Purpose of the study: Radiographs of 24 patients who underwent surgery for total hip arthroplasty (THA) with a locked stem were reviewed at 38 months mean follow-up using a dedicated software. This software enables digital analysis of standard radiographs with semiquantitative evaluation of bone density.

Material and method: Good quality postoperative AP views of the femur and the same view at last follow-up were selected using the same criteria. These images were digitalised then analyses with the software. Bone density was established along a horizontal line 1 cm below the lesser trochanter perpendicular to the femur shaft. Computer analysis of bone density established three categories of patients as a function of cortical density: no cortical modification (n=5 hips), modification of only one cortical (n=11) and modification of both corticals (n=8).

Results: Bone density increased, suggesting improve cortical bone stock as has been reported by most authors using the transfemoral approach and a non-cemented locked stem.

Discussion: This result confirms the data in the literature; data which, unlike our series, were established on qualitative or subjective evaluations. The method presented here has the advantage of a semi-quantitative analysis, simple use, applicable to plain x-rays, and good reproducibility since all measures are made by the software. This study demonstrated the notion of cortical quality since it was not limited to a simple measurement of width, but also bone density, closer to real intraoperative observations.

Conclusion: Use of this method enables longitudinal study to establish the kinetics of bone remodelling, compare results between surgical methods, and search for factors explaining observed variations.

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: Compression of the suprascapular nerve in the superior or inferior scapular incisures is a well-known syndrome compression syndrome triggered in the narrow osteofibrous tunnel. This study was undertaken after observing several cases of nerve compression in the supraspinatus fossa after neruolysis procedures. We wanted to better understand the relations with the supraspinatus fascia.

Material and methods: Thirty human cadaver shoulders were dissected. After exposing the supra and infraspina-tus fossae and section of the scapular spine, the supra and infraspintus tendons were sectioned and folded back medially to expose the suprascapular pedicle in the superior scapular incisure, the supraspinatus fossa, and the inferior scapular incisure. The presence of a fascia sheathing the nerve, of subfascial tissue, and of a transversal inferior (spinoglenoid) ligament was noted together with the histology of the observed structures.

Results: A supraspinatus fascia sheathing the nerve was observed in 29 dissections. This fascia was inserted on the superior border of the scapula and the superior scapular ligament and the floor of the supraspinatus fossa. Diffuse adipose deposits under the fascia was observed in 55.5% of the dissections, or located around the vasculonervous bundle in 44.5%. There was a fibrous buttonhole facing the lateral border of the spine in 28 shoulders with a thickened zone which constituted histologically the equivalent of an inferior transvers ligament in 26 shoulders. One subfascial lipoma was discovered.

Discussion: Sheathing with a supraspinatus fascia could explain suprascapular nerve compression in the supra-spinatus fossa where the nerve is exposed to compression against the bony base on which it runs between the superior and inferior incisures. These anatomic data suggest that suprascapular neurolysis should release the nerve over its entire length and not just at the superior or inferior scapular incisure.

Conclusion: The succession of the superior transverse ligament, the supraspinatus fascia, and the inferior transverse ligament constitutes an osteofibrous tunnel which should be considered as a potential source of a suprascapular tunnel syndrome at three levels.

Purpose of the study: Surgical reconstruction procedures using the gracilus myocutaneous flap may be compromised if partial or total necrosis of the skin cover develops. The purpose of this study was to describe the anatomic blood supply to the gracilus muscle and the corresponding skin cover in an attempt to better understand the arterial afferences to the skin and define the safest topography for a transferable zone of skin.

Material and methods: We dissected the thighs of human adult cadavers to detail the vascular bundles feeding the gracilus muscle.

Selective injections of methylene blue were used in the main gracilus pedicle; the area of skin colored was then measured (greatest and smallest diameter) for computation of the surface area using an imaging software.

Results: Preliminary results of nine dissections showed that the main blood supply of the gracilus muscle arose from the deep femoral artery (n=8 dissections) or the common femoral artery (n=1 dissection) then penetrated the muscle 90.55 mm below the pubis with a mean diameter of 1.32 mm. The muscle was fed by one to four accessory arteries. The skin cover was stained in all cases, the area involved lying over the proximal and mid thirds of the muscle. The surface area was irregular, the mean length being 127.5 mm and the mean width 91.66 mm. The computed surface area was 88.08 cm² on average (range 58–120.95 cm²). Each muscle had two to six perforating vessels issuing from the opposite side of the main pedicle and comprised within a 48 mm long segment before dividing at the subcutaneous level. A mathematical model correlated the skin surface area to the number of perforating arteries.

Discussion and conclusion: Our findings suggest it would be possible to determine the surface area of skin transferable with a gracilus muscle flap based on high-frequency duplex-Doppler assessment of the number and position of the perforating arising from the muscle and feeding the skin surface. The linear distribution of the surfaces measured as a function of the number of perforating arteries suggests that more reliable conditions for gracilus myocutaneous flap harvesting could be proposed to minimize the risk of cutaneous necrosis.

Purpose: The purpose of this study was to establish the map of the motor branches of the median and ulnar nerves of the forearm and to count the Martin-Gruber anastomoses. Knowledge of anatomic variability would be useful for hyponeurotisation surgery of the spastic hand. Variations in the antebrachial emergence of the six motor branches of the medial nerve and the three motor branches of the ulnar nerve were studied.

Material and methods: This study was conducted on twenty anatomic specimens obtained from five men and five women. We measured the length of the forearm and identified the origin of each motor branch of the medial and ulnar nerves using a horizontal line between the meidal and lateral epicondyles as the reference line.

Results: Mean length of the forearm was 26.93±2.6 cm. Unlike the origin of the superior and inferior pronator teres nerves, and the palmaris longus, flexor carpi radialis, and flexor digitorum superficialis nerves which were very variable (coefficient of variation 49%–113%), the origin of the anterior interosseous nerve of the forearm (CV=39%) and its branches, and the flexor pollicis longus nerve and the flexor digitorum profondus nerves (CV =23% and 29% respectively) were much more regular. The superior and inferior origins of the flexor carpi ulnaris nerve were variable (CV = 157 and 22%) while the origin of the nerves for the deep flexor of the IV and V fingers showed a better coefficient of variation (13%). We observed four Martin-Gruber anastomoses (20%).

Conclusion: This study demonstrated the wide anatomic variability of the medial and ulnar nerves both interin-dividually and intraindividually. Emergence of certain nerve branches appeared to be more regular, particularly the lower group of the median nerve and the anterior interosseous nerve of the forearm. It was however impossible to identify two groups exhibiting a statistically significantly greater frequency for the median nerve. The anatomic variations of the ulnar nerve were less pronounced. The inconsistency of the inferior flexor carpi ulnaris is noteworthy.

Purpose: The purpose of our work was to study the effects of sequential arthroscopic section of the anterior capsule of the shoulder joint using an experimental model of retractile capsulitis induced by heat treatment.

Material and methods: Twelve cadaver shoulders were studied. Passive mobility was initially normal. Anterior capsule retraction was first created under arthroscopic control (Arthrocare® generator, power 2). Twelve programmed sequential sections were then performed successively using the thermal probe (Arthrocare®, power 9) on: the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL), the middle gleno-humeral ligament (MGHL), the inferior glenohumeral ligament (IGHL), and the intra-articular portion of the subscapular muscle tendon (SST). The posterior capsule was not studied. At each step, motion was measured independently by two operators. At the end of the sequence, the articulation was opened to verify the sections as was the absence of any injury to noble structures.

Results: Measures were reproducible (mean difference 5° between two series). The sections were correctly achieved. Macroscopically, there were no injuries to noble structures. The role of the different elements studied were as follows: — rotator interval (CHL, SGHL): gain in RE1 (mean 40°) and RE2 (mean 35°) (greater than loss during retraaction; — IGHL: gain in elevation (mean 33°); — IGHL and rotator interval: potentialisation of gain in FE2 (mean 41°) and elevation (mean 50°); — MGHL: moderate increase in external rotation at 45° antepulsion and elevation (mean 20°); —SST: discrete gain in RE1 (10°) but risk of dislocation (n=1).

Discussion: Our model was reproducible. Section of the anterior capsule by a thermal method did not produce macroscopic injury to neighboring tissues. Our study pointed out the preeminent importance of sectioning the rotator interval for recovering external rotation. This section, combined with section of the IGHL has a potentialsing effect. The limitation of our study is the absence of examination of the posterior capsule.

Purpose: During surgery for repair of rotator cuff tears, some authors always associate tenotomy-tenodesis of the long head of the brachial biceps. Others decide as a function of the gross aspect of the tendon and its position in relation to the bicipital groove. It is a classical notion the preservation of the long head of the brachial biceps is a cuase of persistent pain in operated shoulders. This study was conducted to search for a histological validation of the decision to perform tenotomy.

Material and methods: Fifty tendons of the long head of the brachial biceps presented a thick and inflammatory aspect with or without subluxation during 68 procedures to repair recent rotator cuff tears (23 men, 27 women, mean age 53.5 years). Tenodesis of the long head of the brachial biceps was associated with proximal tenotomy. The histological examination concerned the most proximal centimeter of the tendon. Four parameters were studied: two concerned the tendon (organisation of the collagen network and aspect of the interstitial connective tissue), two concerned the synovial border (sub-synoviocytic layer and synovial mesothelium). Sixteen tendons which appeared perfectly healthy were harvested from cadaver shoulders to determine the normal aspect of histological parameters (parallel and cohesive orientation of the collagen network, absence of hypertrophic interstitial connective tissue, thin subsynovio-cytic layer and pluristratified synovial mesothelium).

Results: The tendon. The collagen bundles were oriented in 32 cases but thick in 40 and dissociated in 47. Microscopic signs of fissuration or intratendinous tears were present in 17 cases. The tendinous connective tissue was oedematous in 49 cases, presenting fibroblastic hyper-cellularity in 37 and hypervascularity in 43. Scar-like fibrosis was observed in 28 cases. The synovial layer was regular in 11 tendons and clearly thickened in 26 with a mixed irregular aspect in the others. The subsynoviocytic layer was thick in 33 tendons with signs of hypervascularity or hypercellularity in 12. The synovial mesothelium was paucistratifed in 23 cases, thick in 12, and regular in 15. Lesions had an inflammatory aspect and were intense in 26 cases. Degenerative lesions were observed in 21 tendons. These four histological parameters demonstrated that the lesions were advanced and associated with degenerative sclerosis with reactional synovitis in 30 cases, moderate combined lesions in 13, tendon and synovial inflammation alone in four, and advanced degenerative lesions of the tendon and the synovial in six.

Discussion: Histological lesions of the long head of the brachial biceps tendon are generally degenerative and irreversible while most synovial lesions are reversible inflammatory reactions. The zones of intratendinous fibrosis, vascularity and weak or absent cellularity constitute the anatomic conditions before tendon tears in chronic tendinopathy. This histological study confirmed the validity of the intra-operative decision for tenodesistenotomy of the long head of the brachial biceps in 46 (92%) of the cases. The oedematous and fissu-rated aspect of the tendon appeared to be a reliable criteria while inflammatory synovitis, which surrounds the tendon, does not constitute in itself a formal argument in favour of tendon sacrifice.

Purpose: Collapse or necrosis of the head of the humerus after fracture of the proximal humerus can be an indication for shoulder arthroplasty. The poor results classically reported have led to a search for factors predictive of the anatomic and functional outcome after arthroplasty for fracture sequelae.

Material and methods: Among the 221 Aequalis prostheses implanted for the treatment of sequelae after fracture of the proximal humerus, 137 (62%) developed post-traumatic avascular osteonecrosis of the humeral head with a deformed callus of the tuberosity. Head tilt was in a valgus position in 83 shoulders and in a varus position in 54. Mean age was 61.49 years. The initial fractures were subtuberosity fractures in 20% of the cases, three-fragment fractures in 32%, and cephalobituberosity fractures with four fragments in 48% of the cases.Twenty-five percent of the patients had undergone initial osteosynthesis. The rotator cuff was repaired in 4.5%, and two osteotomies of the less tuberosity and four osteotomies of the greater tuberosity were performed at implantation. Pre- and postoperative clinical and functional outcomes were assessed with the Constant score and a function index composed of eleven usual movements.

Results: Mean follow-up was 44 months (24–104), with a mean 42° gain in anterior elevation and a 29° gain in external rotation. The gain in the Constant score was +32 points (mean score 61), and +43% with the weighted score. The four subscores (pain, motion, activity, force) improved two-fold. Analysis of the eleven usual movements demonstrated recovery in 88% of the patients. The subjective satisfaction index was 86%. The mean Constant score improved significantly more after total arthroplasty (67 points) than after humerus prosthesis (55 points). Complications (per- or postoperative mechanical problem, infection, neurological disorder) or the need for revision were unfavourable elements.

Discussion: Deformation and deviation of the tuberosities, especially the greater tuberosity, often leads to osteotomy during the implantation procedure. In this series, osteotomies were exceptional and functional outcomes showed that deviated tuberosities could be preserved without having an unfavourable effect on functional prognosis. Much on the contrary, the absence of a tuberosity osteotomy simplified the operative procedure and produced much better functional outcome than observed in earlier studies. The rate of complication for secondary prosthetic implantation is not negligible (15%) and a simplified procedure without osteotomy is a useful criterion. Furthermore, rehabilitation may be started earlier after implantation when it is not retarded by osteotomy bone healing, found to be an unfavourable factor.

Conclusion: Implantation of a shoulder prosthesis after collapse or necrosis of the head of the humerus after proximal fracture with varus or valgus impaction has provided good functional outcome without tuberosity osteotomy since the deformation of the tuberosity is generally well tolerated.

Purpose: A fibrous element between the radial capitulum and the fovea is classically described; it is often called a synovial fringe. The term “meniscus” has been proposed to designate a truly rigid peripheral structure partially inter-postioned between the joint surfaces and susceptible of producing joint disease by internal disregulation of repeated pronation supination movements. This led us to study the anatomic and histological properties of this intra-articular structure.

Material and methods: Fifty adult cadaver shoulders were dissected. The en bloc resection included the capsule of the humeroradial joint and the entire annular ligament. We searched for a fibrous structure, noting its soft or rigid aspect, its position relative to the five-part segmentation of the capsuloligament resection, and its size and thickness. Vertical sections were made for the histology study to determine the organized connective tissue or synovial nature of the structure.

Results: An intra-articular element was visible in 43 cases, two structures were observed in two cases, on the deep aspect of the junction between the capsule and the annular ligament. The main positions observed were: circular (n=3), lateral and posterior (n = 11), posterior (n = 10). The anterior (n = 4), or lateral (n = 5) positions were rare. Mean length was 21.4 mm (9–51), mean width between the capsular attachment and the free edge was 2.9 mm (1–10), maxiam mean thickness was 1.7 mm (1–4 mm). The histology report showed two types of structures: a rigid structure with an oriented fibrous armature that had a triangular peripheral base continuous with the superior border of the annular ligament and covered with synovial on both sides of the free edge; a soft flexible structure formed uniquely by two layers of synovial and a more or less villous free edge. Fibrochondroid structures of the meniscal type were not observed. Small nerve fibers were demonstrated in some cases.

Discussion: Certain lateral epiconylalgias of the elbow would suggest involvement of the humeroradial joint, possibly related to injury of the humeoradial “mensiscus”. This study points out the frequency of this synovial or fiborsynovial fringe of variable dimensionts interpose between the radial capitulum and fovea. The structure has a more or less marked connective armature, basically in the lateral and posterior portion, and correctly cannot be termed a “meniscus”. This structure might be involved in inflammatory and painful syndromes observed in epicondylalgias of the humeroradial joint.

Purpose of the study: The aim of this work was to assess results after treatment by nailing of nonunion of the humeral shaft. In particular, we focused on consolidation and factors predictive of failure.

Material and method: A prospective study was conducted in 13 consecutive patients presenting aseptic nonunion of the humeral diaphysis. There were five cases after orthopedic treatment and eight cases after internal fixation. Two patients had iterative nonunions. Locked nailing was performed with three successive types of nails: the Seidel nail in four cases, the Russel Taylor nail in seven, and the ACE nail in two. Anterograde nailing was used for the first three cases and retrograde nailing for the others. All patients were followed regularly in our department. Last follow-up was one to seven years after nailing.

Results: Five nonunions (38%) did not consolidate after locked nailing. Consolidation was achieved in the other patients after four to 18 months. The anatomic result was good in these patients. Between the success and failure groups, there was no significant difference in age, gender, type of fracture, first intention treatment, delay from fracture to nailing, type or diameter of the nail, surgical access or not to the fracture site during nailing, or duration of complementary fixation. Anterograde nail insertion, used in our first three patients in this series, appeared to affect shoulder function. The retrograde route was used in other patients and did not appear to have any impact on the elbow itself or the elbow region.

Discussion: This clinical study was unable to identify clinical factors explaining failures but did provide several arguments suggesting that defective primary stability of the initial fixation could be incriminated in the failures.

Conclusion: Centromedullary locked nailing is a simple technique with potential for resolving difficult problems of nonunion. Good functional outcome can be obtained when consolidation is achieved. Rather than abandoning this technique, it would be advisable to conduct further research to determine what factors are determinant in its failures.

Purpose of the study: A clinical trial on the treatment of humeral shaft nonunions with locked nailing evidenced 5 failures among 13 cases. The circumstances leading to the nonunion, the patient’s condition, and the nailing method were not found to have a predominant effect explaining this outcome. Inversely, clinical data suggested that abnormal mobility of the nonunion appeared to result from play in the assembly. To check this hypothesis, we measured primary stability in three nailing models using cadaver bones.

Materials and methods: Three nailing models, Seidel (S), Russel-Taylor (RT) and ACE were tested, each on 5 cadaver specimens. A 1 cm segmental resection was made in the mid third of the humerus to simulate an unstable nonunion. The nailing was performed in accordance with the instructions furnished by the manufacturers. The nailed specimens were placed in a testing device which alternatively applied a rotation force around the longitudinal axis (± 0.5 Nm), an axial compression-traction force (± 20 N) and a transverse shear force applied at the level of the osteotomy (± 20 N).

Results: This study demonstrated an instability of the three nails when submitted to a rotation force or a shear force: 14 to 28° and 1.6 to 3.4 mm respectively for the RT nail; 8 to 20° and 1 to 3 mm for the S nail; 5 to 15° and 1.7 to 3.2 mm for the ACE nail. The ACE nail appeared to be more stable when submitted to compression-traction force; the S nail accepted a 0.05 to 0.65 mm play which reached 9.7 mm for the RT nail. This instability appeared to result from play in the locking systems.

Discussion: These findings would demonstrate that these nailing systems cannot, in themselves, provide satisfactory primary stability. The experimentally evidenced instability would contribute, probably in association with locally unfavorable physiological or biological conditions, to the failure rate observed when nailing is used alone.

Conclusion: The locking system for tested nails would have to be modified to eliminate play in the assembly before continuing their use for the treatment nonunion of the humeral shaft.