOSE OF THE STUDY: Metal-on-metal bearings in total hip arthroplasty may, in theory, provide an effective answer to osteolysis in active patients. The purpose of this retrospective study was to evaluate the results of a consecutive series of Metasul total hip arthroplasties with a cemented socket. MATERIAL AND METHODS: The series was composed of 28 total hip arthroplasties in 23 patients (13 women and 10 men). The mean age at operation was 44 +/- 8.3 years (range 22-59 years). The initial diagnosis was osteoarthritis (14 hips), osteonecrosis of the femoral head (11 hips) and rheumatoid arthritis (3 hips). Cemented cups with a metal articulation surface molded into the polyethylene were used. The cup was articulated with a 28-mm metallic head. Cemented stems were used in 27 hips, whereas a hydroxyapatite coated stem was implanted in one hip. RESULTS: One hip required revision for deep infection five months postoperatively. One patient (one hip) was lost to follow-up. Twenty-six hips were evaluated at an average 31-month follow-up (range 12-47 months). All hips were rated excellent or very good. Radiographically, seven hips (27%) had a progressive acetabular radiolucent line, including three complete radiolucent lines. The latter always were located at the bone-cement interface. No implant migration was noted. In these cases, the mean socket diameter was lower than for the rest of the cohort (p < 0.001). DISCUSSION AND CONCLUSION: Progression of acetabular radiolucent lines remains of concern in this series of Metasul artificial hips. It is hypothesized that the diminution of polyethylene thickness has led to an increased rigidity of the socket, resulting in a higher rate of constraints at the bone-cement interface. Special attention must be given to these hips.

Brown tumor of the spine and progressive paraplegia in a hemodialysis patient.

STUDY DESIGN: Case report. OBJECTIVE: To describe the radiographic features and management of spinal brown tumor and to document tumor mineralization after parathyroidectomy. SUMMARY OF BACKGROUND DATA: Brown tumors are classic skeletal manifestations of hyperparathyroidism usually seen in severe forms. They are increasingly rare because hyperparathyroidism is now diagnosed and treated at an early stage. METHODS: A case of brown tumor of the spine in a 37-year-old woman on chronic hemodialysis is described. The imaging findings before and after parathyroidectomy are discussed. RESULTS: In a woman on chronic hemodialysis, a brown tumor of T8 caused acute spinal cord compression with paraplegia. Magnetic resonance imaging provided an accurate evaluation of the lesion, and needle biopsy confirmed the diagnosis. Emergent surgery was needed to relieve the spinal compression and stabilize the spine. The vertebral lesion underwent remineralization after parathyroidectomy. CONCLUSION: Brown tumor is a benign tumor that resolves after parathyroidectomy. When brown tumor arises in the spine, surgery may be needed to preserve neurologic function.

A 4-portal arthroscopic stabilization in posterior shoulder instability.

The purpose of this study was to present an arthroscopic stabilization technique with 4 portals for posterior instability used in 11 patients (13 shoulders). There were 7 male and 4 female patients. All patients had an arthroscopic labral suture with anchors and capsular plication with 4 portals. The follow-up period averaged 34 months. No complication or recurrence of instability was noted. A moderate loss of range of motion was noted in 4 shoulders and moderate pain in 2 shoulders. All patients were satisfied. According to the literature, the rate of recurrence of instability is currently lower than 12% when a labral suture and capsular plication are performed. Our results for pain and range of motion are similar to those described in recent publications. However, we think that the 4-portal technique allows a facilitated access to the posteroinferior part of the glenoid and reduces the rate of postoperative instability.

[The superolateral approach for shoulder prosthesis]. / Voie d'abord supéro-latérale pour l'implantation d'une prothèse d'épaule.

We describe a superolateral approach to the shoulder for implantation of total shoulder prostheses or humeral prostheses. The advantages of this approach include preservation of the supraspinatus tendon and an excellent exposure of the posterior part of the glenoid cavity. We illustrate this approach with three clinical examples: total shoulder arthroplasty with reconstruction of the posterior part of the glenoid using a screwed autograft for central degeneration with posterior wear of the glenoid, intermediate arthroplasty for excentric degeneration with irreparable rotator cuff tears, and simple humeral arthroplasty with bone suture of the tuberosities for cephalotuberosity fracture.

[Bipolar arthroplasty in rotator cuff arthropathy: 13 cases]. / Résultats de l'arthroplastie intermédiaire dans le traitement de l'omarthrose excentrée.

PURPOSE OF THE STUDY: A series of 13 patients with an excentered osteoarthritis of the glenoid who underwent bipolar shoulder arthroplasty is reported. MATERIAL AND METHODS: The series included 13 patients treated in two centers between 1995 and 1998. Mean age was 70 years (58-88). Constant's absolute score and Swanson's score were used for clinical assessment. The Hamada and Fukuda classification was used for the radiographic assessment. The follow-up radiography series included an AP view in the three rotation positions, an AP view in maximum abduction to assess intraprosthetic mobility, a lateral view (Lamy) and measurements of both humeri. Several measurements were made to assess humerus lateralization and glenoid wear: deltoid lever arm, lateral humeral displacement, distance between the lateral border of the coracoid and the center of the glenoid and the subacromial space. Mean preoperative Constant score was 23 points: pain 3 pts, activity 5 pts, motion 13 pts, force 2 pts. Mean preoperative Swanson score was 11. Active anteflexion was 78 degrees, active abduction 68 degrees and passive external rotation 17 degrees. The Hamada and Fukuda classification was 9 grade 4 and 4 grade 5. All patients had a full thickness unrepairable rotator cuff tear: three with 2 tendon tears, and 10 with 3 tendon tears. All patients were reviewed clinically and had a complete radiography series at last follow-up (mean 28 months, range 7 - 56 months). RESULTS: At last follow-up, the mean absolute Constant score was 37 points: pain 10 pts, activity 9 pts, motion 14 pts, force 4 pts. Mean Swanson score at last follow-up was 19 points. Mean active anteflexion was 69 degrees, active abduction was 63 degrees and passive external rotation was 29 degrees. A satisfactory deltoid lever arm had been achieved compensating the glenoid wear by a greater lateral displacement of the humerus. At last follow-up, there were no cases of humeral loosening but three cases with important glenoid wear were observed after two years. Comparing the results obtained using small cups (40 and 44) with arthroplasties using large cups (48 and 52) showed a trend favoring small cups: Constant score 43 vs 32 points, Swanson score 21 versus 17 points, anteflexion 72 degrees versus 66 degrees and passive external rotation 34 degrees versus 26 degrees. DISCUSSION: Our results confirmed the efficacy of bipolar arthroplasty for pain relief, but the mobility outcome was less than satisfactory, excepting passive external rotation. It would appear to be preferable to use small cups. Comparing our results with data in the literature, particularly the better results for mobility using simple humeral prostheses, suggests that the principles of shoulder and hip arthroplasty concern different mechanisms: a sufficient deltoid lever arm must be achieved, but without overstretching the periarticular soft tissue (capsule, subcapsule, teres minor), and using a cup size close to the size of the healthy humeral head. Glenoid reaming should not be reserved only for asymmetrical glenoid wear in the horizontal plane. CONCLUSION: Our results suggest that bipolar arthroplasty for excentered osteoarthritis of the glenoid cavity is indicated for: stiffness in external rotation, major concentric wear in patients under 65 years of age, or asymmetric glenoid wear.

The posterolateral portal: A new approach for shoulder arthroscopy.

Since the beginning of shoulder arthroscopy, many different approaches were described for Bankart repair to allow visualization and treatment. The anterior portals do not allow access to the posterior and inferior part of the glenoid. We present a new instrumental portal for shoulder arthroscopy. This approach is perfectly safe, without any anatomic risk. It is particularly helpful in the correct treatment of an anterior Bankart lesion, in repairing posterior and inferior extensions of a Bankart lesion, and in performing a plication in multidirectional hyperlaxity.

[GUEPAR total elbow prosthesis in rheumatoid arthritis. A multicentric retrospective study of 38 cases with an average 4-year follow-up]. / La prothèse totale de coude GUEPAR dans l'arthrite rhumatoïde. Etude multicentrique rétrospective de 38 cas avec un recul moyen de quartre ans.

PURPOSE OF THE STUDY: We conducted a multicentric retrospective analysis of outcome after implantation of 38 GUEPAR elbow prostheses in 36 patients with rheumatoid polyarthritis. MATERIAL AND METHODS: The GUEPAR elbow prosthesis is an anatomic prosthesis developed in 1985 by the Groupe pour l'Utilisation et l'Etude des Prothèses Articulaires (GUEPAR). The recommended surgical technique is described. Patients included in this series had moderate to severe persistent elbow pain. Preoperative motion was 113 degrees flexion with a mean 41 degrees extension deficit. The mean global Mayo Clinic score was 32/100; clinically, the overall assessment was poor in 8 and mediocre in 30. Radiographically there were 16 grade III, 16 grade IV and 4 grade V elbows in the Larsen classification. Two cases were arthroplasty revisions. RESULTS: All patients were seen at a mean 47.6 months follow-up (12 to 97 months). There were two early failures (1 infection and 1 instability) leading to ablation of the prosthesis. Results were analyzed for the 36 remaining arthroplasties. Total pain relief was achieved in 18 cases with only occasional pain in 17 others. Postoperative motion was 132 degrees flexion with a 30 degrees extension deficit, giving a mean 30 degrees gain. The global Mayo Clinic score was 85/100 with 32 excellent, 3 good and 1 mediocre results. Radiography revealed 2 cases of loosening of the humeral component and 1 bipolar loosening that had not required revision at last follow-up. Prosthetic instability was the most frequent among the early and late complications. DISCUSSION: Total elbow arthroplasty is a useful therapeutic option among the treatments proposed (including chemical or isotopic synoviothesis, synovectomy, arthroplastic resection) for rheumatoid elbows. It is indicated for Larsen grades III, IV and V and provides good functional outcome and nearly constant pain relief with an amplitude greater than the 100 degrees, generally accepted as functionally useful. In light of our experience we propose certain modifications of the current GUEPAR implant: adjunction of a condylar extension to the humeral component in order to reduce rotation stress and thus avoid humeral loosening and a radial head element to limit the risk of instability.

[Infection of a total knee prosthesis revealed by an abscess of the posterior leg compartment. A case report]. / Infection d'une prothèse totale de genou révélée par un abcès de la loge postérieure de jambe. A propos d'un cas.

We report a case of infection of a non-cemented total knee prosthesis that led to abscess formation in the posterior compartment of the leg. This case illustrates the deleterious effect of screws used to fix the non-cemented articular surface of the tibia. Infection, like osteolysis due to polyethylene granuloma, can develop along the screw tract and reach the posterior compartment, especially when the screw protrudes through the posterior cortical of the tibia. Diffusion of an intra-articular event into the posterior compartment should be suspected in patients with a total knee prosthesis who experience calf pain.

[Transfer of the clavicular portion of the pectoralis major muscle in the treatment of irreparable tears of the subscapularis muscle]. / Le lambeau du chef claviculaire du grand pectoral dans les ruptures irréparables du subscapulaire.

PURPOSE OF THE STUDY: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome. MATERIAL AND METHODS: Five patients, mean age 54 years (45-71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range=8.5-54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber's lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6-42 months) for clinical and radiological assessment. RESULTS: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean=50, range=30-63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis. DISCUSSION AND CONCLUSION: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration.