Cross-cultural adaptation and translation of the Constant Murley Score into Arabic.

INTRODUCTION: Shoulder pain is a major disorder of the musculoskeletal system. To the best of our knowledge, there is no documentation of an Arabic version of the shoulder disability and pain measurements. Constant Murley Score (CMS) is one of the standard questionnaires for clinical practice and research. The aim of this research centred around the evaluation of the Arabic Constant Murley Score and subsequently assessing the reliability and validity in comparison to disabilities of the arm, shoulder, and hand (DASH). METHODS: Hundred and twenty five patients took part in this research. We did the internal consistency tests with Cronbach's alpha. Intra-correlation coefficient, convergent validity, convergent construct validity, responsiveness, and floor and ceiling effects were also calculated. RESULTS: Principal component analysis showed that the variance was 63.31% with a factor range of 0.42-0.85, which fulfils the uni-dimensionality criterion. Also, the Arabic CMS correlated negatively with the DASH score (-0.82, p < 0.001). The Arabic version of CMS was consistent with Cronbach's alpha of 0.74. With Inter Class Correlation Coefficient (ICC) = 0.83 it also showed a very good test-retest reliability. CONCLUSION: Ours is the first translation and cross-cultural adaptation of the CMS into Arabic. Important evidences of validity were tested such as uni-dimensionality, convergent validity, and internal consistency. Results demonstrate an acceptable Cronbach's alpha of 0.74, ICC = 0.830 indicating excellent reliability and a strong correlation of the Arabic CMS with the DASH score (r = -0.820). Overall, the Arabic version of CMS is a good and reliable diagnostic tool for patients experiencing shoulder pain.

Clinical and radiological outcomes after reverse shoulder arthroplasty in patients with failed deltoid or latissimus dorsi transfers. A review of ten cases.

PURPOSE: The purpose of this study was to report clinical and radiological results of reverse shoulder arthroplasty (RSA) after failure of either a deltoid and/or a latissimus dorsi transfer. METHODS: Between 2001 and 2011, ten patients (average age, 61 years) underwent primary RSA after a failed tendon transfer for irreparable postero-superior rotator cuff tear (five deltoid muscle transfers, four latissimus dorsi transfers and one both). Average follow-up was 48 months. Outcome measures included pain, range of motion and postoperative Constant-Murley score. RESULTS: Pain score improved significantly from a mean 8.3 to a mean 0.3. Mean shoulder elevation improved from 66 to 134°, and absolute Constant-Murley scores increased from 25.8 to 62.8 The mean improvement in external rotation was limited to 7.5°. Subjectively, six patients rated the result as much better and three rated it as better than before surgery. CONCLUSIONS: Failure of the tendon transfer with deterioration of the functional outcomes can be salvaged with a RSA with no impact on the expected outcome.

Endoscopic fibular groove deepening for stabilisation of recurrent peroneal tendons instability in a patient with open physes.

This is a report of a rare case of recurrent traumatic peroneal tendon dislocation in a patient with open physes. Through fibular tendon endoscopy, an intramuscular needle was introduced under direct visualisation and implanted inferiorly to the growth plate while reclining the tendons posteriorly. A fibular groove deepening was performed in order to stabilize the tendons. The patient was able to return to full activity after 3 months. MRI taken 12 months after surgery showed neither signs of recurrence of the lesion nor growth plate disturbance. This is a first case report of peroneal tendons stabilisation by tendoscopic retro-malleolar groove deepening in a child. Level of evidence Case report, Level IV.

Bone mineral density of the coracoid process decreases with age.

PURPOSE: Surgical options in the treatment of recurrent anterior shoulder instability are numerous. The Latarjet procedure is one of the most common procedures performed. It has been previously demonstrated that bone mineral density decreases with age. This reduction thus increases the risk of osteoporosis and osteoporosis-related iatrogenic, traumatic or pathological fractures. The objective of this study was to quantify the bone mineral density of the coracoid process in different age groups. The hypothesis was that mineral bone density of the coracoid process decreases with age. METHODS: Using the hospital's electronic database, 60 patients who underwent a shoulder CT scan were randomly selected retrospectively. Four groups of 15 were formed with mean ages of 20, 30, 40 and 50 years. Bone density, length, width and thickness of the coracoid process 10 mm from the tip were measured four times by two different evaluators. Bone density was expressed in Hounsfield units (HU). RESULTS: The mean bone mineral density of the coracoid process significantly decreased with age (p < 0.0001). A lower but insignificant difference of bone mineral density was observed in females. A good inter- and intra-observer reliability was found for bone mineral density measurement of the coracoid process (0.67 and 0.7, respectively). CONCLUSIONS: The bone mineral density of the coracoid process diminishes with age, thus confirming our hypothesis. There is a good inter- and intra-observer reliability of our CT scan-based coracoid process bone mineral density measurement rendering it reproducible in daily clinical practice. LEVEL OF EVIDENCE: IV.

Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results.

PURPOSE: The transfer of the pectoralis major in cases of irreparable rupture of the subscapularis has been described through different techniques. The aim of this prospective study was to compare the clinical results of transferring the clavicular or the sternal head of the pectoralis major tendon underneath the conjoint tendon. METHODS: Fifteen patients underwent the procedure, including eight clavicular head of the pectoralis major tendon transfers and seven sternal head transfers. The mean age at the time of surgery was 57 years (range, 37-66). Each patient had pre-operative MRI and CT scan. The criteria for an irreparable subscapularis tear were retraction at the level of the glenoid and fatty infiltration of the muscle graded III or IV. Pre-operative and postoperative functions were assessed by the Constant score. Patients were finally asked if they were very satisfied, satisfied or unhappy with the functional outcome. RESULTS: The average follow-up was 24 months (range, 12-50). The mean absolute Constant score of the entire series increased significantly from 36 preoperatively to 69 at the latest follow up (p < 0.01); it improved significantly and similarly in both types of tendon harvested. Nine patients were very satisfied, three were satisfied and three were dissatisfied with the clinical outcome. CONCLUSION: A clavicular or a sternocostal head transfer of the pectoralis major under the coracoid process reduced pain, and improved the strength and function of the shoulder.

Comparison of functional gains after arthroscopic rotator cuff repair in patients over 70 years of age versus patients under 50 years of age: a prospective multicenter study.

PURPOSE: To assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic repair in patients older than 70 years versus patients younger than 50 years. METHODS: We conducted a multicenter, prospective, comparative study of 40 patients younger than 50 years (group A) and 40 patients older than 70 years (group B) treated with arthroscopic rotator cuff repair. Patients older than 70 years were operated on only if symptoms persisted after 6 months of conservative treatment, whereas patients younger than 50 years were operated on regardless of any persistent symptoms. Imaging consisted of preoperative magnetic resonance imaging and postoperative ultrasound. Preoperative and postoperative function was evaluated with Constant and modified Constant scores. Patient satisfaction was also assessed. The evaluations were performed at least 1 year postoperatively. RESULTS: No patient was lost to follow-up. The incidence of both supraspinatus and infraspinatus tears was greater in group B. Greater retraction in the frontal plane and greater fatty infiltration were observed in group B. The Constant score was significantly improved in both groups (51 ± 12.32 preoperatively v 77.18 ± 11.02 postoperatively in group A and 48.8 ± 10.97 preoperatively v 74.6 ± 12.02 postoperatively in group B, P < .05). The improvement was similar in both groups. The modified Constant score was also significantly improved in both groups (57.48 ± 18.23 preoperatively v 81.35 ± 19.75 postoperatively in group A and 63.09 ± 14.96 preoperatively v 95.62 ± 17.61 postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). Partial rerupture of the rotator cuff occurred in 2 cases in group A and 5 cases in group B. Complete rerupture was observed in 2 patients in group B. In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. CONCLUSIONS: Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The intra- and inter-observer reliability of the CT-scan based X index to quantify glenoid bone loss in chronic anterior shoulder instability and its impact on decision making.

PURPOSE: The X index is a measure of the antero-inferior glenoid bone loss on unilateral 2D CT-scans in the preoperative analysis of chronic anterior shoulder instability. Recurrence rate was shown to be higher after stabilization surgery if X index is superior or equal to 0.4. The objective of this study was to assess the intra- and inter-observer reliability of the X index. METHODS: Sixty patients with an X index ≥0.4 were included retrospectively. The X index was measured twice by two independent evaluators, 15 days apart. The measurement was performed on a unilateral 2D CT-scan by dividing the length of the antero-inferior glenoid defect over the maximal antero-posterior diameter of the glenoid. Reliability of X index was assessed with intra-class correlation coefficient (ICC, ρ). Two points were added to the ISIS calculation if its glenoid criterion was "zero" and we compared this modified score to the original one. RESULTS: The intra-observer reliability of the X index measurement was "excellent" (ρ = 0.95 ± 0.01, p < 0.0001) while the inter-observer reliability was "good" (ρ = 0.59 ± 0.08, p < 0.0001). In patients with a glenoid bone loss visualized by the X index, 48.3 % had a negative sclerotic glenoid line sign. This proportion significantly decreased with the augmentation of the X index, p = 0.02. The average original ISIS score was 3.4 ± 1.9 and became 4.3 ± 1.7 (p < 0.00001) when the X index was incorporated. CONCLUSIONS: The X index is a reliable and simple unilateral 2D CT-scan measurement. AP shoulder radiographs significantly underestimated glenoid bony lesions.

Results of 45 arthroscopic Bankart procedures: Does the ISIS remain a reliable prognostic assessment after 5 years?

PURPOSE: The Instability Severity Index Score (ISIS) includes preoperative clinical and radiological risk factors to select patients who can benefit from an arthroscopic Bankart procedure with a low rate of recurrence. Patients who underwent an arthroscopic Bankart for anterior shoulder instability with an ISIS lower than or equal to four were assessed after a minimum of 5-year follow-up. METHODS: Forty-five shoulders were assessed at a mean of 79 months (range 60-118 months). Average age was 29.4 years (range 17-58 years) at the time of surgery. Postoperative functions were assessed by the Walch and Duplay and the Rowe scores for 26 patients; an adapted telephonic interview was performed for the 19 remaining patients who could not be reassessed clinically. A failure was defined by the recurrence of an anterior dislocation or subluxation. Patients were asked whether they were finally very satisfied, satisfied or unhappy. RESULTS: The mean Walch and Duplay score at last follow-up was 84.3 (range 35-100). The final result for these patients was excellent in 14 patients (53.8 %), good in seven cases (26.9 %), poor in three patients (11.5 %) and bad in two patients (7.7 %). The mean Rowe score was 82.6 (range 35-100). Thirty-nine patients (86.7 %) were subjectively very satisfied or satisfied, and six (13.3 %) were unhappy. Four patients (8.9 %) had a recurrence of frank dislocation with a mean delay of 34 months (range 12-72 months). Three of them had a Hill-Sachs lesion preoperatively. Two patients had a preoperative ISIS at 4 points and two patients at 3 points. CONCLUSION: The selection based on the ISIS allows a low rate of failure after an average term of 5 years. Lowering the limit for indication to 3 points allows to avoid the association between two major risk factors for recurrence, which are valued at 2 points. The existence of a Hill-Sachs lesion is a stronger indicator for the outcome of instability repair. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series, Treatment Study.

"Relaxed" biceps proximal tenodesis: an arthroscopic technique with decreased residual tendon tension.

Tenodesis of the long head of the biceps tendon (LHB) at the upper part of the bicipital groove has been related to persistent postoperative bicipital pain. This is possibly due to the inflammation of the remaining tendon within the groove. This, in turn, could be attributed to the continual mechanical stress placed on the tendon in the narrow bicipital groove. Theoretically, should the LHB be more "relaxed," the mechanical stress applied on it would be diminished. On the basis of this rationale, we present an arthroscopic biceps tenodesis technique, according to which the tendon is fixed at the entrance of the bicipital groove, using a bioabsorbable screw, relaxed by 5 mm. In this lax position, the residual LHB tension is expected to be decreased compared with the initial tension, whereas no cosmetic deformity (Popeye sign) or impaired muscular performance is anticipated.

Uncemented metal-back glenoid component in revision of aseptic glenoid loosening: a prospective study of 10 cases with a minimum follow-up of 2 years.

INTRODUCTION: Glenoid component loosening comprises 25 % of all complications related to total shoulder arthroplasties (TSA). This prospective study was undertaken to assess the accuracy of an uncemented metal-back glenoid component in cases of revision of aseptic glenoid loosening. MATERIALS AND METHODS: Between September 2007 and January 2010, a total of ten patients with symptomatic glenoid loosening after TSA (7 cemented and 3 non-cemented) underwent revision surgery with an uncemented metal-back glenoid component (MB). The rotator cuff was functional in all cases. The reconstruction of the glenoid was obtained using an iliac crest graft (8 patients) or synthetic bone substitute (2 patients). The non-cemented glenoid component was fixed into the glenoid native bone, thus stabilizing the graft reconstruction. A clinical and radiological checkup was performed at the long-term follow-up and compared with the preoperative values. The patients were also asked to quantify their pain and satisfaction. RESULTS: There were no intraoperative complications. In all cases, the radiological evaluation showed a good integration of the bone graft with no radiolucency or new glenoid loosening. In one patient, the revision surgery was indicated for the dissociation between MB and polyethylene. After more than 2 years of follow-up, all patients were satisfied or highly satisfied with the outcomes. The pain VAS score (0-10) decreased from 5.1 to 0.6 (p < 0.001). The simple shoulder test increased from 3.4 to 7.9 points (gain 4.5; p < 0.001). The Constant and Murley score increased from 39.4 to 71 points (gain 31.6; p < 0.001). The gain in anterior elevation was 31°, from 118° to 149° (p < 0.001). External rotation elbow to the body (ER1) increased from an average of 34° preoperatively to 47° after surgery (p < 0.001) and external rotation at 90° of abduction from 43° to 66° (p < 0.001). CONCLUSION: This study suggests that revision with a non-cemented glenoid component associated with a bone graft can solve the difficult challenge of glenoid loosening, provided that the rotator cuff is functional and the glenoid is reconstructable. LEVEL OF EVIDENCE AND STUDY TYPE: Cohort studies (prospective) without controls, Level IV.

The feasibility and results of an arthroscopic removal of humeral locking plates and glenohumeral arthrolysis after proximal humeral fractures.

PURPOSE: This study describes the use of standard shoulder arthroscopy techniques to remove a proximal humerus locking plate following proximal humerus fracture. The goal of this study was to assess the feasibility and results of this technique. METHODS: This was a retrospective non-comparative study. Inclusion criteria were fracture union when hardware was removed, significant residual glenohumeral stiffness after 6 months of physiotherapy, arthrogenic screw(s) and/or osteonecrosis (partial or complete) of the humeral head resulting in significant pain. RESULTS: Eleven patients were included in this study. Surgery was successful in all cases, and surgery lasted a mean of 105 ± 10.5 min. Patients' mean age was 54.6 ± 10.6 years and the mean hospital stay 1.6 ± 0.8 days. No patient was lost to follow-up. At the mean last follow-up of 17.7 ± 23.4 months, pain and all functional parameters improved significantly: the Constant score (43.4 ± 8.8 vs 60.5 ± 0.3, p = 0.003), the visual analogue pain score (4.7 ± 1.5 vs 2.8 ± 2.3, p = 0.012), the shoulder abduction (77.7 ± 18.6 vs 104.5 ± 27.3, p = 0.004), the flexion (85.9 ± 30.7 vs 97.7 ± 27.7, p = 0.026) and the external rotation (15 ± 12 vs 31.8 ± 13.6, p = 0.004). Internal rotation improved from L3 to T12. All seven patients who practiced sports before the initial fracture had returned to sports approximately 6 months postoperatively. No infections or wound dehiscence occurred. CONCLUSION: Shoulder arthroscopy was found to be feasible for removal of hardware following proximal humeral fracture and can be associated with diagnostic and therapeutic arthroscopy and glenohumeral arthrolysis if required.

Anatomy of the anterior cruciate ligament related to hamstring tendon grafts. A cadaveric study.

BACKGROUND: The aim of modern techniques for anatomic reconstruction of the ACL is to reproduce ACL footprints, in order to restore anatomy and therefore normal biomechanics. Is there an oversizing of the hamstring grafts related to ACL dimensions? METHODS: Twenty-two paired cadaver knees were dissected. ACL dimensions at mid-portion and ACL footprints were measured after removing the synovial membrane. Hamstrings were harvested and prepared in a quadruple strand graft in order to measure the mean circumference. RESULTS: The average ACL tibial and femoral insertion site areas of the ACL were 117.9mm(2) (range, 90 to 130mm) and 96.8mm(2) (range, 80 to 121mm), respectively. The average diameter and cross sectional area of the ACL tendon at mid-portion were 6.1mm (range, 5 to 7mm) and 29.2mm(2) (range, 20 to 38.9), respectively. The average diameter and cross-sectional area of the 4-stranded hamstring tendons were 6.7 (range, 5 to 8) and 35.3mm(2) (range, 20 to 50), respectively. There was a correlation between the 4-stranded hamstring grafts and ACL dimensions (footprints, ligament at mid substance, p<0.01). The cross sectional area of hamstring tendon was significantly larger than the ACL area at mid-portion (mean 20.9%, p<0.05). CONCLUSION: With current ACL reconstruction techniques, the graft is oversized at a mean of 21%, despite a good correlation between the ACL and the hamstring tendon, especially among small subjects and women. The question arises whether the anatomic reconstruction of the ACL should fill ACL footprints or mimic the ligament itself. CLINICAL RELEVANCE: Hamstrings grafts are significantly larger than native ACL.

Ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon: a non-reliable technique.

PURPOSE: To evaluate the feasibility of ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon via a keyhole incision. METHODS: This was an anatomical study performed on twelve embalmed cadaveric shoulder joints. The rotator cuff and the position of the long head of the biceps tendon were explored by ultrasound prior to beginning the procedure. The biceps tenotomy was performed under ultrasound guidance by a highly experienced sonographer who was trained in shoulder tendon exploration. Arthroscopic exploration of the shoulder was performed immediately after the percutaneous biceps tenotomy to assess the quality and the location of the biceps tenotomy. RESULTS: Three out of twelve tendons (25%) were completely sectioned at the level of the glenoid insertion. More seriously, iatrogenic lesions of the cartilage of the humeral head, the supraspinatus tendon and the subscapularis tendon were observed. CONCLUSION: This study shows that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is not reliable.

Spinal neuroarthropathy associated with Guillain-Barré syndrome.

Since the rarefaction of neurosyphilis, axial neuroarthropathy is mostly secondary to spinal cord pathologies. Peripheral manifestations of neuroarthropathy resulting from Guillain-Barré syndrome have already been reported but to our knowledge, this is the first case of a patient diagnosed with axial involvement. After the acute phase, a 47-year-old woman suffered of paraparesia with a partial loss of sensibility under the tenth thoracic vertebra. As a consequence, she developed first of all neuroarthropathy of both knees and few years later, a spinal involvement was discovered. Multiple surgeries of both knees and of the spine were required, due to non-union, relapse, and infection. Natural evolution of Charcot spine remains unknown. Surgical treatment is recommended but even with circumferential fusion, failures do frequently occur. This observation allows us to report an original case and to discuss the etiology of axial neuroarthropathy, the classical radiographic findings, and the inherent difficulties of its treatment.