[Magnetic resonance imaging of medial meniscus tears with displaced fragment in the meniscal recesses]. / Diagnostic IRM des lambeaux méniscaux médiaux déplacés le long du ligament tibial collatéral.

PURPOSE OF THE STUDY: Displaced meniscus tears generally result from bucket handle tears with subsequent migration of the meniscal fragment into the intercondylar notch. More rarely, the fragment may move into the meniscal recesses. In this situation, the displaced fragment may be difficult to individualize arthroscopically, so preoperative imaging is crucial. Several studies have demonstrated the reliability of magnetic resonance imaging (MRI) for the diagnosis of meniscus injury with fragment displacement in the intercondylar notch. There have been few studies devoted to fragment displacement into the collateral capsuloligamentary structures. The purpose of this study was to describe MRI findings of medial meniscus tears with displaced fragment in the meniscal recesses. MATERIAL AND METHODS: This prospective study was conducted over a 22-month period (May 2003 - February 2005). During this period, we selected 39 patients whose knee MRI displayed a meniscal fragment within the medial collateral recesses. These 39 patients accounted for 15% of knees with MRI-diagnosed meniscal tears (n=272) and 2% of the knee MRI examinations performed during the study period (n=2239). One the MRI series, we studied fragment migration and morphological anomalies of the injured meniscus. For 16 knees, MRI findings could be compared with arthroscopy findings. RESULTS: For 25 knees (65%), the meniscal fragment had migrated downward along the medial tibial plateau and generally (64%) medially to the collateral tibial ligament. For 14 knees (35%) the meniscal fragment had migrated upward, along the medial femoral condyle in 93%, anteriorly to the medial collateral tibial ligament. For 95%, the MRI demonstrated rupture along the free border of the posterior segment and/or the mid segment of the medial meniscus or a decreased height of the posterior segment of the medial meniscus. For 14 of 16 cases, arthroscopy confirmed the meniscal tear and the localization of the displaced fragment. For two knees, arthroscopy confirmed the presence of the meniscal tear but could not identify the displaced meniscal fragment. DISCUSSION: Meniscal tears with fragment displacement into the meniscal recesses has been associated with displacement of a horizontal fissuration which flap tears described arthroscopically by DJ Dandy. Other authors consider these tear flaps as oblique fissurations. In our study, it was sometimes difficult to determine the exact site and orientation of the initial meniscal tear so it is quite likely that meniscal tears with a displaced fragment in the meniscal recesses could correspond to complex predominantly horizontal or oblique meniscal fissurations. The common feature is the presence of an unstable meniscal flap susceptible to migrate. Our findings are in agreement with the literature. Regarding the two cases where the MRI findings could not be confirmed arthroscopically, the MRI visualized a characteristic image of a meniscal fragment displaced downwardly, lying between the medial tibial plateau and the collateral tibial ligament. Arthroscopy visualized the meniscal tear but failed to visualize the displaced fragment. This might be because mobile meniscal fragments return into the joint interspace when the meniscus is manipulated arthroscopically. Small meniscal fragments might also be inaccessible arthroscopically.

[Arthro-C-scan analysis of rotator cuff tears healing after arthroscopic repair: analysis of predictive factors in a consecutive series of 167 arthroscopic repairs]. / Etude par arthroscanner de la cicatrisation tendineuse après réparation arthroscopique de la coiffe des rotateurs: analyse des facteurs predictifs à propos d'une série consécutive de 167 réparations.

PURPOSE OF THE STUDY: Arthroscopic repair of rotator cuff tears is a well described technique with good clinical results. The purpose of this work was to use the arthro-CT-scan to evaluate tendon healing after arthroscopic repair and search for epidemiological, anatomic and technical factors predictive of tendon healing. MATERIAL AND METHOD: This prospective consecutive series included 167 non-randomized shoulders. All patients underwent a preoperative assessment using the crude Constant score and a standard x-ray protocol to evaluate cuff status. Cuff repairs were all performed arthroscopically. The crude Constant score was used to follow patients. A control arthroscan was obtained in 148 patients. RESULTS: Mean patient age was 59 years, 46% men and 77% dominant side. Mean duration of symptoms before repair was nine months. The tears resulted from trauma in 28%, including 9% occupational accidents. The preoperative mean crude Constant score was 52.4 (range 15-77). An isolated tear of the supraspinatus was observed in 68%. Frontal retraction of the supraspinatus was distal in 74%. In 29 cases, reduction was difficult. The quality of the tendon was considered normal in 56 cases and non-anatomic repair was necessary in six. At last follow-up (19 months on average) the mean crude Constant score was 80 (range 49-95). Arthro-CT-scan was performed to control healing in 148 patients and revealed anatomic healing in 69, defective healing in 27, and repeated tears in 52 shoulders. Factors predictive of healing were: tear less than six months old, sedentary occupational activity, non-dominant side, young patient, female gender, isolated small non-retracted tear of the supraspinatus, normal appearance of an easily reduced tendon, and good bone quality. DISCUSSION: Time from tear to repair was long in this series. Tendon and muscle changes occurring after the injury could explain in part the healing failures. CONCLUSION: But this study confirmed good functional and anatomic results given by arthroscopic repair of rotator cuff tears.

Accuracy of CT arthrography in the assessment of tears of the rotator cuff.

CT arthrography and arthroscopy were used to assess tears of the rotator cuff in 259 shoulders. Tear size was determined in the frontal and sagittal planes according to the classification of the French Arthroscopy Society. CT arthrography had a sensitivity of 99% and a specificity of 100% for the diagnosis of tears of supraspinatus. For infraspinatus these figures were 97.44% and 99.52%, respectively and, for subscapularis, 64.71% and 98.17%. For lesions of the long head of the biceps, the sensitivity was 45.76% and the specificity was 99.57%. Our study showed an excellent correlation between CT arthrography and arthroscopy when assessing the extent of a rotator cuff tear. CT arthrography should, therefore, be an indispensable part of pre-operative assessment. It allows determination of whether a tear is reparable (retraction of the tendon and fatty degeneration of the corresponding muscle) and whether this is possible by arthroscopy (degree of tendon retraction and extension to subscapularis).

A 4-portal arthroscopic stabilization in posterior shoulder instability.

The purpose of this study was to present an arthroscopic stabilization technique with 4 portals for posterior instability used in 11 patients (13 shoulders). There were 7 male and 4 female patients. All patients had an arthroscopic labral suture with anchors and capsular plication with 4 portals. The follow-up period averaged 34 months. No complication or recurrence of instability was noted. A moderate loss of range of motion was noted in 4 shoulders and moderate pain in 2 shoulders. All patients were satisfied. According to the literature, the rate of recurrence of instability is currently lower than 12% when a labral suture and capsular plication are performed. Our results for pain and range of motion are similar to those described in recent publications. However, we think that the 4-portal technique allows a facilitated access to the posteroinferior part of the glenoid and reduces the rate of postoperative instability.

[The superolateral approach for shoulder prosthesis]. / Voie d'abord supéro-latérale pour l'implantation d'une prothèse d'épaule.

We describe a superolateral approach to the shoulder for implantation of total shoulder prostheses or humeral prostheses. The advantages of this approach include preservation of the supraspinatus tendon and an excellent exposure of the posterior part of the glenoid cavity. We illustrate this approach with three clinical examples: total shoulder arthroplasty with reconstruction of the posterior part of the glenoid using a screwed autograft for central degeneration with posterior wear of the glenoid, intermediate arthroplasty for excentric degeneration with irreparable rotator cuff tears, and simple humeral arthroplasty with bone suture of the tuberosities for cephalotuberosity fracture.

[Bipolar arthroplasty in rotator cuff arthropathy: 13 cases]. / Résultats de l'arthroplastie intermédiaire dans le traitement de l'omarthrose excentrée.

PURPOSE OF THE STUDY: A series of 13 patients with an excentered osteoarthritis of the glenoid who underwent bipolar shoulder arthroplasty is reported. MATERIAL AND METHODS: The series included 13 patients treated in two centers between 1995 and 1998. Mean age was 70 years (58-88). Constant's absolute score and Swanson's score were used for clinical assessment. The Hamada and Fukuda classification was used for the radiographic assessment. The follow-up radiography series included an AP view in the three rotation positions, an AP view in maximum abduction to assess intraprosthetic mobility, a lateral view (Lamy) and measurements of both humeri. Several measurements were made to assess humerus lateralization and glenoid wear: deltoid lever arm, lateral humeral displacement, distance between the lateral border of the coracoid and the center of the glenoid and the subacromial space. Mean preoperative Constant score was 23 points: pain 3 pts, activity 5 pts, motion 13 pts, force 2 pts. Mean preoperative Swanson score was 11. Active anteflexion was 78 degrees, active abduction 68 degrees and passive external rotation 17 degrees. The Hamada and Fukuda classification was 9 grade 4 and 4 grade 5. All patients had a full thickness unrepairable rotator cuff tear: three with 2 tendon tears, and 10 with 3 tendon tears. All patients were reviewed clinically and had a complete radiography series at last follow-up (mean 28 months, range 7 - 56 months). RESULTS: At last follow-up, the mean absolute Constant score was 37 points: pain 10 pts, activity 9 pts, motion 14 pts, force 4 pts. Mean Swanson score at last follow-up was 19 points. Mean active anteflexion was 69 degrees, active abduction was 63 degrees and passive external rotation was 29 degrees. A satisfactory deltoid lever arm had been achieved compensating the glenoid wear by a greater lateral displacement of the humerus. At last follow-up, there were no cases of humeral loosening but three cases with important glenoid wear were observed after two years. Comparing the results obtained using small cups (40 and 44) with arthroplasties using large cups (48 and 52) showed a trend favoring small cups: Constant score 43 vs 32 points, Swanson score 21 versus 17 points, anteflexion 72 degrees versus 66 degrees and passive external rotation 34 degrees versus 26 degrees. DISCUSSION: Our results confirmed the efficacy of bipolar arthroplasty for pain relief, but the mobility outcome was less than satisfactory, excepting passive external rotation. It would appear to be preferable to use small cups. Comparing our results with data in the literature, particularly the better results for mobility using simple humeral prostheses, suggests that the principles of shoulder and hip arthroplasty concern different mechanisms: a sufficient deltoid lever arm must be achieved, but without overstretching the periarticular soft tissue (capsule, subcapsule, teres minor), and using a cup size close to the size of the healthy humeral head. Glenoid reaming should not be reserved only for asymmetrical glenoid wear in the horizontal plane. CONCLUSION: Our results suggest that bipolar arthroplasty for excentered osteoarthritis of the glenoid cavity is indicated for: stiffness in external rotation, major concentric wear in patients under 65 years of age, or asymmetric glenoid wear.

[GUEPAR total elbow prosthesis in rheumatoid arthritis. A multicentric retrospective study of 38 cases with an average 4-year follow-up]. / La prothèse totale de coude GUEPAR dans l'arthrite rhumatoïde. Etude multicentrique rétrospective de 38 cas avec un recul moyen de quartre ans.

PURPOSE OF THE STUDY: We conducted a multicentric retrospective analysis of outcome after implantation of 38 GUEPAR elbow prostheses in 36 patients with rheumatoid polyarthritis. MATERIAL AND METHODS: The GUEPAR elbow prosthesis is an anatomic prosthesis developed in 1985 by the Groupe pour l'Utilisation et l'Etude des Prothèses Articulaires (GUEPAR). The recommended surgical technique is described. Patients included in this series had moderate to severe persistent elbow pain. Preoperative motion was 113 degrees flexion with a mean 41 degrees extension deficit. The mean global Mayo Clinic score was 32/100; clinically, the overall assessment was poor in 8 and mediocre in 30. Radiographically there were 16 grade III, 16 grade IV and 4 grade V elbows in the Larsen classification. Two cases were arthroplasty revisions. RESULTS: All patients were seen at a mean 47.6 months follow-up (12 to 97 months). There were two early failures (1 infection and 1 instability) leading to ablation of the prosthesis. Results were analyzed for the 36 remaining arthroplasties. Total pain relief was achieved in 18 cases with only occasional pain in 17 others. Postoperative motion was 132 degrees flexion with a 30 degrees extension deficit, giving a mean 30 degrees gain. The global Mayo Clinic score was 85/100 with 32 excellent, 3 good and 1 mediocre results. Radiography revealed 2 cases of loosening of the humeral component and 1 bipolar loosening that had not required revision at last follow-up. Prosthetic instability was the most frequent among the early and late complications. DISCUSSION: Total elbow arthroplasty is a useful therapeutic option among the treatments proposed (including chemical or isotopic synoviothesis, synovectomy, arthroplastic resection) for rheumatoid elbows. It is indicated for Larsen grades III, IV and V and provides good functional outcome and nearly constant pain relief with an amplitude greater than the 100 degrees, generally accepted as functionally useful. In light of our experience we propose certain modifications of the current GUEPAR implant: adjunction of a condylar extension to the humeral component in order to reduce rotation stress and thus avoid humeral loosening and a radial head element to limit the risk of instability.

[The fibrous frame of the rotator cuff. Contributions of an in vivo three dimensional study of the tendons of the rotator cuff]. / Le squelette fibreux de la coiffe des rotateurs. Apports de l'étude tridimensionnelle in vivo des tendons de la coiffe des rotateurs.

The presence of a fibrous frame within the rotator cuff has been recently emphasized. This frame may be of interest in understanding of shoulder physiology and in attempts to improve shoulders disorders treatments. We report an original method to study the fibrous frame. MRI were done in healthy volunteers. 3D reconstruction were obtained and provided a 3D image of the fibrous frame. This technic should allow to calculate, for instance, the angles between the cuff muscles and the upper end of the humerus.

Anatomy and function of the subdeltoid bursa.

An anatomical study was undertaken on 40 non-embalmed normal cadaver shoulders to determine the attachments, boundaries and macroscopic nerve supply of the subdeltoid bursa. Two areas of attachment were observed, one (proximal and superficial) along the free border of the coracoacromial ligament and adjacent deep surface of deltoid, the other (distal and deep) to the humerus distal to the supraspinatus tendon: there were no posterior or anterior attachments. In addition, two blind pouches were observed, one proximal under the coracoacromial ligament and the other beyond the distal attachment. The continuity observed between the lateral border of the coracoacromial ligament and the subdeltoid bursa provides a smooth surface, thereby casting doubt on the aggressive action of the ligament on the rotator cuff.

[Infection of a total knee prosthesis revealed by an abscess of the posterior leg compartment. A case report]. / Infection d'une prothèse totale de genou révélée par un abcès de la loge postérieure de jambe. A propos d'un cas.

We report a case of infection of a non-cemented total knee prosthesis that led to abscess formation in the posterior compartment of the leg. This case illustrates the deleterious effect of screws used to fix the non-cemented articular surface of the tibia. Infection, like osteolysis due to polyethylene granuloma, can develop along the screw tract and reach the posterior compartment, especially when the screw protrudes through the posterior cortical of the tibia. Diffusion of an intra-articular event into the posterior compartment should be suspected in patients with a total knee prosthesis who experience calf pain.

The too-long anterior process calcaneus: a report of 39 cases in 25 children and adolescents.

We observed 39 feet with a "too-long" anteromedial process of the calcaneus (TLAP) in 25 children and adolescents. The abnormality was diagnosed from symptoms (ankle sprains or persistent ankle or foot pain) in 33 cases. Six cases of TLAP were noted on radiographs taken of the patient's opposite, asymptomatic foot. Initial treatment by 3 weeks of strapping failed in seven of seven cases, and 3-6 weeks of primary plaster immobilization failed in 10 of 25 feet. Primary immobilization treatment failed in 17 of 33 symptomatic feet. Resection of the TLAP provided good results in 14 of 15 feet when used as a secondary procedure after failure of immobilization treatment and in one foot in which it was used as primary treatment. We believe that this abnormality is an anatomic variant that becomes symptomatic because of inversion stress with impingement of the abnormally long process between talus and cuboid.