PURPOSE

We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy.

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: The purpose of this study was to analyse outcome of shoulder prostheses after radiotherapy, to define a specific clinicoradiological entity, and evaluate incidence of complications.

Material and methods: Fourteen shoulder prostheses were implanted in 13 women who had been treated for breast cancer with complementary radiotherapy and one man treated for Hodgkin’s lymphoma. The time from radiothearpy to implantation was 16 years, seven months. Two forms were identified on the preoperative x-rays: seven cases with typical avascular osteonecrosis according to the Arlet and Ficat classification, and seven cases with a radiographic presentation of arthritis or degenerative disease. Humeral prostheses were used in five cases and a total shoulder arthroplasty in nine.

Results: Four implants had to be removed, three for sepsis, and five patients required revision surgery. The mean postoperative Constant score for the ten prostheses still in place was 53.1 points with a mean elevation of 111° at three years seven months follow-up. The gain in pain score was 8.5 points with a mean result of 10.9 points. The results were different depending on the initial radiological form, with less favourable outcome observed in typical osteonecrosis.

Discussion: This study demonstrated a particular radio-clinical entity independent of classical osteonecrosis of the humeral head. The surgical procedure was more difficult and the outcome was less satisfactory than in the classical forms with a high rate of complications.

Purpose: We analysed knee prostheses preserving the posterior cruciate ligament (or both cruciates) performed after tibial osteotomy. We determined outcome as a function of any tibial callus deformation created by the tibial osteotomy.

Material and methods: This retrospective study included a consecutive series of 56 knee prostheses with preservation of the posterior cruciate ligament (n=43) or both cruciate ligaments (n=13). The patients had undergone prior tibial osteotomy for valgisation (n=47) or varisation (n=9). Seven groups were defined as a function of the preoperative tibial angle prior to TKA. The angle were measured with telegonometry. Minimum follow-up was one year, mean follow-up 4.1±2.8 years.

Results: The tibial tuberosity was raised in 15 cases. If there was major valgus or rotation deformation, tibial osteotomy was associated with the prothesis (n=9). At last follow-up, the mean IKSg, IKSf and HSS scores were 81.5, 77.6, and 82.3 respectively. The mean femorotibial angle was 177.4±4.2°. The mean tibial angle was 87.8±3° and the mean femoral angle was 89.8±2°. Preoperative tibial deformation was not influenced by clinical results. In case of preoperative tibial deformation situated between 5° valgus and 5° varus, operation time, blood loss, and femoraotibial axis at last follow-up were not significantly different. To correct for tibial valgus greater than 7°, tibial osteotomy was associated with prosthesis implantation during the same operative time in six out of thirteen cases. For preoperative tibial varus greater than 5°, the femorotibial axis was less well corrected.

Discussion: These clinical results were comparable to those reported in other series with preservation or not of the posterior cruciate ligament. Correction of the femorotibial angle was less satisfactory than in certain series, but the deformation and the surgical history were among the most marked in the literature. Preservation of the posterior cruciate ligament (or both cruciates) appears to have increased the technical difficulties for upper tibia exposure and position of the tibia implant. For tibial callus with valgus greater than 7°, the prostheses cannot be expected to provide a solution alone and osteotomy should be associated. For tibial callus with 5° or more varus, the indication for associated tibial osteotomy merits discussion.

Purpose: The purpose of this study was to analyse the factors affecting outcome after prosthesis implantation for osteonecrosis of the humerus in order to ascertain details concerning the indications for humerus or total prostheses in this condition.

Material and methods: Forty-seven women and 27 men, mean age 57 years with osteonecrosis of the humerus underwent surgery for implantation of 80 shoulder prostheses. According to the Arlet and Ficat classification as modified by Cruess there were five grade II, fifteen grade III, 41 grade IV and fourteen grade V shoulders, with five unclassifiable shoulders. there were 14 supraspinatus tears and five infraspinatus tears. The 26 total shoulder prostheses and 54 humeral prostheses were reviewed at a mean 47 months follow-up. Pre-operative x-rays were available for 65 shoulders and postoperative x-rays for 58.

Results: The subjective outcome was considered good irrespective of the grade (very satisfied 60%, satisfied 30%, dissatisfied 4%). The mean postoperative Constant score was 70 ± 15. The preoperative score was lower for more advanced disease but the difference was not significant at postoperative assessment. The total prosthesis provided better results in grade V shoulders and the hemiprosthesis in grade II and III shoulders.

The result of the humeral prostheses depended on the grade of necrosis. The postoperative Constant score was lower for advanced necrosis with lower scores for motion, force and pain (which was not influenced by age). At last follow-up, 31% of the x-rays revealed a significant narrowing of the glenoid-head space. The clinical outcome was significantly less satisfactory for all Constant scores. Rotator cuff tears, preoperative stiffness favoured glenoid wear. Tears of both cuff tendons led to poor outcome. Bone collapse with impaction of the head into the glenoid and medialisation of the humerus was a significant factor predictive of less satisfactory outcome.

Discussion: The grade of necrosis is a determining factor for indications for humerus or total shoulder arthroplasty for the treatment of osteonecrosis. Our objective results lead us to recommend a humeral prosthesis for grade II and III patients and a total shoulder arthroplasty for grade V patients. For grade IV patients, the choice depends on patient age, shoulder stiffness, the status of the cuff, and most importantly, collapsus of the head of the humerus with impaction-medialisation of the humerus.

Purpose: There are three main causes of failure after valgisation osteotomy of the tibia requiring repeated osteotomies: insufficient valgus, excessive valgus, or loss of the valisation correction after a variable delay. The purpose of this study was to evaluate outcome after repeated oseotomies performed in relatively young patients or too active to propose arthroplasty. The technical problems were different for each aetiology.

Material and methods: The series included 47 knees operated on between 1974 and 1998 after a first osteotomy performed at a mean age of 46 years. Mean delay between the two operations was five years (1 to 12). A medial closure osteotomy had been performed at the first operation in 34 cases and a lateral opening osteotomy in 13. For the 19 knees with valgus, the second osteotomy was a medial closure in 14 and a lateral opening in five. A repeat valgisation was performed in 28 cases, 18 by lateral closure, one by medial opening and nine by curviplanar osteotomy. The IKS score was determined to assess function. The femoraotibial axes (HKA angle) were determined on full stance views. The Ahl-back osteoarthritis grading was used. For 17 patients who had undergone operations in other institutions, exact measurements were not always available concerning the preoperative status and the initial correction.

Results: The overall IKS score for function improved in 87% of the cases with a mean follow-up of five years. The IKS knee score improved from 73 to 89 points and the IKS function score from 65 to 81 points. For the 19 over-corrections, the mean HKA angle was changed from 190° to 184°. For the 28 under-corrections, the mean HKA angle was changed from 173° to 182°. The tibial tilt remained unchanged at 7° as did lateral gapping at 3°. Delay to consolidation was a mean 96 days.

Discussion: Revision osteotomies performed for correction defects should be distinguished. For these procedures, it would be logical to expect a good result if a 3 to 5 degree valgus is achieved. Revisions after a long period (33 cases) are different; required for wear, these cases correspond to progressive loss of the initial osteotomy effect. These patients are often candidates for prosthesis if seen after 70 years. Good results can however be obtained with a second osteotomy irrespective of the initial technique. We prefer reoperating with medial opening after initial lateral closure.

Purpose: Several techniques have been described for the treatment of unstable fractures of the upper humerus. None appear to be appropriate for subtuberosity fractures, associated or not with a fracture of the trochiter or impacted valgus cephalotuberosity fractures, allowing a stable fixation with anatomic reduction while preserving blood supply to the bone fragments. For the last year, we have studied prospectively a percutaneous minimally invasive technique for this type of fracture. Our preliminary results are analysed here.

Material and methods: We used this technique for 12 patients aged 30 to 87 years with five displaced subtuberosity fractures, six subtuberosity fractures with a trochiter fracture and one impacted valgus cephalotuberosity fracture. Excepting the cephalotuberosity fracture, the joint fragment of the head was reduced by external manipulation under image amplifier guidance. Fixation was achieved with two 25/10 threaded pins inserted percutaneously in retrograde fashio from the anterolateral cortical to the humeral shaft. For eight cases, a third pin was inserted percutaneously from the trochiter to the medial cortical of the humerus. When percutaneous reduction of the trochiter was impossible (three cases) and for the cephalotuberosity fracture, we used a minimal transdeltoid lateral incision to reduce the trochiter and achieve reduction.

Results: Reduction was very satisfactory in all cases. There was one superficial infection that required pin withdrawal at three weeks leading to the only secondary displacement that was minimal and tolerable. We removed the pins after a mean two months. There were no nonunions. Seven patients have a follow-up greater than six months and exhibited a Constant score of 87% (71% to 100%).

Discussion: This techniques has provided very satisfactory results for rapid and stable fixation of the cephalic fragment without loss of blood supply and with a material easy to remove.

Conclusion: These early results are very encouraging and incite us to pursue this technique and analyse long-term results.