Popeye sign: Tenodesis vs. self-locking "T" tenotomy of the long head of the biceps.

INTRODUCTION: Treatment of long head of the biceps lesions is controversial. A new technique of self-locking "T" tenotomy was developed in our department in 2013. HYPOTHESIS: The main objective of the present study was to assess onset of Popeye sign after "T" tenotomy, with comparison to long head of the biceps tenodesis. MATERIAL AND METHODS: A continuous retrospective study included 180 patients with long head of the biceps lesion, either isolated or associated with rotator cuff tear. RESULTS: 130 underwent "T" tenotomy (group A), and 50 tenodesis (group B). Mean age was 57.9 years (range, 23-88 years) in group A and 50.8 years (range, 20-66 years) in group B. At last follow-up, 27.7% of patients in group A and 24% in group B showed Popeye sign (P=0.616), after equivalence test and adjustment on age and occupational activity. Bicipital groove pain was more frequent in the tenodesis group (44% versus 25.4%; P=0.025). DISCUSSION: Self-locking "T" tenotomy did not significantly differ from tenodesis in onset of Popeye sign or clinical results, and showed better postoperative course. LEVEL OF EVIDENCE: IV, retrospective study.

Intra- and inter-observer agreement in MRI assessment of rotator cuff healing using the Sugaya classification 10years after surgery.

BACKGROUND: The long-term outcomes of rotator cuff repair are unclear. Recurrent tears are common, although their reported frequency varies depending on the type and interpretation challenges of the imaging method used. The primary objective of this study was to assess the intra- and inter-observer reproducibility of the MRI assessment of rotator cuff repair using the Sugaya classification 10years after surgery. The secondary objective was to determine whether poor reproducibility, if found, could be improved by using a simplified yet clinically relevant classification. HYPOTHESIS: Our hypothesis was that reproducibility was limited but could be improved by simplifying the classification. MATERIAL AND METHOD: In a retrospective study, we assessed intra- and inter-observer agreement in interpreting 49 magnetic resonance imaging (MRI) scans performed 10years after rotator cuff repair. These 49 scans were taken at random among 609 cases that underwent re-evaluation, with imaging, for the 2015 SoFCOT symposium on 10-year and 20-year clinical and anatomical outcomes of rotator cuff repair for full-thickness tears. Each of three observers read each of the 49 scans on two separate occasions. At each reading, they assessed the supra-spinatus tendon according to the Sugaya classification in five types. RESULTS: Intra-observer agreement for the Sugaya type was substantial (κ=0.64) but inter-observer agreement was only fair (κ=0.39). Agreement improved when the five Sugaya types were collapsed into two categories (1-2-3 and 4-5) (intra-observer κ=0.74 and inter-observer κ=0.68). CONCLUSION: Using the Sugaya classification to assess post-operative rotator cuff healing was associated with substantial intra-observer and fair inter-observer agreement. A simpler classification into two categories improved agreement while remaining clinically relevant. LEVEL OF EVIDENCE: II, prospective randomised low-power study.

Osteoarthritis after rotator cuff repair: A 10-year follow-up study.

BACKGROUND: Joint surgery is often complicated by gradual bone and cartilage deterioration that eventually leads to secondary osteoarthritis. The primary objective of this study was to identify preoperative risk factors for gleno-humeral osteoarthritis after rotator cuff repair. The secondary objectives were to assess whether the risk of gleno-humeral osteoarthritis was influenced by the operative technique, occurrence of postoperative complications, cuff healing, and muscle degeneration and to determine whether gleno-humeral osteoarthritis affected the clinical outcome. HYPOTHESIS: The development of gleno-humeral osteoarthritis affects the postoperative clinical outcome. MATERIAL AND METHOD: A retrospective multicentre study of patients who underwent rotator cuff repair in 2003 and were re-evaluated at least 10 years later was conducted under the aegis of the Société française de chirurgie orthopédique et traumatique (SOFCOT). Osteoarthritis severity was graded according to the Samilson-Prieto classification. RESULTS: Four hundred and one patients were included. At last follow-up, at least 10 years after surgery, the radiological Samilson-Prieto grades were distributed as follows: 0, n=181 (45%); 1, n=142 (n=35%); 2, n=57 (14%); 3, n=14 (4%); and 4, n=7 (2%). The mean Constant score was significantly higher in the patients without than with osteoarthritis at last follow-up (79/100 vs. 73/100, P<0.001). MRI assessment of cuff healing showed that the proportion of patients with osteoarthritis was significantly higher in the group with unhealed or re-torn cuffs (Sugaya type 4 or 5) than in the group with healed cuffs (Sugaya type 1, 2, or 3) (46% vs. 25%, P=0.012). DISCUSSION: Our study showed no associations linking the risk of gleno-humeral osteoarthritis to the patient activity profile, history of shoulder injury, or preoperative symptom duration. In contrast, statistically significant associations were identified between gleno-humeral osteoarthritis and age, male gender, initial tear severity, and the pain and mobility components of the preoperative Constant score. Decreased invasiveness of the operative technique probably diminishes the long-term risk of osteoarthritis. An unhealed or re-torn cuff increases the risk of osteoarthritis. Osteoarthritis is associated with poorer final clinical outcomes. LEVEL OF EVIDENCE: IV, retrospective non-randomised study.

Critical shoulder angle: Measurement reproducibility and correlation with rotator cuff tendon tears.

BACKGROUND: Associations have been reported linking rotator cuff tears (RCTs) to both greater lateral extension of the acromion and greater inclination of the glenoid cavity. These two factors combined can be assessed using a recently introduced parameter, the critical shoulder angle (CSA). The primary objective of this study was to confirm the association linking a high CSA value to RCTs, and the secondary objective was to assess the reproducibility of CSA measurement using a goniometer. HYPOTHESIS: The null hypothesis was that the CSA value in a group of patients with RCTs was not significantly different from that in patients with anterior shoulder instability and a Bankart lesion, taken as the general population for this study. METHODS: After a power estimation, we retrospectively included 28 patients with a mean age of 55.5 years who had surgery for RCTs and 27 patients with a mean age of 27.2 years who underwent anterior labral repair. Two surgeons used a goniometer to measure the CSA in each patient. Reproducibility was assessed based on Bland-Altman plots and Pearson's correlation coefficient. RESULTS: The mean CSA was significantly higher (P=0.02) in the RCT group (36.4°±4.4°; range: 30°-46°) than in the labral-repair group (33.3°±3.8°; range: 25°-41°). Intra-observer reproducibility was 96.7% and inter-observer reproducibility was 95.5%. CONCLUSION: Our results support previously published evidence that the CSA is significantly greater in patients with RCTs. Thus, an anatomical difference seems to exist between patients with RCTs and the general population. The CSA measured on a standard radiograph using a goniometer provides a reproducible assessment of this anatomical difference. LEVEL OF EVIDENCE: IV, case-control epidemiological study with a power estimation.

Revisions of total shoulder arthroplasty: Clinical results and complications of various modalities.

INTRODUCTION: The number of primary total shoulder arthroplasties has increased exponentially in recent years, with a corresponding increase in the number of revision procedures. OBJECTIVE: To assess clinical results and complications in a series of shoulder implant replacement, of whatever etiology. MATERIALS AND METHODS: Thirty-seven patients, with a mean age of 68.3±11.8 years at time of implant replacement, were included in a retrospective study. Mean interval between primary arthroplasty and revision was 78.4±59.7 months (range, 1-200 months). The main assessment criterion was changed in Constant score between preoperative value and follow-up. Secondary criteria were: onset of intra- and postoperative complications, and reoperation related to a complication. RESULTS: Mean follow-up was 41.5±32.0 months (range, 12-105 months). Absolute Constant score increased by a mean 17.5±15.1 points (P<0.001) and weighted Constant score by 26.3±23.6 points (P<0.001). Intraoperative complications occurred in 24.3% of patients (9/37) and postoperative complications in 29.7% (11/37). Among the patients, 21.6% (8/37) required reoperation for postoperative complications. Overall, 54% of patients (20/37) suffered from intra- or postoperative complications. CONCLUSION: Shoulder implant replacement improved function in the present series, but with a high rate of complications and reoperations. LEVEL OF EVIDENCE: IV, retrospective case-control study without control group.

Arthroscopic elbow joint release with radial head resection arthroplasty: 12 cases.

BACKGROUND: Elbow arthritis typically affects manual labourers aged 40 to 50 years and usually starts in the lateral compartment. The objective of this study was to evaluate the medium-term clinical, functional, and radiological outcomes in 12 patients after arthroscopic elbow joint release and radial head resection arthroplasty. HYPOTHESIS: Our main hypothesis was that pre-operative damage to the radio-capitellar joint was associated with poorer clinical outcomes after elbow joint release. MATERIAL AND METHOD: Consecutive patients treated by a single surgeon at a single centre between July 2006 and May 2014 were studied retrospectively. The 12 patients - 10 males and 2 females with a mean age of 54.5±9.3 years (33-69 years) - had osteoarthritis confined to the radio-capitellar compartment with elbow stiffness and pain and underwent arthroscopic elbow joint release with radial head resection arthroplasty. Among them, 9 had a history of trauma or micro-trauma and 3 had rheumatoid arthritis. The Broberg and Morrey osteoarthritis grade on the pre-operative radiographs was 1 in 4 patients, 2 in 6 patients, and 3 in 2 patients. RESULTS: Mean follow-up was 38.1±33.7 months (5-97). One patient required total elbow arthroplasty. Mean arc of motion was 79.6°±20.5° (30-110) pre-operatively, 123.6±18° (90-140) immediately after surgery, and 109°±11.7° (90-120) at last follow-up. At last follow-up, mean values were 81.4±12.5 (65-100) for the Mayo Elbow Score, 11.1±11.1 (2.3-31.8) for the Quick DASH score, and 1.1±1.6 (0-4) for the visual analogue scale pain score. The radiological assessment at last follow-up showed no evidence of osteoarthritis progression. CONCLUSION: In our case-series, arthroscopic elbow joint release with radial head resection arthroplasty produced good outcomes with a motion arc greater than 100° and little or no pain after a mean follow-up of 3.1 years. LEVEL OF EVIDENCE: IV, retrospective study.

[Feedback on the evaluation of clinical pharmacy activities developed in surgery]. / Retour d'expérience sur l'évaluation des activités de pharmacie clinique développées en chirurgie.

INTRODUCTION: Our current development strategy integrates clinical pharmacy activities prioritized in surgical services. Patients in these services are typically risk patients: transfers, multiple prescribers, frequent medication change, pharmacotherapeutic risk classes. PATIENTS AND METHODS: Three clinical pharmacy activities (admission reconciliation, pharmaceutical analysis, participation doctors round) have been developed in orthopaedic surgery and neurosurgery. Pharmacists prospectively recorded data describing their activities: number of reconciliations and analyzed requirements and time required to achieve them. Data on pharmaceutical interventions were recorded on the basis ActIP®. The clinical significance of interventions was retrospectively rated by a team of two pharmacists and two physicians on the scale adapted Hatoum et al. RESULTS: Four thousand five hundred pharmaceutical analysis and 248 reconciliations were conducted. One hundred and fifty-six pharmaceutical interventions were issued. The average acceptance rate was 80%. A total of 5.8% of pharmaceutical interventions have been listed with a very significant clinical importance and 48.1% with at least significant clinical importance. The activities and documentation required pharmaceutical average daily time (senior pharmacist, resident and external pharmacist) about 6 hours. DISCUSSION AND CONCLUSION: Other studies, including comparative and medico-economic, must be conducted to support these results. Nevertheless, the indicators obtained attend a better readability of the clinical importance of the activities performed by clinical pharmacists and this particularly in surgical services, both by prescribers and authorities.

[Clinical pharmacy and surgery: Review]. / Pharmacie clinique et chirurgie : revue de la littérature.

Clinical pharmacy has been developed and evaluated in various medical hospital activities. Reviews conducted in this area reported a higher value of this discipline. In surgical services, evenly adverse drug events may occur, so clinical pharmacy activities must also help to optimize the management of drug's patient. The objectives of this literature review is to determine the profile of clinical pharmacy activities developed in surgical services and identify indicators. The research was conducted on Pubmed(®) database with the following keywords (2000-2013), "surgery", "pharmacy", "pharmacist", "pharmaceutical care", "impact" and limited to French or English papers. Studies dealing on simultaneously medical and surgical areas were excluded. Twenty-one papers were selected. The most frequently developed clinical pharmacy activities were history and therapeutic drug monitoring (antibiotics or anticoagulants). Two types of indicators were identified: activity indicators with the number of pharmaceutical interventions, their description and clinical signification, the acceptance rate and workload. Impact indicators were mostly clinical and economic impacts. The development of clinical pharmacy related to surgical patients is documented and appears to have, as for medical patients, a clinical and economical value.

Long thoracic nerve release for scapular winging: clinical study of a continuous series of eight patients.

UNLABELLED: Scapular winging secondary to serratus anterior muscle palsy is a rare pathology. It is usually due to a lesion in the thoracic part of the long thoracic nerve following violent upper-limb stretching with compression on the nerve by the anterior branch of thoracodorsal artery at the "crow's foot landmark" where the artery crosses in front of the nerve. Scapular winging causes upper-limb pain, fatigability or impotence. Diagnosis is clinical and management initially conservative. When functional treatment by physiotherapy fails to bring recovery within 6 months and electromyography (EMG) shows increased distal latencies, neurolysis may be suggested. Muscle transfer and scapula-thoracic arthrodesis are considered as palliative treatments. We report a single-surgeon experience of nine open neurolyses of the thoracic part of the long thoracic nerve in eight patients. At 6 months' follow-up, no patients showed continuing signs of winged scapula. Control EMG showed significant reduction in distal latency; Constant scores showed improvement, and VAS-assessed pain was considerably reduced. Neurolysis would thus seem to be the first-line surgical attitude of choice in case of compression confirmed on EMG. The present results would need to be confirmed in larger studies with longer follow-up, but this is made difficult by the rarity of this pathology. LEVEL OF EVIDENCE: III.

Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: a prospective randomized study.

INTRODUCTION: Rehabilitation programs after rotator cuff repair should allow recovery of shoulder function without preventing tendon healing. The aim of this randomized prospective study was to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. PATIENTS AND METHODS: We followed 100 patients, mean age 55 years old, who underwent arthroscopic repair of a non-retracted supraspinatus tear. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks. A clinical evaluation was performed in 92 patients, and CT arthrography in 82. Mean follow-up was 15 months. RESULTS: The mean preoperative Constant score improved significantly from 46.1 points to 73.9 at the final follow-up. The rate of intact cuffs was 58.5%. Functional results were statistically better after immediate passive motion with a mean passive external rotation of 58.7° at the final follow-up versus 49.1° after immobilization (P=0.011), a passive anterior elevation of 172.4° versus 163.3° (P=0.094) respectively, a Constant score of 77.6 points versus 69.7 (P=0.045) respectively, and a lower rate of adhesive capsulitis and complex regional pain syndrome. Results for healing seemed to be slightly better with immobilization, but this was not statistically significant: the cuff had a normal appearance in 35.9% of cases after immobilization compared to 25.6% after passive motion, an image of intratendinous addition was found in 25.6% versus 30.2%, punctiform leaks in 23.1% versus 20.9%, and recurrent tears in 15.4% versus 23.3% respectively. DISCUSSION: The rehabilitation program that results in better tendon healing by preventing postoperative stiffness has not yet been identified. Our results suggest that early passive motion should be authorized: the functional results were better with no significant difference in healing.

Recurrence after arthroscopic Bankart repair: Is quantitative radiological analysis of bone loss of any predictive value?

INTRODUCTION: Bone defects in the humeral head or antero-inferior edge of the glenoid cavity increase recurrence risk following arthroscopic Bankart repair. The present study sought to quantify such preoperative defects using a simple radiological technique and to determine a threshold for elevated risk of recurrence. MATERIALS AND METHODS: A retrospective study conducted in two centers enrolled patients undergoing primary arthroscopic Bankart repair for isolated anterior shoulder instability in 2005. The principle assessment criterion was revision for recurrent instability. Quantitative radiology comprised: the ratio of notch depth to humeral head radius (D/R) on AP view in internal rotation; Gerber's X ratio between antero-inferior glenoid cavity edge defect length and maximum anteroposterior glenoid cavity diameter on arthro-CT scan; and the D1/D2 ratio between the glenoid joint surface diameters of the pathologic (D1) and healthy (D2) shoulders on Bernageau glenoid profile views. Seventy-seven patients were included, with a mean follow-up of 44 months (range, 36-54). RESULTS: Overall recurrence rate was 15.6%. Recurrence risk was significantly greater when the humeral notch length was more or equal to 20% of the humeral head diameter and the Gerber ratio more or equal to 40%. On Bernageau views, mean D1/D2 ratio was 4.2% (range, 0-23%) in patients without recurrence, versus 5.1% (range, 0-19) in those with recurrence (P=0.003). DISCUSSION: Beyond the above thresholds, bone defect as such contraindicates isolated arthroscopic stabilization. The D/R and Gerber ratios are simple and reproducible quantitative measurements can be taken in routine practice, enabling preoperative planning of complementary bone surgery as needed. LEVEL OF EVIDENCE: Level IV; retrospective cohort study.

Relationships of the musculocutaneous nerve and the coracobrachialis during coracoid abutment procedure (Latarjet procedure).

PURPOSE: The aim of this study was first to define first the anatomical relationships between the musculocutaneous nerve and the coracobrachialis, and then the induced modifications of these relationships by a preglenoid transposition of the vertical part of the coracoid process. MATERIALS AND METHODS: Twenty-one embalmed adult trunks and upper limb were dissected. First the coracobrachialis and the musculocutaneous nerve were identified through a deltopectoral approach. We measured the distances between the lateral cord of the brachial plexus and the entry point of the nerve, between the inferior tip of the tip of the coracoid process and the penetration of the nerve or its twigs, and finally the angle between the general axis of the coracobrachialis and the axis of the musculocutaneous nerve. The same measures were performed after the coracoid bone block abutment. RESULTS: Proximal motor branches destined to the coracobrachialis varied from 0 to 3. Mean distance between the lateral cord of the brachial plexus and entry point of the nerve into the muscle was 47.2 mm before and 48.43 mm after the coracoid transfer. Mean angulations between the nerve and the muscle was 121 degrees before and 136 degrees after the transfer of the coracoid process. Mean distance between the inferior tip of the coracoid process and entry point of the nerve into the muscle was 55.7 mm, reduced to 48.6 mm after the coracoid transposition. Finally, the distance between the tip of the coracoid and the first motor twig entering the coracobrachialis was less than 50 mm in 75% of the cases with a mean value of 40.6 mm. CONCLUSIONS: Lesion of the musculocutaneous nerve is a known complication of the coracoid bone block abutment procedure (Latarjet-Bristow). From this study we know that they are due to lengthening of the nerve and modification of the penetration angle of the nerve into the coracobrachialis. We also infer that some motor nerve destined to the coracobrachialis might be damaged during the proximal medial release of the muscle after the detachment of the pectoralis minor muscle.

[Proposal for new anterior portals for wrist arthroscopic as a complementary approach to open anterior wrist surgery]. / Arthroscopie complémentaire de l'ostéosynthèse du radius distal par abord antérieur: bases anatomiques de nouvelles voies arthroscopiques antérieures.

PURPOSE OF THE STUDY: Morphological and morphometric studies of the wrist ligaments are scarce. The radiocapitatum and scapholunate ligaments play a pivotal role in wrist stability. Classically, a posterior approach is used for arthroscopic procedures, but an anterior approach should be possible. We conducted a cadaver study to search for new anterior portals for wrist arthroscopy. MATERIAL AND METHODS: Twenty-five formol-treated upper limbs were dissected. The classical anterior approach for open wrist surgery was executed. The different elements of the capsule-ligament system of the anterior aspect of the wrist were identified and labeled. The dissection was then extended to the ulna in search of soft points which were identified and evaluated. The different structures generally identified during wrist arthroscopy were noted. RESULTS: Two potential portals were identified in all wrists: one between the radiolunate ligament and the radio-scapho-capitatum ligament on the radial aspect and one between the radio-lunate ligament and the ulno-lunate ligament. Arthroscopic exploration enabled observation of the scapho-lunate ligament, the luno-triquetral ligament, the triangular complex of the carpus, and the entire inferior aspect of the radial joint surface, with no risk of vessel or nerve injury because of the exposure allowed by the osteosynthesis approach. DISCUSSION: Wrist arthroscopy is now accepted as a reliable technique not only for diagnostic purposes but also for therapeutic interventions for the treatment of fractures of the lower radius. Most of the arthroscopic portals described in the literature are posterior. The anterior portals described here do not involve any vascular or neurological risk since the radial approach is made under visual control by extension of the open anterior approach and on the ulnar side the noble structures are positioned medially to the ulnar flexor tendon of the carpus. This enables good triangulation necessary for the usual arthroscopic procedures. Finally, these portals have no supplementary morbidity which would be the case with percutaneous portals (injury to the medial nerve, the radial vasculonervous bundle, the radial flexor tendon). CONCLUSION: These new arthroscopic portals are complementary to the anterior approach for open wrist surgery and enable a natural extension of joint exploration via both the radial and ulnar approaches described in this study.

Finite element analysis of the strain distribution in the humeral head tubercles during abduction: comparison of young and osteoporotic bone.

AIM: The aim of this work was to design an accurate 3D digital model of the humerus and rotator cuff muscles. This model was then used to study strain distribution in humeral tubercles according to bone density. MATERIALS AND METHODS: The geometry of bone and muscle structures was reproduced using SURFDRIVER software, based on anatomical sections, CT scans and MRI images from the Visible Human Project image library. The contours were transferred to PATRAN software to rebuild volumes and mesh them. Calculations of strains and their distribution were performed using NASTRAN software. All the elements were considered to be isotropes. RESULTS: The study of the distribution of stress magnitude according to the type of bone modeled, shows that some stresses in cortical bone are greater than those in cancellous bone and are also greater in old bone, implying more deformation in old bone at constant force. This study also shows that stresses do not penetrate deeply into cancellous tissue. CONCLUSION: Observing the simulation results led understanding of the pathology of certain fractures of the proximal end of the humerus. This study also helped explain why certain types of osteosynthesis fail due to tubercles reconstruction failures.

[Arthroscopic surgery of the acromioclavicular joint.] / Arthroscopie de l'articulation acromioclaviculaire.

Lesion of the acromioclavicular joint is a usual clinical condition because of it superficial situation. It is often involved in trauma of the shoulder girdle. Moreover, degenerative changes are quite always observed for patients over 40. Distal clavicle resection as a treatment of acromioclavicular joint disease had been first described in 1941. Clinical results in term of mobility and shoulder pain are good and durable in time. Referring to the expansion arthroscopic techniques, distal clavicle resection lead to same middle and long term results as open surgery. Arthroscopic procedures have the theoretical advantages of no deltoid disruption and may help the surgeon to diagnose and treat associated lesions such as rotator cuff ruptures. More recently, arthroscopic surgeries for fresh and/or chronic acromioclavicular disjunctions were proposed. These procedures remain in development and need further evaluations.

[Arthroscopic surgery of the acromioclavicular joint]. / Arthroscopie de l'articulation acromioclaviculaire.

Lesion of the acromioclavicular joint is a usual clinical condition because of it superficial situation. It is often involved in trauma of the shoulder girdle. Moreover, degenerative changes are quite always observed for patients over 40. Distal clavicle resection as a treatment of acromioclavicular joint disease had been first described in 1941. Clinical results in term of mobility and shoulder pain are good and durable in time. Referring to the expansion arthroscopic techniques, distal clavicle resection lead to same middle and long term results as open surgery. Arthroscopic procedures have the theoretical advantages of no deltoid disruption and may help the surgeon to diagnose and treat associated lesions such as rotator cuff ruptures. More recently, arthroscopic surgeries for fresh and/or chronic acromioclavicular disjunctions were proposed. These procedures remain in development and need further evaluations.

[Arthroscopic resection of pigmented villonodular synovitis pseudotumor of the shoulder: a case report with three year follow-up]. / Exérèse arthroscopique d'une forme pseudo-tumorale de synovite villonodulaire pigmentée de l'epaule: a propos d'un cas au recul de 3 ans.

Pigmented villonodular synovitis can be localized or diffuse. Lesions predominate in the knee but all of the joints can be involved. Thirty cases in the glenohumeral joint have been reported in the literature. The different reports to date have not identified any specific clinical signs. Our female patient presented non-specific shoulder pain which persisted for three years. The plain x-rays were normal. MRI and arthroscan revealed an intra-articular pseudotumor. Arthroscopy was performed for tumor biopsy which was followed by total resection. The diagnosis of villonodular synovitis pseudotumor suspected at arthroscopy was confirmed at the pathology examination. The functional outcome was excellent and no recurrence has been observed at three years follow-up. Arthroscopy is less aggressive than open surgery for arthrotomy. Arthroscopy must be performed for diagnostic purposes since imaging findings are not specific. Arthroscopic synovectomy is the treatment of choice for pigmented villonodular synovitis in both the diffuse and pseudotumor forms.

[Transverse radioulnar branch of the dorsal ulnar nerve: anatomic description and arthroscopic implications from 45 cadaveric dissections]. / Le rameau transverse de la branche dorsale du nerf ulnaire: anatomie et rapports avec les voies arthroscopiques du poignet: quarante-cinq dissections.

PURPOSE OF THE STUDY: We conducted an anatomic study of the transverse branch of the dorsal ulnar nerve to describe its morphology and position in relation to arthroscopic exploration portals. MATERIAL AND METHODS: Forty-five non-side-matched anatomic specimens of unknown age and gender were preserved in formol. The dorsal branch of the ulnar nerve was identified and dissected proximally to distally in order to reveal the different terminal branches. The morphometric analysis included measurement of the length and diameter of the transverse branch and measurement of wrist width. We also measured the smallest distance between the transverse branch and the ulnar styloid process, and between the branch and usual arthroscopic portals (4-5, 6R, 6U) in the axis of the forearm. RESULTS: The transverse branch was inconstant. It was found in 12 of the 45 dissection specimens (27%). In two-thirds of the specimens, the branch ran over less than 50% of the wrist width, tangentially to the radiocarpal joint. Mean nerve diameter was 1 mm. It was found 5-6 mm from the ulnar styloid process and was distal to it in 83% of the specimens. The dissections demonstrated two anatomic variants. Type A corresponded to a branch running distally to the ulnar styloid process, parallel to the joint line (10/12 specimens). Type B exhibited a trajectory proximal to the ulnar styloid process, crossing the ulnar head (2/12 specimens). The relations with the arthroscopic portals (4-5, 6R, 6U) showed that the mean distance from the branch to the portal was 3.75 mm for the 4-5 portal (distally in 11/12 specimens), 3.68 mm for the 6R portal (distally in 10/12 specimens), and 4.83 mm for the 6U portal (distally in 7 specimens and proximally in 5). DISCUSSION: To our knowledge, there has been only one report specifically devoted to this transverse branch. Two other reports simply mention its existence. According to the literature, the transverse branch of the dorsal ulnar nerve occurs in 60-80% of the cases. We found two anatomic variations different than those described in the literature. Based on our findings and data reported previously, we propose a new classification, describing two main types. In Type 1, the transverse branch arises proximally to the ulnar styloid process;type 1A and type IB are described in relation to the direction of the branch. In Type II, the branch arises distally to the ulnar styloid process;type IIA and type IIB again being described in relation to the direction of the branch. On the tangential trajectory over the radiocarpal joint, the morphometric data show a zone of risk described by a rectangle measuring 10 mm wide (6 mm distal and 4 mm proximal to the ulnar styloid process) and covering 50% of the wrist width. The relations with arthroscopic portals describe a zone of risk corresponding to a 5-7 mm radius circle centered on the portals (4-5, 6R, 6U), which includes 83% of the transverse branches.

[Arthroscopic repair of full-thickness cuff tears: a multicentric retrospective study of 576 cases with anatomical assessment]. / Réparation arthroscopique des ruptures transfixiantes de la coiffe des rotateurs: étude rétrospective multicentrique de 576 cas avec contrôle de la cicatrisation.

PURPOSE OF THE STUDY: Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy. MATERIAL AND METHODS: The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%. RESULTS: On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome. CONCLUSION: Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.