Introduction and Objective

Knee osteoarthritis (KOA) is a frequent disease for which therapeutic possibilities are limited. In current recommendations, the first-line analgesic is acetaminophen. However, low efficacy of acetaminophen, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. The primary objective was to compare the analgesic efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) to weak opioids (WO) in the treatment of moderate to severe, nociceptive, chronic pain in knee osteoarthritis patients.

Purpose of the study: Many rotator cuff tears occur in the context of a work accident or an occupational disease (schedule 57-A in the French occupational disease nomenclature). This context is a negative factor for outcome although diverse opinions are expressed in the literature. We wanted to study the occupational outcome of operated patients after rotator cuff repairs and to determine what factors affect this outcome.

Material and method: From 2000 to 2005, 1155 patients underwent rotator cuff repair performed by the same operator. The context was an occupational context (schedule 57-A) in one quarter of these patients (n=290, 25.1%). Among these, 87.6% (n=254) responded to a mail questionnaire. In all 262 shoulders were included in this series (8 bilateral cases). Male gender predominated (72%) and 69% of the tears were in the right shoulder. Mean patient age was 50.53±6.4 years. In this series, 67% of the tears were related to a work accident and 33% to an occupational disease. The patients were salaried workers (75.2%), independent craftsmen (12.6%), and civil servants (11.8%). The occupational category was heavy manual labour (68.3%), light manual labour (25.5%), non manual occupation (6.1%). The injury involved one tendon in 64.1%, two tendons in 28.2% and three tendons in 7.6%. Classical open repair was performed for 70.6%), mini-open repair for 9.2%, and arthroscopic repair for 20.2%.

Results: Patients resumed their occupational activity in 59.64% of the cases (mean age 48±0.8 years); 40.45% did not resume their occupational activity (mean age 54±5.3 years). Excepting cases of retirement or interruption related to another medical condition, the shoulder was the reason for not resuming work in 16% of patients. Young age (p=0.0005) and type of surgery (open procedure p=0.0004) were factors favouring resumption of occupational activity while gender, occupational category and type of injury had no effect. The duration of sick leave (full time) depended on the occupational category (p=0.004) and somewhat on gender, age, occupational situation, work accident or occupational disease, and type of surgery/

Conclusion: Work accidents or occupational disease were not synonymous with failure of rotator cuff repair. Age was the leading prognostic factor.

Purpose of the study: Latissimus dorsi transfer is proposed for irreparable superior and posterior rotator cuff tears, particularly in the effect of deficient active external rotation. The purpose of this study was to analyzed outcome at minimum two years follow-up.

Material and methods: Between 2001 and 2002, eleven patients underwent latissimus dorsi transfer for an irreparable tear of the supraspinatus and infraspinatus. Surgery was proposed because of the patient’s young age and occupational activity level, or because of a disabling deficit of active external rotation. There were six men and five women, mean age 52.5 years (range 36–66 years). There were seven right shoulders and nine dominant shoulders. Symptom onset was progressive in seven with a mean duration of 33 months (range 2–144 months). Active external rotation was measured at −14° to 29° in five patients with a positive dropping test. Three patients presented pseudoparalysis. The preoperative Constant score was 52±12 points. Preoperative the subacromial space measured less than 6 mm in all patients. Muscle degeneration of the infraspinatus was noted grade 2 or greater (Goutallier).

Results: Mean follow-up was 26 months (range 24–36). Subjective outcome was very satisfactory for eight patients, satisfactory for one and disappointing for two. Seven of nine patients resumed their occupational activity. The postoperative Constant score was 73±10 points. None of the patients presented pseudoparalysis at review. Pain was improved in all. Active external rotation was significantly improved in six. Postoperative, the dropping test persisted in two patients. The subacromial space was still 6 mm. Better results were obtained when active deficit was predominant than when anterior elevation (pseudoparalytic shoulder) or external rotation (positive dropping test) were predominant.

Discussion and conclusion: Latissimus dorsi transfer provides a solution for irreparable superior and posterior rotator cuff tears. The pain relief is significant. Active external rotation is improved. This is an interesting alternative in young patients or when the motor deficit is a severe handicap.

Purpose of the study: When repairing rotator cuff tears, injury to the infraspinatus is generally a posterior extension of a supraspinatus tear. The description of isolated tears of the infraspinatus has not been to our knowledge reported in the literature. We report a series of 13 cases with more than one year follow-up.

Material and methods: Thirteen patients underwent surgery for an isolated tear of the infraspinatus between 1995 and 2004. There were ten men and three women. Mean age at surgery was 47 years (range 34–62). The right shoulder was involved in seven of the thirteen cases, and the dominant shoulder in eight. A progressive onset was observed in eleven patients and nine had a history of treated calcified tendinopathy. Clinically, pain was the predominant symptom. The Jobe test was deficient in all patients as was external rotation (except one patient). The preoperative Constant score was 70 (range 62–87). X-rays revealed type C posterior calcification in nine patients. A full-thickness tear was observed in seven cases, a partial deep tear in three, and a partial superficial tear in three. Isolated fatty degeneration of the infraspinatus noted Goutallier grade 2 or greater was observed in seven patients. Open surgical repair was preformed in all patients.

Results: Mean time to revision was 29 months (range 12–82). Subjectively, six patients were very satisfied, six were satisfied, and one was disappointed (failure by secondary tear). Two shoulder-hand syndromes were noted in the postoperative period. At last follow-up, the Constant score was 83.5 (range 64–97). All patients except one were satisfied with pain relief but the lack of force was significant.

Discussion and conclusion: Isolated tears of the infra-spinatus are rare, but there is a notable relationship with calcifying tendinopathy of the same tendon. Repair should be undertaken before the development of fatty degeneration in order to improve the chances of force recovery.

Purpose: The purpose of this work was to assess results of total ankle arthroplasty (TAA) for rheumatoid arthritis and determine the technical difficulties.

Material and methods: Between 1993 and 1999, 32 TAA were performed for rheumatoid arthritis: 26 women and 16 men, mean age at implantation 55 years, age range 32 – 81 years, disease duration 17 years (range 2 – 35 years), long-term corticosteroid treatment 18, metotrex-ate 17. Non-cemented prostheses with a mobile insert were implanted: Buechel-Pappas (n=7), STAR (n=5), Salto (n=20). For 21 patients, subtalar and mediotarsal arthrodesis was associated with the TAA because of associated subtalar deterioration or valgus tilt due to tendiopathy of the posterior tibial tendon. All patients were seen at three, six and twelve months then every year for physical examination and x-rays. None of the patients were lost to follow-up. Mean follow-up was 57 months (range 26 – 90 months). Clinical outcome was assessed with the AOFAS.

Results: There were two failures requiring revision: one loose talar piece migrated four years after implantation requiring arthrodesis; one over-sized talar piece leading to pain had to be changed after one year with good results (AOFAS = 92). Among the other 30 patients, the mean overall score and the pain score were 82/100 (73–92) and 35/40 (20–40) respectively. Several complications were observed: wound necrosis (n=2), impaction of the talar piece (n=1), and impaction of the tibial piece (n=2) which developed at weight bearing then remained unchanged. One anterior translation of the tibial piece was asymptomatic at two years, fractures of the medial malleolus healed without difficulty.

Discussion: TAA is the treatment of choice for rheumatoid tibiotarsal degeneration. Associated lesions of the hind foot influence prognosis and results. Preoperative analysis of the deformation and loss of bone stock must be achieved with careful physical examination and appropriate x-ray or computed tomography imaging. Subtalar valgus deformation or tendinopathy of the posterior tibial tendon require an associated subtalar and mediotarsal arthrodesis.