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 of the study: The purpose of this study was to report the clinical and radiographic outcomes a minimum five years after Latarjet-Patte treatment for recurrent traumatic anterior instability of the shoulder in rugby players. It was hypothesised that the Latarjet-Patte procedure fulfils the needs for shoulder stability in rugby players with anterior instability.

Material and methods: Thirty-four players (37 shoulders) were included. Mean age was 23.4 years (17–33). A bone lesion of the glenoid was noted in 73% of the shoulders, a humeral defect in 68%.

Results: Mean follow-up was 144 months (range 68–237). There was no recurrence (dislocation or subluxation). Apprehension persisted in five patients (14%). Sixty-five percent of the patients resumed playing rugby. Only one patient interrupted his sports activities because of the operated shoulder. The Walch-Duplay and Rowe scores were 86 and 93 points on average. The satisfaction rate was 94%. The block healed in 89% of shoulders (3 fractures, 1 nonunion). Twenty-six shoulders (70%) were free of degenerative disease, 11 shoulders (30%) presented stage 1 lesions.

Discussion: In rugby players, anterior instability exhibits characteristic bone lesions of the humerus and glenoid which can be identified as risk factors for recurrent instability. The Latarjet-Patte procedure provides a stable shoulder allowing resumption of rugby player for most patients with no long-term degradation of the shoulder joint. These results are in favour of our strategy to propose the coracoids block systematically for recurrent anterior instability in rugby players.

The long head of the biceps tendon has been proposed as a source of pain in patients with rotator cuff tears. The purpose of this study is to evaluate the objective, subjective, and radiographic results of arthroscopic biceps tenotomy in selected patients with rotator cuff tears. Three hundred seven arthroscopic biceps tenotomies were performed in patients with full thickness rotator cuff tears. All patients had previously failed appropriate nonoperative management. Patients were selected for arthroscopic tenotomy if the tear was thought to be irreparable or the patient was older and not willing to participate in the rehabilitation required following rotator cuff repair. One hundred eleven shoulders underwent a concomitant acromioplasty. The mean age at surgery was 64.3 years. The mean preoperative radiographic acromiohumeral interval measured 6.6 mm. Patients were evaluated clinically and radiographically at a mean 57 months follow-up (range 24 to 168 months). The mean Constant score increased from 48.4 points preoperatively to 67.6 points postoperatively (p < 0.0001). Eighty-seven percent of patients were satisfied or very satisfied with the result. Nine patients underwent an additional surgical procedure (three for attempt at rotator cuff repair and six for reverse prostheses for cuff tear arthropathy). The acromiohumeral interval decreased by a mean

1.3 mm during the follow-up period and was associated with longer duration of follow-up (p < 0.0001). Preoperatively, 38% of patients had glenohumeral arthritis; postoperatively, 67% of patients had glenohumeral arthritis. Concomitant acromioplasty was statistically associated with better subjective and objective results only in patients with an acromiohumeral distance greater than 6 mm. Fatty infiltration of the rotator cuff musculature had a negative influence on both the functional and radiographic results (p < 0.0001). Arthroscopic biceps tenotomy in the treatment of rotator cuff tears in selected patients yields good objective improvement and a high degree of patient satisfaction. Despite these improvements, arthroscopic tenotomy does not appear to alter the progressive radiographic changes that occur with long standing rotator cuff tears.

Background: Rotator cuff tears involving the subscapularis are less common than those involving the posterior superior rotator cuff. The purpose of this study is to report the results of repair of isolated tears of the subscapularis.

Methods: Eighty-four shoulders that had undergone open repair of the subscapularis tendon were reviewed. The mean age at surgery was 53.2 years. The mean interval from onset of symptoms to surgery was 12.5 months. Fifty-seven tears were traumatic, and twenty-seven were degenerative in etiology. Twenty-three of the tears involved the superior third of the subscapularis tendon, forty-one involved the superior two thirds, and twenty were complete tears. Fifty-four shoulders had a dislocation or subluxation of the long head of the biceps tendon, while ten shoulders had a rupture of the long head of the biceps tendon. Forty-eight shoulders underwent concomitant biceps tenodesis; thirteen shoulders underwent concomitant biceps tenotomy; and four shoulders underwent concomitant recentering of the biceps. Patients were evaluated clinically and radiographically at a mean fortyfive month follow-up (range 24 to 132 months).

Results: The mean Constant score increased from 55.0 points preoperatively to 79.5 points postoperatively (p< 0.001). Seventy-five patients were satisfied or very satisfied with the result. Preoperatively, four patients had mild glenohumeral arthritis. Postoperatively, twenty-five patients had mild glenohumeral arthritis and two patients had moderate glenohumeral arthritis. Tenodesis or tenotomy of the biceps tendon at the time of subscapularis repair was associated with improved subjective and objective results independent of the preoperative condition of the biceps tendon.

Purpose: Partial rotator cuff tears are a frequent source of shoulder pain. At times, diagnosis is difficult and treatment unsuccessful. Historical treatment has involved open debridement when conservative treatment has failed. The purpose of this study was to evaluate the results of arthroscopic treatment of deep partial thickness tears of the supraspinatus tendon in patients over 40 years and to assess the healing radiographically.

Method: Forty-nine patients (mean age: 55 years) underwent treatment of a deep partial thickness tear of the supraspinatus tendon. Exclusion criteria: age < 40 years, associated instability, posterosuperior impingement or previous shoulder surgery. Patients were re-examined with a mean 32 months follow-up. For lesions involving less than 50% of the tendon thickness, an acromioplasty and either a debridement (n=39) or a side-to-side repair (n=3) was performed. For lesions involving greater than 50% of the tendon thickness (n=7), an acromioplasty and a trans-osseous repair was performed after completion of the tear. Twenty patients (41%) had an assessment of tendon healing by CT arthrogram, MRI or MR arthrogram, at a minimum 12 months post-operatively.

Results: Results were good or excellent in 90% of patients, and 94% were satisfied. The Constant score improved from 56 to 82 points (p< 0.0001) and the UCLA score improved from 15 to 30 points (p< 0.0001). Of the 31 patients employed preoperatively, three did not return to work; an occupational injury was predictive of a lower Constant score (p=0.02). Four out of 13 (31%) cases involving less than 50% of the tendon thickness healed and all cases (n=7) involving greater than 50% had healed.

Conclusion: Patients over 40 years with an isolated deep partial thickness tear of the supraspinatus tendon benefited both subjectively and objectively from arthroscopic intervention. For deep tears involving < 50% of the tendon thickness, resolution of pain and return to work is possible after acromioplasty and debridement. For deeper tears, completion of the tendon and reattachment to the greater tuberosity enables tendon healing.

The purpose was to evaluate the results of reverse shoulder arthroplasty (RSA) in proximal humerus fracture sequelae (FS).

Multicenter retrospective series of forty-five consecutive patients operated between 1995 and 2003. Types of FS included: cephalic collapse and necrosis (n=8), chronic locked dislocation (n=5), surgical neck nonunion (n=7), severe malunion (twenty), and isolated greater tuberosity malunion (n=3). Twenty-six patients had surgical treatment of the initial fracture and seventeen had non-surgical treatment; thirty-three Delta and ten Aequalis reverse prosthesis were implanted. Mean age at surgery was seventy-three years (range, fifty-seven to eighty-six). Forty-three patients were available for clinical and radiologic evaluation with a mean follow-up of thirty-nine months (range, twenty-four to ninety-five).

Nine re-operations (21%) and ten complications (23%) were encountered, including four infections (leading to two resection-arthroplasties), two instabilities, one glenoid fracture (converted to hemiarthroplasty) and one axillary nerve palsy. Thirty-six patients (83%) were satisfied or very satisfied with their result. The adjusted Constant score improved from 29% preoperatively to 75% postoperatively (p< 0.0001), the Constant score for pain from fou to twelve points (p< 0.0001), and active anterior elevation from 59° to 114° (p< 0.0001). Active rotations were limited. A positive postoperative hornblower test negatively influenced Constant score (forty-two points compared to 61.5 points, p=0.004) and external rotation (−6° compared to 15°, p=0.004). The lowest functional results were observed in surgical neck nonunions (with five complications) and isolated greater tuberosity malunions. In type four fracture sequelae, patients who had an osteotomy or resection of the GT (n=9) had better forward flexion (140° compared to 110°, p=0.026) and better Constant score (sixty-three points compared to forty-six points, p=0.07).

RSA can be a surgical option in elderly patients with FS, specifically for those with severe malunion (type four fracture sequelae) where hemiarthroplasty gives poor results. By contrast, surgical neck nonunions (type three) and isolated greater tuberosity malunions are at risk for low functional results. The surgical technique and the remaining cuff muscles (teres minor) are important prognostic factors. Functional results are lower and complications/reoperations rates are higher than those reported for RSA in cuff tear arthritis.

The purpose of this study is to report the results of arthroscopic Bankart repair following failed open treatment of anterior instability.

We performed a retrospective review of twenty-two patients with recurrent anterior shoulder instability (i.e. subluxations or dislocations, with or without pain) after open surgical stabilization. There were seventeen men and five women with an average age of thirty-one years (range, 15–65). The most recent interventions consisted of sixteen osseous transfers (twelve Latarjet and four Eden-Hybinette), three open Bankart repairs and three capsular shifts. The causes of failure were additional trauma in twelve patients and complications related to the bone-block in thirteen (poor position, fracture, pseudarthrosis or lysis). All patients were noted to have distension of the anterior-inferior capsular structures. Labral re-attachment and capsulo-ligamentous re-tensioning with suture anchors was performed in all cases with an additional rotator interval closure in four patients and an inferior capsular plication in twelve patients; the bone block screws were removed in eight patients.

At an average follow-up of forty-three months (range, twenty-four to seventy-two months), nineteen patients were evaluated by two independent observers. One patient had recurrent subluxation, and two patients had persistent apprehension. Anterior elevation was unchanged, and loss of external rotation (RE1) was 6°. Nine patients returned to sport at the same level; all patients returned to their previous occupations, including the six cases of work-related injury. Eighty-nine percent were satisfied or very satisfied; the subjective shoulder value (SSV) was 83% ± 23%; the Walch-Duplay, Rowe and UCLA scores were 85 ± 21, 81 ± 23 and 30 ± 7 points respectively. The number of previous interventions did not influence the results. Eight patients (42%) were still painful (six with light pain and two with moderate pain).

Arthroscopic revision of open anterior shoulder stabilization gives satisfactory results. The shoulders are both stable and functional. While the stability obtained with this approach is encouraging, our enthusiasm is tempered by some cases of persistent pain.

Purpose of the study: Depending on the series, fractures of the anteroinferior glenoid labrum have been reported in 3% to 90% of patients with anterior shoulder instability. These fractures disrupt the physiological glenoid concavity and shorten the effective length of the glenoid arch. Indications for treatment depend on the size of the fragment and range from osteosynthesis to resection or suture. We hypothesized that these lesions could be treated arthroscopically (Bankart procedure with fragment suture). The purpose of this work was to analyze clinical and radiological outcome observed in nine patients with anterior instability associated with significant glenoid fracture.

Material and methods: This was a monocentric study of a continuous series of nine glenoid fractures associated with anteromedial dislocation in nine patients (three women and six men), mean age 35.5 years (range 17–75 years). Preoperatively, all of the fractures were considered to involve more than 25% of the glenoid surface. After detaching the capsulolabral lesion with the bony fragment and avivement of the anterior border, the Bankart procedure was performed with anchors and resorbable sutures. The shoulder was strapped for six weeks with passive rehabilitation (pendulum movements) initiated early.

Results: Mean follow-up was 27 months (range 12–48 months). There were no cases of recurrent instability. Seven patients were very satisfied and two were satisfied. Eight patients were able to resume their sports activities at the same level. Apprehension developed in all patients. At last follow-up, joint motion was normal for eight of the nine patients, the Duplay score was 100 for eight patients and 45 for one. All bony lesions healed in an anatomic position (six analyzed with plain x-rays and three with CT scan).

Discussion and conclusion: This short series demonstrates that glenoid fractures can be treated arthroscopically with concomitant treatment of the capsulolabroligament complex in order to reconstruct the glenoid arch, an essential element for restoring shoulder stability. It is thus necessary to identify bony lesions preoperatively to determine the most appropriate therapeutic approach. A long-term follow-up will be useful to assess the rate of recurrent instability and validate this therapeutic option.

Purpose: Appropriate treatment of full-thickness tears of the rotator cuff with subacromial impingement remains a subject of debate. Considering that in most patients, spontaneous tears of the long biceps tendon reduces the pain and that subacromial osteoarthritis is well tolerated by many patients, we proposed arthroscopic tenotomy of the long biceps in this indication with the aim of relieving pain. We report here the long-term outcome.

Material and methods: Between 1988 and 1999, 307 arthroscopic tenotomies of the long biceps tendon were performed in patients with unrepairable tears of the rotator cuff tendons (massive full thickness tears, old patients, non-motivated patients). The procedure was isolated in 64% and associated with acromioplasty in 36%. All patients were given prior medical treatment. Mean age at surgery was 64.3 years. The preoperative subacromial height was 6.6 mm. The tendon lesion was an isolated tear of the supraspinatus in 31%, tears of two tendons in 44.6% and tears of three tendons in 21.8%, and isolated tears of the subscapularis in 2.6%. Mean follow-up was 57 months (24–168).

Results: The Constant score improved from 48.4 to 67.6 points (p< 0.001). Glenohumeral osteoarthritis (Samilson) increased from 38% to 67% of the shoulders postoperatively. Association with acromioplasty improved the objective and subjective result solely in the group of isolated tears of the supraspinatus. The size of the tear and the degree of fatty degeneration of the rotator cuff muscles had a statistically significant influence on functional and radiographic outcome (p< 0.001) while time since surgery had no effect on radiographic outcome (p< 0.001).

Discussion: This simple easy-to-perform procedure yielded pain relief at rest and also nighttime pain. It can be recommended for massive rotator cuff tears with sub-acromial impingement in elderly or poorly-motivated patients whose pain fails to respond to medical treatment. This procedure does not allow recovery of shoulder motion or force.

Purpose: Failure of the glenoid component is the main complication of total shoulder prostheses. When surgical revision is necessary, the surgeon has the option of a new implantation or non-prosthetic plasty (glenoido-plasty). The purpose of the present work was to analyse results obtained with these two techniques in order to propose proper indications.

Material and methods: This retrospective study included 16 patients, mean age 62 years at revision surgery. Fialures included loosening of a cemented glenoid implant (n=9) and failure of non-cemented implants (3 defective anchors, 4 unclipped polyethylene inserts). Mean time to revision was 39 months (2–178) after primary implantation. A new glenoid implant was cemented in nine patients (group A). Seven patients (group 2) had glenoidoplasty with an iliac graft in four.

Results: A mean follow-up of 37 months (19–73), the Constant score had improved from 18 points before revision to 52 points (+34). Two patients experienced a complication requiring a second revision (infection, instability) and one patient underwent subsequent surgery for biceps tenodesis. For the group with glenoidoplasty with iliac graft, insertion of an inverted prosthesis was achieved during a second operative time. In group 1, the mean Constant score at last-follow-up was 63 points (+45) with the pain score of 11, movement score of 29. In group 2, the mean Constant score was 37 (+19) with pain at 6 and motion at 16. In this group, the mean score was 48 points with a glenoid graft and 21 points with simple implant replacement.

Discussion: Revision surgery for a failed glenoid implant remains a difficult procedure but can be effective for pain relief and improved motion score. The small number of patients in this series makes it difficult to perform statistical analysis but the results do point in favour of prosthetic reimplantation when the bone stock is sufficient. For other patients, a graft would be preferable to simple implant removal. This would allow secondary revision if possible.