RESUMEN
INTRODUCTION: Anterosuperior (AS) rotator cuff tear describes a combined tear of the subscapularis and the supraspinatus tendons. We hypothesized that results after AS tendon repairs might be influenced by the size of the subscapularis rupture and the preoperative subscapularis muscle fatty infiltration. METHODS: A prospective multicentric study of 53 AS rotator cuff tears from five centers was performed (January 2008-January 2009). Subscapularis tendon retraction and fatty infiltration were assessed preoperatively. An ultrasonographic healing control was performed 1 year after surgery. RESULTS: Patients were on average 60 years (range, 43-75 years) and were operated on average 16 months (range, 2-72 months) after the beginning of their symptoms. The incidence of AS tears was found to be 18%. Average follow-up was 15 months (range, 12-24). The Constant-Murley (CM) score for the patients with AS ruptures improved significantly from 49 points (range, 35-51 points) preoperatively to 73 points postoperatively (range, 50-95 points)(P=0.0205). CM score gains were 26 for Lafosse group 1 ruptures and 29 for Lafosse group 2 & 3 with pre- and postoperative P values at P<0.0000001 and P<0.000001, respectively. The last follow-up CM score according to the subscapularis fatty infiltration was 70 (range, 48-95) for groups 0-1, 70 (range, 56-87) for group 2, and 56 (range, 53-88) for groups 3-4 with pre- and postoperative P values at P<0.001, P<0.001, and P<0.004, respectively. The global retear rate was 6%. DISCUSSION: Our study showed that the CM score after repairs of AS rotator cuff tears was lower in advanced subscapularis fatty infiltration. However, gains in CM scores were similar whatever the initial subscapularis fatty infiltration. The rate of tendon healing was correlated with subscapularis fatty infiltration. Subscapularis tendon rupture size was not significantly correlated with outcomes. LEVEL OF EVIDENCE: Level III.
Asunto(s)
Tejido Adiposo/patología , Músculo Esquelético/patología , Manguito de los Rotadores/cirugía , Adulto , Anciano , Artroscopía , Femenino , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Periodo Preoperatorio , Estudios Prospectivos , Manguito de los Rotadores/patología , Lesiones del Manguito de los Rotadores , Tomografía Computarizada por Rayos X , Cicatrización de HeridasRESUMEN
PURPOSE: Our aim was to assess the clinical and radiological outcomes of reverse shoulder replacements performed in association with a latissimus dorsi and teres major tendon transfer in cases of irreparable posterosuperior cuff tears including the teres minor tendon. Our hypothesis was that the tendon transfers would improve the clinical results of arthroplasty by restoring active external rotation. METHODS: Fifteen procedures in 14 patients were performed through a single deltopectoral approach. Both tendons were fixed to the proximal anterolateral aspect of the humeral metaphysis. Mean age at the time of surgery was 67.5 years (range 53 to 82 years). All had severe cuff tear arthropathy (Hamada stage 3 or 4) and severe atrophy or fatty infiltration of the infraspinatus and teres minor on preoperative MRI or CT-scan (Goutallier stage 3 or 4). Preoperative and postoperative functions were assessed by Constant score. Satisfaction was assessed by the Simple Shoulder Test (SST). At follow up, radiographs were examined for radiolucent lines, osteolysis and scapular notching. RESULTS: The average follow-up after surgery was 33.2 months (range 24 to 60 months). The mean absolute Constant score improved significantly (P=10(-5)) from 23.7±11.5 preoperatively to 61.1±11.9 postoperatively. Forward flexion and external rotation with the arm at the side improved significantly, respectively from 64.7±35.6° preoperatively to 126±34.4° postoperatively (P<10(-5)) and from -8.7±21.3° to 27.3±12.2° (P<0.0005). Internal rotation was not affected. The mean SST improved from 1.9±1.6 points preoperatively to 7.6±1.8 points postoperatively (P<0.0005). Twelve patients were very satisfied or satisfied (including one with a bilateral procedure) and 2 were unsatisfied with the final result. At final follow-up, radiographs showed no radiolucent lines around the implants nor scapular notching. CONCLUSION: The combined procedure helped restoration of active elevation and external rotation in cases of massive cuff tear including the teres minor tendon. LEVEL OF EVIDENCE: Therapeutic Level IV.
Asunto(s)
Artroplastia de Reemplazo/métodos , Rango del Movimiento Articular , Articulación del Hombro/cirugía , Transferencia Tendinosa , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Rotación , Lesiones del Manguito de los Rotadores , Articulación del Hombro/fisiopatología , Anclas para Sutura , Resultado del TratamientoRESUMEN
INTRODUCTION: Despite the success of reverse shoulder arthroplasty, the rate of scapular notching phenomena is high and represents a significant risk of glenoid prosthetic component loosening over the long term. The aim of this study was to perform an arthroscopic dynamic analysis of the impingement of the humeral cup on the neck of the scapula in order to highlight the causes of the occurrence of this notch and possible ways to avoid it. MATERIALS AND METHODS: The SMR reverse shoulder prosthesis (Lima(®)) was successively implanted in 11 shoulders of seven cadavers. Three glenospheres (36 mm, 36 mm with a 4-mm lowering offset, and 44 mm) were consecutively tested on each shoulder. An arthroscopic study was then performed in each case looking for scapular notching depending on the position of the shoulder, its exact location, and any resulting prosthetic instability. Rates of notching for each glenosphere in the different shoulder positions were compared. RESULTS: For each glenosphere, the highest rates of notching were recorded in the zero abduction position. Increasing abduction reduced the rates of notching and prosthetic instability for all types of glenosphere. External rotation increased both risks with 36-mm glenospheres but reduced them with the 44-mm glenosphere. The lower center of rotation, thus, reduced the risk of notching but increased the risk of instability associated with it. Increasing the prosthetic diameter reduced both risks. CONCLUSION: Reducing the risk of scapular notching and prosthetic instability requires, in addition to a lower center of rotation, the use of glenosphere diameters greater than 36 mm. The use of a humeral cup with a posteroinferior indentation should also contribute to reducing this risk.
Asunto(s)
Artroplastia de Reemplazo/métodos , Artroscopía , Inestabilidad de la Articulación/diagnóstico , Osteoartritis/cirugía , Escápula/patología , Articulación del Hombro/patología , Humanos , Inestabilidad de la Articulación/etiología , Pronóstico , Falla de Prótesis , Escápula/cirugía , Articulación del Hombro/cirugíaRESUMEN
INTRODUCTION: Although the use of the metal-on-metal bearings has been validated over the long term in total hip arthroplasty (THA) for standard 28 and 32 mm diameters, and over the medium term in resurfacing procedures, the use of larger metal head size in conventional THA has not yet been extensively reported. HYPOTHESIS: The large-diameter metal-on-metal head is beneficial in terms of implant stability without altering the result in terms of function and bone fixation compared to the standard 28 and 32 mm diameters. OBJECTIVE: The objective was to test this hypothesis by assessing the short-term clinical and radio graphic results of a metal-on-metal large-diameter heads THA system, using cups from the resurfacing hip concept. MATERIAL AND METHODS: We conducted a retrospective study on a continuous series of 106 uncemented acetabular cups (Durom) implanted in 102 patients (mean age, 66 years): 93 cases of primary or secondary coxarthrosis, 11 cases of aseptic osteonecrosis, one fracture of the femoral neck, and one case of rheumatoid arthritis of the hip. At 30 months of follow-up,the Harris Hip Score and the Merle d'Aubigné (PMA) score were calculated. The radiological investigation included comparison of the implant head with native head diameters, variations of acetabular center of rotation, inspection for implant migration, and search for a gap or radiolucent line. RESULTS: The series included two post-traumatic dislocations as well as spontaneously receding tendinitis of the gluteus medius with no further recurrence. The mean Harris Hip Score improved from 49.3 preoperatively to 91.6 at the latest follow-up and the mean PMA score ranged from 12 to 17. The results were excellent for 70 cases, good for 31 cases, fair for three cases, and poor for two cases. In the last five cases, the overall results were undermined by low pain subscore,with no identifiable explanation. Restoration of the original head diameter was verified for 65 hips. No cup migration was observed. Measurement of the acetabular centre of rotation showed a mean lateralization of 1.1mm. Of the 67 immediate postoperative gaps, only two did no disappear at follow-up. Implant head diameter, cup position, and the existence of a gap were not correlated with the clinical results. DISCUSSION: These results are comparable to 28 mm-diameter metal-on-metal heads in uncemented cups but with improved stability but without demonstrable alteration of the quality of the bone fixation. We found no mechanical or medical cause that could explain the five cases of persistent pain leading to fair or poor results. Long-term follow-up will validate these theoretical advantages in terms of wear and implant survival. LEVEL OF EVIDENCE: IV. Retrospective series.
Asunto(s)
Artroplastia de Reemplazo de Cadera/instrumentación , Prótesis de Cadera , Diseño de Prótesis , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Migración de Cuerpo Extraño/etiología , Luxación de la Cadera/etiología , Humanos , Masculino , Metales , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Rotación , Propiedades de Superficie , Tendinopatía/etiología , Resultado del TratamientoRESUMEN
PURPOSE OF THE STUDY: Many developments have been devoted to improving osteosynthesis of proximal humeral fractures, but indications remain controversial. Anterograde nailing using a locked self-stabilizing nail is an attractive conception which has provided promising results. The purpose of this study was to assess the early results observed in a series of patients treated with a first-intention Telegraph nail. MATERIAL AND METHOD: Thirty-four patients were reviewed for a prospective clinical and radiological assessment. Mean follow-up was 13.6 months (range 3-34 months). Mean age at the time of the accident was 68 years (20-90 years). There were 24 women and 10 men: the left shoulder was fractured in 22 patients. All fractures healed within 1 to 4 months. Groups for statistical analysis were determined by type of fracture using the Neer and Duparc classifications. Qualitative functional analysis used the Constant score in comparison with the opposite side. Anatomic analysis of fracture reduction after healing was based on plain x-rays (ap view in neutral rotation) by measuring the angle of inclination of the head in relation to the diaphyseal axis (alphaF). Normal was 45 degrees; reduction was considered adequate for an alphaF angle between 30 degrees and 60 degrees. The lateral view was used to search for posterior or anterior tilt of the humeral head. RESULTS: Necrosis of the humeral head was observed in four shoulders (11.8%). Three of them after displaced joint fractures. These cases were retained for the analysis. Considering all patients in the study, the raw mean Constant score was 62 points and the age- and sex-weighted score was 82.5%. For two- and three-fragment extra-articular fractures, the mean Constant score was 82.3% (21 shoulders); it was 89% for simple joint fractures (5 shoulders) and 79% for complex joint fractures (8 shoulders). The differential Constant scores, comparing the healthy side with the operated shoulder, showed a difference of 20 points on average (range 0-43 points). 52.9% of patients reviewed displayed mild deficit, 20.6% moderate deficit, and 26.5% major deficit. The mean alphaF angle was 38 degrees (range 0-80 degrees). Reduction was considered good in 18 shoulders with a mean Constant score of 88.7%. Reduction was considered poor in 16 shoulders with a mean Constant score of 75.6%. Four shoulders exhibited posterior tilt of the humeral head, all associated with healing in a valgus position. DISCUSSION: The Telegraph nail provides reliable fixation for the treatment of extra-articular and simple articular fractures of the proximal humerus. Dislocated fractures are classical indications for arthroplasty, with acceptable results for a only slightly invasive procedure. The risk of osteonecrosis does not necessarily deteriorate shoulder function and secondary revision for insertion of a prosthesis is still possible. The radio-clinical correlations show the importance of reduction quality to obtain a good final clinical result. Among the nine cases of poor outcome, six were related to a misaligned callus with persistent valgus deviation of the head (alpha F<30 degrees ) and in some cases, excessive posterior tilt. The solidity and stability achieved with the Telegraph nail enabled healing in all cases of fracture in this series with immediate postoperative reduction in most. The stability being related to the quality of bone stock, primary arthroplasty remains an important indication when it appears that a solid osteosynthesis cannot be achieved.