Purpose

to analyze the survivorship of the RSA with a minimum 10 years follow up.

Background: Rotator cuff tears involving the subscapularis are less common than those involving the posterior superior rotator cuff. The purpose of this study is to report the results of repair of isolated tears of the subscapularis.

Methods: Eighty-four shoulders that had undergone open repair of the subscapularis tendon were reviewed. The mean age at surgery was 53.2 years. The mean interval from onset of symptoms to surgery was 12.5 months. Fifty-seven tears were traumatic, and twenty-seven were degenerative in etiology. Twenty-three of the tears involved the superior third of the subscapularis tendon, forty-one involved the superior two thirds, and twenty were complete tears. Fifty-four shoulders had a dislocation or subluxation of the long head of the biceps tendon, while ten shoulders had a rupture of the long head of the biceps tendon. Forty-eight shoulders underwent concomitant biceps tenodesis; thirteen shoulders underwent concomitant biceps tenotomy; and four shoulders underwent concomitant recentering of the biceps. Patients were evaluated clinically and radiographically at a mean fortyfive month follow-up (range 24 to 132 months).

Results: The mean Constant score increased from 55.0 points preoperatively to 79.5 points postoperatively (p< 0.001). Seventy-five patients were satisfied or very satisfied with the result. Preoperatively, four patients had mild glenohumeral arthritis. Postoperatively, twenty-five patients had mild glenohumeral arthritis and two patients had moderate glenohumeral arthritis. Tenodesis or tenotomy of the biceps tendon at the time of subscapularis repair was associated with improved subjective and objective results independent of the preoperative condition of the biceps tendon.

Scapular notching is of concern in reverse shoulder arthroplasty and has been suggested as a cause of glenoid loosening. Our purpose was to analyze in a large series the characteristics and the consequences of the notch and then to enlighten the causes in order to seek some solutions to avoid it. 430 consecutive patients (457 shoulders) were treated by a reverse prosthesis for various etiologies between 1991 and 2003 and analyzed for this retrospective multicenter study. Adequate evaluation of the notch was available in 337 shoulders with a follow-up of 47 months (range, 24–120 months). The notch has been diagnosed in 62% cases at the last follow-up. Intermediate reviews show that the notch is already visible within the first postoperative year in 82% of these cases. Frequency and grade extension of the notch increase significantly with follow-up (p< 0.0001) but notch, when present, is not always evolutive. At this point of follow-up, scapular notch is not correlated with clinical outcome. There is a correlation with humeral radiolucent lines, particularly in metaphyseal zones (p=0.005) and with glenoid radiolucent lines around the fixation screws (p=0.006). Significant preoperative factors are: cuff tear arthropathy (p=0.0004), muscular fatty infiltration of infraspinatus (p=0.01), narrowing of acromio-humeral distance (p< 0.0001) and superior erosion of the glenoid (p=0.006). It was more frequent with superolateral approach than with deltopectoral approach (p< 0.0001) and with standard cup than with lateralized cup (p=0.02). We conclude that scapular notching is frequent, early and sometimes evolutive but not unavoidable. Preoperative superior glenoid erosion is significantly associated with a scapular notch, possibly due to the surgical tendency to position the baseplate with superior tilt and/or in high position which has been demonstrated to be an impingement factor. Preoperative radiographic planning and adapted glenoid preparation are of concern.

Over the long term, the results of the insertion of a Grammont inverted shoulder prothesis are unknown. The present study reports survivorship curves and the role of the initial aetiology in patients re-examined after 5 to 10 years.

Patients and methods Eighty prostheses (for 77 patients) were implanted between 1992 and 1998: 66 cases of massive cuff tear arthropathy (MCTA) and 24 cases for another aetiology (mainly rheumatoid arthritis and revision).

At the time of follow-up, 18 patients had died and 2 could not be traced. The remaining patients (57 representing 60 prostheses) were seen by an independent examiner. The minimum follow-up was 5 years. The average follow-up was 69,6 months.

Kaplan-Meir survivorship curves for the 60 prostheses were established in order to show the probability of failure as defined by: revision of the prothesis, glenoid loosening, and a functional level< 30 points according to the Constant score.

Results The survivorship curves were as follow:

- for non revision of the prosthesis at 10 years: 91% overall; after 9 years: 95% for MCTA, and 77 % for the others aetiologies. This difference was statistically significant (p< 0,01) ; 6 implants were revised: 3 for MCTA and 3 for other aetiologies.

Discussion

According to revision of the prosthesis, there is a clear rupture in the survivorship curve about 3 years after insertion in aetiologies other than MCTA. This suggests that Grammont inverted total shoulder arthroplasty is not appropriate in these aetiologies (particularly in cases of rheumatoid arthritis).

We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant score had increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. The mean active forward elevation increased from 73° to 138°. The integrity of teres minor is essential for the recovery of external rotation and significantly influenced the Constant score. Five cases of aseptic loosening of the glenoid and seven of dissociation of the glenoid component were noted.

This study confirms the promising early results obtained with the inverted prosthesis in the treatment of a cuff-tear arthropathy. It should be considered in the treatment of osteoarthritis with a massive tear of the cuff but should be reserved for elderly patients.

Aim: To compare results of hemi arthroplasty (Aequalis) and reverse arthroplasty (Delta) in treatment of arthropathy with massive cuff tear.

Methods: This was a multicentric study included 142 shoulder arthroplasties (80 reverse and 62 hemiarthroplasties). The pre-op. status was similar in two population according to Constant score, active anterior elevation (AAE) and active external rotation (AER).

Results: The patients were evaluated with a mean follow-up of 44 months. There were 7 failures needed 5 revisions (2 in hemi group and 3 in reverse one). The Constant score was significantly better (p< 0,01) in reverse group (65.6) than in hemi group (46.2). AAE was significantly better (p< 0,01) in reverse group (138°) than in hemi group (96°). AER was significantly better (p< 0,05) in hemi group (22°) than in reverse group (11°) but external rotation in elevated position and internal rotation were not different. These results stay similar even with a follow up over 5 years. In reverse group, partial glenoid unscrewing was observed in 3 patients, and a notch in pillar of scapula in 50 cases. In hemi group, upward migration was observed in 32 cases.

Conclusions: We found significantly better results for reverse prostheses. The inherent risk of hemiarthroplasties is upward migration wearing the coraco acromialarch. The inherent risk of reverse prosthesis is the notch in scapula, and the strain on glenoid fixation, but the results over 5 years stay satisfactory.

Purpose: Acetabular reconstruction is particularly challenging in case of acetabular loosening with important loss of bone stock. The purpose of this retrospective study was to estimate long-term results after revision procedures using a fragmented allograft and a supporting ring.

Material and methods: From 1987 to 1995, 135 patients (135 hips) underwent this procedure. Ninety-five files were reviewed (15 patients were lost to follow-up and 25 died). The 95 patients retained for analysis were 66 women and 29 men, mean age at surgery 70 years (range 42–86). The preoperative functional score (PMA) was 8/18. The acetabular implants in situ had been cemented in 62% of the cases and non-cemented in 38%. According to the SOFCOT criteria, 79% of the loosenings were associated with grade 3 bony lesions, 15.8% with grade 4 lesions and 5.2% with grade 2 lesions. In all cases, the acetabulum was reconstructed with fragments of allografts. An Eichler ring was used in 56% of the cases, a Ganz ring in 25%, and a Muller ring in 19%.

Results: Mean follow-up was eight years (60–157 months); 39% of the patients developed early postoperative complications including one dislocation and two haematomas. Mean functional score at last follow-up was 14.8/18 with 64% good or excellent results. Reconstruction of the centre of rotation was the only factor significantly affecting results. Radiographically, 85% of the cups presented no sign of loosening at last follow-up. The grafts were considered to be assimilated or unchanged in 81% of the cases, with partial or total lysis in 19%. Actuarial analysis of cumulative survival, considering surgical revision or clinical and radiographic loosening as the endpoint was 87% at 14 years.

Discussion: Fragmented allografts can be perfectly stabilised with a supporting ring to reconstitute bony stock of the acetabulum. Long-term clinical and radiographic results are encouraging.

Purpose: Posterior instability of the shoulder requires surgical treatment in involuntary forms and after failure of functional treatment. As for anterior instability, a bone block can be fashioned from an iliac graft or a pediculated graft harvested from the acromion. This retrospective analysis concerned the results obtained in eighteen consecutive cases.

Material and methods: This series included ten men and eight women, mean age 26 years (15–42) at time of surgery. Fourteen (77%) practised sports activities including four at competition level. Symptoms had persisted for four years on the average. For three patients (16%) posterior instability was expressed by recurrent luxation subluxation. For nine patients (50%) posterior subluxation was a common involuntary event. Six patients suffered from painful shoulders due to an unrecognised posterior instability accident. Diagnosis of posterior instability was establised by arthroscopy in seven patients (39%). For nine shoulders the intervention consisted in a screwed posterior iliac block associated with a tension procedure on the capsule (group 1). For the other nine shoulders the block was harvested from the acromion and pediculated on the deltoid (group 2).

Results: Mean follow-up for all patients was eight years. The Duplay score was 75 points at last follow-up. Twelve patients (85% of the athletes) were able to resume their sports activities, half at the same level. Nine patients were pain free. Six patients (33%) had persistent apprehension but did not present true recurrence at physical examination. The Duplay score was 69.4 points in group 1 (follow-up 12 years) and 82.2 points in group 2 (follow-up three years). Thirteen patients (77%) did not have any sign of joint degeneration at last follow-up. One patient had advanced stage IV degeneration related to an intra-articular screw. All patients felt their shoulder had been improved by surgery and one third were disappointed with the results.

Discussion: Use of a posterior block is an effective treatent for posterior instability giving results comparable with those obtained with anterior blocks in terms of shoulder stability, pain, recovery of motion, and subjective outcome. This procedure favours joint degeneration less than anterior stabilisation. Results obtained with pediculated acromial blocks are encouraging.

Purpose: Failure of the glenoid component is the main complication of total shoulder prostheses. When surgical revision is necessary, the surgeon has the option of a new implantation or non-prosthetic plasty (glenoido-plasty). The purpose of the present work was to analyse results obtained with these two techniques in order to propose proper indications.

Material and methods: This retrospective study included 16 patients, mean age 62 years at revision surgery. Fialures included loosening of a cemented glenoid implant (n=9) and failure of non-cemented implants (3 defective anchors, 4 unclipped polyethylene inserts). Mean time to revision was 39 months (2–178) after primary implantation. A new glenoid implant was cemented in nine patients (group A). Seven patients (group 2) had glenoidoplasty with an iliac graft in four.

Results: A mean follow-up of 37 months (19–73), the Constant score had improved from 18 points before revision to 52 points (+34). Two patients experienced a complication requiring a second revision (infection, instability) and one patient underwent subsequent surgery for biceps tenodesis. For the group with glenoidoplasty with iliac graft, insertion of an inverted prosthesis was achieved during a second operative time. In group 1, the mean Constant score at last-follow-up was 63 points (+45) with the pain score of 11, movement score of 29. In group 2, the mean Constant score was 37 (+19) with pain at 6 and motion at 16. In this group, the mean score was 48 points with a glenoid graft and 21 points with simple implant replacement.

Discussion: Revision surgery for a failed glenoid implant remains a difficult procedure but can be effective for pain relief and improved motion score. The small number of patients in this series makes it difficult to perform statistical analysis but the results do point in favour of prosthetic reimplantation when the bone stock is sufficient. For other patients, a graft would be preferable to simple implant removal. This would allow secondary revision if possible.

Purpose: Maisonneuve fracture is a rare variant of malleolar fractures. Standard surgical care is not well defined. We performed a retrospective analysis of operated patients to propose a system to determine adequate care as a function of the type of lesions observed.

Material and methods: This retrospective analysis involved 20 patients who underwent surgery for Mai-sonneuve fracture between 1989 and 2000. Mean age was 42 years at surgery. Male gender predominated (16 patients). Seven patients (group 1) were treated without a syndesmodesis screw (osteosynthesis of the medial malleolus in six cases and suture of the medial collateral ligament in one). Thirteen patients (group 2) were treated via a first lateral approach and a syndesmodesis screw followed by a complementary medial approach in seven cases (two cases of medial malleolus osteocynthesis and five cases of medial collateral ligament suture). The Duquennoy functional score was determined at last follow-up. Quality of the reduction and presence of degenerative disease were determined on standard x-rays and computed tomographies.

Results: Mean follow-up was four years nine months (range 1–10 years). No case of tibiotalar diastasis was observed at at least one year. Among the five patients reviewed clinically, outcome was excellent in four and fair in one. In group 2 (syndesmodesis), we found two cases of residual diastasis and two cases of tight syndesmosis at at least one year. Among the nine patients reviewed clinically, outcome was excellent in three and fair or poor in six.

Discussion: This retrospective analysis collaborates the few data in the literature on Maisonneuve fractures. Ligament injury has varied greatly (with or without tear of the medial lateral ligament, more or less full thickness rupture of the interosseous membrane). In our experience, it is always difficult to reduce the diastasis via the primary lateral approach. Conversely, the primary medial approach has, after testing, enabled eliminating the syndesmodesis screw, with its recognised deleterious effects, in seven cases.

Conclusion: Due to the diversity of the ligament injuries encountered in patients with Maisonneuve fractures, we have adopted the following surgical strategy. If there is diastasis, after confirmation of any injury to the medical compartment, medial approach to suture the medial collateral ligament or osteosynthesis of the medial malleolus: in the case of diastasis reduction, we advocate a syndesmodesis screw; if diastasis persists, a secondary lateral approach is useful to reduce the medial malleolar rotation and insert a syndesmodesis screw.

Purpose: The glenoid and humeral head curvature radii are mismatched in non-constrained total shoulder prostheses. The purpose of this study was to evaluate the effect of this mismatch on radiographic lucent lines and clinical outcome.

Material and methods: The study population included 319 total shoulder prostheses issuing from a multicentric European cohort. The patients underwent surgery for primary shoulder degeneration. Mean age at surgery was 67 years. Female sex predominated (75%). Partial supraspinatous tears were present in 7% of the shoulders with full-thickness tears also in 7%. A single type of prosthesis was used composed of a humeral pivot with a modular head (seven head sizes) and a cemented polyethylene flat-surface spiked glenoid (three sizes). Variable association of humeral heads and prosthetic glenoids defined the mismatch which varied from 0 to 10 mm (difference in the curvature radii between the head and glenoid). The patients were reviewed clinically and radiologically at a mean follow-up of 53.5 months (24–110 months). Clinical outcome was assessed with the Constant score for pain (15 points), daily activity (20 points), motion (40 points), and force (25 points). The glenoid lucent line was evaluated on the AP view using a 0 to 18 point scale (0=absence, 18=lucent line in 6 zones). Analysis of variance and linear regression were used to assess the effect of mismatch on the glenoid lucent line and clinical outcome.

Results: There was a statistically significant linear relationship between mismatch and glenoid lucent lines. The lucent line score was significantly lower when the mismatch was between 6 and 10mm. Mismatch had no influence on the overall Constant score or the individual scores (pain, motion, force, daily activities) nor on early or late postoperative complications.

Discussion: Based on the results of this study, the first in vivo assessment, the “ideal” gleno-humeral mismatch for total shoulder prostheses would be between 6 and 10 mm, i.e. much greater than is classically recommended (0–5 mm).