Purpose: At a time when total knee arthroplasty (TKA) with an ultra-congruent tibial plateau or a mobile plateau are advocated by many, the question is whether TKA with a fixed plateau preserving the posterior cruciate ligament (PCL) should be abandoned. We analysed the results of 500 Wallaby I TKA with preservation of the PCL and presenting asymmetrical and divergent femoral condyles with a fixed, also assymetrical tibial plateau, at mean follow-up of seven years (1–10).

Material and methods: This prospective multicentric study was performed by junior and senior surgeons. Mean patient age was 70.11 years and 91.4% of the patients had primary or secondary degenerative disease. Prior surgery had been performed in 130 knees, mainly for osteotomy (n=40, mostly tibial) and revision of uni-compartmental or total prostheses (n=18). The mean preoperative IKS knee score was 26.11 points, the function score was 29.54. Preoperative alignment was correct for 11.26% of the knees, 27.16% presented > 4° valgus and 61.56% > 3° varus. Nearly all tibial and patellar pieces were cemented. 5.8% of the femoral pieces were not cemented. A prosthesis was implanted on the patella in all knees except four. There were two early infections, one popliteal sciatic paralysis and twelve wound healing problems. General mobilisation under general anaesthesia was performed in 53 knees (10.6%).

Results: Twenty-two patients were not retained for analysis, fifteen lost to follow-up and seven deceased at one year. Among the 478 knees followed for one to ten years, there were six late infections (1.25%), one aseptic bipolar loosening (0.2%), 25 patellar fractures (5.23%) including three which required revision (two cerclage, one prosthesis removal), three periprosthetic femur fractures without effect on the clinical or radiographic outcome, one traumatic tear of the medial collateral ligament, and two secondary tears of the PCL without clinical consequences. There were no revisions for instability, generally considered the most frequent reason for TKA revision. The mean postoperative IKS score was 90.6 points and the function score was 59.7 points basically due to patient age and comorbidity. The eight-year survival (Kaplan-Meier method) was 98.2% (95%CI: 99.4–96.9) irrespective of the reason for revision and 99.2% (95%CI 100–98.4%) if the revision was performed for a mechanical problem. Radiographically, more than 70% of the knees were aligned (between 3° valgus and 2° varus) and more than 90% were between 5° valgus and 5° varus. Although it was difficult to measure radiographically polyethylene wear, there was only one case of > 2 mm wear with osteolysis found in 50 knees selected randomly among the knees with more than seven years follow-up.

Conclusion: This study, like others reported by authors preserving the PCL, show that preservation of the PCL limits the risk of instability, allowing excellent clinical and radiographic outcome without important polyethylene wear, opening perspectives for good long-term results.

Purpose: Fractures of the upper humerus are frequent in elderly persons. While 80% are generally treated orthopaedically, about 20% are complex complicating treatment. Osteosythesis has given disappointing results due to the poor bone quality. Simple humeral arthroplsaty with simple tuberosity fixation could be a solution.

Material and method: Between 1993 and 1998, 50 patients, 39 women and 11 men, mean age 74.5 years (51–90) were treated for cephalotuberosity fractures with cemented humeral arthroplasty. The dominant side was involved in 80% of the cases; there were 39 fractures with four fragments in the Neer classification with seven associated with anterior dislocation, eleven with three fragments including two associated with anterior dislocation. Three patients had a neurological complication: elongation of the brachial plexus in one and irritation of the ulnar nerve in two. Mean delay to surgery was 2.4 days. Thirty-seven patients were operated via the superolateral approach, 13 via the deltopectoral approach. A total of 37 Neer prostheses were implanted and 13 Guepar prostheses. Three patients had a full thickness cuff tear, sutured in the same operative time. The glenoid cavity was healthy in all cases. the upper limb was immobilised elbow against thorax using an abduction brace for 2& days. Active rehabilitation exercises began during the sixth week.

Results: Mean follow-up was 2.5 years. Twelve patients had died, four were lost to follow-up and six could not be examined due to an alteration of their cognitive functions. The analysis thus concerned 28 patients. The mean absolute Constant score at last follow-up was 47 points, with a weighted score of 70 points. Outcome was good in nine cases, fair in eight, and poor in eleven. 86% of the shoulders were pain free. Overall active mobility was: antepulsion 80.5°, abduction 77°, external rotation 20°; 18 patients had internal rotation at L5or more. Radiographically, there was a tuberosity lysis in eight patients and a defective trochiter callus in nine. No changes in the humeral component cementing were observed. The trochiter lever arm was 28 cm, 92.7% of the offset measured on the healthy side. The distance between the apex of the head and the trochiter was 10 mm on the average. Glenoid wear was noted in ten cases. There was no evidence of periprosthetic ossification. Mean ES was 9.9 mm.

Discussion: Pain relief was good. Amplitudes were correlated with age, the quality of the tuberosity fixation, and the duration of rehabilitation (> 1 year). An associated dislocation did not appear to have a deleterious effect. The approach used or offset did not appear to affect results.

Conclusion: Our patients achieved good pain relief but lost a certain degree of mobility, similar to findings reported in the literature. The main prognostic factors are the quality of the tuberosity reconstruction and patient compliance to rehabilitation.

Purpose of the study: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome.

Material and methods: Five patients, mean age 54 years (45–71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range = 8.5–54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber’s lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6–42 months) for clinical and radiological assessment.

Results: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean = 50, range = 30–63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis.

Discussion and conclusion: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration.