Introduction

Proper rotational alignment of the tibial component in total knee arthroplasty (TKA) could be achieved using several techniques. The self adjustment methodology allows the alignment of the tibial component under the femoral component after several flexion-extension movements. Our hypothesis was that this technique allowed a posterior tibial component alignment parallel to the femoral component posterior bicondylar axis. The aim of this study was to access this hypothesis using a post-operative CT-scan study.

Purpose of the study: For patients aged less than 65 years who have a large rotator cuff tear, potential solutions include anatomic repair, palliative treatment, non-anatomic repair with flaps or cuff prosthesis, and reversed prosthesis. The later solution is not recommended at this age and anatomic repair is not always possible. In this situation, what is best, palliative treatment or flap or prosthesis repair?

Material and method: This retrospective multicentric study included 142 patients, 74 men and 68 women with a large or massive cuff tear. Palliative treatment (group A) involved acromioplasty (n=48) associated as needed with a biceps procedure and partial repair (n=41). Non-anatomic repair (group B) included supra-spinatous translation (n=16), deltoid flaps (n=22), and cuff prostheses (n=15). Preoperatively, the two groups were not statistically different for acromiohumeral height (AH, 6 mm in group A versus 7.5 mm in group B) and percent of fatty infiltration of the infraspinatus > II (55% in group A versus 26% in group B). The Constant score, active and passive range of motion, gain in elevation and external rotation were noted.

Results: Mean follow-up was 74 months in group A and 90 months in group B; the Constant score was 64 and 65, active elevation 145 and 147 and external rotation 17 and 26 respectively. The two groups were not significantly different. For patients with deficient elevation (n=46), the gain was 62 without any difference between the two groups. For patients with deficient external rotation (n=37), the gain was nil in both groups.

Discussion: Although group A had a more severe condition than group B (narrower AH and more advanced fatty degeneration, the final outcome as assessed by the Constant score and range of motion was similar. Both groups recovered active elevation well, but not external rotation. Nevertheless, there were no cases of latissimus dorsi transfer in this series. Repair with a deltoid flap, supraspinatus translation, or cuff prosthesis does not appear to add any supplementary benefit despite the more aggressive surgery.

Purpose of the study: Little is known about the clinical profile of patients aged less than 65 years who present a large or massive rotator cuff tear. We hypothesized that this clinical profile depends on the type of tear.

Material and method: This was a prospective descriptive multicentric study over a period of six months which included 112 patients aged less than 65 years, 66 men and 46 women, mean age 56.3 years (range 35–65) who had a large or massive rotator cuff tear. The Constant score and active and passive range of motion, subacromial height and fatty infiltration according to the Goutallier classification were noted. Patients were divided into four classes according to deficit in active elevation and external rotation: class A (n=55, no deficit), class B (n=19, deficient elevation alone), class C (n=28, deficient external rotation alone), class C (n=10, deficient elevation and external rotation).

Results: These classes were not significantly different for age, sex-ratio, duration of symptoms, or presence of subscapular involvement. Trauma was involved more often in patients in class B and class D. The mean absolute Constant score was significantly lower in patients in class B (30.2) or D (23.5) than in class A (53.3) or C (44.7). The subacromial space was significantly narrower in group D (5 mm) than in the other groups. Fatty infiltration of the infraspinatus scores > II was significantly more common in groups C and D. Severe fatty degeneration of the subscapular (> II) was found in only eight shoulders and was not correlated with defective active elevation.

Discussion: This study demonstrates that deficient external rotation is correlated with the type of tear but has little impact on the Constant score. Conversely, patients with deficient active elevation have a lower Constant score but do not exhibit characteristically different tears than patients without deficient active elevation. Thus, the management scheme should be no different in patients with deficient elevation than in patients with out deficient elevation, excepting cases with a major lesion of the subscapularis.