The complications of prostheses for fractures of the proximal humerus are understudied because the experience of each shoulder surgeon is limited and a standardised registration protocol is not yet available. A prospective study on complications in shoulder arthroplasty for fracture is, therefore, essential to explore variables that influence outcome. The purpose of this study is to report our experience with complications following arthroplasty for proximal humeral fractures.

In a multicenter study, four hundred and six patients treated with arthroplasty for proximal humeral fracture were prospectively followed during a nine year period; three hundred patients with a minimum of two years follow-up, at an average of forty-five months (range, 24–117), were available for review. Objective results were graded with the Constant score and range of motion. Subjective results were reported according to patient satisfaction.

At follow-up, the average Constant score was fifty-four points (range, 14–95) and active forward elevation was 103° (range, 10°–180°). Eighty-one percent of patients were satisfied or very satisfied. We observed a 59% rate of late (after three months) complications, including a high rate of tuberosity-related complications (72% malunion or nonunion). Initial tuberosity malposition was present in 35% of the patients. Secondary migration despite initial good positioning was observed in 24%.

Tuberosity complications were associated with poor final Constant score, poor range of motion and shoulder pain (p=0.001 for all items). A re-operation was performed in 5.3% of the cases. Patients who were mobilised according to the ‘early passive motion’ concept had double the incidence of secondary tuberosity migration, compared to those that were initially immobilised (14% versus 27%, p=0.004). Tuberosity complications are the most frequent late complication and they are associated with poor functional results. It is, therefore, incumbent upon the surgeon to maximise healing with adequate fixation of the tuberosities, followed by sufficient immobilization.

Purpose of the study: The hypothesis of this study was that age over 50 years is not a contraindication for hamstring reconstruction of the anterior cruciate ligament (ACL).

Material and methods: Study period: September 1998 to September 2003. Type of study: prospective, consecutive series. The patient included in this study met the following criteria: age over 50 years at surgery; chronic anterior laxity, alone or associated with meniscal injury; one or more episodes of instability; absence of preoperative medial femorotibial osteoarthritis; no prior history of ligament surgery on the same knee. The same technique was used for all patients: four-strand single fiber arthroscopic hamstring ligamentoplasty using a blind femoral tunnel drilled via an anteromedial arthroscopic portal. All grafts were fixed with resorbable screws in the femur and tibia. The same rehabilitation protocol was used for all patients. IKDC scores were recorded. Plain x-rays were obtained (single leg stance ap and lateral views) as well as 30° patellar and passive Lachman (Telos).

Results: Eighteen patients were included, 12 women, mean age 59.5 years (range 51–66 years. Mean follow-up was 35 months (range 12–59 months). There were no cases of recurrent ACL tears, no loss of extension. Three patients complained of hpoesthesia involving the internal saphenous nerve and two patients presented postoperative knee pain. At last follow-up, the overall IKDC score was 7A, and 11B. All patients considered they had a normal or nearly normal knee. All were satisfied or very satisfied. None of the patients presented instability. The Lachman-Trillat test was hard stop in 13 cases and late hard stop in 5. The pivot test was negative in 16 knees and questionable in two. Mean residual differential laxity was 3.3 mm (range −1 mm to +7 mm) in passive Lachman. There was no evidence of osteoarthritic progression on the x-rays.

Discussion and conclusion: This series demonstrated that age over 50 years is not a contraindication for arthroscopic hamstring ACL grafting. This operation can be used to restore knee stability.

Purpose: The purpose of this work was to evaluate the quality of cemented humeral stem fixation. We analysed the incidence and influence of humeral lucent lines and loosening after implantation of a shoulder prosthesis as a function of aetiology (fracture versus scapular osteoarthritis) and glenoid status (total versus partial humeral prosthesis).

Material and methods: This retrospective series included 1842 first-intention shoulder prostheses reviewed at mean five years (2–10). We selected patients whose initial diagnosis was fracture of the superior portion of the humerus (n=300) and centred osteoarthritis (n=767). All stems implanted for fracture were cemented. For osteoarthritis, there were 610 total prostheses and 157 simple humeral prostheses: 752 stems were cemented and 15 were implanted without cement. The Constant score and radiographic results (AP and lateral view at least) were noted.

Results: For cemented stems, the incidence of radiographic lucent lines and loosening was significantly higher in fractures (40% and 10% respectively) than in centred osteoarthritis (14% and 1%). Lucency and loosening did not influence functional outcome in patients with centred osteoarthritis but had a significantly negative effect on final outcome in fractures. For fractures, the incidence of lucent lines was correlated with migration of the tubercles. For osteoarthritis, there was no difference between total and partial prostheses in terms of loosening, but the functional outcome was significantly better with total prostheses.

Conclusion: Fixation of the humeral implant with cement remains the gold standard for shoulder prostheses implanted for centred osteoarthritis. However, cement fixation yields disappointing results for fractures: defective fixation of the humeral stem is correlated with migration of the tubercles. For osteoarthritis, there are not more lucent lines with a total prosthesis which provides the better functional results.

Purpose: We report a new pathological entity involving the long head of the biceps tendon (LHBT). In this entity, the hypertrophic LHBT becomes incarcerated in the joint during limb elevation, leading to shoulder pain and blockage.

Material and methods: Twenty-one patients were identified. These patients presented hypertrophy of the intra-articular portion of the LHBT with tendon incarceration at limb elevation. The diagnosis was confirmed during open surgery (n=14) or arthroscopy (n=7). All cases were diagnosed in patients with an associated cuff tear. Treatment consisted in resection of the intra-articular portion of the LHBT and appropriate treatment of the cuff.

Results: All patients had anterior shoulder pain and deficient anterior flexion because of the incarcerated tendon. An intra-operative dynamic test consisted in raising the arm with the elbow extended, providing objective proof of the tendon trapped in the articulation in all cases. The positive “hour glass” test produce a fold then incarceration of the tendon between the humeral head and the glenoid cavity. Tendon resection after tenodesis (n=19) or biopolar tenotomy (n=2) yielded immediate recovery of passive complete anterior flexion. The Constant score improved from 38 points preoperatively to 76 points at last follow-up.

Discussion: The “hour glass” long biceps tendon is caused by hypertrophy of the intra-articular portion of the tendon which becomes unable to glide in the bicipital groove during anterior arm flexion. 10°–20° defective motion, pain at the level of the bicipital groove, and images of a hypertrophic tendon are good diagnostic signs. The “hour glass” LGBT must not be confused with retractile capsulitis. The definitive diagnosis is obtained at surgery with the “hour glass” test which shows a fold and incarceration of the tendon during anterior flexion with an extended elbow. Simple tenotomy is insufficient to resolve the blockage. The intra-articular portion of the tendon must be resected after bipolar tenotomy or tenodesis.

Conclusion: Systematic search for “hour glass” LHBT should be undertaken in patients with persistent anterior shoulder pain of unexplained origin associated with deficient anterior arm flexion.

Purpose: We hypothesised that the rate of tendon healing after arthroscopic repair of full-thickness tears of the supraspinatus is equivalent to that obtained with open techniques reported in the literature.

Material and methods: We studied prospectively a cohort of 65 patients with arthroscopically repaired full-thickness tears of the supraspinatus. The patients were reviewed a mean 19 months (12–43) after repair. At arthroscopy, patients were aged 59.5 years on average (28–79). Bone-tendon sutures were performed with resorbable thread and self-locking anchors positioned on the lateral aspect of the humerus. Repair was protected with an abduction brace for six weeks. Forty-one patients (63%) accepted an arthroscan performed six months to two years after arthroscopy to assess tendon healing.

Results: Ninety-four percent of the patients were satisfied with the outcome. The mean Constant score was 51.6±10.6 points preoperatively and 80.2±13.2 at last follow-up (p< 0.001). The arthroscan showed that the rotator cuff had healed in 70% of the cases (29/41). The supra-spinatus had not healed on the trochiter in eight cases (25%) and was partially healed in two (5%). The size of the residual tendon defect was less than the initial tear in all cases except one. The rate of patient satisfaction and function was not significantly different if the tendon had healed (Constant score 81.3/100, satisfaction 93%) or if there was a residual tendon defect (Constant score 77.5/100, satisfaction 92%). Shoulder force in patients with a healed tendon (6±1.9 kg) was better than in those with a tendon defect (4.5±2.8 kg), but the difference was not significant. Factors affecting tendon healing were age > 65 years (43% healing, p< 0.02), and wide tears.

Conclusion: Arthroscopic repair of isolated supraspinatus tears enables tendon healing in 70% of cases as demonstrated by arthroscan. This rate was equivalent to those reported in historical series of open repair. Patients aged over 65 years had significantly less satisfactory healing. The absence of tendon healing does not compromise functional and subjective outcome despite reduced force.

Purpose: The purpose of this study was to compare the bone-patellar-tendon-bone (BPTB) and the four-strand hamstring grafts for anterior cruciate ligament (ACL) reconstruction in patients aged less than 40 years and to evaluate the influence of meniscectomies performed before, during, or after the ACL reconstruction.

Material and methods: Between March 1997 and March 2000, 114 patients who underwent ACL reconstruction (58 BPTB then 56 hamstring) were included. Exclusion criteria were: peripheral ligament repair or associated bone procedures, surgical revision. The continuous series was analysed retrospectively by two surgeons different from the operator. The BTPB group included 58 patients (mean age 28 years) evaluated at a mean 44 months; meniscectomy was associated in eleven cases. The hamstring group included 56 patients (mean age 27.5 years) evaluated at a mean 28 months; there were 19 associated meniscectomies. The IKDC score and laxity (KT2000, Telos) as well as the radiological aspect (AP, lateral and 30° flexion views) were used to assess outcome.

Results: At last follow-up (89 patients, 78%) there were three failures in each group; 77% of patients were in IKDC classes A or B. Subjectively, 90% of the patients considered their knee was normal or nearly normal. For both types of grafts, the outcome was significantly better if the meniscus was preserved. For knees with preserved menisci, there was no difference between BTPB and hamstring reconstruction. Anterior pain was greater after BTPB and posterior thigh pain was greater after hamstring reconstruction. Mean deficit was 14% in extension force in the BTPB group and 25% in flexion force in the hamstring group.

Discussion: Meniscectomy before, during or after ACL reconstruction has a negative effect on the graft outcome for both techniques. If the meniscus is preserved, there is no difference between BTPB and hamstring reconstruction; the morbidities are different, but equivalent (anterior pain for BTPB and posterior for hamstring) and muscle deficit is different (extension for BTPB and flexion for hamstring).

Conclusion: More important than the type of transplant used to reconstruct the ACL, meniscal preservation is a major element affecting outcome.

Purpose: The purpose of our work was to report causes and results of treatment of anterior shoulder instability after implantation of a shoulder prosthesis.

Material and methods: This retrospective multicentric study included 51 patients with prosthetic anterior instability: 42 patients after first-intention shoulder prosthesis and nine after prosthesis revision. There were 39 women (79%) and 12 men, mean age 67 years, who underwent total shoulder arthroplasty (n=29, 57%) or hemiarthro-plasty (n=22, 43%). Thirty-eight patients (75%) had prosthetic dislocation and 13 (25%) subluxation associated with pain an loss of anterior elevation. The initial prosthesis was implanted for degenerative disease (n=29), rheumatoid arthritis (n=7), or fracture (n=15). Anterior prosthetic instability occurred early in 23 shoulders (first six weeks) and lat in 28 shoulders (7 after trauma, 21 without trauma). Conservative treatment by reduction-immobilisation was performed in 16 cases and prosthetic revision in 35. The patients were reviewed radiographically at mean 41 months follow-up (range 24–62).

Results: Subscapular tear or incompetence was the main cause of prosthetic anterior instability, observed in 87% of the cases. Technical errors concerning the prosthesis were also observed: oversized head, malrotation of the prosthesis. Associated complications were frequent: glenoid loosening (24%), polyethylene dissociation from the metal glenoid implant (10%), infection (10%), humeral fracture (4%). The final Constant score was 54 points and 55% of the patients were disappointed or dissatisfied. None of the shoulders were stable after consevative treatment. The prosthetic revision provided disappointing results with 51% recurrent anterior instability.

Discussion: Anterior instability of shoulder prostheses is a serious complication which responds poorly to treatment. Loosening of the subscapular suture is the main cause.

Purpose: The purpose of this study was to analyse the epidemiology, management, and cure rate in 49 infected shoulder prostheses.

Material and methods: This retrospective multicentric study included 2396 shoulder prostheses with at least two years follow-up (mean 34 months): 2146 first intention prostheses and 250 revision prostheses. Results were analysed as a function of: — time to development of infection: 12 acute (less than 2 months after surgery), 6 subacute (2 to 12 months after surgery), and 29 chronic (more than one year after surgery); — cause leading to the first intention implantation; — therapeutic management of the infection.

Results: Two patients died and five were lost to follow-up. The results were thus evaluated in 42 patients. The rate of infection in this series was 1.8% for first intention prostheses and 4% for revision prostheses. Fracture, joint degeneration with massive rotator cuff tears and radiation-related necrosis were factors of high risk of infection (25% for radiation-related necrosis). Thirty patients achieved cure (71%). Three patients had a doubtful cure and nine patients remained infected (29%). The Constant score moved from 20 points before revision to 38 points. Active elevation was below the horizontal (74°). Eighty percent of the acute infections were cured but one-third of the cases required a new revision. Single-procedure replacements provided better functional results and better cure rates. There was a strong correlation between early surgical intervention, adapted antibiotic treatment, and rate of cure.

Discussion: The overall rate of infection in this series is comparable with data in the literature. The rate of certain cure of infection was disappointing (71%). For acute infections, the patients underwent surgery too late and treatment was too aggressive. If there is a doubt about possible infection, revision should be performed as early as possible to allow cure and preserved function. For chronic infections, time to diagnosis and management was too long. This led to anthroplastic resection in one-third of the patients. The choice of the antibiotics and duration of treatment, associated with rigorous surgical technique, should allow switching from arthroplastic to resection prosthetic replacement using one or two surgical times which, for these infected shoulder prostheses, appears to offer the best compromise between cure and function.

Purpose: Nonunion of the surgical neck of the humerus can occur after orthopaedic or poorly-adapted surgery after displaced subtuberosity or cephalotuberosity fracture. The purpose of this study was to report functional and radiographic outcome after treatment with shoulder prosthesis.

Material and methods: Twenty-two patients who had a non-constrained shoulder prosthesis were included in this retrospective multicentric study. Mean age was 70 years and mean follow-up was 45 months (range 2 – 9 years). The initial fracture had two fragments in six patients and was a three-fragment fracture involving the head and the tubercle in thirteen and a four-fragment fracture in three. Orthopaedic treatment was given in ten cases and surgical osteosynthesis was used in twelve. Time from fracture to implant insertion was 20 months. The deltopectoral approach was used for 21 humeral implants and one total shoulder arthroplasty (glenohumeral degeneration). The tuberosities were fixed to the cemented humeral stem and a crown of bone grafts were placed around the nonunion of the surgical neck. All patients were reviewed after a minimum of two years and assessed with the Constant score and x-rays.

Results: The absolute Constant score improved from 23 reoperatively to 39 postoperatively with an anterior elevation of 53° to 63°. Pain score (from 3 to 9, p = 0.001) and external rotation (from 13° to 28°, p = 0.01) were significantly improved. Forty-five percent of the patients were satisfied and 55% were dissatisfied. The type of initial treatment, type of initial fracture, and time before implantation of the prosthesis did no affect final outcome. The complication rate was 36% (eight patients), and led to five revision procedures. The radiographic work-up disclosed six cases of persistent nonunion of the greater tuberosity, two proximal migrations of the prosthesis, and one humeral loosening.

Conclusion: Outcome of shoulder prosthesis for sequela after fracture of the proximal humerus with nonunion of the surgical neck is poor. No improvement in anterior elevation, force, or motion was achieved. Shoulder prosthesis for sequelae of fracture of the proximal humerus with nonunion of the surgical neck should be considered as a “limited-objective” indication only providing beneficial pain relief.

Purpose: Consolidation of the tuberosity is the key to success of shoulder arthroplasty for fracture. The purpose of this study was to assess the number and causes of tuberosity complications in order to find solutions for this problem.

Material and methods: This retrospective multicentric study included 334 shoulder prostheses implanted for fracture between 1991 and 2000. Two different prostheses were used: 300 standard Aequalis prostheses implanted between 1991 and 1997 (mean follow-up four years) and 31 Aequalis Fracture prosthesis between 1999 and 2000 (mean follow-up nine months). Radiological results were assessed on the postoperative and last follow-up x-rays. The Constant score was used for clinical assessment.

Results: For the 300 standard prostheses, the Constant score was 54 points with active anterior elevation = 104°. For the 31 fracture prostheses, the Constant score was 58 points with active anterior elevation = 114°. According to the operator’s assessment, 49% of the postoperative radiological results were fair or poor and objectively 35% of the tuberosities were poorly positioned with the standard prosthesis and 22% with the fracture prosthesis. Twenty-six percent of the good or poorly positioned tuberosities migrated secondarily with the standard prosthesis and 10% with the fracture prosthesis. Statistically significant prognostic factors limiting tuberosity complications were: satisfactory initial osteosynthesis with correct prosthesis height and retroversion facilitated by use of the fracture system, rehabilitation in a specialised centre, relative immobilisation during the first postoperative month limiting exercises to balancing movements which divided the number of secondary migrations by two compared with immediate moblisation (14% versus 27%).

Discussion: A precise analysis of the radiograms revealed a very high rate of tuberosity complications (50%). There has been little study of these complications which are underestimated in the literature. The Aequalis fracture prosthesis can reduce these tuberosity complications two-fold. Postoperative immobilisation also reduces two-fold tuberosity migrations. These observations are against the early passive motion advocated by Neer. Finally, the quality of tuberosity fixation is crucial for success. The surgeon must concentrate on this element, searching to achieve a perfectly positioned prosthesis on the peroperative x-ray.

Purpose: Neer modified the Bankart operation, adding a reinforcement crossing the capsule anteriorly on the humeral side. The purpose of this study was to report results after more than two years.

Material and methods: Between 1991 and 1998, 77 patients underwent surgery for traumatic anteroinferior instability. Clinical and radiological outcome was reviewed in 64 of this patients by an observer different from the operator at a mean follow-up of 45 months (24–120 months). Patients with a unique anterior reinforcement were excluded from the analysis. The patients were generally young (mean 27 years) with sports activities (89%). Recurrent dislocation was observed in 39 patients, subdislocation in seven and painful and unstable shoulders in seven. Ten patients had an associated hyperlaxity, defined by elbow-to-body external rotation greater than 85%, according to the SOFCOT criteria. Three patients had had a prior procedure for a coracoid bone block.

Results: According to the Duplay score: outcome was excellent in 27 cases, good in 22, fair in nine and poor in six. Mean delay to return to former occupational activity was four months; it was seven months for sports activity. The deficit in external rotation was 3.4° on the average. Ten patients had persistent apprehension. Recurrence was observed in seven patients (11%) a mean 25 months after the operation (seven days to six years) as dislocation in two and subdislocation in five and due to trauma in five cases. Young age, hyperlaxity, high-risk sports, an important humeral notch, major capsular distension, and a high number of dislocations or subdislocations were the factors associated with recurrence. According to the Samilson criteria, pre-osteoarthritic lesions of the gleno-humeral joint were present in two cases preoperatively (one grade I and one grade II) and in eight cases postoperatively (four grade I, three grade II, and one grade III).

Discussion, conclusion: The Bankart operation as modified by Neer does not produce a stiff joint as is thought by many, probably due to the upper-lower capsular retention rather than lateral-medial retention. Nevertheless, the stability results are less satisfactory than generally reported for coracoid stop procedures.

Purpose: Cyclope syndrome is described in the literature as a postoperative complication of arthroscopic anterior cruciate ligament (ACL) grafts, leading to permanent flexion. The discovery of this syndrome in ten patients before reconstruction of the ACL led us to revisit the pathophysiology.

Material and methods: Among 250 candidates for ACL grafts, ten presented a positive but dull Lachman-Trillat sign with permanent flexion greater than 10°. The rotation click was negative in two and dull in eight. KT 200 measured differential laxity greater than 4 mm in all. Nine patients were reviewed at consultation, one patient had recently undergone another operation. Clinical and radiographic findings recorded in the patient’s files and operation reports were reviewed by two observers different from the operator.

Results: Arthroscopy revealed a partial tear of the ACL in three cases, a scarred ACL nourished by the PCL in five and a full thickness tear of the ACL in two. There was a fibrous barbell nodule inserted on the tibia in all cases, a characteristic feature of cyclope syndrome. The nodule was interposed between the femur and tibia at extension and was resected in all cases. Pathology reported a ligamentoid structure undergoing fibrous organisation. At last follow-up, greater than two years for nine patients, the IKDC rating was A for six patients and B for three patients. None of the patients had a defective extension differential.

Discussion: Persistent flexion preoperatively in a patient with a torn anterior cruciate ligament suggests possible presence of a ligamento-fibrous nodule interposing between the femur and tibia at extension. This nodule can go unnoticed at arthroscopy but appears to be unmasked in the Cabott position after partial resection of the subpatellar fat. It is particularly important to look for this nodule when the stump of the torn ACL is not found and the patient has experienced a recent sprain. Since we started looking for this nodule in all cases with resection, we have no longer encountered postoperative cyclope syndrome.

Conclusion: This group of arguments strongly suggests that the conditions necessary for the constitution of cyclope syndrome are probably present before reconstruction of the anterior cruciate ligament.