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.

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: 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: The purpose of our retrospective analysis was to describe results of arthroscopic treatment of painful ankle instability without clinical or radiological laxity.

Material and methods: Eighteen patients, mean age 27 years (seven men and nine women) were operated on by the same surgeon between 1999 and 2000. Sixteen patients (90%) were reviewed by an independent investigator at 20±4 months. Fifteen patients were athletes, ten at the competition level, and five had amateur sports activities. The accident caused forced inversion in 15/16 cases, during sports activities in 85.5% of the cases. Mean age at injury was 17±6 years. Mean time between the accident and arthroscopy was eight years. All patients had pain in the anterolateral region associated with effusion in 50% and apprehension or instability for daily life activities. Standard x-rays were normal in fourteen patients (87.5%). Comparative stress images did not demonstrate pathological laxity. Complementary imaging (MRI, CT scan, arthroscan, ultrasonography) was obtained in six patients with 50% negative results. Arthroscopy revealed anterior tissue interposition (antero lateral in thirteen patients (81%) and anteromedial and anterolateral in three) which was removed with the shaver. Joint cartilage was intact in fifteen patients (81.25%).

Results: At last follow-up, functional outcome was good in all patients who had all resumed their sports activities. Subjectively, six patients felt they had normal function, seven nearly normal function and three abnormal function (81% satisfied or very satisfied). Six patients were symptom free even during intense physical activity. Eight patients reported some difficulties for strenuous exercise and two for moderate exercise. Joint motion was normal in ten patients and 5° dorsal flexion deficit was observed in six. There were no recurrent sprains. The x-ray was normal and identical to the initial image in 87.5% of the patients. Globally, 87.5% of the patients had good or excellent outcome. Two patients had fair or poor outcome.

Discussion: Diagnosis of anterolateral ankle conflict can be established in patients with a compatible history and a typical clinical presentation with normal x-rays. Arthroscopic treatment can remove tissue interposition allowing good functional results and total recovery of sports activities. Complementary MRI or arthroscan have little specificity and poor sensitivity.