Continuous passive motion compared with intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines.

OBJECTIVE: To develop clinical practice guidelines concerning the use of continuous passive motion (CPM) compared with intermittent mobilization after total knee arthroplasty (TKA). METHOD: We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review and collection of everyday clinical practice concerning postoperative rehabilitation techniques and external review by a multidisciplinary expert panel, to develop the guidelines. RESULTS: The literature contains no evidence of the advantages of CPM over other techniques of mobilization, although CPM could be adjuvant therapy used to accelerate short-term recovery. However, in France, CPM remains widely used after TKA, both in orthopedic surgery units and in physical medicine and rehabilitation services. CONCLUSION: Good methodological quality studies are needed to assess different CPM modalities and compare them to alternative intermittent mobilization techniques, particularly those with therapy starting from a flexed position.

[Histological lesions of supraspinatus tendons in full thickness tears of the rotator cuff]. / Les lésions histologiques des tendons des supraspinatus dans les ruptures transfixiantes de la coiffe des rotateurs.

PURPOSE OF THE STUDY: Iterative tears after simple tendon bone suture of transfixiant ruptures of the rotator cuff are frequent. The frequency of iterative ruptures had seemed to be correlated to the importance of the preoperative fatty degenerations of the cuff muscles. But fatty degeneration cannot account for iterative ruptures occurring with no or little preoperative muscle fatty degeneration. The authors have tried to know if iterative ruptures could also be accounted for by the presence on repaired tendinous stumps of histological lesions which are known to lower their mechanical quality, and if such was the case, they have tried to know what could be the impact of these lesions on the repairing technique by suturing cuff ruptures. MATERIAL AND METHOD: Thirty-two distal stumps of ruptured supraspinatus, resected on more than 1 cm to eliminate macroscopic tendinous lesions (thin, lacerated, cleaved, hardened or whitish tendons) and to reach a new stump, slightly bleeding and thick enough to hold the stitches correctly, have been studied on longitudinal histological slides. RESULTS: All the tendinous resected stumps had histological anomalies: dilacerations lesions of the conjunctive tissue, fatty infiltrations, necrosis, scar lesions and micro calcifications were found. The histological lesions were often associated. The histological lesions were an average 4 mm shorter than those of the tendinous resection. In 18 cases however the whole of the resected tendon was histologically abnormal. DISCUSSION: Tendinous histological lesions found on the whole or almost the whole length of the macroscopically abnormal tendinous stumps diminish the mechanical quality of the tendons. Insufficient resection of the tendinous stumps leaving macroscopical lesions and therefore histological lesions could account for iterative ruptures in the first post operative year. Yet complete resection of the macroscopically abnormal tendinous stump does not entail that the neo tendinous stump to be repaired is histologically normal. This encourages to put the stitches well within the zone of the tendinous resection and to bury the tendinous stumps into a highly vascular bony trough. But tendinous resection although logical from the histological and mechanical point of view widens the rupture of the cuff to be repaired. It can make sutures under tension, which can entail iterative ruptures. Musculo-tendinoplasty appears then necessary to perform sutures without tension. CONCLUSION: Histological lesions of tendinous stumps of cuff ruptures correspond roughly to tendinous macroscopic lesions. They could be at the origin of iterative ruptures that take place after simple tendon-bone sutures of ruptured cuffs which are not accounted for by muscular fatty degeneration. They could also partly account for iterative ruptures taking place when pre operative fatty degeneration is evident. It seems logical to resect macroscopically abnormal tendinous stumps before performing a suture. But the tendon-bone suture without tension is then often possible only with musculo-tendinoplasties.

Ultrasound investigation of the rotator cuff after computed arthrotomography coupled to bursography.

OBJECTIVES: To evaluate the diagnostic performance of ultrasound rotator cuff imaging after injection of contrast medium into the glenohumeral joint and subacromial bursa. PATIENTS AND METHODS: Twenty-eight patients underwent ultrasonography before and after injection into the glenohumeral joint and subacromial bursa of a mixture of iodinated contrast medium and lidocaine solution. Findings were compared with those from computed tomography of the joint and bursa. RESULTS: Sixteen 16 (16/28, 57%) post-contrast ultrasound scans revealed or confirmed rotator cuff lesions. For supraspinatus and infraspinatus lesions, there were three false-negatives and no false-positives. Three false-negatives were recorded for subscapularis lesions. All false-negatives occurred both before and after the contrast medium injections. CONCLUSION: Injecting contrast medium into the glenohumeral joint and subacromial bursa improves the diagnostic yield of rotator cuff ultrasonography. We suggest that ultrasonography be performed after injections of drugs into the shoulder structures, particularly the subacromial bursa.

[Analysis of the scintigraphic image of bone grafts in reconstruction of total hip prostheses]. / Analyse de l'image scintigraphique des greffes osseuses dans les reprises de prothèses totales de hanche.

Eighteen total hip prostheses required reoperation after loosening of the acetabular component. The authors used autografts (8 cases) or allografts (9 cases) or both (1 case) to reinforce the acetabulum. The fate of the grafts was analysed using Technetium 99 scintigraphy. There were 8 shelf operations and 10 massive grafts replacing either the anterior or posterior wall of the acetabulum. The scintigraphic study came to the conclusion that autografts resulted in intense reaction with fixation after two to sixteen months. From this it can be assumed that their rehabilitation was satisfactory. In contrast, allografts were poorly incorporated. Scintigraphy in these cases was of low intensity, scattered and was not long-lasting. The authors consider that this type of graft has little chance of producing a solid and homogeneous mass of bone in the long term. They consider that, when necessary, a mixture of autograft and allograft should be used.

[A study of the neurologic risk in tendino-muscular advancement of supra-spinatus and infra-spinatus in the repair of large rotator cuff rupture]. / Etude du risque neurologique á l'avancement tendino-musculaire des supra-épineux et infra-épineux dans les réparations des larges ruptures de coiffe.

PURPOSE OF THE STUDY: An anatomical study by Warner et al. (1992) showed that an advancement of supra and infra-spinatus of more than 3 cm could be deleterious for the suprascapular nerve or its branches. In pathological conditions, the limit of possible advancement could even be less than 3 cm. The authors wanted to know whether this technique, which they use for the repair of large rotator cuff tears, could have neurological effects in surgical practice. MATERIAL: 24 shoulders among 24 patients having had a rotator cuff repair using a musclar advancement have been studied. In 13 cases only the supraspinatus had been advanced, and in 11 cases both supra and infraspinatus have been advanced. METHODS: The suprascapular nerve status has been studied postoperatively by EMG. EMG was performed at a mean 8.5 months follow-up. Motor unit potentials were studied at rest and after maximal contraction. Electro-stimulation at Erb's point was used to evaluate muscular latency. All repairs have been controlled by opaque arthrography, and a CT scan grading of muscular fatty degeneration was performed. In 19 cases EMG had also been performed preoperatively. RESULTS: At revision, 17 EMG were considered normal. In one case there was an impairment of the first primary trunk, already noticed preoperatively. Only 6 EMG anomalies probably related to surgery have been noticed, although the width of the tear in the coronal plane was nearly always of more than 3 cm. 4 of these 6 shoulders had been explored preoperatively by EMG, and were recorded as normal before surgery. Electric impairment was limited to the supraspinatus in 3 cases (increase of muscular latency after single advancement in two cases, polyphasic motor unit potential after double advancement in one case), to the infraspinatus in one case (polyphasic motor unit potentials recorded in the infraspinatus after single advancement of the supraspinatus), and concerned both muscles in 2 cases (increase of muscular latencies after double advancement). DISCUSSION: Muscular advancement was usually performed for tears of more than 2.5 cm wide, and so should be deleterious for suprascapular nerve, according to Warner et al. studies. But in most cases no neurological impairment could be observed in surgical practice. This could be due to the fact that the gap to repair is due not only to a loss of substance in the tendons but also to muscular retraction. In a first step, the muscular release allows to correct this muscular retraction ("muscular" advancement). The advancement remaining then to be performed is about 2 cm wide ("tendino-muscular" advancement). CONCLUSION: It appears that in surgical practice supra and infraspinatus advancement threatens only moderatly the suprascapular nerve or its branches, even if the width of the tear is greater than 3 cm. Postoperative immobilization in slight lateral elevation further reduces the importance of this advancement.

[Impact of fatty degeneration of the suparspinatus and infraspinatus msucles on the prognosis of surgical repair of the rotator cuff]. / Influence de la dégénérescence graisseuse des muscles supraépineux et infraépineux sur le pronostic des réparations chirurgicales de la coiffe des rotateurs.

PURPOSE OF THE STUDY: Rupture of the cuff tendons can induce a fatty degeneration of cuff muscles. In 1989 the authors proposed a grading in 5 stages of this degeneration based on CT scan. The purpose of this study was to determine whether this degeneration had an influence on anatomical and clinical results after surgical repair of the cuff. MATERIAL AND METHODS: Seventy-four patients operated for a ruptured cuff had prospectively a pre-operative CT scan grading of muscular degeneration, and a post-operative anatomical control by opaque arthrography at about 10.5 months follow-up. Forty-four patients were males and 30 were females. The mean age at operation was 58.7 (40 to 75). Fifty-two ruptures were large involving the supraspinatus and infraspinatus in 17 cases, the supraspinatus and the subscapularis in 20 cases and all three tendons in 15 patients. Twenty-two ruptures were smaller and involved only the supraspinatus. To repair the cuff, it was necessary to advance the supraspinatus muscle in 28 cases and both supra and infraspinatus in 24 cases. No patient was lost for follow-up, and 51 of the 56 having more than one year of follow-up (mean 3 years, maximum 7.5 years) were evaluated according to Constant and Murley score. Two reoperated patients were excluded from the final analysis. RESULTS: Complete supraspinatus tears after repair recurred in 16 cases (22 p.cent). No infraspinatus rupture occurred after 32 infraspinatus repairs. Re-tears were observed only when a muscular advancement had been performed. Except in one case, re-tears occurred only when supraspinatus and/or infraspinatus were degenerated. The mean Constant score at revision for 49 patients was 66.6 points. According to this scoring system, 67.3 p.cent had a satisfactory result, 24.5 p.cent a fair result, and 8.2 p.cent a bad result. The mean score of the 39 patients having a continent cuff was 67.4 points, and was not significatively better than that of the patients with a re-tear (63.7 points). The best results were noted for the postero-superior tears (74.6 points). The type of repair had no significative influence on the final Constant score. The best improvements in external rotation were observed when a double advancement was performed. The stage of fatty degeneration, particularly of the infraspinatus, had an influence on the final range of motion, particularly in external rotation, and on the final strength. DISCUSSION: The fatty degeneration of supra and infraspinatus is an important prognostic factor of the anatomical and functional results after surgical repair of the cuff. More-over, when it is present, the surgeon may have some difficulties to close the tear during surgery. This study confirms that it is probably better to operate rotator cuff tears before the appearance of irreversible muscular damage, particularly when the lesions extend posteriorly to the supraspinatus.

Acromio humeral distance less than six millimeter: its meaning in full-thickness rotator cuff tear.

UNLABELLED: The present study sought to identify full-thickness rotator cuff tears liable to induce an acromiohumeral distance (AHD) of less than 6 mm. The hypothesis was that, less than 6mm AHD is found exclusively in association with total full-thickness infraspinatus tear. MATERIALS: A continuous single-center series recruited 109 shoulders, free of glenohumeral osteoarthritis, presenting with full-thickness tear requiring surgery. Preoperative acromiohumeral distance, rupture location and extension on the various tendons and muscular fatty degeneration (FD) were known. METHODS: Full-thickness tears were categorized by location and extension on the various tendons. For each group, the number of shoulders showing AHD<6 mm was determined. RESULTS: Total full-thickness infraspinatus tears were almost the only tendon lesions able to induce AHD<6 mm, but this only when the infraspinatus muscle showed FD equal to or greater than 2.25: i.e., when the tear was longstanding. DISCUSSION: Unlike previous reports, the present study took account of the total or partial nature of infraspinatus and subscapularis tendon tear. The findings may suggest that AHD<6 mm is induced by posterior migration of the humeral head secondary to longstanding total infraspinatus tear, reducing AHD projection height on X-ray. CONCLUSION: AHD<6 mm is a sign of rotator-cuff rupture almost systematically involving longstanding total infraspinatus tear, not always amenable to suture repair due to advanced fatty degeneration. AHD equal to or greater than 6mm is of no diagnostic relevance and in no way indicates whether there is subscapularis tear and, if so, whether suture repair is feasible.

Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis?

INTRODUCTION: When suture of the torn subscapularis could not be performed, a superior trapezius transfer was used for repair of the tendinous defect. The aim of this article is to report the mid-term functional and radiographic outcome of this technique when complete watertight rotator cuff healings were achieved and to investigate the usefulness of the trapezius transfer. The hypothesis of this work was that the trapezius transfer could not be considered as a useful treatment option. MATERIALS: The study included 20 shoulders demonstrating watertight healing of the rotator cuff on arthro CT-scan control performed 13.5 months after open surgery consisting of a trapezius transfer and suture of all other torn tendons. The mean age at surgery was 58.4 years. The trapezius transfer operative technique is described. METHODS: The functional status of the shoulders was assessed preoperatively and at a mean follow-up of 30 months according to the non-weighted Constant score and by measurement of active external rotation, arm at the side. Radiographic and CT-scan assessments were performed preoperatively and at a mean follow-up of 28.5 months. The functional results obtained at last follow-up were compared with those "theoretically estimated" after anatomically successful suture of the torn supra and infraspinatous without associated repair of the torn subscapularis. RESULTS: Between the pre- and postoperative periods, pain, daily activities and Constant score had all statistically improved. Arthritis was not aggravated but the preoperative anterior subluxation of the humeral head persisted in most cases. The reported Constant scores correlated those "theoretically estimated" in case of non-associated subscapularis repair. DISCUSSION: This series is comparable to those evaluating the pectoralis major transfer technique and reports an identical functional outcome. CONCLUSION: Since the Constant scores obtained after trapezius transfer correlate those estimated when not combining a subscapularis repair and taking into account the very frequent lack of improvement regarding the preoperative anterior subluxation of the humeral head, the trapezius transfer does not appear as a recommendable treatment option.

Intermediate term functional outcome prediction following full thickness rotator cuff tear reparative or not reparative surgery.

UNLABELLED: Although simple suturing repair of a full thickness cuff tear can be performed when the preoperative fatty degeneration index (FDI) is 2 or less, it is not known if the functional results will be better than palliative surgical treatment. The aim of this study is to describe and validate a method to predict the intermediate term unweighted Constant scores of different surgical treatments based on preoperative FDI. The hypothesis of this study is that the preoperative and final follow-up ratios FDI/final follow-up Constant scores regression lines, established on a previous "reference study"[5] (a series of 29 shoulders with cuff tears and sutured intact rotator cuff), could be used for this purpose. MATERIAL: The present study included seven series of sutured cuffs (five, which resulted in intact cuffs and two in recurrent tears) and one series of cuffs treated with palliative surgery. Knowledge of the preoperative FDI and the location of the recurrent or unrepaired tears were required criteria for these series inclusion in the study. METHOD: For each of the series in this study the Constant scores and selected score items were compared to scores calculated with the same mathematical formulas previously used to determine the regression lines in the reference study series (resulting in Constant scores in relation to preoperative and final follow-up FDI). RESULTS: The calculated Constant scores were similar to those reported by the authors, which validate the proposed method. DISCUSSION: Because of the small size of the series of sutured cuffs with recurrent tears and of cuffs that underwent palliative surgery and arthroscopic treatment it is impossible to definitely confirm the validity of this method. CONCLUSION: The intermediate term results of different surgical treatments can reasonably be predicted for full thickness tendon tears based on the preoperative FDI and the location of these tears. With this method the best treatment should be chosen for a rotator cuff tear on a case-by-case basis. LEVEL OF EVIDENCE: Level IV.

How repaired rotator cuff function influences Constant scoring.

UNLABELLED: The function level influence of an intact rotator cuff on the unweighted Constant score and its corresponding items is unknown. The aim of this study was to evaluate this contribution. The hypothesis was that the shoulder muscles other than the rotator cuff ones ensure a "basic" shoulder function level that is improved by the rotator cuff depending on its fatty degeneration index (FDI) MATERIAL AND METHODS: This study was based on a continuous series of 29 non-osteoarthritic shoulders whose sutured rotator cuff tears remained intact after 9 years of follow-up. The preoperative FDI was 0.9 (0-2) and 1.26 (0.2-2.2) at the final follow-up. The Constant score was 76.85 at the final follow-up (range 42-93). There was a strong negative correlation between preoperative and follow-up FDI's and all the Constant scores at the final follow-up. Linear regression analysis was performed. The two linear regression lines were superimposed. RESULTS: For a given FDI value, all Constant scores were lower when linear regression was based on preoperative FDI scores that included postoperative deterioration of the FDI. The two linear regression lines converged as the FDI increased and intersected at an FDI of 2.25. Thus, the impact of intact repaired rotator cuff function was null when the FDI was above 2.25, leaving other shoulder muscles (including the deltoid), to ensure "basic" shoulder function at a Constant score of approximately 62 points. DISCUSSION: The "basic" shoulder function found in this study is supported by the similar Constant scores found in reverse shoulder prostheses, and in painless shoulders with full thickness rotator cuff tears. CONCLUSION: The deltoid and the shoulder muscles other than the rotator cuff seem to be responsible for "basic" shoulder function and represent 60% of the unweighted Constant score. The lower the FDI, the more the function of an intact repaired cuff improves this "basic" function level. LEVEL OF EVIDENCE: Level IV.

Tension-free cuff repairs with excision of macroscopic tendon lesions and muscular advancement: results in a prospective series with limited fatty muscular degeneration.

Recurrent tears after rotator cuff repairs are frequent. These could be influenced by excessive tension on a degenerated tendinous stump and by fatty degeneration of the cuff muscles. The goal of this study was to evaluate the anatomic and functional results of tension-free cuff repairs with the excision of macroscopic tendon lesions in a series with limited muscular fatty degeneration of the infraspinatus and a global fatty degeneration index of rotator cuff muscles equal to or lower than 2. We studied 27 tears, comprising 13 cases involving both supraspinatus and infraspinatus tears, 13 cases with 3-tendon tears, and 1 case with only a supraspinatus tear. All shoulders were operated on through a transacromial approach easily repaired with 2 titanium screws with washers. To obtain a repair without tension, a single advancement was performed in 20 cases and a double advancement of both the supraspinatus and infraspinatus was done in 7 cases. The shoulders were evaluated clinically preoperatively and postoperatively with the non-weighted Constant score and anatomically with computed arthrotomography scans. The mean age at operation was 59.5 years, and the length of follow-up ranged from 1 to 4 years. Of the cuffs, 23 (85%) were watertight 1 year after surgery. No predictive factor of retear could be found. The functional improvement was statistically significant only for watertight cuffs, with an improvement of the Constant score from 57.8 to 75. The only predictive factor of functional outcome in this watertight group was the preoperative Constant score. Single and double advancements yielded similar functional results regardless of the extent of the initial tear, provided that the cuff was watertight at revision.

Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.

A preoperative computed tomography (CT) scan grading muscular fatty degeneration in five stages was done in 63 patients scheduled for repair of a torn rotator cuff. The results were compared with postoperative evaluation done after a mean of 17.7 months in 57 patients. Postoperative arthrographies were also performed in 56 patients. Preoperative CT scans demonstrated that infraspinatus fatty degeneration can occur in the presence of large anterosuperior tears even when the infraspinatus tendon is not torn; it worsens with time. The subscapularis rarely degenerates, and when it does it degenerates moderately, even when its tendon is not torn. After an effective surgical repair, moderate supraspinatus degeneration regressed in six of 14 patients; that of the infraspinatus never regressed but rather, increased, in three patients. One of these deteriorations, involving both supra- and infraspinatus, could probably be attributed to a partial subscapular nerve injury. Infraspinatus degeneration was correlated with functional pre- and postoperative impairment of active external rotation. Recurrence of infraspinatus tear was never observed, but recurrence occurred in 25% of supraspinatus repairs. Infraspinatus degeneration had a highly negative influence on the outcome of supraspinatus repairs. It seems preferable to operate on wide tears before irreversible muscular damage takes place.

Fatty infiltration of disrupted rotator cuff muscles.

The extent of fatty infiltration of rotator cuff muscles was evaluated on computed tomography displays using a five-point scoring system in 63 shoulders before surgery for a rotator cuff tear and in 57 of these shoulders after surgical repair of the tear (the quality of cuff repair was evaluated in these 57 shoulders by arthrography, usually coupled with computed tomography, after a mean time interval of 8 months since the procedure). Preoperatively, significant fatty infiltration of the supraspinatus muscle was uncommon. Severe fatty infiltration of the infraspinatus and subscapularis muscles was seen in some patients. In most instances, fat accumulated in those muscles whose tendons were torn; however, tendon cleavage was associated with mild fatty infiltration of the corresponding muscle in some instances, and wide tears of the supraspinatus and subscapularis muscles were sometimes accompanied with severe fatty infiltration of the infraspinatus muscle. In half the cases, fatty degenerescence of the infraspinatus muscle occurred within six months of the tendon rupture. After surgery, in most shoulders without evidence of rotator cuff leakage on the postoperative arthrogram, no further accumulation of fat occurred. However, a decrease in the amount of existing fat was rarely documented and occurred only in the supraspinatus muscle. Before and after surgery, increasing severity of the fatty infiltration of the infraspinatus muscle was associated with increasing functional impairment of the same muscle. Recurrent rotator cuff tears, which involved only the supraspinatus muscle, were considerably more common when there was severe preoperative fatty infiltration of the infraspinatus muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolated subacromial decompression for the treatment of chronic shoulder pain with rotator cuff calcification. A review of twenty-seven shoulders, including eighteen evaluated by magnetic resonance imaging after surgery.

We conducted a retrospective study of functional results and imaging study changes after isolated anterosuperior decompression of 27 chronically painful shoulders with calcification of the supraspinatus tendon at the time of surgery (n = 22) or at an earlier date (n = 5). Mean duration of pain at surgery was 4.5 years. Mean time between surgery and evaluation of results was three years. Absence of pain and full range of motion were noted in most cases (70%), usually after four to six months. There were no postoperative exacerbations of pain. The best results were obtained in those patients with a heterogeneous supraspinatus calcification. Most calcifications (18/22) disappeared within one year of surgery. Magnetic resonance imaging findings at last follow-up are reported for 18 shoulders. Functional results were nearly as good as those reported after calcification removal. In patients with shoulder pain and rotator cuff tendon calcifications who fail to respond to conservative therapy and aspiration with lavage, anterosuperior decompression may be the treatment of choice when the calcification is either heterogeneous and located within the tendon or no longer visible. In contrast, curettage may be the best treatment for superficial homogeneous calcifications that can be removed without damaging the rotator cuff.