Analysis of four-fragment fractures of the proximal humerus: the interest of 2D and 3D imagery and inter- and intra-observer reproducibility.

The treatment of the four-part fractures of the proximal humerus remains a therapeutic challenge. The decision-making is based on preoperative criteria concerning the displacement of the fracture, the stability of the fracture and the risk of avascular necrosis of the humeral head. The aim of this study was to analyse the inter- and intra-observer reproducibility of those criteria previously described by Hertel. Three observers analysed three times 20 radiologic files comprising 2D X-rays, 2D CT scan and 3D reconstructions for the intra-observer study, and an expert committee was used to assess the inter-observer reproducibility. The Kappa coefficient was used to measure agreement. The Kappa coefficient founded poor to moderate agreement for the majority of the criteria after the 2D X-ray analysis. This coefficient was improved with the use of 2D CT scan and 3D reconstructions, in particular for the medial hinge assessment, the humeral head fracture and the metaphyseal extension. The reproducibility of the criteria described by Hertel on 2D X-rays is at least moderate. Reproducibility could be considerably improved by associating 2D scans and 3D reconstruction, in particular for the criteria related to prognosis for the vascularisation of the humeral head.

Transcultural validation of the Oxford Shoulder Score for the French-speaking population.

PURPOSE: Patient-reported outcome measures (PROMs) have been gaining in popularity over the last decade. The Oxford Shoulder Score (OSS) is a well-established self-administered questionnaire for shoulder evaluation adapted for the English-speaking population. The aim of the present study was to develop a translation and a transcultural adaptation of the OSS and to assess its validity in native French-speaker patients with shoulder pain. METHODS: The translation process was carried out following a translation/back-translation methodology by two translators. All patients completed the French OSS, the Subjective Shoulder Value (SSV), and the Constant score. Internal consistency was tested using Cronbach's α coefficient. Validity was assessed by calculating the Pearson correlation coefficient between the OSS and the Constant score and the SSV. RESULTS: One hundred forty-four patients suffering from degenerative or inflammatory diseases of the shoulder were included in this study. The average time required to complete the French OSS was 2min and 45s. Seventy patients were asked to complete the questionnaire twice (test/retest reliability). Internal consistency was high with Cronbach's α coefficient=0.93. The intraclass correlation coefficient was 0.91 (95% CI: 0.88-0.94) for test/retest reliability. The French OSS score was significantly correlated with the Constant-Murley score (r=0.73 and P<0.0001) and with the SSV (r=0.68 and P<0.0001). CONCLUSIONS: The present study shows that the French version of the OSS is reliable, valid, and reproducible. The sensitivity to change now needs to be evaluated. This score was adapted to the French-speaking population for the self-assessment of patients with degenerative or inflammatory disorders of the shoulder. LEVEL OF EVIDENCE: Level 1, Test of previously developed criteria, diagnostic test study.

[Post-traumatic mucormycosis due to Lichtheimia corymbifera: three case reports]. / Mucormycoses post-traumatiques à Lichtheimia corymbifera: à propos de 3 cas.

We report 3 cases of post-traumatic cutaneous mucormycosis caused by Lichtheimia corymbifera, two of them occurring after a farm working accident. Management of post-traumatic mucormycoses consists of a wide excision of the infected tissue, combined with immediate antifungal therapy. Liposomal amphotericin B is the recommended first line treatment. Few studies have evaluated the efficacy of posaconazole. All 3 patients received a surgical debridement and liposomal amphotericin B, which was followed by posaconazole in 2 cases. The duration of the antifungal treatment is not yet well defined. All three patients received a treatment of five weeks with a favorable outcome.

Primary shoulder reverse arthroplasty: surgical technique.

Total reverse shoulder replacement is now a very common surgical procedure that has been shown to be effective in the treatment of rotator cuff tear arthropathies or massive rotator cuff tears with pseudo paralysis, even without arthritis. However, the survival curves of the oldest series decrease between 8 and 10 years after arthroplasty (events: implant survival, or worsening of clinical outcome) which explains why the indication for this type of arthroplasty is usually limited to patients over seventy. Moreover, details and technical modifications have been suggested to improve the surgical technique, the quality of fixation and the mechanical conditions of this non-anatomical prosthesis to improve clinical outcome and implant survival. Within the framework of primary surgery, excluding traumatic or revision surgery, the primary indications for this option are massive rotator cuff tears with (or without) osteoarthritis and primary osteoarthritis with rotator cuff tears and/or with severe glenoid wear and finally, rheumatoid arthritis. The purpose of this conference was to assess and describe the most important preoperative criteria and surgical conditions necessary for this procedure as well as specific technical details about the surgical procedure itself based on available options and options under evaluation such as the positioning of the glenoid component (lateralization, bone graft, orientation) and the association of muscle transfers.

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).

Shoulder hemi arthroplasty radiological and clinical outcomes at more than two years follow-up.

INTRODUCTION: Humeral head replacement is used for glenohumeral osteoarthritis in young or active patients, for conditions sparing glenoid cartilage or when glenoid implantation does not appear feasible. These surgical procedures usually give satisfactory results but there is a risk of glenoid erosion and a possible deterioration of long-term outcomes. HYPOTHESIS: There is a risk of glenoid erosion after humeral head replacement which can be radiographically measured. The importance and progression of this erosion should be evaluated to determine its clinical relevance. PATIENT AND METHODS: This is a retrospective study in 15 patients (19 shoulders) who underwent humeral head replacement between 1999 and 2006. There were 11 women and four men with an average age of 54.5 years. Etiologies were avascular necrosis (11 cases) and glenohumeral osteoarthritis (eight cases). All patients were reviewed in 2008 with more than two years follow-up. Clinical evaluation included measurements of range of motion and determination of the Constant and Murley score. In addition, the patients were asked to provide a subjective evaluation of their shoulder. Radiographic analysis included computer-assisted measurements. RESULTS: The average follow-up was 45.8 months (26-108). At one year postoperative and at the final follow-up, clinical parameters such as the Constant and Murley score (37.4/100 preoperative to 64.4/100 at final follow-up) were significantly increased. During the first year, the rate of glenoid wear was 1.03 mm/year in case of avascular necrosis and 0.27 mm/year in case of osteoarthritis (p<0.001). Glenoid depth at the final follow-up was 6.97 mm for osteoarthritis compared to 4.59 mm for avascular necrosis (p<0.01). We did not find any correlation between glenoid erosion severity and clinical results. DISCUSSION: Isolated humeral head replacement may result in glenoid erosion. The rate of progression of this erosion is clearly influenced by the etiology and therefore by the preexisting condition of the glenoid cartilage. At the average follow-up, the radiological glenoid deterioration is not correlated with pain or deterioration of clinical results. LEVEL OF EVIDENCE: Level IV. Therapeutic study.

Esophageal perforation after fracture of the cervical spine: case report and review of the literature.

We present a posttraumatic esophageal tear that occurred in a 55-year old patient after a truck accident. He sustained a two-level injury with a type II odontoid fracture and a unilateral fracture of the left superior articular process of C6 with an incomplete quadriplegia at C5. Both lesions were treated nonoperatively. The tear was attributed to the stretching of the esophagus over anterior degenerative spurs at the level of the lesion (C5-C6) during hyperextension. The diagnosis of the esophageal perforation was delayed for 6 days. The treatment consisted of surgical debridement, volume expansion, antibiotic therapy, hyperbaric oxygenation, assisted ventilation, and esophageal exclusion. A complete review of the literature was performed.

[Rotator cuff ruptures with predominant involvement of the subscapular tendon]. / Ruptures de la coiffe des rotateurs avec atteinte prédominante du sous-scapulaire.

Among the all rotator cuff tears, the subscapularis lesions are quite rare. But a careful analysis leads to recognize them specially in case of antero-medial impingement between the coracoid process and the head of the humerus. This study of 25 observations where the rupture of the subscapularis was the predominant lesion, allows to emphasize some characteristics of them. The patients are often younger than for the other ruptures, a traumatic experience is not rare at the beginning of the history, the pain is usually the first symptom before the functional disability, the alterations of the rotator-interval and of the biceps tendon are very frequent, the arthroscanner is a very good help for the diagnosis and satisfying stitches are possible in case of early diagnoses. Lastly, the prognosis of these limited lesions is quite different than the one of very large cuff tears including the suscapularis tendon.