Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis?

INTRODUCTION: When suture of the torn subscapularis could not be performed, a superior trapezius transfer was used for repair of the tendinous defect. The aim of this article is to report the mid-term functional and radiographic outcome of this technique when complete watertight rotator cuff healings were achieved and to investigate the usefulness of the trapezius transfer. The hypothesis of this work was that the trapezius transfer could not be considered as a useful treatment option. MATERIALS: The study included 20 shoulders demonstrating watertight healing of the rotator cuff on arthro CT-scan control performed 13.5 months after open surgery consisting of a trapezius transfer and suture of all other torn tendons. The mean age at surgery was 58.4 years. The trapezius transfer operative technique is described. METHODS: The functional status of the shoulders was assessed preoperatively and at a mean follow-up of 30 months according to the non-weighted Constant score and by measurement of active external rotation, arm at the side. Radiographic and CT-scan assessments were performed preoperatively and at a mean follow-up of 28.5 months. The functional results obtained at last follow-up were compared with those "theoretically estimated" after anatomically successful suture of the torn supra and infraspinatous without associated repair of the torn subscapularis. RESULTS: Between the pre- and postoperative periods, pain, daily activities and Constant score had all statistically improved. Arthritis was not aggravated but the preoperative anterior subluxation of the humeral head persisted in most cases. The reported Constant scores correlated those "theoretically estimated" in case of non-associated subscapularis repair. DISCUSSION: This series is comparable to those evaluating the pectoralis major transfer technique and reports an identical functional outcome. CONCLUSION: Since the Constant scores obtained after trapezius transfer correlate those estimated when not combining a subscapularis repair and taking into account the very frequent lack of improvement regarding the preoperative anterior subluxation of the humeral head, the trapezius transfer does not appear as a recommendable treatment option.

Acromio humeral distance less than six millimeter: its meaning in full-thickness rotator cuff tear.

UNLABELLED: The present study sought to identify full-thickness rotator cuff tears liable to induce an acromiohumeral distance (AHD) of less than 6 mm. The hypothesis was that, less than 6mm AHD is found exclusively in association with total full-thickness infraspinatus tear. MATERIALS: A continuous single-center series recruited 109 shoulders, free of glenohumeral osteoarthritis, presenting with full-thickness tear requiring surgery. Preoperative acromiohumeral distance, rupture location and extension on the various tendons and muscular fatty degeneration (FD) were known. METHODS: Full-thickness tears were categorized by location and extension on the various tendons. For each group, the number of shoulders showing AHD<6 mm was determined. RESULTS: Total full-thickness infraspinatus tears were almost the only tendon lesions able to induce AHD<6 mm, but this only when the infraspinatus muscle showed FD equal to or greater than 2.25: i.e., when the tear was longstanding. DISCUSSION: Unlike previous reports, the present study took account of the total or partial nature of infraspinatus and subscapularis tendon tear. The findings may suggest that AHD<6 mm is induced by posterior migration of the humeral head secondary to longstanding total infraspinatus tear, reducing AHD projection height on X-ray. CONCLUSION: AHD<6 mm is a sign of rotator-cuff rupture almost systematically involving longstanding total infraspinatus tear, not always amenable to suture repair due to advanced fatty degeneration. AHD equal to or greater than 6mm is of no diagnostic relevance and in no way indicates whether there is subscapularis tear and, if so, whether suture repair is feasible.

Intermediate term functional outcome prediction following full thickness rotator cuff tear reparative or not reparative surgery.

UNLABELLED: Although simple suturing repair of a full thickness cuff tear can be performed when the preoperative fatty degeneration index (FDI) is 2 or less, it is not known if the functional results will be better than palliative surgical treatment. The aim of this study is to describe and validate a method to predict the intermediate term unweighted Constant scores of different surgical treatments based on preoperative FDI. The hypothesis of this study is that the preoperative and final follow-up ratios FDI/final follow-up Constant scores regression lines, established on a previous "reference study"[5] (a series of 29 shoulders with cuff tears and sutured intact rotator cuff), could be used for this purpose. MATERIAL: The present study included seven series of sutured cuffs (five, which resulted in intact cuffs and two in recurrent tears) and one series of cuffs treated with palliative surgery. Knowledge of the preoperative FDI and the location of the recurrent or unrepaired tears were required criteria for these series inclusion in the study. METHOD: For each of the series in this study the Constant scores and selected score items were compared to scores calculated with the same mathematical formulas previously used to determine the regression lines in the reference study series (resulting in Constant scores in relation to preoperative and final follow-up FDI). RESULTS: The calculated Constant scores were similar to those reported by the authors, which validate the proposed method. DISCUSSION: Because of the small size of the series of sutured cuffs with recurrent tears and of cuffs that underwent palliative surgery and arthroscopic treatment it is impossible to definitely confirm the validity of this method. CONCLUSION: The intermediate term results of different surgical treatments can reasonably be predicted for full thickness tendon tears based on the preoperative FDI and the location of these tears. With this method the best treatment should be chosen for a rotator cuff tear on a case-by-case basis. LEVEL OF EVIDENCE: Level IV.

How repaired rotator cuff function influences Constant scoring.

UNLABELLED: The function level influence of an intact rotator cuff on the unweighted Constant score and its corresponding items is unknown. The aim of this study was to evaluate this contribution. The hypothesis was that the shoulder muscles other than the rotator cuff ones ensure a "basic" shoulder function level that is improved by the rotator cuff depending on its fatty degeneration index (FDI) MATERIAL AND METHODS: This study was based on a continuous series of 29 non-osteoarthritic shoulders whose sutured rotator cuff tears remained intact after 9 years of follow-up. The preoperative FDI was 0.9 (0-2) and 1.26 (0.2-2.2) at the final follow-up. The Constant score was 76.85 at the final follow-up (range 42-93). There was a strong negative correlation between preoperative and follow-up FDI's and all the Constant scores at the final follow-up. Linear regression analysis was performed. The two linear regression lines were superimposed. RESULTS: For a given FDI value, all Constant scores were lower when linear regression was based on preoperative FDI scores that included postoperative deterioration of the FDI. The two linear regression lines converged as the FDI increased and intersected at an FDI of 2.25. Thus, the impact of intact repaired rotator cuff function was null when the FDI was above 2.25, leaving other shoulder muscles (including the deltoid), to ensure "basic" shoulder function at a Constant score of approximately 62 points. DISCUSSION: The "basic" shoulder function found in this study is supported by the similar Constant scores found in reverse shoulder prostheses, and in painless shoulders with full thickness rotator cuff tears. CONCLUSION: The deltoid and the shoulder muscles other than the rotator cuff seem to be responsible for "basic" shoulder function and represent 60% of the unweighted Constant score. The lower the FDI, the more the function of an intact repaired cuff improves this "basic" function level. LEVEL OF EVIDENCE: Level IV.

Transsupraspinatus arthrotomy through an enlarged transacromial approach for total shoulder replacement.

The authors describe a step-by-step technique for anatomic total shoulder arthroplasty using transsupraspinatus arthrotomy via the enlarged transacromial approach. This technique seems ideal to ensure adequate postoperative tensional balance of the infraspinatus and the subscapularis, which is critical for the rotator cuffs to function properly and to achieve optimal arthroplasty stability. Reviewing these different steps helps understanding each rotator cuff individual component's contribution to achieve optimal arthroplasty stability.

[Reproducibility of whole lower limb X-rays made in supine position after total knee replacement: comparison with reproducibility of whole lower limb X-rays of normal knees]. / Reproductibilité des gonométries en position couchée après implantation d'une prothèse totale de genou. Comparaison avec la reproductibilité des gonométries des genoux non prothésés.

PURPOSE OF THE STUDY: Outcomes after total knee replacement are correlated with the postoperative HKA angle. Therefore, it seems crucial to determine the precision of the whole lower limb X-rays which are currently used to determine the frontal knee alignment. The aim of the study was to analyze the precision of the whole lower limb X-Rays made in supine position, after total knee replacement. MATERIAL AND METHOD: A prospective study included 100 knees which were analyzed with two whole lower limb X-rays made at eight days interval. Seventy knees were non-replaced and 30 had total replacement with a posterior stabilized knee prosthesis. The X-rays were made in supine position and neutral rotation using the patella as a reference mark. One independent observer compared the HKA angle on the two consecutive X-Rays in order to evaluate the reproducibility of the X-Rays. RESULTS: In the group of patients with total knee replacement, the reproducibility was poor with a low correlation coefficient (0.5) and a poor precision of 5 degrees . On the contrary, in the non-replaced knee group, the reproducibility was very good with a high correlation factor between the two X-rays (0.99, p<0.0001) and a very good precision of 1.7 degrees (p<0.05). The group of patients with an HKA angle of less than 8 degrees had a significantly better precision (1.5 degrees ) than the group of patients with an angle HKA above 8 degrees (3 degrees , p<0.04). CONCLUSION: Reproducibility and precision of whole lower limb X-rays made in supine position is poor in patients with total knee replacement. Thus, we should be very careful for the analysis of the influence of the mechanical axis on the outcomes after total knee replacement.

[Total knee arthroplasty with bicruciate preservation: Comparison versus the same posterostabilized design at eight years follow-up]. / Prothèse totale de genou Hermès conservant les deux ligaments croisés : comparaison avec la version postérostabilisée au recul de huit ans.

PURPOSE OF THE STUDY: The purpose of this study was to determine the functional, clinical and radiographic results obtained with total knee arthroplasty (TKA) preserving both cruciate ligaments using the Hermès prosthesis with a fixed plateau. Mid-term results at eight years mean follow-up were compared with the outcome achieved at the same follow-up with posterior-stabilized (PS) Hermès TKA with a fixed bearing. MATERIAL AND METHODS: The results of a continuous series of 41 TKA with bicruciate preservation implanted between 1991 and 1994 with and extra-articular distractor were analyzed at one and eight years follow-up using the IKS scores and radiographic findings. A change in the medial femoral and tibial angles greater than 2 degrees was considered to indicate implant loosening. Results were compared with those of a continuous series of TKA with PS knees implanted during the same period without a distractor and with independent bone cuts. The patients and operated knees were not different between the two groups: femoral and tibial implants were cemented in the large majority of knees with press-fit metal-backed patellar implants and comparable postoperative alignment (179 degrees ). RESULTS: The knees with the TKA bicruciate preservation were painful (37.6%) and exhibited limited mobility (106 degrees ) from the first postoperative year, but the function score was good (80.8 points). Four tibial implants exhibited varus displacement greater than 2 degrees (mean 6.5 degrees ) and six femoropatellar changes were noted (five with lateral displacement of the patella on a non-cemented patellar implant). The knees with a posterior-stabilized TKA were almost all pain-free (44.3 points) and exhibited better range of motion (113.8 degrees ). Among the PS designs, there was the same number of tibial loosenings which were favored, as for the bicruciate preservation TKA, by excessive frontal laxity in extension at one year. Femoropatellar modifications appeared to be less common with the posterior PS knees (one event). There was no measurable polyethylene wear. DISCUSSION: The good clinical and radiological results obtained by Cloutier, who used the same distractor for the same TKA implants with bicruciate preservation, suggest that the less favourable clinical results and the radiographic modifications of the patellofemoral component, which were more frequent in our bicruciate preserved implants, can be explained by an inadequate use of the distractor. By creating greater ligament tension (which we attempted to achieve), the independent bone cuts do not allow perfect respect of the dynamics of the cruciate ligaments compromising the frontal femoropatellar mechanics. CONCLUSION: The risk of prosthetic loosening is not greater with TKA bicruciate sparing designs than with PS knees when the postoperative frontal laxity and the frontal realignment are satisfactory. They enabled better function but greater operative precision is required to achieve pain-free knees with a good range of motion.

Tension-free cuff repairs with excision of macroscopic tendon lesions and muscular advancement: results in a prospective series with limited fatty muscular degeneration.

Recurrent tears after rotator cuff repairs are frequent. These could be influenced by excessive tension on a degenerated tendinous stump and by fatty degeneration of the cuff muscles. The goal of this study was to evaluate the anatomic and functional results of tension-free cuff repairs with the excision of macroscopic tendon lesions in a series with limited muscular fatty degeneration of the infraspinatus and a global fatty degeneration index of rotator cuff muscles equal to or lower than 2. We studied 27 tears, comprising 13 cases involving both supraspinatus and infraspinatus tears, 13 cases with 3-tendon tears, and 1 case with only a supraspinatus tear. All shoulders were operated on through a transacromial approach easily repaired with 2 titanium screws with washers. To obtain a repair without tension, a single advancement was performed in 20 cases and a double advancement of both the supraspinatus and infraspinatus was done in 7 cases. The shoulders were evaluated clinically preoperatively and postoperatively with the non-weighted Constant score and anatomically with computed arthrotomography scans. The mean age at operation was 59.5 years, and the length of follow-up ranged from 1 to 4 years. Of the cuffs, 23 (85%) were watertight 1 year after surgery. No predictive factor of retear could be found. The functional improvement was statistically significant only for watertight cuffs, with an improvement of the Constant score from 57.8 to 75. The only predictive factor of functional outcome in this watertight group was the preoperative Constant score. Single and double advancements yielded similar functional results regardless of the extent of the initial tear, provided that the cuff was watertight at revision.

[Histological lesions of supraspinatus tendons in full thickness tears of the rotator cuff]. / Les lésions histologiques des tendons des supraspinatus dans les ruptures transfixiantes de la coiffe des rotateurs.

PURPOSE OF THE STUDY: Iterative tears after simple tendon bone suture of transfixiant ruptures of the rotator cuff are frequent. The frequency of iterative ruptures had seemed to be correlated to the importance of the preoperative fatty degenerations of the cuff muscles. But fatty degeneration cannot account for iterative ruptures occurring with no or little preoperative muscle fatty degeneration. The authors have tried to know if iterative ruptures could also be accounted for by the presence on repaired tendinous stumps of histological lesions which are known to lower their mechanical quality, and if such was the case, they have tried to know what could be the impact of these lesions on the repairing technique by suturing cuff ruptures. MATERIAL AND METHOD: Thirty-two distal stumps of ruptured supraspinatus, resected on more than 1 cm to eliminate macroscopic tendinous lesions (thin, lacerated, cleaved, hardened or whitish tendons) and to reach a new stump, slightly bleeding and thick enough to hold the stitches correctly, have been studied on longitudinal histological slides. RESULTS: All the tendinous resected stumps had histological anomalies: dilacerations lesions of the conjunctive tissue, fatty infiltrations, necrosis, scar lesions and micro calcifications were found. The histological lesions were often associated. The histological lesions were an average 4 mm shorter than those of the tendinous resection. In 18 cases however the whole of the resected tendon was histologically abnormal. DISCUSSION: Tendinous histological lesions found on the whole or almost the whole length of the macroscopically abnormal tendinous stumps diminish the mechanical quality of the tendons. Insufficient resection of the tendinous stumps leaving macroscopical lesions and therefore histological lesions could account for iterative ruptures in the first post operative year. Yet complete resection of the macroscopically abnormal tendinous stump does not entail that the neo tendinous stump to be repaired is histologically normal. This encourages to put the stitches well within the zone of the tendinous resection and to bury the tendinous stumps into a highly vascular bony trough. But tendinous resection although logical from the histological and mechanical point of view widens the rupture of the cuff to be repaired. It can make sutures under tension, which can entail iterative ruptures. Musculo-tendinoplasty appears then necessary to perform sutures without tension. CONCLUSION: Histological lesions of tendinous stumps of cuff ruptures correspond roughly to tendinous macroscopic lesions. They could be at the origin of iterative ruptures that take place after simple tendon-bone sutures of ruptured cuffs which are not accounted for by muscular fatty degeneration. They could also partly account for iterative ruptures taking place when pre operative fatty degeneration is evident. It seems logical to resect macroscopically abnormal tendinous stumps before performing a suture. But the tendon-bone suture without tension is then often possible only with musculo-tendinoplasties.