Reproducibility and reliability of subscapularis tendon assessment using CT-arthrography.

BACKGROUND: Computed tomography (CT) coupled with arthrography remains the reference standard for the preoperative evaluation of rotator cuff tears. The objectives of this study were to evaluate intra-observer and inter-observer reproducibilities of CT-arthrographic assessment of the subscapularis tendon and to assess the validity and reliability of this investigation. HYPOTHESIS: CT-arthrography is reliable and reproducible for the preoperative characterisation of subscapularis tendon lesions. MATERIAL AND METHODS: We retrospectively reviewed 67 shoulders with rotator cuff tears in one or more tendons managed by arthroscopy, both to confirm the diagnosis and to allow therapeutic interventions. Each of the 67 preoperative CT-arthrograms was evaluated by three readers, of whom the first two evaluated the images twice at an interval of 30 days. The following were recorded at each reading: partial- or full-thickness tear in one or more rotator cuff tendons, intra-tendinous delamination, tendon stump retraction, and fatty degeneration of the muscles. The position of the long head of biceps tendon was assessed. A statistical analysis was performed using Fleiss' method to compute intra-observer and inter-observer variabilities in CT-arthrography assessment of the subscapularis tendon status. Validity of this assessment was measured by computing the concordance coefficients between CT-arthrography and arthroscopy. RESULTS: Specificity of CT-arthrography was satisfactory for assessing the subscapularis tendon. Sensitivity was low. Significant inter-observer and intra-observer variabilities were documented. The concordance coefficients between CT-arthrography and arthroscopy indicated that major differences were common with all three readers. When assessing the subscapularis tendon by CT-arthrography, all readers experienced difficulties in distinguishing intact tendons, delaminated tendons, and tendons with tears confined to the upper third. DISCUSSION: Although CT-arthrography remains the reference standard for the preoperative investigation of rotator cuff tears, significant variability occurs in assessing the continuity of the subscapularis tendon. Reliability of this assessment is not optimal, as shown by our evaluation of concordance with arthroscopy. Although our data should be interpreted in the light of the investigation and measurement biases present in our study, they suggest that CT-arthrography may fail to provide a valid and reproducible assessment of the subscapularis tendon. The development of magnetic resonance (MR) imaging and MR-arthrography will probably improve the preoperative evaluation of subscapularis tears in the near future. LEVEL OF EVIDENCE: Level III; diagnostic value study.

Acute grade III and IV acromioclavicular dislocations: outcomes and pitfalls of reconstruction procedures using a synthetic ligament.

INTRODUCTION: Acromioclavicular dislocation (ACD) is frequent, at 8% of all shoulder traumas. Management in grade III lesions remains controversial. The present study assessed objective and subjective results at medium-term follow-up (mean, 60 months; range, 12-120 mo) in 27 patients managed by Ligastic(®) ligament reconstruction for acute dislocation. PATIENTS AND METHODS: This is a multicenter, multi-surgeon retrospective study. Between 1998 and 2006, 59 patients were operated on for grade III or IV ACD, in one teaching hospital (Lille, France) and one general hospital (Tourcoing, France). Follow-up was performed by an independent (non-operator) observer. The 27 acute cases followed up underwent comparative bilateral radioclinical shoulder examination. Initial X-ray assessment found 14 grade-III (52%) and 13 grade-IV (48%) dislocations using Patte's classification. RESULTS: Mean Constant score was significantly lower on the operated side (82.44 vs 90.04; p<0.05). Specific strength analysis, on the other hand, showed no significant difference with the contralateral shoulder. Coracoclavicular distance was significantly greater on the operated side (p<0.05), with and without traction. Periprosthetic osteolysis was found in 24% of cases, and seemed to worsen over follow-up. There were no cases of fracture on osteolysis. There were no cases of sepsis or of implant intolerance. Four patients, however, required surgical revision. CONCLUSION: In light of literature findings and our own experience, surgery is not to be recommended in grade-III ACD, and the authors have given up use of this device in this group due to the rate of associated osteolysis. LEVEL OF EVIDENCE: Level IV.

Anterior tarsectomy long-term results in adult pes cavus.

PURPOSE OF THE STUDY: Anterior tarsectomy for pes cavus in adults is designed to relieve pain and correct the deformity. The present study reports radiological and clinical results with anterior tarsectomy in 39 cases of pes cavus. MATERIAL AND METHODS: The study concerned 39 cavus feet in 33 patients (22 males, 11 females; mean age: 31 years, range 16-49 years). Clinical outcome was assessed in terms of pain, function and motion, using the AOFAS classification. Radiological assessment (anteroposterior and lateral stress X-ray, views with Méary superficial wire-marking) measured the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints. RESULTS: Mean follow-up was 9.8 years (range, 1-25). Mean AOFAS score at follow-up was 69.2/100 points (range, 14-100). Pain decreased considerably in 75% of cases, and 68% of patients recovered normal activity. The foot was aligned correctly in 67% of cases. At last follow-up, pes cavus remained undercorrected in 80% of feet, but mean Djian angle had improved from 100 degrees to 111.3 degrees. Calcaneal valgus improved from 30.8 degrees to 24.8 degrees and the podoscopic footprint was normal in 51% of feet. In 74% of feet, adjacent joints presented progressive osteoarthritic degeneration. Subjectively, 70% of patients were very satisfied or satisfied with minor reservations. Objective outcome was excellent or good in 66% of feet. DISCUSSION AND CONCLUSION: Outcome in terms of function, motion, complications and satisfaction was good, although pain relief results were poor. Anterior tarsectomy is able to correct initial pes cavus deformity and compensate anomalies of the hindfoot, but its correction capacity is limited, and its efficacy in case of clawfoot is poor. Anterior tarsectomy spares the adjacent Chopart complex and Lisfranc joints while inducing hypermobility, and leads to arthritis in 74% of cases. Better results are obtained in cases of reestablishment of the Méary-Tomeno line and of hindfoot valgus, as well as in cases of correction of equinus and clawfoot deformities. Worse results are observed in case of neurological evolutive disease or insufficient correction of the preceding deformities. LEVEL OF EVIDENCE: Level IV. Therapeutic Study.

[Long-term results of midtarsal arthrodesis for flatfoot in adults]. / Résultats à long terme du traitement du pied plat valgus de l'adulte par arthrodèse médiotarsienne.

PURPOSE OF THE STUDY: Arthrodesis proposed for the surgical treatment of reducible pes planovalgus (flatfoot) in adults is designed to relieve pain and correct the deformity. The purpose of this work was to present the radiological and clinical results obtained with midtarsal arthrodesis performed in 22 cases of pes planovalgus. MATERIAL AND METHODS: This study concerned 22 cases of reducible flatfoot (Johnson grade 2) in 19 patients (11 males, 8 females, mean age 43 years, age range 15-75 years). Clinical outcome was assessed in terms of pain, function and motion using the AOFAS and Mann classifications. Radiological assessment (loaded anteroposterior and lateral views with Méary cerclage) noted the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints. RESULTS: Mean follow-up was 7 years 4 months (range 6 months-20 years 3 months). Two nonunions resolved favorable after cancellous grafting. The Kitaoka score was 73.5/100 points (range 53-94). Pain and function improved from 2.8 to 1.1 points (/4 points) and from 3.45 to 1.6 points (/4) on the Mann scale. Flexion-extension remained unchanged. The foot was aligned correctly in 68% of cases. The mean talar slope and the talocalcaneal divergence were normal at last follow-up but there was a persistent undercorrection of the Djian angle in 68% of the feet and a break in the Méary line in 41%. Calcaneal valgus was reduced 6.6 degrees (16.6 to 10 degrees ) but the podoscope footprint was still the flatfoot type in 86% of the feet. For 50%, the neighboring joints presented progressive osteoarthritic degeneration. Subjectively the patients were very satisfied or satisfied with minor reservations for 73%. None of the patients was disappointed with the results. The objective outcome was excellent or good in 68% of the feet. DISCUSSION AND CONCLUSION: The results in terms of pain relief, function, motion, complications, and rate of satisfaction were comparable with results presented in the literature. Midtarsal arthrodesis provides effective pain relief and satisfactory functional recovery without creating any morbidity greater than simple talonavicular fusion. Nevertheless, it was noted that while correct alignment is achieved in the majority of cases, the clinical and radiological restoration of plantar cavum is limited. Furthermore compensatory hypermobility of the adjacent joints leads to the development of moderate osteoarthritic remodeling which remains asymptomatic more than seven years after the operation.

[Hydroxyapatite-coated Esop modular femoral stem: three to ten year outcome in 155 cases]. / La prothèse fémorale Esop revêtue d'hydroxyapatite à modularité métaphysodiaphysaire: résultats à 5 ans de recul moyen d'une cohorte de 155 implants.

PURPOSE OF THE STUDY: Primary and secondary stability of the Esop prosthesis depends exclusively on cementless metaphyseal anchoring. This modular implant is composed of an hydroxyapatite-coated metaphysis on which a diaphyseal piece is added intraoperoperatively simply to act as a centering device. The purpose of this retrospective analysis of a consecutive series was to assess primary and secondary stability of the Esop implant by measuring axial migration over time. MATERIAL AND METHODS: Between 1995 and 2001, 172 primary total hip arthroplasties (THAs) were performed with the Esop femoral implant and the Atlas III acetabular implant. Six patients lost to follow-up and eleven patients who died were excluded from the analysis. The review thus concerned 155 THA in 128 patients (66 women and 32 men), mean age 57 years (age range 28-77 years), 53% with an occupational activity at the time of surgery. Degenerative hip disease and aseptic osteonecrosis were present in 87% of patients. Imagika, a dedicated software, was used to measure axial migration and overall offset of the THA at four distinct times: on the immediate pre- and postoperative films, after introduction of weight-bearing, and at last follow-up (mean 61 months, range 35-114 months). Survival and clinical and radiographic outcome were also assessed with the Postel-Merle-d'Aubigné (PMA) score. RESULTS: THA survival was 98%, all causes of failure included. The PMA score showed 97% excellent, very good or good outcome. Axial migration greater than 5 mm was demonstrated in ten hips (6.4%). Among these ten, seven exhibited migration during the first month than did not move further up to last follow-up. Comparison between the pre- and postoperative images revealed a 10 mm reduction in offset in 38% of hips, showing that the hip rotation center was medialized. DISCUSSION: Migration observed in ten implants corresponded to restablization at weight-bearing in seven. There was no correlation with the clinical outcome or poor radiological osteointegration. CONCLUSION: Primary and secondary stabilization of the Esop implant is satisfactory. In this series, the rotation center of the hip was globally medialized so that it would be useful to have available lateralized implants.