Quand faut-il opérer une rupture de la coiffe des rotateurs [When to operate a rotator cuff tear?]

Rotator cuff disease is the most common pathology causing shoulder pain with an overall prevalence rate of 30%. There is a significant association between increasing age and the presence of rotator cuff tears. Spontaneous healing of clinically relevant tears has not been observed. Although satisfactory pain relief is possible without rotator cuff tendon healing, functional outcome is better for healed repairs. Operative treatment must be considered in the context of the reasonable expectations for success. Repairability and potential of surgically tendon construct to heal are important considerations in surgical indications. There is no difference of outcomes between the arthroscopic and the open techniques.

Evaluation of muscular activity duration in shoulders with rotator cuff tears using inertial sensors and electromyography.

Shoulder disorders, including rotator cuff tears, affect the shoulder function and result in adapted muscle activation. Although these adaptations have been studied in controlled conditions, free-living activities have not been investigated. Based on the kinematics measured with inertial sensors and portable electromyography, the objectives of this study were to quantify the duration of the muscular activation in the upper trapezius (UT), medial deltoid (MD) and biceps brachii (BB) during motion and to investigate the effect of rotator cuff tear in laboratory settings and daily conditions. The duration of movements and muscular activations were analysed separately and together using the relative time of activation (TEMG/mov). Laboratory measurements showed the parameter's reliability through movement repetitions (ICC > 0.74) and differences in painful shoulders compared with healthy ones (p < 0.05): longer activation for UT; longer activation for MD during abduction and tendency to shorter activation in other movements; shorter activation for BB. In daily conditions, TEMG/mov for UT was longer, whereas it was shorter for MD and BB (p < 0.05). Moreover, significant correlations were observed between these parameters and clinical scores. This study thus provides new insights into the rotator cuff tear effect on duration of muscular activation in daily activity.

Acute flare induced by the calcific tendonitis of the rotator cuff: inhibition of IL-1 a potential therapeutic target?

Introduction: Calcific tendonitis of rotator cuff is observed on plainradiographs in 10% of adults, but remains asymptomatic in half thesecases. Sometimes, these calcifications induce acute flares withmassive inflammation similar to gout or CPPD crisis. Analgesics/anti-inflammatory medications are usually not sufficient to controlssymptoms in these situations. Local steroid infiltration with or withoutremoval of the calcific deposition with a needle aspiration may beuseful. A new approach could be IL-1 inhibitors. Indeed, basic calciumphosphate crystals are capable of stimulating the release of activeIL-1β in vitro. These crystals trigger IL-1β release, in an analogousmanner to MSU crystals in acute gout, suggesting that IL-1β blockademay be clinically useful.Case presentation: This report describes a 70-year old woman withacute rest pain of the right shoulder since 48 hours. On examination,we found massive limitations of active and passive movements. Thepatient evaluated, on the visual scale, her symptoms at 10/10 the nightand 5/10 the day. The radiography and showed a rounded, 8 mmcalcification in the subscapularis tendon. The ultrasound aspectrevealed a heterogeneous calcification partially non solid, surroundedby massive inflammation on Doppler. C-reactive protein anderythrocyte sedimentation rate were high (74 mg/ml, 54 mm/hour).The patient received subcutaneous injections of anakinra: 100 mgdaily for 3 days (D1-D3). We evaluated the patient in our consult at dayD1, D2, D3, D7, D16 and by phone at D70.This treatment rapidly relieved the inflammatory symptoms (within afew hours with no relapse). The mobility of the shoulder, the biologicsparameters improved and the size of the calcification as well thedegree of inflammation regressed on ultrasound after 3 days.Conclusion: This is the first report of a woman with an acute flareinduced by calcific tendonitis who received anakinra. IL-1 inhibitionmay be a therapeutic target in calcific tendonitis. To analyse thisresponse more precisely and elaborate definitive conclusions, aprospective pilot study is on-going in our ambulatory institute.

A pilot study of the efficacy of IL1 blockade by anakinra in acute calcific periarthritis of the rotator cuff

Background/Purpose: Calcific periarthritis of rotator cuff can induce acute and severe shoulder pain and is accompnied by signs of acute inflammation. The calcific deposits are composed of calcium phosphate crystals such as hydroxyapatite or basic calcium phosphate. These crystals stimulate the production and release of IL1b from macrophages, in an analogous manner to MSU and CPPD crystals. As IL1 blockade is effective in reducing signs and symptoms of inflammation in acute gout, we performed a pilot study to study if it is also effective in calcific periarthritis Methods: 5 consecutive patients were included (mean age: 62, 3 females, 2 males) between March 2011 and March 2012. Symptoms of acute shoulder pain at rest had to be present for _7 days before inclusion, associated with limitation of shoulder mobility and the presence on calcification in the rotator cuff by conventional radiography. None of the patients had responded to at least 48 hours of high doses of NSAIDs. Exclusion criteria included no corticosteroid therapy in the last 2 weeks and the exclusion of other rheumatologic or infectious diseases- .Clinical evaluation consisted of patient assessment of pain (total, rest and activity) by VAS (100mm scale) at days 0, 1, 3, 15, 42 and clinical examination of shoulder mobility at days 0, 3, 15. ESR and CRP were measured at days 0, 3. Plain radiographs were performed at days 0 and 15 and an ultrasound examination (including Doppler) was performed at days 0, 3, 15. Anakinra 100mg daily was administered for 3 consecutive days after the first evaluation (day 0). Rescue analgesics were allowed and recorded. Results: At inclusion, all patients had severe shoulder pain: mean (SD) VAS day pain of 72mm (_25mm), mean VAS night pain of 96 (_ 5) and impaired shoulder mobility. CRP was elevated in all of them (mean of 3X). Treatment with anakinra lead to rapid relief of pain in all patients, starting already on the first night following the first injection. The reduction of VAS pain was particularly striking for rest pain: mean (SD) VAS of 4mm (_ 5) at day 1 and this response was maintained for the 5 patients at the end of the three injections without any need of rescue medication. Mean rest VAS was 6 (_8) at day 3. The effect on day pain was less spectacular: mean (SD) VAS at D1 of 30 (_ 18), at D3 of 27 (_ 11). Shoulder mobility also improved and the CRP normalized in 4 of 5 patients at day 3. At day 42, 4 of 5 the patients were still totally asymptomatic. On X rays and US, the calcifications were reduced in size: mean maximal diameter of 21 mm at day 0 to 12 mm at day 15, but did not disappear in any patient. The main change on US was a significant and rapid (at day 3) reduction of Doppler activity around the calcification. Conclusion: This pilot open study suggests that IL-1_ inhibition may be an interesting therapeutic approach in acute calcific periarthritis, especially in patients who have not responded adequately to NSAIDs. The effect on pain seems to be more rapid (within a few hours) than steroid injection although a randomized controlled study needs to be performed to confirm this observation.

Alteration and recovery of arm usage in daily activities after rotator cuff surgery.

BACKGROUND: The objective measurement of dominant/nondominant arm use proportion in daily life may provide relevant information on healthy and pathologic arm behavior. This prospective case-control study explored the potential of such measurements as indicators of upper limb functional recovery after rotator cuff surgery. METHODS: Data on dominant/nondominant arm usage were acquired with body-worn sensors for 7 hours. The postsurgical arm usage of 21 patients was collected at 3, 6, and 12 months after rotator cuff surgery in the sitting, walking, and standing postures and compared with a reference established with 41 healthy subjects. The results were calculated for the dominant and nondominant surgical side subgroups at all stages. The correlations with clinical scores were calculated. RESULTS: Healthy right-handed and left-handed dominant arm usage was 60.2% (±6.3%) and 53.4% (±6.6%), respectively. Differences in use of the dominant side were significant between the right- and left-handed subgroups for sitting (P = .014) and standing (P = .009) but not for walking (P = .328). The patient group showed a significant underuse of 10.7% (±8.9%) at 3 months after surgery (P < .001). The patients recovered normal arm usage within 12 months, regardless of surgical side. The arm underuse measurement was weakly related to function and pain scores. CONCLUSION: This study provided new information on arm recovery after rotator cuff surgery using an innovative measurement method. It highlighted that objective arm underuse measurement is a valuable indicator of upper limb postsurgical outcome that captures a complementary feature to clinical scores.

Distribution of arm velocity and frequency of arm usage during daily activity: objective outcome evaluation after shoulder surgery.

In clinical settings, functional evaluation of shoulder movement is primarily based on what the patient thinks he/she is able to do rather than what he/she is actually performing. We proposed a new approach for shoulder assessment based on inertial sensors to monitor arm movement in the daily routine. The detection of movement of the humerus relative to the trunk was first validated in a laboratory setting (sensitivity>95%, specificity>97%). Then, 41 control subjects and 21 patients suffering from a rotator cuff tear were evaluated (before and after surgery) using clinical questionnaires and a one-day measurement of arm movement. The quantity of movement was estimated with the movement frequency and its symmetry index (SIFr). The quality of movement was assessed using the Kolmogorov-Smirnov distance (KS) between the cumulative distribution of the arm velocity for controls and the same distribution for each patient. SIFr presented differences between patients and controls at 3 month follow-up (p<0.05) while KS showed differences also after 6 months (p<0.01). SIFr illustrated a change in dominance due to the disorder whereas KS, which appeared independent of the dominance and occupation, showed a change in movement velocity. Both parameters were correlated to clinical scores (R(2) reaching 0.5). This approach provides clinicians with new objective parameters for evaluating the functional ability of the shoulder in daily conditions, which could be useful for outcome assessment after surgery.

Reversed shoulder arthroplasty baseplate fixed according to the major columns principle

Purpose Cadaveric study at our institution has demonstrated that optimal basaplate fixation of a reversed shoulder arthroplasty (RSA) could be achieved with screws in three major columns. Our aim was to review our early rate of aseptic glenoid loosening in a series of baseplate fixed according to this principle. Material and Methods Between 2005 and 2008, 48 RSA (Aequalis Reversed) were implanted in 48 patients with an average age of 74.4 years (range, 56 to 86 years). There were 37 women and 11 men. Twenty-seven primary RSAs were performed for cuff tear arthropathy, 3 after failed rotator cuff surgery, 6 for failed arthroplasties, 7 for acute fractures and 5 after failed ORIF. All baseplate fixation were done using a nonlocking posterior screw in the spine, a nonlocking anterior screw in the glenoid body, a locking superior screw in the coracoid and a locking inferior screw in the pillar. All patients were reviewed with standardized radiographs. The number of screws were reported. We measured the position of the screws in relation to the scapular spine and the coracoid process in two different views. We defined screw positions as totally, partially or out of the target. Finally we reported glenoid aseptic loosening which was defined as implant subsidence. Results Four patients were lost to follow-up. Thus, 44 shoulders could be reviewed after a mean follow-up of 13 months (range, 6 to 32 months). All baseplates were fixed with 4 screws. Thirty-seven (84%) screws were either partially or totally in the spine. Thus, 7 (16%) scapular spine screws were out of the target. No coracoid screw was out the target. Two (4.5%) patients had glenoid loosening. Both had a scapular spine and a coracoid screw partially in the bone. Conclusion Early aseptic glenoid loosening occurred before the two years follow-up and is most of time related to technical problems and/or insufficient bone stock and bone quality. Our study demonstrate that baseplate fixation according to the three columns principle is a reproducible technique and a valuable way to prevent early glenoid loosening.

Reversed shoulder arthroplasty baseplate fixed according to the three major columns principle

Introduction: Glenoid bone volume and bone quality can render the fixation of a reversed shoulder arthroplasty (RSA) basis plate hazardous. Cadaveric study at our institution has demonstrated that optimal baseplate fixation could be achieved with screws in three major columns. Our aim is to review our early rate of aseptic glenoid loosening in a series of baseplates fixed according to this principle. Methods: Between 2005 and 2008, 48 consecutive RSA (Reversed Aequalis) were implanted in 48 patients with an average age of 74.4 years (range, 56 to 86 years). There were 37 women and 11 men. Twenty-seven primary RSAs were performed for cuff tear arthropathy, 3 after failed rotator cuff surgery, 6 for failed arthroplasties, 7 for acute fractures and 5 after failed ORIF. All baseplate fixations were done using a nonlocking posterior screw in the scapular spine, a nonlocking anterior screw in the glenoid body, a locking superior screw in the coracoid and a locking inferior screw in the pillar. All patients were reviewed with standardized radiographs. We reported the positions of the screws in relation to the scapular spine and the coracoid process in two different views. We defined screw positions as totally, partially or out of the target. Finally, we reported aseptic glenoid loosening which was defined as implant subsidence. Results: Four patients were lost to follow-up. Thus 44 shoulders could be reviewed after a mean follow-up of 16 months (range, 9 to 32 months). Thirty-seven (84%) screws were either partially or totally in the spine. Thus, 7 (16%) scapular spine screws were out of the target. No coracoid screw was out of the target. At final follow-up control, we reported no glenoid loosening. Conclusion: Early glenoid loosening occurred before the two years follow-up and is most of time related to technical problems and/or insufficient glenoid bone stock and bone quality. Our study demonstrate that baseplate fixation of a RSA according to the three columns principle is a reproducible technique and a valuable way to prevent early glenoid loosening.

Anatomic shoulder arthroplasty: consequences of humeral head malposition

Purpose Third generation anatomic total shoulder prostheses offer a wide range of adaptability (size, thickness, retroversion and offset of the humeral head, cervico-diaphyseal angle) in order to reproduce anatomy and biomechanics of the shoulder as normal as possible. The large variability of the implants may also induce malposition. Our goal was to analyse the consequences of a humeral head malposition, which is one of the most frequent placement errors. Material and Methods A 3D finite element model of the glenohumeral joint, including the rotator cuff muscles and the deltoid, was used with the Aequalis anatomic prosthesis. Active abduction was simulated. Three humeral head placements were compared : anatomic positioning (A), 5 mm inferior positioning (B), 5 mm superior positioning (C). The effect of humeral head malposition was evaluated through the following quantities : the range of motion free of impingements, the glenohumeral contact pattern, and the stress within the polyethylene and the cement. Results Inferior positioning (B) of the humeral head produced a superior impingement before 90° of abduction, an inferior eccentric contact point on the glenoid, and 165% increase of cement stress. Superior positioning (C) of the humeral head produced a postero-superior eccentric contact point on the glenoid, 300% increase of glenohumeral contact pressure, 450% increase of polyethylene stress, and 207% increase of cement stress. Conclusion Malposition of the humeral head of anatomic prostheses induces biomechanical consequences that may preclude the glenoid survival. Particular attention must be paid to reproduce the humeral anatomy as normal as possible.

Scores de mesure fonctionnelle articulaire pour le praticien [Joint functional outcome score for the clinician].

The sports clinician faces multiple treatment options when dealing with overload injuries, and it is important to evaluate their outcomes. Multiple scores exist, some clincian rated (CRO), others patient rated (PRO), the latter being currently favoured. This review presents some of these scores and we selected the ones we feel are the most appropriate for a sports clinician. We considered these common problems: tennis elbow, rotator cuff issues, groin pain, patellofemoral pain syndrome, achilles tendinopathy and ankle instability. In addition, an activity level score is useful to weigh the result in the context of return to performance. These scores help to create a common language between therapists and to evaluate treatments objectively.

Simulated joint and muscle forces in reversed and anatomic shoulder prostheses.

Reversed shoulder prostheses are increasingly being used for the treatment of glenohumeral arthropathy associated with a deficient rotator cuff. These non-anatomical implants attempt to balance the joint forces by means of a semi-constrained articular surface and a medialised centre of rotation. A finite element model was used to compare a reversed prosthesis with an anatomical implant. Active abduction was simulated from 0 degrees to 150 degrees of elevation. With the anatomical prosthesis, the joint force almost reached the equivalence of body weight. The joint force was half this for the reversed prosthesis. The direction of force was much more vertically aligned for the reverse prosthesis, in the first 90 degrees of abduction. With the reversed prosthesis, abduction was possible without rotator cuff muscles and required 20% less deltoid force to achieve it. This force analysis confirms the potential mechanical advantage of reversed prostheses when rotator cuff muscles are deficient.