Patient information in orthopedic and trauma surgery. Fundamental knowledge, legal aspects and practical recommendations.

Providing information to surgery patients is a form of health-care governed by clearly defined therapeutic and medicolegal rules, and in particular in France by the Act of March 4, 2002 and the Code of Good Practice. The patient's right to information is implemented in a face-to-face consultation, which should be fully codified, and in a specific clinical examination, followed by information regarding the affected organ, pathology, treatment options, possible surgery, and the preconditions, risks and results associated with the procedure. Information should be personalized and as complete as possible, communicating the state of knowledge as validated by scientific societies and medical institutions. State of the art technology (dedicated website, on-line information suites, etc.) is indispensable but needs to be mastered and to adhere to the guidelines of the Council of the National Order of Medicine. Information traceability, the retraction period and proof of content of the information are essential. A signed document delivered in an informative atmosphere optimizes the exercise. Patient information is an ethical and medicolegal obligation, but above all is the expression and demonstration of the health-care potential of the practitioner and our contribution to reducing the information gap, reinforcing the cement holding our society together.

New design of a cementless glenoid component in unconstrained shoulder arthroplasty: a prospective medium-term analysis of 143 cases.

The uncemented glenoid implants in total anatomical shoulder arthroplasty are likely to be accused of problems like dissociations, secondary rotator cuff tear, and wear of polyethylene (PE). This work is a clinical and radiological prospective review of 143 cases of anatomical total shoulder arthroplasty using a new metal back uncemented glenoid implant (MB) in order to see if this new implant induces those complications. A total of 143 cases were operated between 2003 and 2011. In a first part, the whole series of 143 cases was radiologically studied in order to quantify the lateralisation induced by the MB implant. In a second study, 37 cases had a mean follow-up of 38 months (24-75, mean 32) and served for the clinical and radiological final study. Pre- and postoperative clinical evaluation was done using the Constant-Murley score and the simple shoulder test from Matsen. The final X-rays served to detect an eventual secondary narrowing of the joint space and to analyse the frequency of radio lucent lines (RLL) and loosenings. Despite a small radiological lateralisation in comparison with the normal contralateral side (0.36 cm, p = 0.02), the clinical results after 2 years were similar to the published cemented glenoid implants series but without any RLL, glenoid loosening or joint narrowing. Some dissociations occured in the beginning and definitely eliminated by a design modification of the PE tray. The discussion tried to show that, despite a still short follow-up, this series is encouraging to continue to use this new MB implant. Different applications of the concept of universality and conversion are discussed, this tray been also the support of a glenosphere in reverse arthroplasty.

Comparison and critical evaluation of rehabilitation and home-based exercises for treating shoulder stiffness: prospective, multicenter study with 148 cases.

INTRODUCTION: The goal of this study was to evaluate the effectiveness of individual exercises performed as classic rehabilitation or a home program on the clinical progression of patients with shoulder stiffness. Based on this information, the secondary goal was to develop a new rehabilitation protocol. PATIENTS AND METHODS: This prospective, comparative series included 148 cases of shoulder stiffness. There were three treatment groups: T1: classic rehabilitation performed below the pain threshold (58 cases); T2: home program with provocation above the pain threshold (59 cases); T3: home program supervised by a physical therapist (31 cases). The execution, pain level and time spent doing each exercise were compiled for each work session - every day for the first 6 weeks, then every week up to 3 months. Clinical (Constant score) and range of motion evaluations were performed at enrollment, week 6 and month 3.Changes were compared between groups; correlation tests were used to analyse the effectiveness of each exercise during each session. RESULTS: Other than physical therapy and balneotherapy, classic rehabilitation exercises had a negative effect on clinical progression during the first 3 to 5 weeks (P<0.05), but this did not hinder the occurrence of a slow, continuous clinical improvement (P<0.05). Home programs led to rapid functional progression with improvement directly related to the number of exercises actually performed (P<0.05), however, pain during the day increased and pain at night decreased. Supervision by a physical therapist helped to optimize the home program, with the same result at week 6, but a better result at month 3 (P<0.05). CONCLUSIONS: Based on the results of this study, a new treatment protocol for shoulder stiffness was proposed that combines an intensive patient home program with a well-informed physical therapist, who progressively adds classic rehabilitation techniques when they provide the best treatment value for each exercise. Patient education is the key to treatment success.

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases.

INTRODUCTION: Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined. PATIENTS AND METHODS: This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements). RESULTS: Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05). DISCUSSION: The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.

Pain management in the rehabilitation of stiff shoulder: prospective multicenter comparative study of 193 cases.

INTRODUCTION: The present study investigated the impact of respecting pain threshold on clinical recovery in stiff shoulder. PATIENTS AND METHODS: A prospective multicenter comparative study followed up 193 cases of shoulder stiffness for a mean 12-month period (range, 8-31 months) after four different treatment protocols: (1) conventional sub-pain-threshold rehabilitation (58 cases); (2) self-rehabilitation exceeding the pain threshold (59 cases); (3) supervised suprathreshold rehabilitation (31 cases); and (4) capsulotomy with sub-threshold rehabilitation (45 cases). Follow-up was daily for the first 6 weeks then weekly for the next 6; each session included assessment of the painfulness, feasibility and duration of each rehabilitation and self-rehabilitation exercise and of pain status, disability and psychological status. The surgeon followed patients up at 6 weeks, 3 months, 6 months, 1 year and at last follow-up. RESULTS: Sub-threshold rehabilitation provided progressive results, limited in time (P<0.05). Suprathreshold self-rehabilitation provided reduced pain (P<0.05) as of the first days, with nocturnal pain ceasing after 7 days' rehabilitation in 43% of cases. Supervision of self-rehabilitation exercises optimized the clinical result (P<0.05). Capsulotomy did not influence pain evolution over the first 8 weeks, but then improved it. Failure (at 1 year, 14-17%; last follow-up, 3.5%) correlated directly with the number of exercises performed by the patient (P<0.05). DISCUSSION: The dogma of respecting the pain threshold is dated: pain inflicted on a passive patient impairs clinical evolution, but pain managed by an informed active patient under experienced supervision provides rapid recovery of function and pain-free status.

[Arthroscopic rotator cuff repair: a multicentric retrospective study of 87 cases with anatomical assessment]. / Réparation endoscopique des ruptures de la coiffe des rotateurs. (et la Société Française dArthroscopie)

PURPOSE OF THE STUDY: The aim of this study was to evaluate the anatomical and technical limits of endoscopic rotator cuff repair. Anatomical results were also compared with functional assessment of the shoulder. MATERIAL AND METHODS: A multicentric serie of 87 patients presenting a full thickness rotator cuff tear repaired endoscopically was retrospectively reviewed at 25.4 months (mean) post surgery. Limits of the surgical technique were studied in correlation with functional results and anatomic radiographic evaluation (arthroscans in 93 p. 100). RESULTS: Anatomical repair (normal thickness and no contrast in the subacromial space on arthroscan) was achieved in 83 p. 100 of the rotator cuffs with limited damage to the frontal part of the supra spinatus tendon. This percentage fell to 57.8 p. 100 in case of posterior extension of the tear to the supra spinatus tendon and further dropped to 40.8 p. 100 in case of retraction to the apex of the humeral head. Functional outcome evaluated with the Constant score was strongly related to the radiographic cuff condition (p <0.05). For distal and anterior tears of the supra spinatus tendon, the Constant score at revision was 89.8 points in cases with anatomic repair at revision. This score fell to 75 when the rotator cuff tear was evidenced radiographically (p <0.0001). For tears involving the entire supra spinatus tendon repaired by arthroscopy, the functional difference at revision was 8 points on the Constant scale. Objective and subjective analysis of the surgical procedure identified significant peroperative elements predictive of clinical and anatomical outcome (difficult reduction, p <0.05; subjective degree of solidity, p <0.0001; anatomical aspect of the repaired cuff, p <0.05). DISCUSSION: A comparison of our findings with data on equivalent lesions reported in the literature suggests that endoscopic surgery for rotator cuff tears offers both functional and anatomic results equivalent to those achieved with conventional open surgery. This assumes that the surgical procedure is carried out by surgeons experienced in shoulder arthroscopy who can precisely gauge the posterior/anterior extension of the tears and the limits of the surgical technique.

Arthroscopic assessment of full-thickness rotator cuff tears.

SUMMARY: To evaluate the reliability of the arthroscopic assessment of full-thickness rotator cuff tears, 117 cases were prospectively investigated by imaging, arthroscopy, and open surgery. The confidence of the surgeon, his accuracy, and the surgeon-dependent character of arthroscopic assessment were evaluated in terms of the description of the main anatomic parameters. The surgeons were confident and accurate in diagnosing a full-thickness tear of the supraspinatus, but they underestimated its coronal and sagittal extent and its reducibility to the greater tuberosity. Conversely, the technique appeared very accurate in describing the rotator interval. Endoscopic assessment was particularly operator-dependent in the anteroposterior analysis of the tear. This study shows the limits of endoscopic assessment of full-thickness rotator cuff tears. It illustrates the need for an adequate arthroscopic technique with a thorough knowledge of normal and pathological anatomy of the rotator cuff.

[Arthroscopic debridement of full-thickness tears of the rotator cuff: a retrospective multicenter study of 283 cases with 3-year follow-up]. / Le débridement endoscopique des ruptures transfixiantes de la coiffe des rotateurs: étude rétrospective multicentrique de 283 cas à plus de 3 ans de recul.

PURPOSE OF THE STUDY: The purpose of this study was to assess clinical and radiological course of full-thickness rotator cuff tears treated by arthroscopic debridement and to discuss surgical indications according to patient demands and anatomical lesions. MATERIAL AND METHODS: This retrospective and multicentric study included patients with a minimal 3 years follow-up. The coronal extent of the supraspinatus tear was described as distal, intermediate or retracted. The sagittal extent to the infraspinatus and/or subscapularis and rotator interval was detailed. All patients were evaluated pre and post-operatively using Constant score and radiological A-P view for sub-acromial space measurement. In order to assess the influence of age, anatomical extent of the tear and follow-up, results were analyzed for 4 groups of patients according to their age: group I (19 cases less than 50 years), group II (88 cases from 51 to 60 years), group III (58 cases from 61 to 65 years) and group IV (118 cases over 65 years). Results were finally evaluated according the arthroscopic procedure (isolated acromioplasty and biceps tenotomy, or association of both). RESULTS: 283 patients, aged 63.1 years (range 32 to 82) entered this study. A complete antero-posterior tear of the supra-spinatus tendon was noticed in 93.2 p. 100 of cases. The tear extended to the infraspinatus tendon in 57.3 p. 100, and to the subscapularis tendon in 29 p. 100 of cases. The long head of the biceps was involved in 73 p. 100 of cases. 218 acromioplasties and 116 biceps tenotomies were performed. The 2 procedures were combined in nearly 25 p. 100 of cases. At final revision (mean follow-up of 4.7 years), 98 patients (34.6 p. 100) were very satisfied, 122 (43.1 p. 100) satisfied, 43 (15.2 p. 100) moderatly satisfied and 20 (7.1 p. 100) were disappointed. The average Constant score increased from 42.4 to 67.6 points. The radiological study showed a 1 mm narrowing of the sub-acromial space. Objective results were surprisingly good for group I at a 5.4 years follow-up but dropped from group II to group IV, mainly in relation with the extent of the tear. A deleterious effect of the isolated biceps tenotomy was demonstrated in case of subacromial space superior to 7 mm. Inversely after this procedure patients with a narrowed space improved. DISCUSSION: Even if traditional bias of retrospective and mullticentric study could not be avoided, the large number of patients and long follow-up of this study are superior to most of the published papers. The extent of the supraspinatus tear seems to progress during the 50-60 years decade. Objective results appeared to be much more related to the anatomical lesions than to the arthroscopic procedure. CONCLUSION: This series did not demonstrate a secondary clinical or radiological deterioration after an endoscopic treatment without repair of full-tickness rotator cuff tears. Subacromial decompression and/or biceps tenotomy indications depend on age and extension of the tear.

[Meningeal metastases of ovarian cancer. Contribution of imaging]. / Métastases méningées du cancer de l'ovaire. Apport de l'imagerie.

BACKGROUND: Secondary meningeal localizations are uncommon and may disclose reactivation of a malignant disease. Most meningeal metastases occur in breast cancer, exceptionally in primary ovarian cancer. CASE REPORT: We report 2 cases of secondary meningeal localizations of ovarian cancer. The diagnosis was clinical, supported by cerebrospinal fluid analysis and computed tomography and magnetic resonance imaging. DISCUSSION: Establishing the diagnosis of carcinomatous meningitis may be difficult. Clinical signs and biological data are not always conclusive. If spinal tap is contraindicated or negative, imaging, particularly magnetic resonance imaging is highly contributive in establishing the diagnosis of secondary localization. A precise evaluation of the invaded tissues is quite helpful in guiding therapeutic management based on chemotherapy, tumor resection or radiotherapy.

Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study.

The aim of this study was to evaluate the evolution of intraarticular disease in posttraumatic shoulder instability. Ninety-one patients with posttraumatic shoulder instability were examined arthroscopically. The intraarticular disease was recorded on a special documentation sheet (containing 67 descriptive items). The patients were divided into 5 subgroups: first-time dislocation (n = 9); first or second recurrence (n = 12); 3 to 5 recurrences (n = 23); 6 or more recurrences (n = 32); and chronic subluxations (n = 15). All data were examined statistically. Each lesion was correlated with stage of evolution, age, and number of recurrences. The most frequent lesions were regrouped into "lesion families." The initial and most constant lesion was the periosteal disinsertion of the anteroinferior labrum (single lesion). The labral detachment was succeeded in a second stage by the disinsertion of the glenohumeral ligament complex (double lesion). With additional recurrences, stress mechanisms altered the detached structures through tissue damage (triple lesion). The fourth stage saw the extension of the degenerative process, which led to failure at the insertion site and destruction of the labrum-ligament complex (quadruple lesion). This study reveals that recurrences progressively damage stabilizing structures. A pathophysiological classification into 4 stages is proposed, however, that would permit a precise therapeutic strategy for arthroscopic shoulder stabilization.

A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty.

We followed 210 cases of rotator cuff tears treated in four French centers by arthroscopic acromioplasty in 195 cases and by a tenotomy of the Long Head of Biceps (LHB) in 15 cases. All patients were evaluated by means of the Constant score (CS) and radiographic imaging. The mean age was 61 years and the mean follow-up period was 26.6 months (range, 12 to 93 months). The preoperative CS was 38.2 points; 41% were supraspinatus tears, 40.2% were supra and infraspinatus tears, 10.5% were three-tendon tears, and 8.1% were supraspinatus and subscapularis tears. The LHB was altered or disrupted in 77% of cases, dislocated or subluxated in 44% of cases. Acromioplasty was associated to tear debridement in 183 cases (88%) and to a tenotomy of the LHB in 38 cases (19%) of which 15 did not benefit from an associated acromioplasty. Global objective results shown by the corrected CS reached 79.7% and were satisfying in 73% of cases. Poor clinical factors were preoperative shoulder stiffness, postoperative painful crises, worker compensation, a preoperative history longer than 4 years, and young age. The poor anatomic factors were osteoarthritis, a lesion of the acromioclavicular joint or of the LHB tendon. An isolated supraspinatus tear will produce much better results than a triple-tendon tear. The persistence of an aggressive acromion was a prejudicial factor. The benefits of LHB tenotomy were evident and could be isolated in case of massive rotator tears. It seems that LHB tenotomy was particularly effective for massive tears of two or more tendons. Arthroscopic acromioplasty is an excellent indication for elderly patients without professional activity, functionally less demanding that a younger patient.

[Interscalenic block and surgery of the shoulder. A prospective study of a continuous series of 167 patients]. / Bloc interscalénique et chirurgie de l'épaule. Etude prospective d'une série continue de 167 patients.

OBJECTIVES: To determine the relationship between minimal stimulating current and success rate of interscalene brachial plexus block (IBPB), to assess the quality of anaesthesia and postoperative analgesia, and to evaluate the benefits and drawbacks of this technique in shoulder surgery. STUDY DESIGN: Prospective study of a continuous series of clinical cases. PATIENTS: Series of 167 patients undergoing shoulder surgery under IBPB, obtained with Winnie's technique, in 1995. METHODS: The plexus was located with a nerve stimulator and an insulated needle, 25 mm long and with a short 30 degrees bevel (Stimuplex, Braun). Data were collected with questionnaires, filled in by the anaesthetists, the surgeon and patients. RESULTS: Shoulder surgery was performed either under IBPB alone in 51.5% of cases (group A), or under IBPB associated with sedation (midazolam: 1-3 mg) in 31.7% (group B), or under IBPB associated with general anaesthesia either on the patient's request (11.4% = group C) or due to IBPB failure (5.4% = group D). The success rate was 94.6% and the efficiency of postoperative analgesia obtained in 100% of cases (no pain at admission in the recovery room). For the nerve location a minimal stimulating current of 0.08 to 1 mA (mean minimal stimulating current 0.42 +/- 0.17 mA) had been required, with a significant difference (P = 0.0001) between group A (0.38 +/- 0.14 mA) and the others (0.43 +/- 0.15 mA in group B, 0.50 +/- 0.21 mA in group C, 0.59 +/- 0.23 mA in group D). CONCLUSIONS: The correlation between minimal stimulating current and success rate has clearly shown the benefit of the nerve stimulation. IBPB, which provides a successful and efficient anaesthesia with minimal risk and satisfactory postoperative analgesia, has become the standard technique for shoulder surgery.

[Arthroscopic aspects and chronologic outcome of lesions of the labro-ligament complex in post-traumatic antero-inferior instability of the shoulder. A prospective study of 91 cases]. / Aspects arthroscopiques et évolution chronologique des lésions du complexe labro-ligamentaire dans l'instabilité antéro-inférieure post-traumatique de l'épaule. Etude prospective sur 91 cas.

PURPOSE OF THE STUDY: The authors present a prospective and mono-operator study of 91 gleno-humeral arthroscopies for post-traumatic antero-inferior instability of the shoulder. The aim of the study was to obtain a dynamic understanding of the relationship between the anatomic lesions to allow the integration of all the described lesions into literature and to produce a natural history of lesions in antero-inferior shoulder instability. MATERIALS: 91 endoscopies for post-traumatic instability of the shoulder were performed by the same surgeon. Revision chart comprised 67 purely descriptive items. For the purpose of the study, the patients were divided into 4 groups of dislocation (first dislocation: 9 cases, 1 to 2 recurrences: 12 cases; 3 to 5 recurrences: 23 cases; more than 5 recurrences: 32 cases) and 1 group of subluxation (15 cases). METHOD: The statistical evaluation of each individual data item gathered value allowed the selection of the most significant lesions and to regroup them into "lesions families", relations to the same physiopathological mechanism (traumatic or degenerative). The correlation between each lesion in terms of evolution, age and number of recurrences was studied. RESULTS: The first and most constant lesion is the periosteal avulsion of the antero-inferior labrum ("single lesion": healing potential of +/- 30 per cent, in ectopic position in +/- 90 per cent). With recurrences, the avulsion of the gleno-humeral ligament adds this "single lesion" ("double lesion". Healing potential of +/- 50 per cent, in ectopic position in +/- 90 per cent). Continuing the recurrence, we also noted a degenerative and plastic deformation under the level of the glenoid rim ("triple lesion": infra-glenoid degenerescence) then over the glenoid rim ("quadruple lesion": supra glenoid degenerescence). The age factor and duration of evolution were not negligible and one must associate the "labro-ligament complex" studies with the avulsion lesions of the long head of the biceps (SLAP lesions) in which the frequency varies from 15 per cent to 30 per cent and which was consistently present in patients above 35 years of age. DISCUSSION: The authors believe that recurrences give rise to a progressive worsening of the lesions by the sum of the separate lesions. They propose a physiopathological classification in 4 stages where each lesions has its own healing potential, which explains the apparent large variation in endoscopic aspects of antero-inferior shoulder instability. CONCLUSION: This classification should permit a precise therapeutic strategy in post-traumatic anterior instability, according to the most recent techniques of endoscopic reattachment of the labro-ligament complex.

[Results of surgical treatment of metastases of renal carcinomas in 65 operated cases]. / Résultats du traitement chirurgical des métastases de cancer du rein -A propos de 65 métastases opérées.

Several reports have assessed that the prognosis of metastatic renal cell carcinoma was better if patient's general condition was good, if primary tumor had been resected, if the time between nephrectomy and metastasis was long, if metastases are only pulmonary and bone marrow was not involved. The bone metastases of renal cell cancer have a bad reputation because of their haemorragic caracteristics and their resistance to radiotherapy.In the Orthopaedic and Traumatologic Department of the University hospital in Strasbourg, the authors had operated on 65 metastatic renal cell cancers. There were 55 patients (41 were men and 14 female), aged of 60 (range 41-84). Eight of them had 2 operations and 1 had 3 metastatic localisations.In 23% the metastases were present at the time of primary tumor diagnosis; in 17% the metastasis was even a signal metastasis. There were pathologic fractures in half of the cases (33 cases) and in the other half the metastasis had not fractured. The commonest site was the femur (40 of the 65 cases). The second site was the humerus (15 cases). There were also 7 vertebrae, 6 of them with neurologic deficit.The authors performed closed osteosynthesis in 27 cases (15 intramedullary nails, 7 Ender nails, 4 bipolar pinnings, 1 gamma nail), arthroplasty in 19 cases (6 standard prosthesis and 13 reconstruction prostheses) and an open osteosynthesis in 12 cases. They performed also 3 vertebrectomies by an anterior approach and 4 posterior decompressions and stabilisations.The average post operative survival was 15 months (range 0-109). Six patients died in the first post-operative month. Three non specific complications were observed: 2 prosthetic dislocations and one infected nail failure. 6 tumor extensions were observed on 2 prostheses, 3 intramedullary nails and 1 open osthesynthesis.The results were good for pain in 83% of the patients, the functional result good or fair in 78%.The efficacy of adjuvant medications was discussed, based on the literature data. Two groups of metastatic renal cell cancer were studied: the first with multiple metastases and a high speed progressive disease, the other with single metastasis and a low speed progressive disease. The surgical indications should be different in the two groups.

[Functional and anatomical results after surgical treatment of ruptures of the rotator cuff. 1: Preoperative functional and anatomical evaluation of ruptures of the rotator cuff]. / Résultats fonctionnels et anatomiques après traitement chirurgical des ruptures de la coiffe des rotateurs. 1ère partie: évaluation fonctionnelle et anatomique préopératoire des ruptures de la coiffe des rotateurs.

PURPOSE OF THE STUDY: In a consecutive series of 98 patients presenting 100 full thickness cuff tears and managed by the same medico-surgical team, the authors studied the correlation between preoperative shoulder function values and the anatomic lesions found at surgery. Predictive factors of tear size were evaluated and any elements that were likely to improve preoperative function were determined so that patients could be best prepared for surgery. The validity of preoperative radiographic assessment of lesions was examined. MATERIAL AND METHODS: Prior to surgery, each patient was given the same rehabilitation program, the same arthrotomographic assessment of lesions and each was rated functionally using Constant's scoring method. Preoperative radiographic assessment of lesions showed supra-spinatus tears in 69 per cent, combined supraspinatus and infraspinatus tears in 22 per cent, and tears involving the supraspinatus, infraspinatus and subscapularis in 9 per cent. RESULTS: The preoperative Constant score averaged 46/100 points. The score was higher when patients had been prepared by preoperative rehabilitation to overcome stiffness. The optimum duration of rehabilitation was found to be 3 months (p < 0.05). Active range of motion was 90 per cent of normal in 84 per cent of cases. The patients in this series therefore underwent surgery more for continuing severe pain (25 per cent) and muscle weakness (86 per cent) than for reduced active motion. DISCUSSION: Examination of the correlations existing between an anatomic lesion and the preoperative rating of shoulder function shows that the Constant preoperative score provides a good prediction of the size of the tear to be repaired (p = 0.0063). The greater the tear size, the lower the preoperative Constant sore is. Active range of motion (especially in abduction and external rotation) and muscular strength are factors with the most predictive value contrary to pain and discomfort which are influenced by tear size. CONCLUSION: Preparing patients suffering full thickness cuff defects through preoperative rehabilitation to overcome stiffness provides the best conditions for surgery. Constant's functional scoring method gives a reproducible and reliable reflection of the anatomic rotator cuff lesion to be repaired. Its use for preoperative rating is useful for determining a reference value for function prior to surgery.

[Functional and anatomical results after surgical treatment of ruptures of the rotator cuff. 2: postoperative functional and anatomical evaluation of ruptures of the rotator cuff]. / Résultats fonctionnels et anatomiques après traitement chirurgical des ruptures de la coiffe des rotateurs. 2ème partie: évaluation fonctionnelle et anatomique postopératoire des ruptures de la coiffe des rotateurs.

PURPOSE OF THE STUDY: The authors examined the anatomic condition and the function of the rotator cuff obtained after an average period of four years following surgical repair in a series of 100 full thickness rotator cuff tears. The aim was to assess the validity of Constant's scoring method and to analyse risk factors and the frequency of recurrent tears. MATERIAL AND METHODS: The series comprised 98 patients, 62 men and 36 women whose average age was 56 years. It included 69 tears of less than 2 cm in size (39 cases) or between 2 to 4 cm (3 cases) of the supra-spinatus, 22 tears of the supra- and infraspinatus measuring between 2 to 4 cm, and 9 massive tears. The tendon of the long head of the biceps was pathological in 1/3 of cases. All 98 patients were operated on by the same surgeon using the same repair technique, and all followed ambulatory rehabilitation along the same principles of self-rehabilitation applied pre operatively. In each patient function was assessed using Constant's scoring method, and the condition of the repaired cuff was determined by ultrasonography at the time of clinical follow-up. The average follow-up period was 4 years (2 to 6 years). RESULTS: Ultrasonography revealed intact cuffs in 65 per cent, thinned cuffs in 11 per cent and recurrent full thickness tears in 24 per cent of cases. The risk of recurrent tear increased with the extent of the tear to be repaired (57 per cent), in older patient (25 per cent) and with a higher level of post-surgical occupational use (18 per cent). A drop in the post-operative Constant score had a predictive value for a full thickness recurrent defect. DISCUSSION: Constant's scoring method appears to be a reliable, reproducible method for analysing functional results following surgical repair of full thickness cuff tears and to reflect the anatomic condition of the repaired cuff. At clinical follow-up, the anatomic condition of the cuff is more determinant of final functional results than initial tear size. CONCLUSIONS: Assessment of functional results must be complemented by anatomic examination using ultrasonography in order to specify the size of any possible recurrent defect and to detect thinning of the cuff which cannot be identified by Constant's score. Analysis of the risk factors for recurrent tear led the authors to question the necessity of repairing massive tears in older patients and pointed to the valuable advantages of reinforcing fragile cuffs during initial repair especially in very active patients.

Functional and anatomical results after rotator cuff repair.

The anatomic condition of the rotator cuff and the functional results obtained were studied in a homogeneous series of 100 full thickness cuff tears in 98 patients with an average followup of 4 years. Constant's functional score, used by the European Society for Shoulder and Elbow Surgery, was done preoperatively and postoperatively in each patient, in addition to ultrasonography at followup. There was a close correlation between the anatomic condition of the cuff and Constant's functional score before surgery (p = 0.0063) and after repair, irrespective of the type of tear repaired (p = 0.0012) or the sonographic appearance of the cuff at followup (p = 0.0001). Ultrasonography showed 65% intact cuffs, 11% intact but thinned cuffs, and 24% recurrent defects. Three predisposing factors for recurrence were noted: size of tear to be repaired (p = 0.0001) accounted for 57%, age (p = 0.063) for 25%, and degree of occupational use for 18%. The functional results obtained were more related to the anatomic condition of the repaired cuff at followup than to the tear size at surgery. Predictive clinical factors for recurrence included overall Constant's functional score, reduced ability to perform daily activities, reduced active flexion, abduction and external rotation, and loss of muscular strength. Constant's functional score reflected the functional results with accuracy, reliability, and reproducibility. Additional ultrasonography appears necessary to specify the exact size of the recurrent defect and to distinguish between certain anatomic types, such as thinned cuffs, which can give rise to difficult problems in manual workers after defect repair.