Purpose of the study: The objective was to analyse shoulder motion, particularly abduction and anterior elevation, in patients with an reversed prosthesis. A radiocinematographic study enable an analysis of the movements of the prosthesis it self and movements due to scapulothoracic participation.

Material and methods: This study was based on the analysis of 33 patients with an reversed shoulder prosthesis. A videoscopic recording (25 images per second) of anterior elevation from a workstation used for abduction arteriography was used. The Constant score was noted and a standard x-ray work-up (four views) was obtained for all patients.

Results: The cohort was a homogeneous continuous series of 21 women and 12 men, mean age 72.5 years (range 39–84). Two modes of motion were observed. The first (group 12, n=17 shoulders) was «monoarticular»: shoulder motion was almost exclusively related to movement of the scapulothoracic junction. Abduction did not exceed 90°. The second mode (group 2, n=16 shoulders) was «bi-articular»: joint motion began with the prosthesis (50° on average) followed by scapulothoracic participation (50° on average). The implant then was involved in the final part of the motion (in six of the 16 shoulders in group 2) to complete the range of motion exceeding 120° abduction and anterior elevation.

Discussion: This study confirmed the presence of an initial intrinsic mobility of the prosthesis followed by scapulothoracic participation. It was noted however, that for the majority of cases, the intrinsic mobility of the prosthesis was limited. In all cases, the range of motion recorded by clinical examination was greater than the range of motion measured objectively by radiocinematography.

Discussion: This study demonstrated the in vivo mobility of the reversed prosthesis. However, a range of motion greater than 100° anterior elevation and abduction is exceptional. Clinical findings reflect imperfectly the real mobility of this type of prosthesis.

Purpose of the study: Morton neurinoma is a well defined anatomic entity despite certain questions about the pathogenic mechanisms. Diagnosis of the metatarsalgia sometimes produced can be difficult due to the frequency of an associated static metatarsalgia. Magnetic resonance imaging has not met expectations. We have oriented our research towards ultrasonography which can provide high quality information with good reliability.

Material and methods: We reviewed the files of 11 patients with Morton neurinoma which led to 14 operations (bilateral cases or two localizations on the same foot). The series included three men and eight women, mean age 56 years. The operation was conducted under locoregional anesthesia and consisted in tumor resection via the plantar commissure, with removal of the entire neurinoma. Ultrasonography used a high-frequency probe (6–13 MHz linear scan). The compartments were studied via the plantar aspect and the dorsal aspect using static and stress positions. MRI had been performed in two patients before the ultrasound.

Results: Eight of the eleven patients had an associated syndrome (hallux valgus, disharmonious length with mid metatarsal weight bearing). Objective signs (Mudler’s sign, hyoesthesia), were noted in seven patients. The neurinoma was confirmed in all cases at surgery; in two cases, ultrasonography demonstrated a neurinoma where the MRI had been negative. The operative specimen was typical. Two compartments were explored because of the ultrasound results which were highly suggestive; two tumors were demonstrated at surgery. Clinical outcome at mean seven months was good in ten patients and fair in one.

Discussion: Ultrasonography should no longer be considered as «operator-dependent». It enables the detection of mid-sized neurinomas measuring about 2 cm. Magnetic resonance imaging has been less productive for diagnosis; many studies have been reported without surgical confirmation of MRI-negative cases. False negatives are frequent and patient follow-up is insufficient to determine whether the symptoms persist or resolve after surgery.

Conclusion: Ultrasonography is a simple examination devoid of iatrogenic risk. The use of stress images has greatly improved performance. This low cost examination may not however be necessary because the diagnosis of Morton is basically clinical.

Purpose: Transscaphoretrolunate dislocation is the most frequent perilunate dislocation of the carpus (65% according to Herzberg). Treatment remains controversial. The aim of this work was to analyse functional outcome in a homogeneous series of 15 patients treated by open reduction and fixation.

Material and methods: This retrospective analysis of 15 patients, mean age 34 years was conducted at four years follow-up. Clinical outcome was based on the Cooney clinical scoring chart. Static and dynamic x-rays of the wrist were studied. The dislocations were: type I=9, type IIa=5, type II=1 according to the Alnot classification. The scaphoid fractures were: types III and IV=13, type II=2. A dorsal approach was used for six cases, an anterolateral approach for four and a double approach for five. The carpal tunnel was opened in seven cases. The scaphid fracture was fixed by pins in eleven cases, by screws in four, and associated with a corticocancellous graft in five. The carpus was fixed in seven cases with scapholunate pins, with lunotriquetral pins in seven, and radiolunate pins in three.

Results: Mean score was 70±20% with mean flexion 50±17° and mean extension 54±20°. Grip force was 32/45±11 (Jamar). The thumb-index force was 14±5.1. Pain was negligible in 33% of the patients and was disabling in 17%. Climatic pain was reported by 50% of patients; 75% were able to resume their occupational activities. Radiographically we found osetonecrosis of the lunate (n=1), osteonecrosis of the proximal pole of the scaphoid (n=2), non-union of the scaphoid (n=3), radiocarpal osteoarthritis (n=4), SLAC (n=1) and SNAC (n=2).

Discussion: Our outcomes were slightly less favourable than those reported in the literature concerning joint motion. Conversely, for pain, duration of sick leave, and percentage of occupational reclassing, our results were the same as reported in the literature. The series shows that radiographic outcome was favourable with 13% radiocarpal osteoarthritis (38% for Herzberg in 2002 at 96 months. The stability of the scaphoid osteosynthesis remains the key to success (two nonunions for four single pin fixatons). A new analysis at longer follow-up would be interesting to determine the arthrogenic results.

Purpose: The purpose of this study was to analyse total shoulder arthroplasty failures and the outcome after simple ablation of the prosthesis or revision with a Grammont inverted prosthesis.

Material and methods: This was a longitudianal prospective study of patients with a failed shoulder prosthesis who underwent either simple ablation of the prosthesis or revision athroplasty with an inverted Grammond prosthesis. Clinical (Constant score) and radiographic analysis was performed before revision and at last follow-up using identical criteria. The shoulder prosthesis was removed in case of failure due to infection. For all other causes of failure, an inverted Grammond prosthesis was implanted.

Results: The series included nine patients (eight women and one man) reoperated between January 1st 1995 and December 31st 1999. Mean follow-up was 47 months (12–108). Delay between the first procedure and revision surgery was 26 months (6–72). The cause of the failure of the first implant was: infection (four patients), dislocation (one patient), three-tendon rotator cuff tears (four cases). The overall Constant score before revision surgery was 18.5 (6–30). Mean Constant score at last follow-up was 40.1 (35–54). Mean gain in pain score was 9.4 points (0–15) and mean gain in hand position was 2.75 points (0–10).

Discussion: Complications after shoulder arthroplasty are not uncommon (14% according to Wirth, 1994) and treatment is difficult (Sperling 1999). Instability, rotator cuff tears, glenoid loosening, and infection are the most frequent causes of failure (Wirth 1994). The patients in this series had a very poor Constant score involving all the subscores, although deterioration of the pain score predominated. The gain, both with ablation and revision total shoulder arthroplasty, was greater than 25 points on the average. This gain was proportional to the initial score before revision and patients who had a revision total shoulder arthroplasty had a better gain (p < 0.001). Simple implant ablation did however improve the mean Constant score among patients with infection whose initial score was lower than the others (p < 0.001). the final outcome was moderate. The only patients who recovered muscle force were those who had a total revision prosthesis (p < 0.05).

Conclusion: Revision of a shoulder prosthesis gives disappointing results in terms of absolute outcome score, even though the gain over the initial functional situation is encouraging. Simple ablation of an implant is still indicated in certain patients, in particular those who have an initial Constant score under 20 points.