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

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

How repaired rotator cuff function influences Constant scoring.

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

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

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

[Effect of osseous torsions of the lower limb on the development of lateral femorotibial knee arthrosis]. / Influence des torsions osseuses des membres inférieurs sur l'apparition des gonarthroses fémoro-tibiales latéralisées.

PURPOSE OF THE STUDY: Frontal deformation of the knee is certainly not the only factor involved in the occurrence of lateralised tibio-femoral arthrosis. The aim of the study was to analyze if any kind of tibial torsion or femoral torsion could be able to induce lateralized arthrosis. MATERIAL AND METHODS: Femoral torsion, tibial torsion and tibio-femoral index (tibial torsion minus femoral torsion) have been measured on 59 knees with lateral arthrosis (8 knees) or with medial arthrosis (51 knees). For each knee, two frontal deformations were measured: 1) the actual arthrosis deformation was calculated on a hip knee ankle radiograph, 2) the pre arthrosis deformation is the arthrosis deformation minus the angle made by the femoral condyle tangent and the tibial plateau tangent. A knee has no frontal deformation if the angle between the mechanical axis of the femur and the mechanical axis of the tibia is between 178 degrees and 182 degrees; there is a varus deformity if the angle is inferior to 178 degrees; there is a valgus deformation if the angle is superior to 182 degrees. RESULTS: Out of the 8 knees with lateral arthrosis, 2 showed initially no frontal deformation and 6 had a valgus deformation; out of the 51 knees with medial arthrosis, 34 showed initially no frontal deformation, 6 had a valgus deformity and 11 a varus deformity. The tibio-femoral index in lateral FT arthrosis was statistically different from those in medial FT arthrosis (p 0.0001). When a lateral arthrosis appeared whatever the pre arthrosis deformation was the index was always negative (tibial torsion lower than femoral torsion); when a medial FT arthrosis appeared, whatever the pre arthrosis deformation was, the index (except for two cases) was always positive (tibial torsion higher than femoral torsion). CONCLUSION: Femoral and tibial torsions play a part in lateralised arthrosis occurrence together with frontal mechanical factors. Perhaps troubles in torsion explain some spontaneous or post-therapeutic evolutions not explained by frontal mechanical factors.

-Cysts of the glenoid labrum-. / Kystes du bourrelet glénoïdien.

Cysts of the glenoid labrum are ganglia cysts extending near the glenohumeral joint with frequent clinical signs and symptoms of a compression of the subscapularis nerve. They are detected through MR examination. They are frequently associated to instability of the glenohumeral joint.

[Isolated lesions of the subscapularis tendon and internal malpositions of the biceps tendon. Apropos of 45 cases]. / Lésions isolées du tendon subscapularis et malpositions internes du tendon long biceps. A propos de 45 observations.

Our series consists of 45 lesions of the subscapularis tendon investigated by arthrography and CT arthrography. Arthrography demonstrated opacification of the subacromial bursa in 24% of cases, internal malposition of the long head of biceps in 46% of cases and direct signs of a lesion of the subscapularis tendon in 91% of cases. CT arthrography showed incomplete transverse avulsion in 18% of cases and complete transverse avulsion in 82% of cases. The biceps was dislocated in 35% of cases, and subluxed in 11% of cases. The subscapularis muscle was infiltrated by fat in 46% of cases. Isolated lesions of the subscapularis can be difficult to diagnose clinically and are more frequent than generally thought. CT arthrography must therefore be requested at the slightest doubt, as the intraoperative search for a lesion of the subscapularis tendon is sometimes difficult.

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

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

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

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

Fatty infiltration of disrupted rotator cuff muscles.

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

[The labrum glenoidale]. / Le bourrelet glénoïdien.

The value of assessment of the labrum glenoidale has increased with the development of CT arthrography and arthroscopy. Assessment of the labrum glenoidale must be preceded by standard radiological assessment looking for of a lesion of the glenoidal margin. CT arthrography is currently the most reliable technique due to the definition and fine sections which can be obtained. Morphological variations of the labrum glenoidale and glenohumeral ligaments are the main causes of diagnostic errors. MRI also provides AP sections, but is less effective. MR arthrography is more effective and may constitute the technique of the future, but it requires intra-articular puncture and is expensive. Schematically, there are four sites of lesion of the labrum glenoidale: anteroinferior secondary to anterior instability, posterior secondary to posterior instability, Snyder's SLAP lesions and the anterosuperior lesions described by Andrews and Carson. The demonstration and interpretation of SLAP lesions is difficult, particularly types I and II. Analysis of the labrum glenoidale is limited. It is essentially indicated in unstable and painful shoulders, possibly secondary to a missed instability accident when the antero-inferior glenoidal margin is normal or doubtful. However, when looking for a lesion of the labrum glenoidale, it is logical to perform CT arthrography rather than arthroscopy, which is far more invasive and expensive.

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

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

Magnetic resonance imaging findings in shoulders of hemodialyzed patients.

Twenty two patients (24 shoulders) who had undergone hemodialysis for a mean of 13.4 years, and who had reported chronic shoulder pain for > 6 months, were examined by magnetic resonance imaging (MRI), including T1 and T2 echo gradient images in the frontal plane and T1 images after gadolinium. An increase in thickness of the rotator cuff as well as synovitis and bursitis were documented. Twenty shoulders demonstrated a mean thickness of 8.05 mm. Most often, the signal intensity of T2 and T1 weighted images was intermediate, and T1 images failed to show an uptake of gadolinium. Of the 24 shoulders, 20 had subacromial subdeltoid bursitis and 21 had glenohumeral synovitis. These results indicate that MRI is of help in the early diagnosis of arthropathy in long term hemodialyzed patients. Magnetic resonance imaging findings are more precise than those of ultrasound, particularly for thickness measurements. Moreover, MRI films are easier to read and permit the detection of synovial involvements. The therapeutic value of MRI lies in the fact that it can isolate the two principal causes of shoulder pain in hemodialyzed patients. The increase in cuff thickness leading to impingement syndrome can be treated by surgical decompression; the synovitis can be treated by radioisotope synovectomy.

[Examination of the non-injured shoulder]. / Die Untersuchung der nicht traumatischen Schulter.

Modern imaging methods are undeniably very attractive. They should make possible an easy study of the musculotendinous rotator cuff of the shoulder joint, lesions of which are the cause of most painful or stiff shoulder syndromes. However, not all shoulder symptoms are due to rotator cuff lesions. Also, not all methods of imaging are equally suited to showing the different cuff lesions. Further, one cannot consider the treatment of a symptomatic shoulder without having an assessment of the present condition upon which to gauge the functional improvement due to the treatment. Hence clinical examination of the painful shoulder remains essential. This makes it possible (1) to exclude an extra-articular pathology, (2) to choose the method of imaging most suited to showing the suspected lesion, and finally (3) to quantify the functional state of the shoulder.

Roentgenographic assessment of the rotator cuff.

In assessment of the rotator cuff, roentgenograms are mandatory. They permit judgment of the degree and site of bony involvement, assessment of the relationship between humeral head and glenoid, and differential diagnosis. Single-contrast arthrography is used to confirm the presence or the absence of a tear in the rotator cuff, particularly when a small tear is suspected. If the tear is large or if active lateral rotation is absent, tomoarthrography using air should be performed in the frontal and sagittal planes. If an anteromedial dislocation of the long head of the biceps or a tear of the subcapularis is suspected, computed tomoarthrography (CTA) is indicated. CTA shows the major part of the anterior cuff tendons. Computed tomography (CT) densitometry of the rotator cuff muscles, performed routinely before and after surgery, permits an objective evaluation of their functional status.

[Imaging of the shoulder in orthopedic pathology]. / Imagerie de l'épaule en pathologie orthopédique.

Radiological examination of an unstable shoulder relies on straight X-ray images which are better than CT scans to detect bone lesions consecutive to anterior destabilizing accidents. The indications of CT arthrography are very limited. Radiological studies of the rotator cuff must necessarily include a standard radiological examination. Contrast arthrography is used either to find out whether or not the cuff is damaged, or when the tear is thought to be small. Arthropneumotomography is useful in the preoperative assessment of severe postero-superior tears. CT arthrography is very good to explore the subscapular muscle and to detect medial dislocation of the biceps long head tendon. The first results of MRI are encouraging, and when the cost of this method is reduced it might replace arthrography.