Mid-term results of a stemless ceramic on polyethylene shoulder prosthesis - A prospective multicentre study.

INTRODUCTION: Early reports of stemless shoulder arthroplasty have shown promising clinical and radiological outcomes. The purpose of this study was to report on the mid-term results of an implant that utilises a ceramic humeral head. METHODS: A prospective, consecutive, multicentre study of stemless shoulder prosthesis with a minimum of four years of follow-up was conducted between August 2009 and May 2012. The adjusted Constant-Murley Score (CMS), revision rate and presence of radiolucent lines were recorded at intervals. RESULTS: A total of 207 patients were eligible for study inclusion; 62.8% were female and mean age was 64.8 years (range 30-86). Mean follow-up was 70.7 months (range 48-100), 73% underwent TSA and 27% hemiarthroplasty. The mean CMS improvement was 42.6 (p < 0.0001) at 48 months. Radiolucencies were present in 2.7% of humeral zones and 14% of glenoid zones at 48-month follow-up. The revision rate was 6.3% with rotator cuff failure (2.9%) the most common indication. CONCLUSIONS: Mid-term results demonstrate that the studied stemless implant with a ceramic humeral head had clinical and radiological outcomes that are comparable to other reported studies.

Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair.

INTRODUCTION: Although arthroscopic rotator cuff repair is minimally invasive, there is still considerable postoperative pain, especially during the first 48 hours. The present study assessed the short-term efficacy and safety of multimodal analgesic (MMA) injection associated to corticosteroids in arthroscopic rotator cuff tear surgery. MATERIAL AND METHOD: A single-center prospective randomized study included 50 patients undergoing arthroscopic rotator cuff tear surgery. The study group received subacromial injection of a mixture of morphine, ropivacaine and methylprednisolone associated to intra-articular injection of morphine plus methylprednisolone; the control group received only isotonic saline. All patients had had 24 hours self-administered morphine associated to standard analgesia. Postoperative data were recorded at 30 minutes and 1, 2, 4, 6, 12, 18 and 24 hours: pain intensity, morphine intake and side effects, and also time to first morphine bolus and additional analgesic intake. Constant, ASES and SST functional scores were recorded at 3 months. RESULTS: Postoperative pain was significantly less intense in the MMA group than in controls at 30 min, H1, H4, H6, H12, H18 and H24 (P<0.05). A rebound at D10 occurred in both groups. During the first 24 hours, MMA significantly reduced cumulative resort to morphine (P<0.05 at H1/2, P<0.001 at H1-24). Mean time to first bolus was significantly longer in the MMA group (71.6 vs. 33 min; P<0.05). The rate of opioid-related side effects was similar between groups. At last follow-up, functional scores were similar between groups. There were no cases of infection or delayed skin healing. CONCLUSION: MMA associated to corticosteroids after arthroscopic rotator cuff tear surgery provided immediate benefit in terms of analgesia and morphine sparing, without apparent risk of infection. The practice is presently little known in France and deserves longer-term assessment, especially as regards functional rehabilitation and tendon healing. LEVEL OF EVIDENCE: 2.

Intraosseous xanthoma without lipid disorders. Case-report and literature review.

A case of intraosseous xanthoma in a patient with a normal lipid profile is reported. Hyperlipidemia is present in most patients with xanthomas. Intraosseous xanthomas are rare, particularly in normolipidemic patients, in whom the presenting symptom is pain without skin lesions. A lytic lesion with a rim of sclerosis is seen on radiographs. Histology shows foam cells, giant cells, and fibrosis. Intraosseous xanthoma is a benign tumor, and other diagnoses must be ruled out (histiocytosis X, Erdheim Chester disease, clear cell carcinoma metastasis). Surgical excision of the lesion is the elective treatment.

Rotator cuff tears after 70 years of age: a prospective, randomized, comparative study between decompression and arthroscopic repair in 154 patients.

INTRODUCTION: Arthroscopic repair of rotator cuff tears leads to better clinical outcomes than subacromial decompression alone; however the former is rarely proposed to patients above 70 years of age. Our hypothesis was that arthroscopic repair would be superior to decompression in patient 70 years or older. The primary goal was to compare the clinical results obtained with each technique. The secondary goal was to analyze the effects of age, tendon retraction and fatty infiltration on the outcome. METHODS: This was a prospective, comparative, randomized, multicenter study where 154 patients were included who were at least 70 years of age. Of the included patients, 143 (70 repair and 73 decompression) were seen at one-year follow-up; these patients had an average age of 74.6 years. Shoulders had a complete supraspinatus tear with extension limited to the upper-third of the infraspinatus and Patte stage 1 or 2 retraction. Clinical outcomes were evaluated with the Constant, ASES and SST scores. RESULTS: All scores improved significantly with both techniques: Constant +33.81 (P<0.001), ASES +52.1 (P<0.001), SST +5.86 (P<0.001). However, repair led to even better results than decompression: Constant (+35.85 vs. +31.8, P<0.05), ASES (+56.09 vs. +48.17, P=0.01), SST (+6.33 vs. +5.38, P=0.02). The difference between repair and decompression was not correlated with age; arthroscopic repair was also better in patients above 75 years of age (Constant, ASES and SST scores P<0.01). There was no significant correlation between the final outcomes and initial retraction: Constant (P=0.14), ASES (P=0.92), SST (P=0.47). The difference between repair and decompression was greater in patients with stages 0 and 1 fatty infiltration (Constant P<0.02) than in patients with stages 2 and 3 fatty infiltration (Constant P<0.05). CONCLUSION: There was a significant improvement in all-clinical scores for both techniques 1 year after surgery. Repair was significantly better than decompression for all clinical outcomes, even in patients above 75 years of age. The difference observed between repair and decompression was greater in patients with more retracted tears and lesser in patients with more severe fatty infiltration.

Arthroscopic repair of the rotator cuff: prospective study of tendon healing after 70 years of age in 145 patients.

INTRODUCTION: The level of activity of patients older than 70 years is tending to increase, as are their expectations in terms of joint function recuperation. It has not been proven that rotator cuff repair healing is satisfactory in the elderly. The main hypothesis of this study was: repair of supraspinous lesions in patients older than 70 years is reliable in terms of both clinical results and healing. The secondary hypothesis was: tendon healing is significantly correlated with the Constant, ASES, and SST scores as well as with age, tendon retraction, and fatty infiltration. MATERIAL AND METHODS: Multicenter prospective study on 145 patients older than 70 years, with 135 patients reviewed at 1 year (93%). The mean age was 73.9 years. Full-thickness tears of the supraspinatus extended at most to the upper third of the infraspinatus and retraction limited to Patte stages 1 and 2 were included. Clinical assessment was carried out in accordance with the Constant, ASES, and SST scores. Healing was evaluated with ultrasound. RESULTS: A significant improvement was noted in the Constant (44/76)+31.5 (P<0.0001), ASES (35/90)+54.4 (P<0.0001), and SST (3.5/10)+6.6 (P>0.0001) scores at 1 year of follow-up. The healing rate was 89% with 15 re-tears, nine of which were stage 1 and six stage 2. The clinical result was not correlated with patient age (Constant, P=0.24; ASES, P=0.38; SST, P=0.83) nor with the retraction stage (Constant, P=0.71; ASES, P=0.35; SST, P=0.69) or the stage of fatty infiltration (P>0.7). Healing was correlated with the quality of the clinical result (Constant, P=0.02; ASES, P=0.03) and age (P=0.01) but was not correlated with retraction or the fatty infiltration stage (P>0.3). DISCUSSION/CONCLUSION: Arthroscopic repair significantly improves the clinical results, even in patients older than 70 years. The clinical results are not correlated with age (but deterioration of the result was not noted after 75 years) or frontal retraction (but the study only included retractions limited to stages 1 and 2). The healing rate is satisfactory, but this study is limited to small ruptures of the supraspinatus, and the postoperative ultrasound analysis probably inferior to CT imaging with contrast agent injection, often used as the reference. Healing proves to be correlated with the quality of the clinical result and patient age.

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.

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.

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.

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases.

INTRODUCTION: Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined. PATIENTS AND METHODS: This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements). RESULTS: Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05). DISCUSSION: The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.