Percutaneous fixation of valgus displaced fracture of the proximal humerus using a single screw.

Valgus-impacted proximal humerus fracture is a classic but rare entity in shoulder traumatology. Surgical treatment is controversial, with increasing use of minimally invasive techniques. Our technique uses a minimally invasive approach under fluoroscopic control. Raising the humeral head to reduce the valgus enables spontaneous and well-positioned reduction of the tuberosities and screw fixation between the greater tuberosity and the humeral shaft. Indications comprise valgus-impacted fracture without comminution of the medial epiphyseal-metaphyseal hinge or greater tuberosity; the rotator cuff contributes to reduction and must be intact. This type of fixation restores proximal humerus anatomy and achieves consolidation with low risk of secondary necrosis. Minimally invasive single-screw fixation is an alternative of choice for surgical treatment of valgus-impacted proximal humerus fracture.

Glenoid exposure in total shoulder arthroplasty.

Glenoid exposure is agreed to be a difficult step, but is also a key step in total shoulder arthroplasty, both anatomic and reverse. It conditions unhindered use of the ancillary instrumentation and thus correct glenoid component positioning. The main stages comprise arthrotomy, by opening the rotator cuff, humeral head cut, and inferior glenohumeral release, enabling shifting of the humerus and good exposure of the glenoid cavity. The two main approaches are deltopectoral and anterosuperior transdeltoid. Using the deltopectoral approach, arthrotomy is performed through the subscapularis muscle, by various techniques. This approach enables extensive inferior glenohumeral release and thus an approach to the inferior apex of the glenoid cavity, which is a key area for glenoid implant positioning. The main drawbacks are postoperative shoulder instability and limited access to the posterior part of the glenoid in case of significant retroversion. Moreover, subscapularis healing is uncertain, which can impair the clinical outcomes, with risk of glenoid component loosening. Advantages, on the other hand, include the fact that it can be implemented in all cases, even the most difficult ones, and that the deltoid muscle is respected. The transdeltoid approach has the advantage of being simple, providing direct exposure of the glenoid cavity through a rotator cuff tear after passing through the deltoid. It is therefore especially indicated for reverse prosthesis in case of rotator cuff tear, and in traumatology. However, the approach to the inferior part of the glenoid cavity can be restricted, with insufficient exposure and a risk of glenoid component malpositioning (superior tilt). The preoperative assessment is essential, to detect at-risk situations such as severe stiffness and anticipate difficulties in glenoid exposure.

Open side-to-side repair for non-repairable tendon-to-bone rotator cuff tear. Clinical and anatomic outcome at a mean 5 years' follow-up.

INTRODUCTION: Anatomical tendon-to-bone repair of retracted rotator cuff tear is a difficult challenge given the high rate of recurrence. HYPOTHESIS: The study hypothesis was that side-to-side repair of U-shaped retracted tear allows tendon healing with satisfactory medium-term clinical results. MATERIALS AND METHODS: Between 1999 and 2007, 35 patients (mean age 53.5 years) were operated on with this open technique. On the De Orio and Cofield classification, tendon lesions were medium in 5 cases, large in 25 and massive in 5. Subacromial space was in all cases greater than 7 mm. Fatty infiltration grade was less than or equal to 2 on Goutallier's classification in all cases except for 1 grade3 (supraspinatus only). At last follow-up, patients were assessed clinically (Constant score) and radiographically. Tendon healing was assessed by ultrasound (31 cases) or CT-arthrography (4 cases). RESULTS: Mean follow-up was 60 months. Constant score improved significantly, from 64.7 ± 10 preoperatively to 77.1 ± 14 postoperatively (P < 0.05). Recurrence rate was 17.1%. Subacromial space was < 6 mm postoperatively in 2 cases. DISCUSSION: Side-to-side repair, bringing the posterior cuff onto the anterior edge of the tear, allowed tension-free repair of retracted tear if the preoperative reparability criteria are met: subacromial space equal to or greater than 7 mm, and absence of fatty infiltration significantly greater than grade 2 on the Goutallier classification. Under these conditions, clinical and anatomical results were satisfactory at a mean 5 years' follow-up. LEVEL OF EVIDENCE: IV, retrospective.

Endoscopic repair of partial-thickness undersurface tears of the gluteus medius tendon.

UNLABELLED: Partial-thickness tear of the gluteus medius and minimus muscles has recently been recognized as a cause of chronic trochanteric pain resistant to medical treatment. The present article reports an original endoscopic technique of identification and repair. It uses a standard arthroscope at 30°, with the patient in lateral decubitus, without fluoroscopy. In case of partial-thickness undersurface tear, careful hook palpation followed by bursa exploration enables the pathological tendon to be diagnosed. A trans-tendinous approach then allows debridement, with systematic resection of the bone structures implicated in the impingement, followed by side-to-side tendon suture. LEVEL OF EVIDENCE: Level IV (case series).

Arthroscopic repair of subscapularis tears: preliminary data from a prospective multicentre study.

BACKGROUND: Until the introduction of arthroscopic-assisted surgery for rotator cuff repair, the frequency of subscapularis tears was underestimated. These tears remain challenging to treat even with arthroscopy. The absence of a specific classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tears. The objective of this prospective multicentre study was to validate the relevance of arthroscopic subscapularis tendon repair based on an assessment of short-term outcomes according to the initial extent of the anatomic lesions. METHODS: A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 208 patients with subscapularis lesions that were either isolated or associated with limited anterosuperior tears. The Constant and UCLA scores were used to assess clinical outcomes. Anatomic and prognostic results were evaluated based on the physical examination, preoperative and postoperative imaging study findings, and anatomic lesions. Clinical data were available for 103 patients after at least 1 year of follow-up and radiological data for 129 patients after at least 6 months. RESULTS: The preliminary clinical results in 103 patients with at least 1 year of follow-up showed overall statistically significant improvements in the Constant and UCLA scores, with resolution of the clinical manifestations. The degree of improvement seemed to increase over time. The clinical results varied significantly across patient groups based on a classification system distinguishing four lesion types. Postoperative imaging studies to assess the anatomic results in all patients with at least 6 months of follow-up (n=129) showed tendon healing in 92% of cases but also indicated muscle wasting of the upper subscapularis muscle in 18.6% of cases and increased fatty degeneration of the muscle belly. DISCUSSION: Our study confirms the good clinical and radiological results reported in the literature. Our classification system distinguishing four lesion patterns was applicable during the imaging workup. The main finding from this classification system was the difference in results between Type 2 and Type 3 lesions. The trend towards improvements over time requires confirmation by longer-term studies, which will also have to establish that the increased wasting of the upper subscapularis muscle and fatty degeneration of the muscle belly have no adverse effects.

Diagnosis of subscapularis tendon tears: are available diagnostic tests pertinent for a positive diagnosis?

HYPOTHESIS: Clinically, subscapularis tendon tears are suggested by the presence of increased passive external rotation compared to the opposite side, resisted internal rotation manoeuvres (Lift-Off test [LOT], Belly-Press test [BPT], Napoleon test and Bear-Hug test [BHT] and positive Internal Rotation Lag Sign and/or Belly-Off Signs). Associated bicipital involvement is frequent with subscapularis tendon tears, because it participates in the formation of the biceps pulley. The Palm-Up test (PUT) is used for the biceps, and the Jobe test for the supraspinatus. MATERIAL AND METHODS: In this multicenter study, we evaluated the positive diagnostic value of the clinical tests, LOT, BPT, BHT, PUT, and the Jobe test for subscapularis tears as well as their anatomical value. The relationships of the different parameters studied were compared statistically by analysis of variance (ANOVA). This prospective multicenter study was performed from January 2009 to February 2010 and included 208 cases of subscapularis tendon tears, isolated or associated with partial (Ellman 1, 2 or 3) or full thickness (SFA stage 1) supraspinatus tears. RESULTS: The severity of the subscapularis tear was quantified according to the SFA classification into four stages and according to the level of injury (the lower 1/3 and upper 2/3). The three tests LOT, BPT and BHT were correlated to the severity of observed tears (P<0.05). The more deficient the test results were, the more severe the anatomical damage. The LOT is the test that cannot be performed most often (18%) but when it is positive, it is predictive of very severe tears. The BHT is the most sensitive of all tests (82%). The frequency of biceps involvement was correlated to the severity of subscapularis damage. There was no significant correlation between biceps involvement and subscapularis tests, or between supraspinatus involvement and subscapularis tests. There was no correlation between the Palm-Up test and subscapularis tears with associated supraspinatus involvement however, it was significantly correlated to biceps involvement (P<0.05). The Jobe test was disappointing because it was often positive even for isolated subscapularis tears. CONCLUSION: Even though all three tests were performed (LOT, BPT, BHT), 24% of the subscapularis tears were only diagnosed during surgery. The role of the Internal Rotation Lag Sign and Belly-Off Sign in improving the diagnosis of tears was not studied in this work.

New endoscopic classification for subscapularis lesions.

BACKGROUND: The absence of a coherent classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tendon lesions. In addition, a reliable classification system allows comparisons of epidemiological and therapeutic data. The classification systems used until now fail to incorporate the radiological and intraoperative abnormalities of the bicipital sling, and they do not consider the degree of subscapularis tendon cleavage. Here, we describe a new arthroscopy-based classification system intended for therapeutic and prognostic purposes. METHODS: A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 150 isolated subscapularis lesions with or without limited anterosuperior involvement. The bicipital sling and insertion of the deep subscapularis layer were routinely investigated by arthroscopy with video recording. Each lesion was classified after a consensus was reached among four surgeons. RESULTS: We identified four lesion types based on the bicipital sling findings. Type I was defined as partial separation of the subscapularis tendon fibres from the lesser tuberosity with a normal bicipital sling. Type II consisted of a partial subscapularis tear at the lesser tuberosity attachment combined with partial injury to the anterior wall of the bicipital sling, without injury to the superior glenohumeral ligament. Type III was complete separation of the subscapularis fibres from the lesser tuberosity with extensive cleavage of the bicipital sling. Finally, in Type IV, all the subscapularis fibres were detached and, in some cases, conjunction of the subscapularis and supraspinatus fibres produced the comma sign. Nearly all the lesions identified intraoperatively during the study fit one of these four types. DISCUSSION: A reproducible classification system that allows different surgeons to establish comparable homogeneous patient groups is useful for both therapeutic and prognostic purposes. We defined four types of subscapularis lesions that are easy to identify as either isolated lesions or combined with anterosuperior rotator cuff tears. Long head of biceps tendon abnormalities and fatty degeneration of the shoulder muscles can be added to our classification system. Studies of intraobserver and interobserver reproducibility are needed to complete the process of validating the diagnostic and/or prognostic usefulness of this new classification scheme.

Occupational outcome after surgery in patients with a rotator cuff tear due to a work-related injury or occupational disease. A series of 262 cases.

UNLABELLED: The goals of this study were to establish the occupational outcome after surgery in patients with a rotator cuff tear from a work-related injury (WRI) or occupational disease (OD) and determine which factors and conditions affected return to work. HYPOTHESIS: return to work was possible for this type of patient. This questionnaire-based study comprised 262 shoulders in 254 patients with a WRI/OD who had surgery performed on their shoulder between 2000 and 2005. The average age was 50.5 ± 6.4 years. The following variables were analysed: employment status (private sector, self-employed, government employee), type of work (non-manual, manual, heavy manual labour), nature of tendon injury and surgical technique (open, mini-open and arthroscopy). Return to work occurred in 59.5% of the cases. Factors that prevented return to work (40.4% of the cases) included retirement (14.1%), an unrelated medical condition (10.3%), and the outcome of the operated shoulder (16.0%). Age had an impact on return to work (P<5 × 10(-4)). The type of work and nature of tendon injury did not affect return to work, but did affect time away from work. Employment status and surgical technique had an effect on return to work, but not on time away from work. Age was a decisive factor for return to work. Retirement seemed to be the most common choice starting at 55 years of age. Arthroscopy seemed to have reduced the impact of the WRI on the results, particularly on the time away from work. A preoperative evaluation of the patient's probability of returning to work should be done based on occupational and injury features. There may be a longer delay in returning to work for certain profiles of work (manual labour) and tendon injury. Patient management can be improved by knowing the factors and conditions that influence return to work. LEVEL OF EVIDENCE: Level IV - Retrospective study.

Musculotendinous infraspinatus ruptures: an overview.

BACKGROUND: Musculotendinous infraspinatus ruptures belong to the category of "muscle strain injuries". They differ from a classic rotator cuff tear by the following features: tendon attachment remains intact and the acute initial stage typically undergoes an intense muscular edema, replaced, 6 to 12 months later, by complete and permanent fatty infiltration of this muscle. METHODS: Between 1993 and 2007, we prospectively identified 59 musculotendinous ruptures of the infraspinatus muscle tendon complex. Fifty-eight percent of these patients were females. The average age at presentation was 50 years old. Onset was non traumatic in 78% of these cases. Twenty-nine patients were seen at the acute lesion stage with pain and, on T2 fat saturated MRI sequences, muscular edema. A second group of 30 patients presented with a stage 4 fatty infiltration of the infraspinatus muscle associated with a musculotendinous disruption. Twenty-three patients underwent EMG testing which was normal in all cases. None of these patients had a full thickness tear of the rotator cuff tendons, 21% of the patients presenting in the acute phase had a partial thickness tear of the supraspinatus, which increased to 70% in patients presenting in the chronic phase suggesting a more degenerative etiology. Calcific tendonitis was seen in 61% of patients. RESULTS: Twenty-four patients underwent surgery, while the remaining 35 were treated conservatively. The average follow-up, for all of them, was 46 months (12-125). The Constant score increased from 51.7 to 69.4 (p<0.001). There was no significant difference between the operated and the non-operated groups (p=0.325). All the patients seen at the acute painful edematous stage progressed to stage 4 complete fatty infiltrations, irrespective of selected treatment. None of the patients who underwent surgery had any regression of their fatty infiltration. CONCLUSIONS: Early diagnosis of this lesion can be made using T2 fat saturated MRI imaging. We hypothesize that early tendon repair which restores muscle tension in the infraspinatus may halt the progression of this entity and prevent complete functional loss of this muscle. LEVEL OF EVIDENCE: Level IV: Therapeutic study.

Results of latissimus dorsi tendon transfer for irreparable cuff tears.

Rupture of the supraspinatus and infraspinatus tendon (and teres minor) can cause loss of active external rotation (ER), entailing severe functional disability in daily activities. Latissimus dorsi tendon transfer (LDTT), proposed by Gerber in 1988, appears to be the best adapted solution in these cases of irreparable posterior and superior cuff tears. Between 2001 and 2004, 30 patients were operated on by the technique described by Gerber, with the transfer fixed anteriorly to the subscapularis tendon and laterally to the greater tuberosity by transosseous suture. One patient, subsequently requiring revision with a reversed prosthesis, was considered as a failure. Twenty-six patients were reviewed with a mean follow-up delay of 34+/-12 months. There were 14 men and 13 women. Mean age was 55.5 years (36 to 71 years). Preoperatively, active ER was symmetric in seven cases, loss of active ER was moderate with positive lag sign in five cases, significant with positive dropping sign in six cases, and severe in nine cases. Fatty muscular degeneration was present and significant in all cases for the infraspinatus muscle and in 14 cases for the teres minor muscle (associated with significant ER loss). Subjectively, 85% of the patients were very satisfied or satisfied and the Subjective Shoulder Value (SSV) was 68+/-17%. The pain score improved from 4.8+/-3 preoperatively to 12.2+/-2 postoperatively, strength from 3.7+/-2 kg to 4.2+/-1.8 kg, mean Constant score from 50+/-12 to 74+/-9, and Constant score adjusted for age and gender from 62+/-15% to 91+/-11%. Mean active ER gain was 7 degrees (-30 degrees to +50 degrees). The loss of active ER was aggravated in one case, unchanged in three, improved in nine and corrected in six. Hornblower sign was corrected in six cases and persisted in nine. Postoperatively, 8% of the patients were unable to eat and drink, compared to 64.7% preoperatively. The results of this series are comparable to those found in the literature for first-intention cases. LDTT restored active ER, but the results were incomplete and variable. Improvement was better in case of severe preoperative active ER deficit and insufficiency of the teres minor muscle. Recovery of strength was not observed in the present series. A narrow subacromial space and grade-3 Hamada classification had negative impact. In spite of an expected tenodesis effect, LDTT did not recenter the humeral head. LDTT compensates the deficient teres minor muscle rather than the infraspinatus muscle. The optimal indication for LDTT is irreparable superior and posterior rotator cuff rupture with loss of active ER associated with a deficient teres minor muscle. It is debatable whether LDTT is indicated in the absence of active motion deficiency: improvement was observed in these cases, but only in terms of subjective criteria.

[Recurrent anterior instability of the shoulder associated with full thickness rotator cuff tear: results of surgical treatment]. / Luxation récidivante antérieure de l'épaule et rupture de la coiffe des rotateurs : résultats du traitement chirurgical.

PURPOSE OF THE STUDY: Recurrent anterior dislocations associated with full thickness rotator cuff tear (RCT) carry a difficult therapeutic problem: should we treat instability and rotator cuff tear at the same time or only one of both pathologies? The goal of this study was to analyse a retrospective series of patients operated on to try to answer this question. MATERIAL AND METHODS: Twenty-eight shoulders (27 patients) were operated on between 1988 and 2002. The mean age at first dislocation was 47 years (16-65), the average delay between first dislocation and operation was 6.1 years. Twenty-four shoulders presented with recurrent dislocations and four shoulders with recurrent subluxations; the average number of dislocations was 2.6 (1-20). Preoperatively, Hill-Sachs lesion was present in 96%, anterior glenoid rim fracture in 53.5% and glenohumeral osteoarthritis was observed in 37.5%. All the cases had full thickness rotator cuff tears: isolated supraspinatus in 43%,, Supra- plus infraspinatus in 35%, supraspinatus plus subscapularis in 4% and rupture of the three tendons in 18%. An isolated open stabilization with the technique of Trillat was performed in 19 cases when the cuff was not repairable or when the patient was not willing to accept rotator cuff (RC) repair (age and motivation); the mean age of the patients was 59.3 years in this group. Whereas an open anterior stabilization (Latarjet procedure) associated with RC repair was done in nine cases (average age at operation: 40 years). All the patients were followed up and had clinical-radiographic examinations more than two years after the operation. RESULTS: With a mean follow-up of 73.5 months (24-178), the average Constant score progressed from 63.1 to 78.1 points (p<0.05). Three patients who had isolated anterior stabilization had recurrence of instability (16%) whereas none of the patients with both anterior stabilization and RC repair had recurrence. Subjectively, 96% of the patients were satisfied with their operation. Postoperatively, the rate of osteoarthritis progressed to 64.3%. DISCUSSION: The decision not to repair the RCT in 19 cases was justified by the size of the tear, the muscular fatty infiltration of the RC muscles and the age-motivation of the patients. This decision lead to a greater rate of recurrence (16%) and less satisfactory functional results but the age at FU was 20 years higher in this group than in the group with cuff repair. No patient had an isolated RC repair because 92.5% of the patients in this series had either a bony Bankart (53.5%) or a Bankart type lesion (39%). The recurrent instability in this series was clearly under the dependence of the "anterior mechanism" and not under the dependence of the "posterior mechanism". Therefore, isolated repair of the cuff has never been performed because of the fear of higher rate of postoperative instability leading to RC re-tear. CONCLUSION: In case of recurrent dislocations associated with rotator cuff tear, treatment of instability should be proposed whereas the concomitant repair of the cuff depends upon the possibility to perform it: size of the rupture, fatty infiltration, age and motivation of the patients.

[Reverse prosthesis and os acromiale or acromion stress fracture]. / Prothèse d'épaule inversée en présence de mésoacromion ou d'acromion fracturé

PURPOSE OF THE STUDY: We reviewed cases of acromion stress fracture or os acromiale among a consecutive series of 240 reverse prostheses implanted between 1995 and 2003. MATERIAL AND PATIENTS: Ten patients presented os acromiale, ten fracture-fragmentation of the acromion, and one nonunion of the scapular spine. The reverse prosthesis was implanted via a deltopectoral approach with no specific procedure on the acromion. There were 17 women and four men, mean age 72 years. The dominant side was involved for 70%. The prosthesis was indicated for excentered glenoid deterioration (n=14), massive rotator cuff tears without osteoarthritis (n=5), and failure of a hemiarthroplasty (n=2). Seventeen patients were reviewed with more than two years follow-up. RESULTS: 87.5% of the acromial lesions became dislocated postoperatively due to the traction of the deltoid. There was no significant difference between os acromiale and acromion stress fracture. The acromial displacement did not compromise the objective outcome since the Constant score was comparable to that obtained in 179 cases with no acromial lesion reviewed with the same follow-up. Unlike these later shoulders, there were two cases of scapular spine fracture postoperatively, leading to poor function (pain and motion scores less than the global score). CONCLUSION: Acquired or congenital acromial lesions are not a contraindication for reverse prosthesis. Postoperative fracture of the scapular spine is less well tolerated and may required revision for osteosynthesis.

[Isolated lesion of the infraspinatus at the myotendinous junction: a new lesion]. / Lésion isolée de l'infra-épineux à la jonction myotendineuse: une nouvelle lésion.

PURPOSE: We have identified a previously unpublished lesion of the infraspinatus muscle at the myotendinous junction. We describe its presentation and MRI appearance, notably the absence of other tendinous pathology in the rotator cuff. MATERIALS AND METHODS: We retrospectively reviewed 25 patients with isolated infraspinatus lesions and associated edema identified on the fat-suppressed T2-weighted images of MRI. Imaging exams and medical records collected over a 7-year period were reviewed by a team of radiologists and surgeons specializing in the shoulder. A presentation of the mechanism of injury, radiological analysis of MRI scans and other investigations (arthro-CT and EMG studies) were carried out; all MRI included at least two fat-suppressed T2-weighted (transverse and coronal) sequences and one T1-weighted (transverse) sequence. RESULTS: The lesion was characterized by tearing or delamination at the myotendinous junction, which was accompanied by edema of the infraspinatus muscle in the initial phase. Over time the edema was seen to resolve and muscle atrophy and fatty degeneration became predominant. We identified two groups by the onset of their symptoms. In the "chronic" group (44%), onset was gradual, with these patients frequently having had one or more infiltrations at presentation to us. In the "acute" group (56%), there was an initial traumatic event that was variable in intensity and mechanism. CONCLUSION: This isolated lesion of the infraspinatus at the myotendinous junction has not been previously described. It is recognized by its characteristic MRI appearance and is not generally seen on CT arthrograms as there is no communication with the joint. Its natural history appears to be of a progression from edema to fatty degeneration with or without myotendinous retraction and scarring. Its etiology has not yet been clearly established.

[Shoulder arthroscopy. Partial thickness tears of the rotator cuff.] / Arthroscopie de l'épaule. Rupture partielle de la coiffe des rotateurs.

Partial tears are frequent in rotator cuff pathology. Articular-side lesions, bursal-side lesion and interstitial lesion inside the thickness of the tendon are described. Etiopathogeny is not clearly known. It seems a multifactory association with intrinsic tendinous factors (vascularity, normal ageing of the tendon), extrinsic mechanical factors (impingement syndrome) and trauma. Clinically, the complaint is a painful shoulder with full range of motion. The rotator cuff examination does not shown weakness but pain. The onset is traumatic or degenerative. It could be the consequence of overuse specially in case of overhead sport. Diagnosis is confirmed by arthro-CT or/and (arthro) MRI. It is useful for the treatment to determine the size of the rupture regarding the thickness of the tendon. Natural history shows that partial tears do not healed. Treatment of the partial tear of the cuff is still debatable particularly for intertstitial lesion (acromioplasty, debridment, repair). Isolated acromioplasty permit to obtain pain relief but do not prevent evolution to full-thickness tear when the lesion concern more than 50% of the thickness of the tendon. In this case, arthroscopic tendon repair gives good and reliable results.

[Shoulder arthroscopy. Partial thickness tears of the rotator cuff]. / Arthroscopie de l'épaule. Rupture partielle de la coiffe des rotateurs.

Partial tears are frequent in rotator cuff pathology. Articular-side lesions, bursal-side lesion and interstitial lesion inside the thickness of the tendon are described. Etiopathogeny is not clearly known. It seems a multifactory association with intrinsic tendinous factors (vascularity, normal ageing of the tendon), extrinsic mechanical factors (impingement syndrome) and trauma. Clinically, the complaint is a painful shoulder with full range of motion. The rotator cuff examination does not shown weakness but pain. The onset is traumatic or degenerative. It could be the consequence of overuse specially in case of overhead sport. Diagnosis is confirmed by arthro-CT or/and (arthro) MRI. It is useful for the treatment to determine the size of the rupture regarding the thickness of the tendon. Natural history shows that partial tears do not healed. Treatment of the partial tear of the cuff is still debatable particularly for intertstitial lesion (acromioplasty, debridment, repair). Isolated acromioplasty permit to obtain pain relief but do not prevent evolution to full-thickness tear when the lesion concern more than 50% of the thickness of the tendon. In this case, arthroscopic tendon repair gives good and reliable results.

[Effect of age on the natural history of the shoulder: a clinical and radiological study in the elderly]. / Etude du vieillissement naturel de l'épaule: étude clinique et radiographique d'une population de personnes âgées.

PURPOSE OF THE STUDY: Classically, the shoulder joint is thought to age more by its tendons than by its cartilages, the incidence of rotator cuff tears being considered to increase with age. The purpose of this work was to assess the natural history of the shoulder joint based on a clinical and radiological study of 200 patients aged 70 to 101 years. MATERIAL AND METHODS: The cohort was composed of 48 men (34%) and 152 women (76%), aged 84.25 +/- 6.7 years. All patients underwent a physical examination and the Constant score was established. The radiographic examination included an AP view in neutral rotation of both shoulders. The Hamada classification was used to stage full thickness cuff tears. The glenohumeral compartment was analyzed to search for osteophyte formation and joint narrowing. RESULTS: The subacromial height was greater than 6 mm, mean 9.89 +/- 2 mm, in 349 shoulders (87.25%), corresponding to stage I in the Hamada classification; it measured less than 6 mm, mean 3.08 +/- 1.7 mm in 51 shoulders (12.75%) in 38 subjects (19% of the total cohort). The Hamada classification for the other shoulders was stage II (n = 21 shoulders, 5.25%), and stage III (n = 16 shoulders, 4%), stage IV (n = 5, 1.25%) and stage V (n = 5, 1.25%). The Hamada stage could not be determined for four shoulders. There was a strong statistical correlation between the Constant score and Hamada stage. The glenohumeral space was normal in 288 shoulders (72%). Ninety-three shoulders (23.25%) in 62 patients (31%) presented humeral and/or inferior glenoid osteophytes without glenohumeral impingement and 19 shoulders (4.75% in 14 patients (7%) presented complete glenohumeral impingement. There was a significant correlation between the Constant score and severity of the glenohumeral degradation. The proportion of subacromial impincement increased significantly and regularly with degradation of the glenohumeral space (p < 104). For half of the shoulders, glenohumeral impingement was associated with subacromial impingement (eccentric osteoarthritis). DISCUSSION: The results of this study confirm that the frequency of rotator cuff tears increases with age. One out of five patients aged 70-90 years presented subacromial impingement versus one out of three among patients aged over 90 years. Clinical tolerance of subacromial impingement or subacromial osteoarthritis is good. Glenohumeral impingement, associated or not with subacromial impingement, is poorly tolerated, the patients presenting shoulder pain and marked stiffness. CONCLUSION: Our results demonstrate that the natural history of the shoulder does not exhibit a regular linear relationship with the Hamada radiological classification.

[Coraco-humeral space and rotator cuff tears]. / Espace coraco-huméral et rupture de la coiffe des rotateurs de l'épaule.

PURPOSE OF THE STUDY: The anterior or subcoracoïd impingement is often mentioned but remains unprecise as far as clinical, radiological or even anatomical lesion are concerned. The purpose of our work was to study the different factors influencing the subcoracoïd space in case of cuff tear. METHODS: Our study was based on 206 shoulders operated for full-thickness rotator cuff tear. The SubCoracoïd Space (SPS), measured in millimeters on pre-operative arthro-CT-scan, was defined by the shortest distance between the coracoïd process and the humeral head. Muscular statement of the rotator cuff componants was graded according to Goutallier's and Bernageau's classification. According to literature data, we chose "6 mm" value as an inferior limit for normality. Shoulders were dispatched into three groups: group 1 was composed of supraspinatus +/- infraspinatus tears (59 cases), group 2 was composed of isolated lesions of the subscapularis (57 cases) and group 3 was composed of large cuff tears (supraspinatus +/- infraspinatus) involving also the subscapularis (90 cases). RESULTS: There was a statistically significant relationship between SCS narrowing, duration of symptoms and the non-traumatic onset. When there was no subscapularis lesion (group 1) the mean SCS was 9 +/- 2 mm, in 3 cases the SCS was inferior to 6 mm. In group 2 (isolated lesion of the subscapularis), the results were similar with 9 mm as an average and 3.5 p. 100 SCS inferior to 6 mm. On the contrary, in group 3 we found the major percentage of SCS inferior to 6 mm (27 p. 100) with an average of 7.7 +/- 3.5 mm. The long head of the biceps had no influence on the SCS. There was a strong statistically significant relationship between SCS size and fatty degeneration of the subscapularis muscle (p < 10-4) and infraspinatus muscle (p = 0.0004). Eventually, there was a statistically significant correlation between the subcoracoïd space and the sub acromial space. DISCUSSION: Measurements of the SCS in isolated lesions of the subscapularis show that the coracoïd process is not the mechanical factor responsible for tendon rupture. SCS narrowing is the consequence of a large cuff tear involving both the subscapularis and the infraspinatus tendon. Subscapularis tear is a necessary but not a sufficient condition by itself for SBS narrowing. Complete tear of the infraspinatus tendon and above all the muscular degeneration of the infraspinatus muscle is the other necessary condition for SCS narrowing. The horizontal control of the humeral head depends on subscapularis-infraspinatus muscular balance control. According to Patte's hypothesis SCS narrowing corresponds to an horizontal anterior translation of the humeral head due to fatty degeneration of subscapularis and infraspinatus muscle.

Subluxations and dislocations of the tendon of the long head of the biceps.

Seventy-one cases of subluxation or dislocation of the long head of the biceps tendon (LHB) were retrospectively evaluated. Subluxation was observed in 25 (35%) cases combined with partial tearing of the subscapularis tendon and in 70% with tears of the supraspinatus tendon. Dislocation was defined as a permanent loss of contact between the tendon and the intertubercular groove; it was observed in 46 (65%) cases. Dislocation was associated with complete rupture of the subscapularis tendon in 23 cases, with partial tearing in 21 cases, and with an intact subscapularis tendon in 2 cases. Out of a series of 445 rotator cuff repairs, medial displacement of the LHB was found in 16%. In 70% of all cases dislocation of the long biceps tendon was associated with massive rotator cuff tears including the supraspinatus and infraspinatus tendons. Although "pseudoparalysis" of the shoulder (sudden loss of active elevation) was observed in 46% of all cases, no specific clinical test correlated to the presence of medial displacement of the LHB. Arthrography revealed displacement of the LHB in 28%, whereas arthro-computed tomography demonstrated lesions in 76%. The authors believe that medial displacement of the LHB can easily be overlooked during open surgery, and opening of the rotator interval is an essential part of rotator cuff repair.

Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting.

Twenty patients with pseudarthrosis of the upper humerus underwent surgery with the intramedullary bone peg technique. A 6 to 10 cm corticocancellous autogenous bone graft (11 iliac crest, 6 anterior tibial crest, 3 middle-third of the fibula) was pegged] into the humerus and bridged the pseudarthrosis. Stability of the fracture site was obtained by plate osteosynthesis; an additional peripheral cancellous graft was performed. Our patient series included 15 women and five men with an average age at operation of 58 years; the dominant side was involved in 12 cases. Eleven had undergone 22 previous operations. The average delay between fracture and surgery was 12 months, (range 6 to 72 months). The patients were monitored an average of 42 months (range 12 to 120 months). Union was confirmed in 19 cases; the last case demonstrated no peripheral callus. No necrosis of the humeral head was seen. Active anterior elevation of the shoulder improved from an average of 60 degrees to an average of 131 degrees. According to Constant's scale adjusted according to age and sex, the results obtained averaged 81.2%. Subjectively, 65% of patients were very satisfied, 30% were satisfied, and 5% were disappointed. The rate of union (96%) is in contrast with the results reported in the literature, underlining the importance of an intramedullary bone graft in association with peripheral osteosynthesis in the treatment of pseudarthrosis of the surgical neck of the humerus.