Purpose of the study: Arthroscopic repair of rotator cuff tears is a painful technique. We conducted a randomized controlled trial to analyze prospectively the level of postoperative pain after this procedure and to assess the efficacy of three anti-pain techniques.

Material and method: This prospective randomized study included 140 patients attending two centres specialized in shoulder surgery who underwent arthroscopic rotator cuff repair from January to November 2008. Preoperatively, patients were assigned to three anti-pain techniques: interscalenic catheter (KTIS) (n=44 patients), subacromial catheter (KTSA) (n=64 patients), unique subacromial injection of 2% ropivacaine (INJ) (n=32 patients). The procedure was performed under general anaesthesia in all cases. Criteria used to evaluate the efficacy of the anti-pain techniques were: pain as assessed by a visual analogue scale (VAS) the day before operation to the 30th postoperative day; daily consumption and total dose of opiates; subjective satisfaction with pain management assessed on day 30.

Results: The pain profile was the same as demonstrated last year with a painful displacement on day 1 and progressive decline in pain through day 30 when the pain level was lower than preoperatively. Two risk factors were noted: isolated distal tears of the supraspinatus and concomitant acromioplasty. On day 0, the VAS was ≤ 1.7 in the KTIS group versus 3.6 and 3.5 respectively in the KTSA and INJ groups (p< 0.05). On day 1, the respective values were 3.1, 3.5 and 3.8 (NS). On day 2 and beyond, there was no difference between the three groups. Overall morphine consumption on day 0 was 10.8 mg in the INJ group versus 6.9 and 2.1 mg in the KTSA and KTIS groups, with a significant difference between the INJ and the KTIS groups. There was no difference beyond day 1. Patient satisfaction with pain management during the first 30 postoperative days reached 94.4, 82.9 and 84% respectively for INJ, KTIS and KTSA, with no statistically significant difference between the groups.

Conclusion: The interscalenic catheter technique is more effective than the two other techniques. The subacromial catheter is not better than a single injection of local anaesthetic and is associated with greater risk, suggesting its use should be revisited.

Purpose of the study: Orthopedic treatment is generally proposed for minimally displaced fractures of the scapula. Surgery is indicated in the event of medialization or disorientation of the glenoid cavity. The purpose of this study was to identify rules for management of problematic cases.

Material and methods: This retrospective study included 27 patients, 22 men and five women, mean age 46.7 years (range 22–83 years). The fracture was limited to the scapula in 17 and was part of thoracic syndrome in ten. Injury to the plexus was noted in three patients. Associated lesions were noted in 55% of patients. Orthopedic treatment was proposed for 15 patients (group 1) and surgical treatment for 12 (group 2): neck osteosynthesis (n=4), clavicle fixation (n=5), combined osteosynthesis (n=3).

Results: Mean follow-up was 47.3 months; 21 patients were reviewed (four lost to follow-up, two deaths). Per primam healing was achieved for all fractures. There were no complications related to the surgical procedure in group 2 and no secondary displacement in either group. Mean time to resumed occupational activity was four months (range 0.2–25 months): 2.2 months (1–5 months) in group 1 and 5.5 months (0.2–25 months) in group 2. The age and gender weighted Constant score for the overall series was 96.2% (range 80–100%) with 81% excellent and very good functional outcomes. In group 1, the Constant score was 95.4% (81–100%) with 70% excellent and very good functional outcomes. It was 97% (80–100%) in group 2 with 91% excellent results. At last follow-up, there was only one case of Samilson grade 2 osteoarthritis.

Discussion and conclusion: The functional outcome observed after treatment of scapular fractures is satisfactory. Orthopedic treatment should be reserved for non-displaced fractures. If there is significant medial offset of the glenoid cavity or instability, osteosynthesis of the scapular neck is indicated, possibly with reinforcement by fixation of the clavicle. Isolated osteosynthesis of the clavicle stabilizes the scapular ring but does not reduce the scapular fracture.

Purpose of the study: Resection of the lateral quarter of the clavicle is an effective treatment for painful acromio-clavicular arthropathy. An open procedure can create a disgraceful or painful scar or be associated with secondary instability and muscle weakness. Arthroscopic resection would avoid these complications.

Material and methods: Between 1992 and 2002, 35 patients were treated arthroscopically for isolated painful acromioclavicular arthropathy after failure of medical treatment. Twenty-seven patients (mean age 44 years) were reviewed clinically (Constant score, subjective outcome, stability) and radiographically (quality of resection, coraco-clavicular space, ossification) at more than two years follow-up. Acromioplasty was performed in all cases to improve exposure in 14 or because of an aggressive acromion (n=7). A scarf orthesis was worn to prevent pain. Self-controlled rehabilitation exercises were proposed.

Results: There were no postoperative complications excepting one case of retractile capsulitis in the context of an occupational accident. Excluding this case, mean sick-leave was five weeks (range 3–20). At mean follow-up of seven years, all scars were pain free and minimally visible. There was no problem with frontal or sagittal instability. The Constant score improved 24 points on average compared with the preoperative score with a significant gain for pain (+9 points). Two patients were disappointed: one retained a sequellar capsulitis and one persistent pain after insufficient resection. On average, the resection measured 10 mm (range 6–20 mm). Three patients had an insufficient posterosuperior resection. The coracoclavicular interval remained unchanged in all cases and four patients presented secondary ossification of the resection zone. Two patients were sensitive to acromioclavicular palpation with a positive cross arm test (one had an insufficient resection and the other ossifications at last follow-up).

Discussion and conclusion: Arthroscopic acromio-clavicular resection reduced operative morbidity. The operation does not destabilize the joint. The total joint surface area can be resected to avoid a residual pos-terosuperior impingement which would be a source of persistent pain. The presence of secondary ossifications in the zone of resection has led us to propose NSAID treatment although the prophylactic effect remains to be demonstrated.

Purpose of the study: The revision modular femoral prosthesis (PFM-R) (Centerpulse) uses a cone-shaped straight femoral stem with winglets for press-fit revision fixation in the femoral shaft. The risk of secondary migration further into the shaft is well known. The purpose of this paper was to assess the degree of PFM-R stem migration and to search for predictive factors in order to better ascertain the limits of this type of revision anchorage in the femoral shaft.

Material and methods: Fifty-three files (48 patients) were reviewed retrospectively at minimum none months follow-up. Mean patient age was 56.6 years. Revision was required for loosening (SOFCOT classification): grade 1 (n=5), grade 2 (n=8), grade 3 (n=17), grade 4 (n=10). For 13 hips, the implant to be replaced was not cemented (monobloc stem, infection), or a first-intention PFM-R.

Results: Mean migration was 4.1 mm (0–17 mm), less than 5 mm in 73.5% of cases. There was no correlation between migration and SOFCOT grade. Conversely, there was a significant difference in migration between the grade 1 and grade 3B and between Paprosky grade 1 and 4 (p=0.05). The degree of migration was correlated with the length of the persistent isthma (p< 0.0001), with the morphology of the isthma [conic/inverted conic (p< 0.01), conic/cylindric (p< 0.051)], with the cortical index (p=0.06), the length of the anchor wings (p=0.051), but not with the length of the femorotomy bridge. The length of the wing anchorage was correlated with the length of the persistent isthma (p=0.002) and with the morphology of the isthma [(conic/inverted conic p=0.02), cylindric/inverted conic (p=0.02)], but did not increase significantly with bridging length. There was a trend towards migration in osteoporotic bone (p=0.07).

Discussion and conclusion: Use of a straight stem for anchorage in the femur is associated with secondary migration which depends on the quality of the bone in the anchorage zone and the extent of the press-fit. The persistence of a cone-shaped or cylindrical isthma measuring greater than 4 cm associated with a cortical index greater than 45% and a long wing anchorage can provide excellent primary stability. It would be useless to use long stems since they do not increase the quality of anchorage. The absence of an isthma and the presence of osteoporosis are limitations for this concept.

Purpose: The purpose of this study was to assess long-term functional outcome after arthroscopic acromioplasty for full-thickness rotator cuff tears, to evaluate the efficacy of complementary procedures (biceps tenotomy, extended acromioclavicular resection), and to examine the course of anatomic lesions.

Material and methods: From 1988 to 1994, 141 full-thickness rotator cuff tears were treated by arthroscopic acromioplasty. Ninety-eight patients, mean age 60 years, were reviewed clinically, radiographically, and sonographically at more than eight years. The mean preoperative Constant score was 48.5 points. The tear involved the supraspinatus in 18 cases, the supraspinatus and infraspinatus in 40, the supraspinatus and the subscapularis in ten, and all three tendons in 20. Coronal extension showed a distal tear in four, an intermediate tear in 52, and a retracted stump in 32. Systemic acromioplasty was associated in 36 patients with tenotomy of the long head of the brachial biceps and in 44 with acromioclavicular extension.

Results: At mean follow-up of 10.7 years (8–13.5), the mean Constant score was 60 points. The clinical outcome was excellent or good in 39.7%, fair in 45.5%, and poor in 14.8. 62.5% of the patients were satisfied or very satisfied. The height of the subacromial space was 5.19 mm at last follow-up compared with 4.3 mm preoperatively. The antalgesic effect of biceps tenotomy was significant when the initial acromiohumeral space was less than 5 mm. This procedure did not produce any significant change in the subacromial height or development of osteoarthritis at last follow-up. Sonography showed stability of the size of the tear in 83.8% of the cases. The results were significantly less satisfactory when the initial tear involved the subscapularis or all three tendons.

Conclusion: The clinical results of arthroscopic acropmioplasty for full-thickness tears show long-term stability. Biceps tenotomy improves the antalgesic effect significantly, particularly if the subachromial space measures less than 5 mm preoperatively, without causing significant radiological degradation. Extension to the acromioclavicular level should be systematic in patients with acromioclavicular pain preoperatively and/or radiological anomalies.

Purpose: In 1988, the conclusions of the SOFCOT symposium appear to condemn use of cemented implants for revision of loosened femoral elements. Eleven years later, at the 1999 Symposium, Vidalain demonstrated that cementing remains a reasonable alternative. The purpose of this retrospective analysis was to estimate long-term results of revisions using a long cemented stem without bone stock reconstruction.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent revision surgery with this technique. We retained for analysis 95 hips (15 lost to follow-up 25 deceased patients) in 66 women and 29 men, mean age 70 years at revision (42–86). The preoperative Postel Merle d’Aubigné (PMA) function score was 8/18. Femoral implants in place had been cemented in 80% of the hips. Using the SOFCOT criteria, 65% of the loosenings were stage II, 29.5% stage III. All were aseptic loosenings and the same revision technique was used in all cases: removal-replacement of both prosthetic elements, use of a long cemented stem without associated grafting.

Results: Mean follow-up was eight years (60–157). Thirty nine percent of the patients had early postoperative complications. The mean function score at last follow-up was 14.8/18 with 62.4% of the outcomes considered good or very good. Age, restitution of the rotation centre, quality of cementing, and stem/femur fit influenced the result significantly. Radiographic analysis showed a progressive lucent line in 32% of the hips, only 36% of the femoral stems were totally free of lucent lines. Cumulative actuarial survival was 87% at 14 years and fell to 65.5% considering certain radiographic loosening as the endpoint.

Conclusion: Use of a long cemented femoral stem for revision total hip arthroplasty provides acceptable long-term functional outcome. Results are significantly affected by imperfect technique. This type of implant, which destroys any hop for restoration of bone stock, should be reserved of elderly subject where a more “ambitious” procedure were be too risky.

Purpose: Acetabular reconstruction is particularly challenging in case of acetabular loosening with important loss of bone stock. The purpose of this retrospective study was to estimate long-term results after revision procedures using a fragmented allograft and a supporting ring.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent this procedure. Ninety-five files were reviewed (15 patients were lost to follow-up and 25 died). The 95 patients retained for analysis were 66 women and 29 men, mean age at surgery 70 years (range 42–86). The preoperative functional score (PMA) was 8/18. The acetabular implants in situ had been cemented in 62% of the cases and non-cemented in 38%. According to the SOFCOT criteria, 79% of the loosenings were associated with grade 3 bony lesions, 15.8% with grade 4 lesions and 5.2% with grade 2 lesions. In all cases, the acetabulum was reconstructed with fragments of allografts. An Eichler ring was used in 56% of the cases, a Ganz ring in 25%, and a Muller ring in 19%.

Results: Mean follow-up was eight years (60–157 months); 39% of the patients developed early postoperative complications including one dislocation and two haematomas. Mean functional score at last follow-up was 14.8/18 with 64% good or excellent results. Reconstruction of the centre of rotation was the only factor significantly affecting results. Radiographically, 85% of the cups presented no sign of loosening at last follow-up. The grafts were considered to be assimilated or unchanged in 81% of the cases, with partial or total lysis in 19%. Actuarial analysis of cumulative survival, considering surgical revision or clinical and radiographic loosening as the endpoint was 87% at 14 years.

Discussion: Fragmented allografts can be perfectly stabilised with a supporting ring to reconstitute bony stock of the acetabulum. Long-term clinical and radiographic results are encouraging.

Purpose: Arthroscopic treatment of calcified tendinopathy is classically performed in two times: exploration of the glenohumeral joint followed by subacromial arthroscopy to evacuate the calcification. In our experience, glenohumeral arthroscopy has only exceptionally provided a diagnostic element. In addition, the principal complication of this procedure is retractile capsulitis which may be a secondary effect of glenohumeral aggression. We conducted a retrospective analysis to assess the effect of systematic exploration of the glenohumeral joint.

Material and methods: Two homogeneous groups of patients were identified. Group 1 included 32 patients who had had glenohumeral arthroscopy then resection of the calcifications using a bursoscope. Group 2 included 32 patients whose treatment was limited to subacromial arthroscopy for resection. The preoperative Constant score (52 in group 1 and 54 in group 2), disease duration (34 and 40 months respectively), and localisation of the calcification were comparable for the two groups. Acromioplasty was not performed in these patients. All were reviewed at minimal follow-up of 6 months for assessment of the Constant score and a radiography study.

Results: At last follow-up the mean Constant score was 70 in group 1; calcifications had disappeared in 84% of the cases and delay to recovery (total pain relief and return to work) was 11 months. There were 4 cases of postoperative capsulitis (12.5%). The mean Constant score was 79 in group 2; calcifications had disappeared in 78% of the cases and delay to recovery was 6.5 weeks (p = 0.0001). There was one case of retractile capsulitis (3%). In group 1, glenohu-meral arthroscopy did not lead to the discovery of specific elements except in two cases where it identified partial tear of the deep aspect of the supraspinatus. Acromioplasty was never performed.

Discussion-Conclusion: Systematic glenohumeral arthros-copy is not warranted in patients undergoing treatment for calcified tendinopathy. The fact that glenohumeral exploration did not disclose any particular element and had no effect on healing and capsulitis rates favours the use of a subacromial approach alone.