Outbreak of postoperative shoulder arthritis due to Propionibacterium acnes infection in nondebilitated patients.

We investigated an outbreak of postoperative shoulder arthritis due to Propionibacterium acnes infection in nondebilitated patients. Risk factors were male sex, the order in which surgery was performed during the daily operating schedule, and increased duration of the surgical procedure. After modification of the ventilation system and implementation of improved cleaning methods in the operating theater, no new cases were recorded.

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

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

Considerations about a unique clinical pattern: flexion block of the shoulder.

Frozen shoulder is a well-defined nosologic entity characterized by retraction of the anterior portion of the glenohumeral joint capsule. When clinical findings are inconclusive, arthrography can differentiate a frozen shoulder from a stiff and painful shoulder. We report three cases of stiffness of the shoulder that we believe was due to a unique pathological process. Flexion was restricted to 120 degrees and a sensation suggestive of mechanical blockage was felt upon passive flexion. Medical rotation was restricted and painful, whereas lateral rotation with the elbow held against the torso was normal. Findings upon arthrography or magnetic resonance imaging were normal, with no evidence of capsulitis or chronic rotator cuff lesions. Our pathogenic hypotheses include a lesion of the proximal portion of the long head of the biceps brachii or a focal ligamentous lesion. Treatment should consist of specific physical therapy and, in refractory forms, gentle mobilization under general anesthesia.

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

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

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

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

Functional and anatomical results after rotator cuff repair.

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

Sports injuries of the shoulder.

Much strain is placed on the shoulder joint in all sports. Sports injuries may be caused by a single, violent incident. Fractures of the clavicle, acromioclavicular and sternoclavicular traumas, isolated fractures of the greater tuberosity and shoulder dislocations are frequent clinical pictures which today can be managed by well established procedures. Other sports injuries, however, involve over-use of the shoulder which, through repetitive harmful movements, can bring about microtraumatic lesions of the rotator cuff, glenoid labrum, acromioclavicular joint and certain peripheral nerves around the suprascapularis. In all cases, a programmed, comparative, clinical examination and complementary, sequential examinations will indicate suitable curative and preventive treatment.

[Stabilization of the external condyle of the knee in chronic anterior laxity. Importance of the popliteal muscle]. / Stabilisation du condyle externe du genou dans les laxités antérieures chroniques. Importance du muscle poplité.

The authors have made an anatomical and experimental study in cadavers. They consider that one of the main features of chronic anterior instability of the knee is related to the instability of the lateral femoral condyle. This is due to the loss of its two stabilizers: the anterior cruciate ligament and the popliteal muscle. The signs of a lesion of the postero-lateral structures have to be looked for: antero-posterior drawer sign in extension, hypermobility of the tibia in lateral rotation and varus laxity. Such instability leads to arthrosis in the long-term. The proposed treatment is based on a reconstruction of the anterior cruciate ligament, using semitendinosus associated with a postero-lateral reconstruction using either the biceps or the fascia lata, or a free transplant from the patellar ligament. Corrective osteotomy of an associated varus deformity may be indicated.