Objectives

To date, no study has considered the impact of acromial morphology on shoulder range of movement (ROM). The purpose of our study was to evaluate the effects of lateralization of the centre of rotation (COR) and neck-shaft angle (NSA) on shoulder ROM after reverse shoulder arthroplasty (RSA) in patients with different scapular morphologies.

The indications for reverse shoulder arthroplasty (RSA) continue to be expanded. Associated impairment of the deltoid muscle has been considered a contraindication to its use, as function of the RSA depends on the deltoid and impairment of the deltoid may increase the risk of dislocation. The aim of this retrospective study was to determine the functional outcome and risk of dislocation following the use of an RSA in patients with impaired deltoid function. Between 1999 and 2010, 49 patients (49 shoulders) with impairment of the deltoid underwent RSA and were reviewed at a mean of 38 months (12 to 142) post-operatively. There were nine post-operative complications (18%), including two dislocations. The mean forward elevation improved from 50° (sd 38; 0° to 150°) pre-operatively to 121° (sd 40; 0° to 170°) at final follow-up (p < 0.001). The mean Constant score improved from 24 (sd 12; 2 to 51) to 58 (sd 17; 16 to 83) (p < 0.001). The mean Single Assessment Numeric Evaluation score was 71 (sd 17; 10 to 95) and the rate of patient satisfaction was 98% (48 of 49) at final follow-up.

These results suggest that pre-operative deltoid impairment, in certain circumstances, is not an absolute contraindication to RSA. This form of treatment can yield reliable improvement in function without excessive risk of post-operative dislocation.

Cite this article: Bone Joint J 2013;95-B:1106–13.

Purpose of the study: Therapeutic options for retractile capsulitis ranges from therapeutic abstention to arthroscopic arthrolysis. The purpose of this work was to examine the efficacy of a simple therapeutic option (arthrodistention + self-mobilisation).

Material and methods: This was a prospective study of a consecutive series of 41 patients (28 female, 13 male), dominant shoulder 57%. Inclusion criteria were deficient in passive range of motion ≥ 50% compared with the other side in at least two planes, without notion of trauma or surgery. Diagnosis and inclusion: one surgeon. Arthrodistension with corticosteroid injection: one radiologist. Recommendations for self-rehabilitation, the day of the arthrodistension: one physical therapist. Patients were reviewed at 30, 90 and 180 days to analyse pain (visual analogue scale, VAS), daily life activities (Constant score), range of motion.

Results: From day 1 to 6 months –VAS regressed from 5.8 (2 – 9) to 0.8 (0/2). Constant daily activity score improved from 1/4 to 3.6/4; FA from 82 (60/115) to 170; (150/180); Re1 from 5 (−10/30) to 50 (20/70); RI from 12 (0 – 30) to 30 (10/60). Recovery was correlated with deficit in RI (p< 0.005). The greater the RI deficit the less rapid the recovery.

Discussion: We did not use the overall Constant score because of the difficulty in evaluating force. An analysis of the literature shows that therapeutic abstention can provide recovery, but with a delay of about two years. Arthroscopic arthrolysis, interscalenic blocks provide a much quicker recovery (6 months). The results obtained here are comparable with those obtained with these more complex methods./

Conclusion: This study shows that a simple management strategy enables the same results as with more invasive and more costly techniques. The patient should be warned that an important deficit in RI will undoubtedly lead to a slower recovery.

Purpose of the study: Little is known about the clinical profile of patients aged less than 65 years who present a large or massive rotator cuff tear. We hypothesized that this clinical profile depends on the type of tear.

Material and method: This was a prospective descriptive multicentric study over a period of six months which included 112 patients aged less than 65 years, 66 men and 46 women, mean age 56.3 years (range 35–65) who had a large or massive rotator cuff tear. The Constant score and active and passive range of motion, subacromial height and fatty infiltration according to the Goutallier classification were noted. Patients were divided into four classes according to deficit in active elevation and external rotation: class A (n=55, no deficit), class B (n=19, deficient elevation alone), class C (n=28, deficient external rotation alone), class C (n=10, deficient elevation and external rotation).

Results: These classes were not significantly different for age, sex-ratio, duration of symptoms, or presence of subscapular involvement. Trauma was involved more often in patients in class B and class D. The mean absolute Constant score was significantly lower in patients in class B (30.2) or D (23.5) than in class A (53.3) or C (44.7). The subacromial space was significantly narrower in group D (5 mm) than in the other groups. Fatty infiltration of the infraspinatus scores > II was significantly more common in groups C and D. Severe fatty degeneration of the subscapular (> II) was found in only eight shoulders and was not correlated with defective active elevation.

Discussion: This study demonstrates that deficient external rotation is correlated with the type of tear but has little impact on the Constant score. Conversely, patients with deficient active elevation have a lower Constant score but do not exhibit characteristically different tears than patients without deficient active elevation. Thus, the management scheme should be no different in patients with deficient elevation than in patients with out deficient elevation, excepting cases with a major lesion of the subscapularis.

Purpose: In 1996, we reported the results of 65 coracoid blocks for chronic anterior instability. We found 6% true recurrence and 34% persistent apprhension. In order to improve these results, we modified our operative technique, associating capsuloplasty in the event of hyperlaxity. The purpose of the present work was to assess mid-term results.

Material and methods: Eighty-eight coracoid blocks were performed between 1995 and 2000 by the same operator. In 41 cases, the classical technique was used. In 47 cases we associated capsuloplasty. The indication for surgery was documented recurrent instability in all cases, with radiographic, MRI or endoscopic confirmation of an anteroinferior capusloligament lesion. Capsuloplasty was associated if signs suggested hyperlaxity: self-reducing dislocation, absence of notch, external rotation arm to body (RE1) greater than 80°, presence of a significant groove, laxity of the inferior flap of a T capsulotomy. Mean patient age was 24 years (14–42) and mean follow-up was 40 months (24–60). Clinical results were assessed with the Duplay criteria and three x-rays were obtained (standard AP, Lamy lateral view and glenoid lateral view).

Results: Eighty-five percent of the patients achieved a good or very good result according to the Duplay criteria. Eighty-eight percent of the blocks held without modification and 12% developed osteolysis. There were no cases of degeneration. One patient experienced recurrent dislocaion. The rate of persistent apprehension declined (12%) compared with our earlier experience. This improvement was achieved at the cost of greater loss of RE1 in the group with capsuloplasty (−20° versus −8°), but without impact on sports activity (82£% returned to their sports activities including 72% at the same level without significant difference between the groups with and without capsulotomy).

Discussion: These results demonstrate that capsuloplasty is warranted if there are signs of hyperlaxity. This technique allowed us to improve results concerning recurrence and persistent apprehension at the cost of less mobility but without effect on sports activities. We detail the objective criteria used to define hyperlaxity and describe the usual clinical expression of radiographic, arthroscopic, and arthroscopic findings.

Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces.

Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more.

Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling.

Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling.

Conclusion: Vascularised fibula transfer is a reliable technique which can be recommended for major resections (mean 160 mm) in active subjects. Axial compression forces applied to the graft and use of light osteosynthesis appear to favour healing and remodelling.

Purpose: A spacer can be used for two-phase replacement of an infected total hip prosthesis. The goal is to facilitate reimplantation by avoiding soft tissue retraction. Several types of spacers can be used. We searched for a spacer which avoids wear debris due to methacrylate friction against bone, delivers a local antibiotic, is easily removed, and does not worsen bone damage. Since 1995, we have used a Charnley Kerboull type prosthesis as a spacer. The purpose of the present study was to 1) verify the absence of spacer-related complications, 2) assess outcome in terms of cure of infection and improved function.

Material and methods: We used 14 articulated spacers for two-phasee prosthesis replacement in nine men and five women, mean age 64 years. Erythrocyte sedimentation rate was 32 and C-reactive protein was 17. The mean Postel-Merle d’Aubigné (PMA) score was 3+5+2. All patients were reviewed at a minimum 37 months follow-up. Technique: The approach was generally a digastric trochanterotomy, associated with a more or less extensive femoral procedure (depending on the length of the plug to remove) to achieve removal of all implants and cement. A small-size polyethylene cup was inserted with cement delivering at least one antibiotic on a Surgicel bed to facilitate later extraction. A long small-diameter femoral stem was then inserted (bridging the femoral window) and blocked with cement, also on a Surgicel bed. Partial then total weight bearing was authorised between the phases.

Results: There were no dislocations. All patients achieved total weight bearing between the two phases. The same germ identified at the first operation was also identified at the second in two patients, requiring prolonged antibiotic therapy. There was one septic failure, in a different patient. The mean PMA score was 5.7+5.8+5.2.

Conclusion: This technique avoids methacrylate wear induced by classical spacers and does not modify polymorphonuclear chemotactism, facilitating the efficacy of medical treatment. Patient comfort is also improved between the two phases and muscle atrophy, which could compromise long-term function, is avoided.

We used a trochanteric slide osteotomy (TSO) in 94 consecutive revision total hip arthroplasties (90 with replacement of both the cup and stem). This technique proved to be adequate for removing the components, with few complications (two minor fractures), and for implanting acetabular allografts (18%) and reinforcement devices (23%). Trochanteric union was obtained in most patients (96%), even in those with septic loosening (18/19), major femoral osteolysis (32/32), or previous trochanteric osteotomy (17/18). TSO is versatile, since it can be extended by a femoral flap (four cases) or a distal femoral window (eight cases). Despite significant bone loss, in 24% of the femora and 57% of the acetabula, favourable midterm results were achieved and only six reoperations were required, including two for trochanteric nonunion and two for loosening. It leaves the lateral femoral cortex intact so that a stem longer than 200 mm was needed in only 25% of patients. This is a considerable advantage compared with the extended trochanteric osteotomy in which the long lateral flap (12 to 14 cm) requires an average length of stem of 220 mm beyond the calcar.

TSO provides an approach similar in size to the standard trochanteric osteotomy but with a rate of nonunion of 4% versus 15%. It reduces the risk of difficulties with removal of the stem, and removes the need for routine distal anchoring of long revision stems. The limited distal femoral compromise is very important in patients with a long life expectancy.

Purpose: The purpose of this study was to: 1) analyse sequelae after fracture of the lateral process of the talus (deformed callus or nonunion) in six patients included five who were operated, the impact on the talocrural and subtalar joint, and treatments that can be proposed and expected results; 2) emphasise the fact that this lesion is not often recognised in its initial stage, leading to late diagnosis despite the better results obtained with early treatment.

Material and methods: Six patients were seen at consultation at the sequelar stage. There were six men, mean age 40 year (20–60); three were high-level athletes. The injury was cause by fall from a high level, two accidents leading to multiple injuries with an unanalysable mechanism, and ankle “sprain” in one patient. Delay to therapeutic management was four months to ten years (mean two years). Pain and joint stiffeness involving the talocrural joints and/or subtalar joints were the predominant signs. The deformed calluses involved the subtalar joint in five cases with one case of nonunion. Five of the patients had been treated surgically: four resections, one screw fixation of the nonunion, and one patient desired surgery. In all the operated cases, pain had disappeared almost entirely but the amplitude of the joints was not totally recovered.

Discussion: Two aspects are particularly important. first fractures of the lateral process of the talus must be considered globally. Frequency has been estimated at 1% of all ankle trauma, certainly an underestimation since these fractures often go unrecognised in the early stages and are too often confused with ankle sprains. Incidence is also increasing with the practise of snow boarding where this injury occurs in 15% of all ankle traumas. The injury results from distraction via the talocalaneal ligaments in an inversion trauma or by compression during dorsiflexion and pronation. Clinical diagnosis is difficult and plain x-rays poorly visualise the lesion, irrespective of the anatomic type (MacCrory classification). CT scan is required to obtain an exact analysis of the fracture and its displacement, necessary for correct treatment: simple immobilisation if there is no displacement or resection of the fragment or osteosynthesis depending on the size of the fragment. Secondly, the pathology of this injury is important to recall: deformed callus or nonunion. The volume of the lesion and its site explain the observed impact, but in all cases, the injury involves the talocruaral joint (painful impingement of the fibular ligament) and talar disorganisation (pain, stiffness or osteoarthritis at the later stages). Depending on the case, treatment consists in excision of the deformed callus, fixation of the nonunion and, for cases seen late, subtalar arthrodesis. An improvment in pain can be achieved but there is almost always loss of joint amplitude.

Conclusion: Whatever treatment is used, the results at the sequelar stage are never excellent. Only early diagnosis with a rigorous clinical examination and adapted imaging (CT scan) can lead to coherent early treatment which provides the best result.