Purpose of the study: Completely arthroscopic repair of rotator cuff tears is widely considered as the standard treatment. We reviewed a multicentric retrospective series of patients.

Material and methods: This series of arthroscopic repairs of full-thickness tears of the supraspinatus and infraspinatus were assess with the Constant score together with arthroMRI or arthroscan at one year follow-up at least. Data were analyzed with SPSS10. The series included 576 patients who underwent surgery from January 2001 to June 2003. Mean age was 57.7 years, 52% males and 60% manual laborers. Mean preoperative Constant score was 46.4/100 (r13.4). The tear was limited to the supraspinatus in 69% of patients with extension to the upper third of the infraspinagus for 23.5% and to all tendons for 7.5%. The supraspinatus tear was distal in 41.7% of patients, intermediary for 44%, and retracted for 14.3%. Arthroscopic repair was performed in all cases, with locoregional anesthesia for 60.9%. Implants were resorbable for 33% and metallic for 62.1%. Acromioplasty was performed for 92.7% and capsulotomy for 14.9%.

Results: The mean subjective outcome was scored 8.89/10. The Constant score improved from 46.3±13.4 to 82.7±10.3 with 62% of patients being strictly pain free. The force score improved from 8.5±3.7 to 13.6±5.4. Outcome was excellent or very good for 94% of the shoulders at 18.5 mean follow-up. The rate of complications was 6.2% with 3.1% of patients presenting prolonged joint stiffness, 2.7% reflex dystrophy, 0.2% infection and 0.2% implant migration. The cuff was considered normal in 55.7% of the shoulders with an intratendon addition image for 19%, i.e. 74.7% non-torn cuffs. A point leakage was noted in 9.5% with pronounced leakage in 15.7%, i.e. 25.2% recurrent tears.

Discussion and conclusion: The functional outcome obtained after arthroscopic repair of rotator cuff tears is good. Arthroscopy has the advantage of a low rate of complications yet provides good clinical and anatomic results. Age is correlated with functional outcome and healing, but should not be considered as a contraindication.

Purpose of the study: The objective of this study was to identify clinical and anatomic factors which could affect the outcome of tendon healing after arthroscopic repair of rotator cuff tears.

Material and methods: This prospective cohort study included 122 patients who underwent arthroscopic treatment between May 1999 and September 2002. One hundred twelve patients (114 shoulders) were reviewed (93.4%). Mean age at surgery was 61 years. An arthroscan (78% of patients) or magnetic resonance imaging (MRI) were performed six months postoperatively. Mean follow-up was 24 months (range 13–46 months).

Results: Rotator cuff tears healed completely in 64% of the shoulders (n=73) and partially in 7% (n=8). No healing was observed in 29% (n=33). The Constant score was 49.8 preoperatively and 82.4 at last follow-up (p< 0.0001). Cuff healing improved clinical outcome with a Constant score of 85 points versus 77, particularly for force, 14.5 points versus 10 without healing. Four factors were statistically predictive of tendon healing: duration from symptom onset to operation (24 months for healed tears versus 37 months, p< 0.05); age at cuff repair (81% healed tears in patients aged less than 50 years versus 50% for patients aged over 65 years, p< 0.002); sagittal extension of the rotator interval or extension to the upper third of the infrascapularis (45% healed tears versus 79% without anterior extension, p< 0.0001); fatty degeneration (69% of healed tears for Goutallier grade 0 versus 38% for grade 1 and 2, p< 0.01).

Conclusion: This study demonstrated that four factors can predict tendon healing: time to treatment, age at surgery, anterior extension of the tear, fatty degeneration.

Purpose of the study: Arthroscopic reinsertion of SLAP lesions is the most commonly used approach. Tenodesis of the long biceps could be proposed as an alternative to reinsertion. The purpose of our study was to report the results of tenodesis and reinsertions for the treatment of type II SLAP lesions.

Material and methods: This was a consecutive monocentric comparative series analyzed retrospectively. Isolated type II SLAP lesions treated arthroscopically were retained for study: 25 cases treated from January 2000 to May 2004. Exclusion criteria were: associated instability, associated cuff tears, history of surgery. The long biceps tendon was reinserted on the glenoid tubercle using two threads mounted on resorbable anchors in ten patients (all men), mean age 27.5 years (range 19–57 years). Tenodesis of the long biceps in the gutter was performed in fifteen patients (six women and nine men), mean age 52.2 years (range 28–64 years). All patients were reviewed by an independent observer.

Results: In the reinsertion group, mean follow-up was 35 months (range 12–57 months). Three patients had revision tenodesis due to persistent pain and three others were disappointed because they were unable to resume their former sport. Four others were very satisfied. The mean Constant score improved from 65 to 83 points. Force was 16 kg in flexion and 5 kg in supination. In the tenodesis group, mean follow-up was 34 months (range 12–56 months). There were no revision procedures in this group. Subjectively, one patient was disappointed (atypical pain), two were satisfied and 12 very satisfied. The mean Constant score improved from 59 to 89 points. Force was 14.5 kg in flexion and 4.8 kg in supination.

Discussion: This series showed that results obtained with reinsertions can be disappointing: three revisions and three disappointed patients among ten procedures. In the tenodesis group, 14 of 15 patients were satisfied or very satisfied. Tenodesis of the long head of the biceps can be considered as an alternative to reinsertion for the treatment of type II SLAP lesions, particularly in older athletes.

Purpose of the study: The current approach for improving the performance of compact bone substitutes is to seed them with selected mesenchymatous stem cells amplified and differentiated to the osteoblastic line in vitro. We hypothesized that the preservation of all these elements in the bone marrow would be most effective for bone tissue formation.

Material and methods: Subcutaneous and intramuscular implantation in C57BL/6 mice. We developed a new approach for bone tissue engineering based on an extemporaneous incorporation of total bone marrow into an injectable bone substitute (IBS2). IBS2 is a new polymerizable hydrogel associated with beads of calcium phosphate (BCP) which can be used to implant total bone marrow. A subcutaneous and intramuscular implantation model in mice was tested to analyze the feasibility of this type of graft. Total bone marrow cells from C57BL/6 male mice were seeded in IBS (10 million cells per 100 microliters). This implant was injected subcutaneously (dorsal position) and intramuscularly (left hind foot) in C57BL/6 female mice. TRAP activity was measured under optical microscopy on paraffin embedded HES stained slices at 4 and 8 weeks.

Results and discussion: Incorporation of total bone marrow cells in injectable IBS2 produced implants which were rich in mesenchymatous cells, vessels, osteo-clasts, collagen fibers, and osteoid tissue. This demonstrated the great potential of this new approach. In addition, this method is simple and can be performed in the operative room without ex vivo culture. Comparison of this model of extemporaneous cell therapy with a graft of meschymatous cells amplified ex vivo is currently under way.

Purpose of the study: A statistical analysis of correlations between clinical outcome and anatomic results after arthroscopic repair of rotator cuff tears.

Material and methods: This multicentric series of rotator cuff tears was limited to the supraspinatus and infraspinatus. The statistical analysis searched for correlations between the clinical outcome (Constant score) and anatomic results (arthroscan and arthroMRI). The series included 576 patients, mean age 57.7 years, 52%μ males and 60% manual laborers. The tear was limited to the suprapsinatus in 69% of patients, with extension to the upper third of the infraspinatus in 23.5% and all tendons in 7.5%. The supraspinatus tear was distal in 41.7% of patients, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 59.7%, 1 in 27.1%, 2 in 10.8% and 3 in 2.4%.

Results: The Constant score (46.3 preoperatively and 82.7 postoperatively) was strongly correlated with successful repair. The correlation was found for force, motion, and activity, but not for pain. The clinical outcome was correlated with extension, retraction, cleavage, and degeneration of the preoperative injury. The anatomic result was statistically less favorable for older, more extended, retracted, and cleaved tears or tears associated with fatty degeneration. Age was correlated with the extent of the initial tear and also with less favorable clinical and anatomic results. Work accidents were correlated with less favorable clinical outcome.

Discussion: The large number of anatomic controls with contrast injection facilitated demonstration of several statistically significant correlations. This enabled disclosure in a single series of evidence confirming earlier reports in the literature: repair of cuff tears improves the overall functional outcome for massive tears; the anatomic result depends on the size of the initial tear; pre-operative fatty degeneration is an important prognostic criteria; cuff healing is age-dependent.

Conclusion: Study of anatamoclinical correlations helps guide therapeutic decision making and enables the establishment of reliable prognostic criteria after arthroscopic repair of rotator cuff tears.

Purpose of the study: Depending on the series, fractures of the anteroinferior glenoid labrum have been reported in 3% to 90% of patients with anterior shoulder instability. These fractures disrupt the physiological glenoid concavity and shorten the effective length of the glenoid arch. Indications for treatment depend on the size of the fragment and range from osteosynthesis to resection or suture. We hypothesized that these lesions could be treated arthroscopically (Bankart procedure with fragment suture). The purpose of this work was to analyze clinical and radiological outcome observed in nine patients with anterior instability associated with significant glenoid fracture.

Material and methods: This was a monocentric study of a continuous series of nine glenoid fractures associated with anteromedial dislocation in nine patients (three women and six men), mean age 35.5 years (range 17–75 years). Preoperatively, all of the fractures were considered to involve more than 25% of the glenoid surface. After detaching the capsulolabral lesion with the bony fragment and avivement of the anterior border, the Bankart procedure was performed with anchors and resorbable sutures. The shoulder was strapped for six weeks with passive rehabilitation (pendulum movements) initiated early.

Results: Mean follow-up was 27 months (range 12–48 months). There were no cases of recurrent instability. Seven patients were very satisfied and two were satisfied. Eight patients were able to resume their sports activities at the same level. Apprehension developed in all patients. At last follow-up, joint motion was normal for eight of the nine patients, the Duplay score was 100 for eight patients and 45 for one. All bony lesions healed in an anatomic position (six analyzed with plain x-rays and three with CT scan).

Discussion and conclusion: This short series demonstrates that glenoid fractures can be treated arthroscopically with concomitant treatment of the capsulolabroligament complex in order to reconstruct the glenoid arch, an essential element for restoring shoulder stability. It is thus necessary to identify bony lesions preoperatively to determine the most appropriate therapeutic approach. A long-term follow-up will be useful to assess the rate of recurrent instability and validate this therapeutic option.

Introduction: The purpose of this study is to compare the radiographic results of two glenoid preparation techniques by analyzing periglenoid radiolucencies.

Material and methods: The series consists of 72 shoulder arthroplasties with primary osteoarthritis. Shoulders were divided into 2 groups based on glenoid preparation technique:

Group 1: 37 shoulders operated on between 1991 and 1995 with flat back, polyethylene glenoid implants cemented after curettage of the keel slot.

Group 2: 35 shoulders operated on between 1997 and 1999 with the same glenoid implants cemented after cancellous bone compaction of the keel slot.

At least 3 of the following 4 fluoroscopically positioned, postoperative AP radiographs were analyzed: immediate postoperative, between the 3rd and 6th months, at one year and at two years postoperative. The immediate and the two year radiograph were required for study inclusion. The radiolucent line score (RLLS) was calculated using the technique of Molé, involving the summation of radiolucencies in each of six specified zones. The RLLS was compared between the two groups.

Results: On the immediate postoperative radiographs the average of the total RLL score of the 9 analyzes was 2.39 in Group 1 and 1.67 in Group 2 (p=0.042). There was a statistically significant association between the glenoid preparation technique and the incidence of radiolucency around the keel as well (p=0.001). There was no significant difference in radiolucency behind the faceplate between the two groups (Group 1: 1.54 and Group 2: 1.41; p=0.394). On the 2-year postoperative radiographs the average RLL score of the 9 analyzes were 6.44 in the Group1 (4.05 under the tray, and 2.39 around the keel), and 4.19 in Group2 (p=0.0005) (2.86 under the tray, and 1.33 around the keel). The radiolucency around the keel and behind the faceplate (p=0.0005) was significantly more important (p=0.001) in the curettage glenoid preparation population. A significantly higher degree of progression of the total RLL score (p=0.002) and of the radiolucency behind the faceplate (p=0.001) was observed in the curettage glenoid preparation group.

Discussion/conclusion: Preparation of the glenoid component keel slot with cancellous bone compaction is radiographically superior to the curettage technique with regard to periglenoid radiolucencies.

Purpose: The purpose of this work was to evaluate the quality of cemented humeral stem fixation. We analysed the incidence and influence of humeral lucent lines and loosening after implantation of a shoulder prosthesis as a function of aetiology (fracture versus scapular osteoarthritis) and glenoid status (total versus partial humeral prosthesis).

Material and methods: This retrospective series included 1842 first-intention shoulder prostheses reviewed at mean five years (2–10). We selected patients whose initial diagnosis was fracture of the superior portion of the humerus (n=300) and centred osteoarthritis (n=767). All stems implanted for fracture were cemented. For osteoarthritis, there were 610 total prostheses and 157 simple humeral prostheses: 752 stems were cemented and 15 were implanted without cement. The Constant score and radiographic results (AP and lateral view at least) were noted.

Results: For cemented stems, the incidence of radiographic lucent lines and loosening was significantly higher in fractures (40% and 10% respectively) than in centred osteoarthritis (14% and 1%). Lucency and loosening did not influence functional outcome in patients with centred osteoarthritis but had a significantly negative effect on final outcome in fractures. For fractures, the incidence of lucent lines was correlated with migration of the tubercles. For osteoarthritis, there was no difference between total and partial prostheses in terms of loosening, but the functional outcome was significantly better with total prostheses.

Conclusion: Fixation of the humeral implant with cement remains the gold standard for shoulder prostheses implanted for centred osteoarthritis. However, cement fixation yields disappointing results for fractures: defective fixation of the humeral stem is correlated with migration of the tubercles. For osteoarthritis, there are not more lucent lines with a total prosthesis which provides the better functional results.

Purpose: The purpose of this study was to compare the bone-patellar-tendon-bone (BPTB) and the four-strand hamstring grafts for anterior cruciate ligament (ACL) reconstruction in patients aged less than 40 years and to evaluate the influence of meniscectomies performed before, during, or after the ACL reconstruction.

Material and methods: Between March 1997 and March 2000, 114 patients who underwent ACL reconstruction (58 BPTB then 56 hamstring) were included. Exclusion criteria were: peripheral ligament repair or associated bone procedures, surgical revision. The continuous series was analysed retrospectively by two surgeons different from the operator. The BTPB group included 58 patients (mean age 28 years) evaluated at a mean 44 months; meniscectomy was associated in eleven cases. The hamstring group included 56 patients (mean age 27.5 years) evaluated at a mean 28 months; there were 19 associated meniscectomies. The IKDC score and laxity (KT2000, Telos) as well as the radiological aspect (AP, lateral and 30° flexion views) were used to assess outcome.

Results: At last follow-up (89 patients, 78%) there were three failures in each group; 77% of patients were in IKDC classes A or B. Subjectively, 90% of the patients considered their knee was normal or nearly normal. For both types of grafts, the outcome was significantly better if the meniscus was preserved. For knees with preserved menisci, there was no difference between BTPB and hamstring reconstruction. Anterior pain was greater after BTPB and posterior thigh pain was greater after hamstring reconstruction. Mean deficit was 14% in extension force in the BTPB group and 25% in flexion force in the hamstring group.

Discussion: Meniscectomy before, during or after ACL reconstruction has a negative effect on the graft outcome for both techniques. If the meniscus is preserved, there is no difference between BTPB and hamstring reconstruction; the morbidities are different, but equivalent (anterior pain for BTPB and posterior for hamstring) and muscle deficit is different (extension for BTPB and flexion for hamstring).

Conclusion: More important than the type of transplant used to reconstruct the ACL, meniscal preservation is a major element affecting outcome.

Purpose: We report a new pathological entity involving the long head of the biceps tendon (LHBT). In this entity, the hypertrophic LHBT becomes incarcerated in the joint during limb elevation, leading to shoulder pain and blockage.

Material and methods: Twenty-one patients were identified. These patients presented hypertrophy of the intra-articular portion of the LHBT with tendon incarceration at limb elevation. The diagnosis was confirmed during open surgery (n=14) or arthroscopy (n=7). All cases were diagnosed in patients with an associated cuff tear. Treatment consisted in resection of the intra-articular portion of the LHBT and appropriate treatment of the cuff.

Results: All patients had anterior shoulder pain and deficient anterior flexion because of the incarcerated tendon. An intra-operative dynamic test consisted in raising the arm with the elbow extended, providing objective proof of the tendon trapped in the articulation in all cases. The positive “hour glass” test produce a fold then incarceration of the tendon between the humeral head and the glenoid cavity. Tendon resection after tenodesis (n=19) or biopolar tenotomy (n=2) yielded immediate recovery of passive complete anterior flexion. The Constant score improved from 38 points preoperatively to 76 points at last follow-up.

Discussion: The “hour glass” long biceps tendon is caused by hypertrophy of the intra-articular portion of the tendon which becomes unable to glide in the bicipital groove during anterior arm flexion. 10°–20° defective motion, pain at the level of the bicipital groove, and images of a hypertrophic tendon are good diagnostic signs. The “hour glass” LGBT must not be confused with retractile capsulitis. The definitive diagnosis is obtained at surgery with the “hour glass” test which shows a fold and incarceration of the tendon during anterior flexion with an extended elbow. Simple tenotomy is insufficient to resolve the blockage. The intra-articular portion of the tendon must be resected after bipolar tenotomy or tenodesis.

Conclusion: Systematic search for “hour glass” LHBT should be undertaken in patients with persistent anterior shoulder pain of unexplained origin associated with deficient anterior arm flexion.

Purpose: We hypothesised that the rate of tendon healing after arthroscopic repair of full-thickness tears of the supraspinatus is equivalent to that obtained with open techniques reported in the literature.

Material and methods: We studied prospectively a cohort of 65 patients with arthroscopically repaired full-thickness tears of the supraspinatus. The patients were reviewed a mean 19 months (12–43) after repair. At arthroscopy, patients were aged 59.5 years on average (28–79). Bone-tendon sutures were performed with resorbable thread and self-locking anchors positioned on the lateral aspect of the humerus. Repair was protected with an abduction brace for six weeks. Forty-one patients (63%) accepted an arthroscan performed six months to two years after arthroscopy to assess tendon healing.

Results: Ninety-four percent of the patients were satisfied with the outcome. The mean Constant score was 51.6±10.6 points preoperatively and 80.2±13.2 at last follow-up (p< 0.001). The arthroscan showed that the rotator cuff had healed in 70% of the cases (29/41). The supra-spinatus had not healed on the trochiter in eight cases (25%) and was partially healed in two (5%). The size of the residual tendon defect was less than the initial tear in all cases except one. The rate of patient satisfaction and function was not significantly different if the tendon had healed (Constant score 81.3/100, satisfaction 93%) or if there was a residual tendon defect (Constant score 77.5/100, satisfaction 92%). Shoulder force in patients with a healed tendon (6±1.9 kg) was better than in those with a tendon defect (4.5±2.8 kg), but the difference was not significant. Factors affecting tendon healing were age > 65 years (43% healing, p< 0.02), and wide tears.

Conclusion: Arthroscopic repair of isolated supraspinatus tears enables tendon healing in 70% of cases as demonstrated by arthroscan. This rate was equivalent to those reported in historical series of open repair. Patients aged over 65 years had significantly less satisfactory healing. The absence of tendon healing does not compromise functional and subjective outcome despite reduced force.

Aims: The purpose of this study is to compare the radiographic results of two different glenoid component designs by analyzing the radiolucent lines (RLL).

Methods: Sixty-three shoulder arthroplasties with primary osteoarthritis were divided into two groups based on glenoid component type: thirty-five shoulders with flat back, and thirty-one shoulders with convex back, polyethylene glenoid implants. The radiolucenct lines were analyzed on fluoroscopically positioned, postoperative AP radiographs. The RLL Score (RLLS) was calculated using the technique of Molé. The RLLS was compared between the two groups.

Results: On the immediate postoperative radiographs the average of total RLL score was 1.67 in Group 1 and 0.98 in Group 2 (p< 0.0005). There was a statistically significant association between the type of implant and the incidence of radiolucency behind the faceplate as well (p< 0.0005). On the 2-year postoperative radiographs the average RLL score was 4.19 in the Group1 (2.86 under the tray, and 1.33 around the keel), and 3.23 in Group2 (p=0.02) (2.09 under the tray, and 1.14 around the keel). The radiolucency behind the face-plate (p< 0.0005) was significantly greater in the flat back group, but not around the keel (p=0.427). There was no significant difference between the two groups regarding the degree of RLL score progression.

Conclusions: The initial and mid-term RLLS is better with convex than fl at back glenoid component.

Aims: The purpose of this study is to compare the radiographic results of two glenoid preparation techniques by analyzing periglenoid radiolucencies. Methods: Seventy-two shoulder arthroplasties with primary osteoarthritis were divided into two groups based on glenoid preparation technique: thirtyseven shoulders with “curettage” of the keel slot, and thirty-five shoulders with cancellous bone compaction. The radiolucent lines were analyzed on fluoroscopically positioned, postoperative AP radiographs. The RLL Score (RLLS) was calculated using the technique of Molé. The RLLS was compared between the two groups. Results: On the immediate postoperative radiographs the average of the total RLL score was 2.39 in Group 1 and 1.67 in Group 2 (p=0.042). There was a statistically significant association between the glenoid preparation technique and the incidence of radiolucency around the keel as well (p=0.001). On the 2-year postoperative radiographs the average RLL score was 6.44 in the Group1, and 4.19 in Group 2 (p=0.0005). The radiolucency around the keel and behind the face-plate (p=0.0005) was significantly greater (p=0.001) in the “curettage” glenoid preparation population. A significantly higher degree of progression of the total RLL score (p=0.002) and of the radiolucency behind the face-plate (p=0.001) was observed in the “curettage” glenoid preparation group. Conclusions: Preparation of the keel slot with cancellous bone compaction is radiographically superior to the “curettage” technique.

Purpose: Failure of the glenoid component is the main complication of total shoulder prostheses. When surgical revision is necessary, the surgeon has the option of a new implantation or non-prosthetic plasty (glenoido-plasty). The purpose of the present work was to analyse results obtained with these two techniques in order to propose proper indications.

Material and methods: This retrospective study included 16 patients, mean age 62 years at revision surgery. Fialures included loosening of a cemented glenoid implant (n=9) and failure of non-cemented implants (3 defective anchors, 4 unclipped polyethylene inserts). Mean time to revision was 39 months (2–178) after primary implantation. A new glenoid implant was cemented in nine patients (group A). Seven patients (group 2) had glenoidoplasty with an iliac graft in four.

Results: A mean follow-up of 37 months (19–73), the Constant score had improved from 18 points before revision to 52 points (+34). Two patients experienced a complication requiring a second revision (infection, instability) and one patient underwent subsequent surgery for biceps tenodesis. For the group with glenoidoplasty with iliac graft, insertion of an inverted prosthesis was achieved during a second operative time. In group 1, the mean Constant score at last-follow-up was 63 points (+45) with the pain score of 11, movement score of 29. In group 2, the mean Constant score was 37 (+19) with pain at 6 and motion at 16. In this group, the mean score was 48 points with a glenoid graft and 21 points with simple implant replacement.

Discussion: Revision surgery for a failed glenoid implant remains a difficult procedure but can be effective for pain relief and improved motion score. The small number of patients in this series makes it difficult to perform statistical analysis but the results do point in favour of prosthetic reimplantation when the bone stock is sufficient. For other patients, a graft would be preferable to simple implant removal. This would allow secondary revision if possible.

Purpose: The purpose of our work was to report causes and results of treatment of anterior shoulder instability after implantation of a shoulder prosthesis.

Material and methods: This retrospective multicentric study included 51 patients with prosthetic anterior instability: 42 patients after first-intention shoulder prosthesis and nine after prosthesis revision. There were 39 women (79%) and 12 men, mean age 67 years, who underwent total shoulder arthroplasty (n=29, 57%) or hemiarthro-plasty (n=22, 43%). Thirty-eight patients (75%) had prosthetic dislocation and 13 (25%) subluxation associated with pain an loss of anterior elevation. The initial prosthesis was implanted for degenerative disease (n=29), rheumatoid arthritis (n=7), or fracture (n=15). Anterior prosthetic instability occurred early in 23 shoulders (first six weeks) and lat in 28 shoulders (7 after trauma, 21 without trauma). Conservative treatment by reduction-immobilisation was performed in 16 cases and prosthetic revision in 35. The patients were reviewed radiographically at mean 41 months follow-up (range 24–62).

Results: Subscapular tear or incompetence was the main cause of prosthetic anterior instability, observed in 87% of the cases. Technical errors concerning the prosthesis were also observed: oversized head, malrotation of the prosthesis. Associated complications were frequent: glenoid loosening (24%), polyethylene dissociation from the metal glenoid implant (10%), infection (10%), humeral fracture (4%). The final Constant score was 54 points and 55% of the patients were disappointed or dissatisfied. None of the shoulders were stable after consevative treatment. The prosthetic revision provided disappointing results with 51% recurrent anterior instability.

Discussion: Anterior instability of shoulder prostheses is a serious complication which responds poorly to treatment. Loosening of the subscapular suture is the main cause.

Purpose: The purpose of this study was to analyse the epidemiology, management, and cure rate in 49 infected shoulder prostheses.

Material and methods: This retrospective multicentric study included 2396 shoulder prostheses with at least two years follow-up (mean 34 months): 2146 first intention prostheses and 250 revision prostheses. Results were analysed as a function of: — time to development of infection: 12 acute (less than 2 months after surgery), 6 subacute (2 to 12 months after surgery), and 29 chronic (more than one year after surgery); — cause leading to the first intention implantation; — therapeutic management of the infection.

Results: Two patients died and five were lost to follow-up. The results were thus evaluated in 42 patients. The rate of infection in this series was 1.8% for first intention prostheses and 4% for revision prostheses. Fracture, joint degeneration with massive rotator cuff tears and radiation-related necrosis were factors of high risk of infection (25% for radiation-related necrosis). Thirty patients achieved cure (71%). Three patients had a doubtful cure and nine patients remained infected (29%). The Constant score moved from 20 points before revision to 38 points. Active elevation was below the horizontal (74°). Eighty percent of the acute infections were cured but one-third of the cases required a new revision. Single-procedure replacements provided better functional results and better cure rates. There was a strong correlation between early surgical intervention, adapted antibiotic treatment, and rate of cure.

Discussion: The overall rate of infection in this series is comparable with data in the literature. The rate of certain cure of infection was disappointing (71%). For acute infections, the patients underwent surgery too late and treatment was too aggressive. If there is a doubt about possible infection, revision should be performed as early as possible to allow cure and preserved function. For chronic infections, time to diagnosis and management was too long. This led to anthroplastic resection in one-third of the patients. The choice of the antibiotics and duration of treatment, associated with rigorous surgical technique, should allow switching from arthroplastic to resection prosthetic replacement using one or two surgical times which, for these infected shoulder prostheses, appears to offer the best compromise between cure and function.

Purpose: The purpose of this study was to analyse outcome of shoulder prostheses after radiotherapy, to define a specific clinicoradiological entity, and evaluate incidence of complications.

Material and methods: Fourteen shoulder prostheses were implanted in 13 women who had been treated for breast cancer with complementary radiotherapy and one man treated for Hodgkin’s lymphoma. The time from radiothearpy to implantation was 16 years, seven months. Two forms were identified on the preoperative x-rays: seven cases with typical avascular osteonecrosis according to the Arlet and Ficat classification, and seven cases with a radiographic presentation of arthritis or degenerative disease. Humeral prostheses were used in five cases and a total shoulder arthroplasty in nine.

Results: Four implants had to be removed, three for sepsis, and five patients required revision surgery. The mean postoperative Constant score for the ten prostheses still in place was 53.1 points with a mean elevation of 111° at three years seven months follow-up. The gain in pain score was 8.5 points with a mean result of 10.9 points. The results were different depending on the initial radiological form, with less favourable outcome observed in typical osteonecrosis.

Discussion: This study demonstrated a particular radio-clinical entity independent of classical osteonecrosis of the humeral head. The surgical procedure was more difficult and the outcome was less satisfactory than in the classical forms with a high rate of complications.

Purpose: Evaluate outcome after isolated intra-articular ACL graft in patients aged 40 to 60 years using patellar bone-tendon and gracilis grafts.

Material and methods: This retrospective comparative study included 30 consecutive patients who underwent arthroscopic surgery between September 1996 and September 1999 performed by the same operator: 14 patellar bone-tendon grafts and 16 gracilis grafts. The indication for surgery was knee instability in everyday or sports activities. Exclusion criteria were associated peripheral ligament plasty or bone procedures. The two populations were strictly identical except for gender and follow-up: patellar bone-tendon group: mean age 49 years, 12 men, follow-up 46 months, 6 associated menisectomies; gracilis series: mean age 48 years, 13 women, mean follow-up 30 months, 6 associated menisectomies. The IKDC score, laximetry (KT 2000), x-rays (AP, single stance lateral, 30° flexion) were used by two operators different from the operating surgeon to assess outcome.

Results: At last follow-up, there was a significant difference between functional and anatomic outcome in the two groups. 83% of the patients were classed IKDC A or B. Subjectively, 90% of the patients were satisfied or very satisfied. The pivot test was negative in 24 (80%), doubtful in 5 and positive in 1. 86% of the patients had a differential laxity less than 3 mm. In the gracilis group, two patients developed chronic hamstring pain. In the patellar bone-tendon group, two patients developed persistent patellar pain. Two patients underwent a second procedure for meniscectomy. At last follow-up the x-rays demonstrated early signs of degeneration in 20% of the patients and signs of medial femorotibial degeneration in 10%.

Discussion: Gracilis and patellar bone-tendon grafts provide strictly identical results; residual pain is not more prevalent after patellar graft; control of laxity is not less satisfactory after hamstring graft. In our series, ACL graft in patients over 40 years of age provided functional, laximet-ric, and radiographic results comparable to those in patients undergoing ACL grafts before the age of 40 years.

Conclusion: 1) ACL graft can be indicated after the age of 40 years for patients with knee instability bothersome for everyday or sports activities. 2) Functional and anatomic results are identical with those obtained in younger subjects. 3) Irrespective of the graft used, patellar or hamstring, outcome is satisfactory and morbidity is not different.

Purpose: The glenoid and humeral head curvature radii are mismatched in non-constrained total shoulder prostheses. The purpose of this study was to evaluate the effect of this mismatch on radiographic lucent lines and clinical outcome.

Material and methods: The study population included 319 total shoulder prostheses issuing from a multicentric European cohort. The patients underwent surgery for primary shoulder degeneration. Mean age at surgery was 67 years. Female sex predominated (75%). Partial supraspinatous tears were present in 7% of the shoulders with full-thickness tears also in 7%. A single type of prosthesis was used composed of a humeral pivot with a modular head (seven head sizes) and a cemented polyethylene flat-surface spiked glenoid (three sizes). Variable association of humeral heads and prosthetic glenoids defined the mismatch which varied from 0 to 10 mm (difference in the curvature radii between the head and glenoid). The patients were reviewed clinically and radiologically at a mean follow-up of 53.5 months (24–110 months). Clinical outcome was assessed with the Constant score for pain (15 points), daily activity (20 points), motion (40 points), and force (25 points). The glenoid lucent line was evaluated on the AP view using a 0 to 18 point scale (0=absence, 18=lucent line in 6 zones). Analysis of variance and linear regression were used to assess the effect of mismatch on the glenoid lucent line and clinical outcome.

Results: There was a statistically significant linear relationship between mismatch and glenoid lucent lines. The lucent line score was significantly lower when the mismatch was between 6 and 10mm. Mismatch had no influence on the overall Constant score or the individual scores (pain, motion, force, daily activities) nor on early or late postoperative complications.

Discussion: Based on the results of this study, the first in vivo assessment, the “ideal” gleno-humeral mismatch for total shoulder prostheses would be between 6 and 10 mm, i.e. much greater than is classically recommended (0–5 mm).

Purpose: Nonunion of the surgical neck of the humerus can occur after orthopaedic or poorly-adapted surgery after displaced subtuberosity or cephalotuberosity fracture. The purpose of this study was to report functional and radiographic outcome after treatment with shoulder prosthesis.

Material and methods: Twenty-two patients who had a non-constrained shoulder prosthesis were included in this retrospective multicentric study. Mean age was 70 years and mean follow-up was 45 months (range 2 – 9 years). The initial fracture had two fragments in six patients and was a three-fragment fracture involving the head and the tubercle in thirteen and a four-fragment fracture in three. Orthopaedic treatment was given in ten cases and surgical osteosynthesis was used in twelve. Time from fracture to implant insertion was 20 months. The deltopectoral approach was used for 21 humeral implants and one total shoulder arthroplasty (glenohumeral degeneration). The tuberosities were fixed to the cemented humeral stem and a crown of bone grafts were placed around the nonunion of the surgical neck. All patients were reviewed after a minimum of two years and assessed with the Constant score and x-rays.

Results: The absolute Constant score improved from 23 reoperatively to 39 postoperatively with an anterior elevation of 53° to 63°. Pain score (from 3 to 9, p = 0.001) and external rotation (from 13° to 28°, p = 0.01) were significantly improved. Forty-five percent of the patients were satisfied and 55% were dissatisfied. The type of initial treatment, type of initial fracture, and time before implantation of the prosthesis did no affect final outcome. The complication rate was 36% (eight patients), and led to five revision procedures. The radiographic work-up disclosed six cases of persistent nonunion of the greater tuberosity, two proximal migrations of the prosthesis, and one humeral loosening.

Conclusion: Outcome of shoulder prosthesis for sequela after fracture of the proximal humerus with nonunion of the surgical neck is poor. No improvement in anterior elevation, force, or motion was achieved. Shoulder prosthesis for sequelae of fracture of the proximal humerus with nonunion of the surgical neck should be considered as a “limited-objective” indication only providing beneficial pain relief.