Postoperative rotator cuff integrity: can we consider type 3 Sugaya classification as retear?

BACKGROUND: Sugaya classification is a widely accepted classification system that is used to analyze postoperative rotator cuff tendon integrity. However, there are inconsistencies in the literature as to whether type 3 Sugaya should be considered as a retear or healed tendon. PURPOSE: We aimed to show that type 3 Sugaya is not a retear by comparing the long-term supraspinatus and infraspinatus muscle degeneration and the functional outcomes of type 3 with those of type 4 and 5 Sugaya. We hypothesized that the clinical course of type 3 Sugaya would be different from type 4 or 5 Sugaya. METHOD: The study was a retrospective multicenter review of all the rotator cuff repair done in 2003-2004. We included all the patients who had undergone supraspinatus repair with 10-year follow-up (magnetic resonance imaging done with full functional assessment). Data collection included pre- and postoperative supraspinatus and infraspinatus fatty infiltration, supraspinatus muscle atrophy, and Constant score with a separate analysis of its Strength subsection. Supraspinatus tendon integrity at 10-year follow-up was determined according to Sugaya classification. The patients were divided into 2 groups: type 3 Sugaya and type 4 and 5 Sugaya. Statistical comparison was done between the groups. RESULTS: There was no significant difference in the preoperative fatty infiltration of the supraspinatus and infraspinatus, supraspinatus muscle atrophy, and Constant score between the 2 groups. However, type 3 Sugaya patients had significantly better scores in the preoperative Strength subsection. Postoperatively, type 3 Sugaya patients showed significantly lesser fatty infiltration of the supraspinatus and infraspinatus, lesser supraspinatus muscle atrophy, and higher Constant score compared with type 4 and 5 Sugaya (P < .001). CONCLUSION: Patients with type 3 Sugaya supraspinatus tendon exhibited lesser muscle degeneration in the supraspinatus and infraspinatus and performed better in functional assessment compared with type 4 and 5 Sugaya patients. We inferred that type 3 Sugaya should not be considered as a retear.

Isometric Characteristics of the Anterolateral Ligament of the Knee: A Cadaveric Navigation Study.

PURPOSE: To measure the variations in length during flexion and internal tibial rotation of the 3 different femoral insertions of the anterolateral ligament (ALL) while maintaining a fixed tibia insertion. METHODS: Twelve fresh-frozen cadaver knees were analyzed using a navigation system. Maximal distance variations of the 3 different anatomic femoral insertions of the ALL were measured during knee flexion and internal tibial rotation at 20° (IR20°) and 90° (IR90°). The 3 different femoral attachments were, as published, at the center of the lateral epicondyle, distal and anterior from this position, and proximal and posterior. Each of these 3 femoral insertions was coupled to the same tibial insertion at the tibial margin, halfway between the tip of the fibular head and the prominence of the Gerdy tubercle. RESULTS: During IR20°, variation in the distance between paired points is not different between the proximal-posterior, epicondyle, and distal-anterior femoral insertions. These variations were statistically different during IR90° for the 3 different femoral locations. In increasing degrees of flexion, there was a length decrease between paired points observed with the proximal-posterior position. A length increase was observed for both the epicondyle location and the distal-anterior location. CONCLUSIONS: The ALL did not reveal an isometric behavior at any of the femoral insertion locations but had different length change patterns during knee flexion and internal tibial rotation at 90°. The proximal and posterior to epicondyle femoral position is the only position with a favorable isometry, as shown by being tight in extension and in internal rotation at 20° and then relaxed when the knee goes to flexion at 120° and during internal rotation at 90°. CLINICAL RELEVANCE: Clinical relevance is significant with respect to optimizing the femoral position of an ALL reconstruction.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis.

INTRODUCTION: The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HYPOTHESIS: We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function. MATERIALS AND METHODS: Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. RESULTS: Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. CONCLUSIONS: Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. LEVEL OF EVIDENCE: IV, retrospective study.

Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases.

INTRODUCTION: The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival. HYPOTHESIS: The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies. METHODS: Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)]. RESULTS: Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer. CONCLUSION: Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Surgical treatment of tibial metastases: Retrospective, multicenter, observational study of 25 patients.

INTRODUCTION: Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition. HYPOTHESIS: We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature. MATERIAL AND METHODS: The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient. RESULTS: Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment. CONCLUSION: Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort. LEVEL OF EVIDENCE: IV, retrospective study.

Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series.

INTRODUCTION: The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival. HYPOTHESIS: The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival. MATERIAL AND METHODS: The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy. RESULTS: After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]). CONCLUSIONS: Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted. LEVEL OF EVIDENCE: IV, retrospective study.

Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series.

INTRODUCTION: Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors. HYPOTHESIS: The French data for clinical results, survival and complications are in agreement with the international literature. MATERIALS AND METHOD: The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%). RESULTS: There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before. CONCLUSION: The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture. LEVEL OF EVIDENCE: IV, retrospective study without control group.

The Involvement of the Anterolateral Ligament in Rotational Control of the Knee.

BACKGROUND: Rotational control of the knee is crucial for knee stability. The anterolateral ligament (ALL) has been identified as a potentially important structure involved in rotational control of the knee. PURPOSE/HYPOTHESIS: The purpose of this study was to determine, utilizing a navigation system, the involvement of the anterior cruciate ligament (ACL), the iliotibial band (ITB), and the ALL in tibial internal rotational control of the knee. The hypothesis was that the ALL would be involved in rotational control of the knee at varying degrees of knee flexion. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric knees were tested in internal rotation at 20° and 90° of flexion and then subsequently tested using a simulated pivot-shift test consisting of coupled axial rotation at 30° of flexion. Serial sectioning of the ACL, ALL, and ITB was performed. On the contralateral knee, sectioning was performed in the reverse order. Measurements were collected using a surgical navigation system before and after each sectioning. RESULTS: After ACL sectioning, an incision of the ALL induced a significant increase in internal rotation (+19.2% [P = .0002] at 20°; +21.8% [P = .0029] at 90°) and in coupled axial rotation (+43.0%; P = .0035) compared with the intact knee as well as a significant increase in internal rotation at 90° (+13.4%; P = .009) and in coupled axial rotation (+30.8%; P = .0124) compared with the ACL-deficient knee. After ITB sectioning, an additional ALL section caused a significant increase in internal rotation (+39.0% [P = .002] at 20°; +63.0% [P = .0147] at 90°) and in coupled axial rotation (+59.7%; P = .0003) compared with the intact knee as well as a significant increase in internal rotation at 90° (+14.8%; P = .0067) in comparison to the ITB-deficient knee. CONCLUSION: The ALL is involved in rotational control of the knee at varying degrees of knee flexion and during a simulated pivot shift. Concomitant to an ACL or ITB transection, sectioning the ALL further increased rotational laxity. CLINICAL RELEVANCE: This laboratory study demonstrated that the ALL provides rotational control of the knee in combination with the ACL and/or ITB.