Objectives: Management of patients over 50 years old with a rotator cuff tear (RCT), remains complex and individually driven. We assessed long-term clinical and radiological outcomes under conservative treatment and searched for any feature that would better define medical strategy.Methods: A prospective multicentric cohort. Ten participating tertiary level centers. We included 127 patients, aged 50 to 75, with a symptomatic RCT confirmed by MRI and not warranting surgical repair on the short term, according to current practice recommendations. 104 of them (82% retention rate) were evaluated at 2-year follow-up visit. Among those 104 patients,78 agreed to participate in an extension phase until 5-year final follow-up and 75 of them were evaluated at this time-point.The principal objective was to determine clinical outcome 2 years following diagnosis, using Constant score. Secondary objectives were to evaluate clinical outcomes at 5-year follow-up and radiological outcomes, centrally assessed by MRI, at baseline, 2 and 5-year follow-up visits.Results: Among the 104 patients that remained in follow-up at 2 years, 8 had shoulder surgery and 8 reported a worsening clinical evolution at M24. Only 4 of the 78 enrolled in the extension phase had worsening of Constant score at 5-year follow-up visit. MRI evaluation was carried out in 94 patients at 2-year and 70 at 5-year follow-up. Among them, 70 % at 2-year and 60% at 5-year follow-up evaluation had no radiological worsening of their RCT, compared to baseline. We also observed a significant degradation of muscle status, including atrophy or fatty infiltration, in 54.3% of patients at 2-year and 71.4% at 5-year follow-up. No correlation was found between Constant score and this structural muscle evolution.Conclusion: Patients with RCT had a favorable clinical outcome under conservative treatment, while a majority of RCT remained stable in those who remained in a 5-year follow-up. However, progression of fatty muscle infiltration seems an inexorable process, independent of clinical evolution.Trial registration. NCT02510352

Background The effectiveness of platelet-rich plasma (PRP) injections in chronic tendinopathies remains debated. Although the product's characteristics play a role, the impact of postinjection recommendations remains poorly investigated.Objective To establish principles and guidelines for post-PRP injection rehabilitation and return to activity/sports.Design We conducted a Delphi survey based on a "recommendations by formal consensus" methodology. Three clinicians and researchers of the GRIIP (International Research Group on Platelet Injections), experts in sports medicine and rehabilitation, performed a comprehensive literature review of MEDLINE, searching for (1) rehabilitation protocols after PRP injection for chronic tendinopathy and (2) fundamental studies of tendon healing. This review highlighted the main points to be clarified to establish a standardized post-PRP injection protocol. Fourteen points were identified, grouped into three dimensions (immediate postprocedure, rehabilitation, and follow-up and resumption of sports/activity). With a modified Delphi method, the propositions were submitted to a panel of 23 experts from five French-speaking countries. The recommendations were classified as appropriate or not appropriate, with strong or relative agreement, or uncertain when consensus was not reached.Results Ten recommendations (postprocedure avoidance of nonsteroidal anti-inflammatory drugs, rehabilitation principles and timeline, follow-up) were classified as appropriate: six with strong and four with relative agreement; four propositions regarding immediate postprocedure were deemed uncertain.Conclusion Agreement was reached for 10 of the 14 recommendations but with low level of evidence, mainly based on experts' opinion. This work should help standardize a post-PRP injection protocol for chronic tendinopathies, which will minimize bias due to variations in rehabilitation protocols in further studies.

Intra-articular injections of platelet-rich plasma (PRP) are increasingly utilized in the management of knee osteoarthritis (KOA) and various other medical specialties. However, the efficacy of PRP remains a contentious issue; some experts consider it to be a placebo, while others advocate for its therapeutic value. Evidence from controlled clinical trials and meta-analyses has often yielded contradictory results, frequently failing to demonstrate a clear clinical benefit despite favorable outcomes observed in real-world settings. Several factors may contribute to these inconsistencies, with the lack of standardization in PRP preparation and the heterogeneity of KOA phenotypes being the most significant. Phenotyping is more effectively accomplished in specialized clinical environments, which may elucidate the improved outcomes associated with better patient selection. After delineating the specific characteristics of PRP injections and the primary sources of variability, we emphasize the necessity for comprehensive characterization of the injected product and accurate phenotyping of KOA. Additionally, we examine the methodological biases that impede the interpretation of clinical results and propose a treat-to-target approach as a more suitable evaluation strategy. These methodological challenges should not undermine the potential of regenerative medicine, which offers considerable promise. Compared to conventional therapies, regenerative medicine is generally more compatible with human physiology, better tolerated, and potentially less expensive. However, the advancement of this field necessitates strict scientific rigor and objectivity. This involves a meticulous recognition of biases and methodological limitations, as well as a deeper understanding of the underlying mechanisms of action, to refine and optimize therapeutic protocols.

L’arthrose est une affection chronique dégénérative du cartilage des articulations. L’évolution de cette affection se caractérise principalement par les symptômes suivants : douleur, craquement et raideur entraînant une limitation de l’activité physique. En France, la population de patients atteints de gonarthrose de plus de 40 ans représenterait pour l’année 2017 près de 2,5 millions de personnes [1]. Il n’existe pas de traitement curatif ciblant la maladie arthrosique. La prise en charge est donc symptomatique, antalgique, fonctionnelle et pour améliorer la qualité de vie. Toutes les recommandations thérapeutiques internationales et françaises proposent la combinaison de traitements non-pharmacologiques (activités physique, perte de poids, …) et de traitements pharmacologiques, à utiliser selon le phénotype et la douleur. Un essai clinique récent randomisé, contrôlé [2] d’un nouveau TENS miniaturisé, porté sur la cuisse et connecté à un smartphone (« Wearable TENS », W-TENS) versus opioïdes faibles a montré une efficacité significativement supérieure sur la douleur et la gêne fonctionnelle et une bien meilleure tolérance. Une enquête en ligne (10–28 août 2023) a été envoyée par l’intermédiaire de l’application smartphone à 759 patients atteints de gonarthrose douloureuse, suivies par des médecins rhumatologues et utilisant le système W-TENS. L’évaluation de l’amélioration globale de la douleur, de la qualité de vie, de la limitation d’activité au quotidien, de l’impact psychologique et de la consommation de médicaments du patient a été mesurée par une échelle PGIC à 7 points. 82 patients ont répondu à cette enquête en ligne. 39 % des patients utilisaient le W-TENS depuis plus de 3 mois, 29 % entre 1 et 3 mois, et 32 % moins d’un mois. La zone de stimulation est équitablement répartie entre le genou droit et le genou gauche. 74 % des patients effectuent des séances de stimulation dont la durée se situe entre 30 minutes et 2 heures, les autres l’utilisant moins de 30 minutes. La fréquence des séances est plus variée : 45 %, 28 % et 11 % des patients se stimulent respectivement une, deux et trois fois par jour. 11 % se stimulent à chaque épisode douloureux. Les patients qui utilisent le W-TENS perçoivent une amélioration de leurs douleurs (69 %), de leur qualité de vie (67 %), de leur fonction (64 %) et de l’impact psychologique (52 %). L’utilisation du traitement a également un impact sur la consommation des médicaments, 49 % des patients rapportent une diminution de leur prise médicamenteuse. Notre enquête sur l’effet d’un TENS porté sur la personne et connecté, chez des patients gonarthrosiques semble indiquer une amélioration symptomatique, sur la douleur, la qualité de vie, la fonction, l’impact psychologique et la consommation de médicaments. Il paraît donc pertinent d’entreprendre une étude de plus grande ampleur pour confirmer ces résultats préliminaires encourageants et mieux appréhender les facteurs de succès de cette thérapie.

Introduction: Despite their poor tolerance, especially in the elderly, weak opioids (WO) remain commonly prescribed for patients with knee osteoarthritis (KOA). We compared the efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) device with WO for the treatment of moderate-to-severe, nociceptive KOA chronic pain. Methods: The study was a non-inferiority, multicentric, prospective, randomized, single-blind, controlled, 2-parallel groups Trial. A total of 110 patients with KOA were included (Kellgren-Lawrence radiographic grade ⩾2; American College of Rheumatology criteria), with chronic moderate-to-severe nociceptive pain (mean 8-day pain intensity (PI) ⩾ 4 on an 11-point numerical rating scale), in failure to non-opioid analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs). Patients with neuropathic pain were excluded. The co-primary endpoints were mean PI at 3 months (M3) and number of potentially treatment-related adverse events (TRAEs). Secondary outcomes included Western Ontario MAC Master University function subscale (range, 0–68), additional pain and quality of life measures, and responder rates. Results: The non-inferiority of W-TENS was demonstrated in both the per protocol (PP) and intent-to-treat (ITT) populations. At M3, PI in PP population was 3.87 (2.12) compared with 4.66 (2.37) [delta: −0.79 (0.44); 95% CI (−1.65, 0.08)] in W-TENS and WO groups, respectively. A planned superiority analysis showed a significant superiority of W-TENS over WO on PI at M3 (p = 0.0124). The number of TRAEs was significantly lower in the W-TENS group (n = 7) than in the WO group (n = 36) (p < 0.001). Other secondary outcomes also favored W-TENS. Conclusion: W-TENS was more effective and better tolerated than WO in the treatment of chronic nociceptive KOA pain and offers an interesting non-pharmacological analgesic alternative in the management of KOA. Trial Registration: ClinicalTrials.gov: NCT03902340

Le traitement antalgique médicamenteux recommandé en première intention dans la gonarthrose est le paracétamol. Du fait de son efficacité limitée, il est fréquemment remplacé par les opioïdes faibles (OF) malgré leur mauvaise tolérance, particulièrement chez les patients âgés. L’objectif de cette étude était de comparer l’efficacité antalgique et la tolérance d’un nouveau dispositif TENS de dernière génération, miniaturisé, flexible et connecté au smartphone (C-TENS) à celles des OF dans la prise en charge de la douleur chronique, modérée à sévère, chez des patients souffrant de gonarthrose. Étude de phase 3, en non-infériorité, multicentrique, prospective, randomisée, en simple aveugle sur le critère principal d’efficacité, contrôlée sur 3 mois, en deux groupes parallèles et comparant C-TENS aux OF. Critères principaux d’évaluation : intensité moyenne de la douleur à M3 (échelle numérique de 0 à 10) et nombre d’EI potentiellement liés aux traitements et évalués sur 3 mois de suivi (per protocole [PP] et intention de traiter [ITT]). Dans le groupe C-TENS, les patients positionnaient les électrodes selon un protocole standardisé. Dans le groupe OF, les investigateurs pouvaient choisir le traitement, l’adapter et/ou le remplacer si besoin. La limite de non-infériorité retenue a été 0,825 (limite en valeur absolue de la différence entre deux traitements actifs dans la douleur) et en deçà d’une différence cliniquement significative. Cent dix patients (55 par groupe) ont été randomisés : 48/55 (C-TENS) (87,3 %) et 44/55 (OF) (80,0 %) ont été suivis 3 mois. La non-infériorité du C-TENS a été démontrée en ITT et PP. À M3, intensité de la douleur (PP population) était de 3,87 (2,12) (C-TENS) comparée à 4,66 (2,37) (OF) (différence : −0,79 [0,44]). Une analyse de supériorité en ITT, prévue au protocole, a mis en évidence une meilleure efficacité de C-TENS (p = 0,0124). Le nombre d’EI potentiellement imputables aux traitements a été inférieur dans le groupe C-TENS (n = 7 vs n = 36, p < 0,001). À M3, le groupe C-TENS a atteint la réduction minimale cliniquement importante d’intensité de la douleur de 2,0 points avec −2,1 (2,3) alors que dans le groupe OF la réduction n’était que de −1,1 (2,1) ; différences inter-groupes significatives : 1,3 [0,6–2,0] p = 0,0007 (M1) et 0,9 [0,2–1,7], p = 0,0247 (M3). Dans le groupe OF, les EI ont été systémiques, correspondant à ceux rapportés avec les opioïdes alors que dans le groupe C-TENS ils étaient locaux (réactions cutanées de type érythème). C-TENS s’est montré plus efficace et mieux toléré que les OF pour traiter la douleur chronique de la gonarthrose. Ce nouveau dispositif TENS pourrait constituer une alternative non-pharmacologique intéressante aux traitements pharmacologiques de la douleur de gonarthrose.

Purpose: Knee osteoarthritis (KOA) is a frequent disease for which therapeutic possibilities are limited. In current recommendations, the first-line analgesic is acetaminophen. However, low efficacy of acetaminophen, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. The primary objective of this study was to evaluate analgesic efficacy and safety of wearable transcutaneous electrical nerve stimulation (W-TENS) compared to WO in the treatment of moderate to severe, nociceptive, chronic pain in KOA patients. Methods: This was a phase 3, non-inferiority multicentric, prospective, randomized, single-blinded for primary efficacy outcome, controlled, in 2-parallel groups, clinical study comparing W-TENS versus WO on two periods: a 3-month controlled period and an additional, optional, non-controlled, 3-month follow-up for patients in the W-TENS group. Eligible participants were KOA patients, ≥55 years old, with a Kellgren-Lawrence radiographic grade ≥2, with moderate to severe nociceptive chronic (≥3 months) pain ≥4 on a 11-point numerical rating scale (0-10 NRS), and in treatment failure with non-opioid analgesics (acetaminophen and/or NSAIDs). Patients with neuropathic pain (DN4: global score ≥4 and/or a positive response to a specific question on clinical examination) were excluded. Co-primary endpoints were, for efficacy, mean pain intensity (PI), during the previous 8 days before assessment at M3 and, for safety, the number of adverse events (AE) during the 3-month follow-up period. Secondary endpoints were: function assessed using the physical function subscale of the WOMAC at D0, M1, and M3, PI assessed at D0, M1 and M3, numbers of patients achieving a ≥30% and/or a ≥50% decrease of PI at M1 and M3 and, in the W-TENS group, number of patients asking for a 3-month treatment extension. The study was open-labelled except for the co-primary efficacy endpoint assessment which was collected by phone, before each visit by a blinded observer. Patients were assessed at baseline, 1 and 3 months and in the W-TENS group at 6 months (end of the non-controlled period). In the W-TENS group, an advanced, mobile app enabled, wearable TENS was used (actiTENS®, SUBLIMED SAS, Moirans, France). Electrodes were positioned as presented in the Figure 1. A high and low frequency stimulations were delivered as followed:-100 Hz conventional TENS, i.e. gate control mode, on channel 1 connected to two 50x50mm square electrodes positioned on the path of the infrapatellar nerve, branch of the saphenous nerve and innervating the joint.-2 Hz low frequency TENS, i.e. endomorphinic mode, on channel 2 connected to two 50x90mm rectangular electrodes positioned on the quadriceps. In the WO group, investigators were pragmatically authorized to choose, for each patient, the best suitable drug and its daily dose and to switch to another WO and/or adapt its daily dose when necessary. The five authorized WO were: immediate release (IR) or slow release (SR) tramadol, dihydrocodeine and fixed acetaminophen-codeine, acetaminophen-tramadol and acetaminophen-opium-powder combinations.A non-inferiority analysis was performed on primary efficacy endpoint using a pre-defined non-inferiority margin (0.825 point) on PI NRS, below the minimal clinically significant improvement. Results: Demographic and baseline characteristics were balanced across both groups. At D0, 110 patients (55/group) were randomized (intent-to-treat, ITT, population) and 99 patients (52 in W-TENS and 47 in WO groups) included in the per protocol (PP) population. 48/55 (87.3%) and 44/55 (80.0%) patients completed the 3-month follow-up in W-TENS and WO groups respectively. The numbers of prescriptions of IR WO were balanced with 25.4% for codeine, 30.1% for opium-powder with or without caffeine and 22.2% for tramadol with or without acetaminophen. SR tramadol accounted for 17.5% of prescriptions. Non-inferiority of the W-TENS was demonstrated in the PP and ITT populations (Table 1).Table 1Non-inferiority analyses on PI at M3. ITT and PP populations. Since the 95% CI of the between-treatments difference did not included the 0 value in the ITT population, a superiority analysis was performed in this population, demonstrating that W-TENS was significantly superior to WO at M3 (p=0.0124) on PI. The number of AEs was significantly lower (p<0.001) in the W-TENS (n=7) than in the WO (n=36) groups. Results for secondary endpoints are summarized in Tables 2 and 3.Table 2Other efficacy parameters at M1. ITT population.Table 3Other efficacy parameters at M3. ITT population.Table 3Other efficacy parameters at M3. ITT population. Thirty-nine (70.9%) patients wished to extend the W-TENS treatment for 3 additional months and only one patient discontinued the study during the M3 to M6 period. For these patients, results obtained at M3 remained stable at M6 (data not shown).In WO group, AEs were those typically reported with opioids: dry mouth, constipation, nausea, vomiting, dizziness, drowsiness and pruritus while those in the W-TENS group were local, related to the technique used such as local cutaneous reaction (erythema). Conclusions: These results indicate that W-TENS treatment is more effective and better tolerated than WO in the management of nociceptive KOA chronic pain and could represent an interesting alternative option to weak opioids.

Background: In knee osteoarthritis (KOA) recommendations, the first pharmacological analgesic line is paracetamol. However, its low efficacy, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. Objectives: The primary objective was to compare analgesic efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) to those of WO in the treatment of moderate to severe, nociceptive, chronic pain in KOA patients. Methods: ArthroTENS study was a phase 3, non-inferiority, multicentric, prospective, randomized, single-blinded for primary efficacy outcome, controlled, in 2-parallel groups, clinical study comparing W-TENS versus WO on two periods: a 3-month controlled period and an additional, optional, non-controlled, 3-month follow-up for patients in W-TENS group. Eligible participants were KOA patients, ≥55 years old, at Kellgren-Lawrence radiographic grade ≥2, with moderate to severe nociceptive chronic (≥3 months) mean 8-day pain ≥4 on a 11-point numerical rating scale, and in treatment failure with non-opioid analgesics, including NSAIDs. Patients with neuropathic pain were excluded. Co-primary endpoints were, for efficacy, mean pain intensity (PI), assessed at M3 and, for safety, the number of adverse events (AE) during the 3-month follow-up period. In W-TENS group, an advanced, mobile app enabled, wearable TENS was used. High (100 Hz) and low (2 Hz) frequency stimulations were delivered via electrodes with standardized positioning (Figure 1). Figure 1. Electrode’s positioning In WO group, investigators chose, for each patient, the best suitable WO and its daily dose, and could switch to another WO, and/or adapt its daily dose if necessary. A non-inferiority analysis was performed on the primary efficacy endpoint using a pre-defined non-inferiority margin (0.825 point) on PI, below the minimal clinically significant improvement. Results: Demographic and baseline characteristics were balanced across both groups. 110 patients (55/group) were randomized and 48/55 (87.3%) and 44/55 (80.0%) patients completed the 3-month follow-up in W-TENS and WO groups, respectively. WO’s prescriptions were balanced between codeine, opium-powder, tramadol and WO-paracetamol combinations. Non-inferiority of W-TENS was demonstrated in the PP and ITT populations (Table 1). Since the 95% confidence interval (CI) of the between-treatments difference was below 0 in the ITT population, a planned superiority analysis was performed showing that W-TENS was significantly superior to WO at M3 (p=0.0124) on PI. Additionally, the number of AEs was significantly lower (p<0.001) in W-TENS (n=7) group than in WO (n=36) group. In WO group, AEs were systemic AEs usually reported with WO while AEs in W-TENS group were local, related to the technique used, such as local cutaneous reaction (erythema). Table 1. Non-inferiority analyses on pain intensity at M3. ITT and PP populations. Least squares means for each study group and study group difference estimate and corresponding 95% CI Group Population Within-group change Between-group difference W-TENS WO W-TENS - WO ITT Population (n) 55 55 Non inferiority Mean (SD) 3.83 (0.28) <0.001 4.74 (0.28) <0.001 -0.92 (0.40) Non inferiority‡ demonstrated 95% CI [3.27, 4.40] [4.18, 5.30] [-1.71, -0.12] PP Population (n) 52 47 Mean (SD) 3.87 (0.30) <0.001 4.66 (0.32) <0.001 -0.79 (0.44) Non inferiority‡ demonstrated 95% CI [3.28, 4.46] [4.03, 5.28] [-1.65, 0.08] ‡ Noninferiority was demonstrated when 95% CI < 0.825 Thirty-nine (70.9%) patients wished to extend W-TENS treatment for 3 additional months. Only one patient discontinued this additional period and results obtained at M3 remained stable at M6. Conclusion: In this study, W-TENS was more effective and better tolerated than WO in the treatment of nociceptive KOA chronic pain and should represent an interesting non-pharmacological alternative to WO. Acknowledgements: We gratefully thank P. Fardellone (Amiens), E. Coudeyre (Clermont-Ferrand), Y. Donazzolo (Gieres), A. Amouzougan (Saint-Etienne), L. Grange (Grenoble), T. Conrozier (Belfort), E. Senbel (Marseille), J.P. Sanchez (Billere), R. Forestier (Aix-les-Bains), H. Bard (Paris) and E. Gibert (Ivry-sur-Seine) for their active contribution throughout arthroTENS study Disclosure of Interests: Emmanuel Maheu Speakers bureau: TRB chemedica, Consultant of: SUBLIMED, Moirans, FRANCE; Sandrine Soriot-Thomas Speakers bureau: Grunenthal, Consultant of: SUBLIMED, Moirans, FRANCE; Grunenthal Kyowa Kirin pharma, Grant/research support from: Grunenthal Sanofi Teva Mylan Therable, Eric Noel Consultant of: SUBLIMED, Moirans, FRANCE; Eric Lespessailles Consultant of: SUBLIMED, Moirans, FRANCE; Bernard Cortet Consultant of: SUBLIMED, Moirans, FRANCE;

The article Intra‑articular injections of platelet‑rich plasma in symptomatic knee osteoarthritis: a consensus statement from French‑speaking experts, written by Florent Eymard, Paul Ornetti, Jérémy Maillet, Éric Noel, Philippe Adam, Virginie Legre-Boyer, Thierry Boyer, Fadoua Allali, Vincent Gremeaux, Jean-Francois Kaux, Karine Louati, Martin Lamontagne, Fabrice Michel, Pascal Richette, Hervé Bard on behalf of the GRIP (Groupe de Recherche sur les Injections de PRP, PRP Injection Research Group), was originally published electronically on the publisher’s internet portal on 24 June 2020 without open access.

La pratique du sport peut être source de douleurs de l’épaule, les pathologies rencontrées variant en fonction du type de sport, du niveau et de l’intensité de la pratique, de l’âge du sportif et du contexte traumatique ou non. Dans un contexte traumatique, chez un sportif âgé de moins de 35 ans, les lésions de la coiffe sont moins fréquentes que les fractures, les accidents d’instabilité, les lésions acromio-claviculaires, ou les lésions neurologiques (sports mécaniques). Chez le sujet plus âgé, les lésions de la coiffe sont les plus fréquentes. Dans un contexte micro-traumatique, les pathologies rencontrées (coiffe des rotateurs, syndromes canalaires) sont liées aux gestes répétitifs dans les sports d’armé et de lancer (Tennis, Hand Ball, Volley Ball, javelot voire Base-Ball) ou à des erreurs techniques. C’est dans ce contexte que l’on rencontrera des lésions de la coiffe des rotateurs y compris chez des sportifs jeunes. Leurs fréquences augmentent avec l’intensité et l’ancienneté de la pratique. The practice of sport can be a source of shoulder pain, the pathologies encountered varying according to the type of sport, the level and intensity of the practice, the age of the athlete and the traumatic context or not. In a traumatic context, in an athlete under 35 year old, rotator cuff injuries are less common than fractures, instability, acromioclavicular lesions, or neurological lesions (motor sports). In the older patient, lesions of the rotator cuff are the most frequent. In a micro-traumatic context, the pathologies encountered (rotator cuff, canal syndromes) are linked to repetitive gestures in armed and throwing sports (Tennis, Handball, Volley Ball, Javelin or even Baseball) or to technical errors. It is in this context that we will encounter rotator cuff lesions, even in young athletes. Their frequencies increase with intensity and the number of year of practice.

Purpose: To report the early outcomes of endoscopic repair of tears of the gluteus medius tendon and to determine whether the fatty degeneration had an influence on clinical results. Methods: Between October 2012 and June 2014, data were prospectively collected and retrospectively reviewed for all patients who underwent endoscopic gluteus medius repair. Patients were assessed pre- and postoperatively using the modified Harris hip score, the nonarthritic hip score, and visual analog scale for pain. The gluteus minimus and the 3 distinct parts of the gluteus medius (anterior, middle, and posterior) were assigned a grade of fatty degeneration on preoperative magnetic resonance imaging scans. Results: Twenty-two hips (in 20 patients) were assessed with the mean follow-up of 31.7 months (range: 24 to 47 months). There were 15 partial-thickness and 7 full-thickness tears. No patient was lost to follow-up. The mean age at the time of surgery was 66 years (range: 45 to 82 years). Of the 20 magnetic resonance imaging-assessed hips included in the study, 14 had fatty degeneration of the gluteus medius (partial-thickness tears: n = 8, full-thickness tears: n = 6). The mean gluteus medius fatty degeneration index was 1.57 (range: 0.33 to 3.33). Postoperative improvement was seen in modified Harris hip score (33.7 points vs 80.2 points, P = .0001), nonarthritic hip score (47.7 points vs 76.8 points, P = .0001), and in the visual analog scale for pain (7.2 vs 3.2, P < .05). Increasing preoperative fatty degeneration index of the gluteus medius correlated with decreased postoperative functional hip score values (regression coefficient, 0.5839; P < .0001). Tear characteristics (partial or full-thickness) did not correlate with fatty degeneration or muscular atrophy and did not affect postoperative outcomes. Conclusions: Endoscopic surgical repair can be an effective treatment of gluteus medius tears in the short term. Fatty degeneration of the gluteus medius and minimus has a negative impact on clinical outcomes of endoscopic gluteus medius repair.

I dolori alla spalla costituiscono il secondo motivo di visita in reumatologia. La diagnosi deve essere basata su un iter ben codificato che associa: un interrogatorio minuzioso, che analizzerà particolarmente le caratteristiche del dolore, ma che preciserà anche il contesto della sua comparsa, un esame clinico standardizzato, che ricercherà una rigidità e valuterà i tendini della cuffia dei rotatori, un bilancio radiografico standard con immagini di fronte e un profilo della cuffia, come minimo, e un esame ecografico eseguito da un medico esperto. La patologia della cuffia dei rotatori è in prima linea tra le cause di dolore alla spalla e riunisce le calcificazioni, le tendinopatie e le rotture parziali o a tutto spessore. La rigidità della spalla, anch’essa molto frequente e facilmente evidenziata dall’esame clinico, è identificata solo se viene ricercata in un esame standardizzato. Le sue cause sono molteplici e la sua gestione deve essere specifica e adeguata; in caso contrario, il peggioramento clinico è la regola. Altri esami complementari possono essere realizzati in seconda intenzione (artro-TC, risonanza magnetica [RM] o artro-RM) e sono particolarmente indicati in caso di fallimento del trattamento medico oppure di dubbio diagnostico. Possono essere realizzati a titolo medicolegale (contesto di infortunio sul lavoro o di malattia professionale) o preoperatorio. Essi devono essere realizzati da medici esperti e permettono di precisare lo stato della cuffia miotendinea e dell’articolazione gleno-omerale. La gestione terapeutica è, di norma, medica, in prima intenzione, salvo casi particolari. L’insuccesso del trattamento medico porta a discutere la chirurgia, le cui indicazioni sono ben codificate. La qualità dei risultati è stata notevolmente migliorata dai progressi compiuti nella diagnosi, dallo sviluppo dell’artroscopia e della chirurgia protesica e dall’ottimizzazione della rieducazione postoperatoria.

Les auteurs passent en revue les principaux éléments de l’histoire et l’examen physique et décrivent les manœuvres qui peuvent être utilisés pour parvenir à un diagnostic approprié. L’examen de l’épaule doit comprendre l’inspection, la palpation, l’évaluation de l’amplitude des mouvements et des tests de provocation.

Tears in the gluteus medius and minimus tendons have been recognized as an important cause of recalcitrant greater trochanteric pain syndrome. Because of the frequency of partial-thickness undersurface tears, this relatively unknown pathology is often misdiagnosed and left untreated. Surgery is indicated in case of 4 associated conditions: (i) Failure of conservative treatment with duration of symptoms > 6 months; (ii) magnetic resonance imaging showing a tendon tear; (iii) positive ultrasound-guided infiltration test; and (iv) the absence of an evolved fatty degeneration or atrophy of the gluteus medius and minimus muscle. Endoscopic repair of partial or full-thickness tears, with systematic resection of the bony structures implicated in the impingement, and a complete bursectomy appear to give satisfactory results, although these results remain to be confirmed by clinical studies with longer follow-up. The degree of tendon degeneration may compromise the tissue left for reattachment, raising concerns over its healing capacity, durability, and ultimate strength of the repair.

In some patients, resection of the fragment of an os acromiale or overzealous acromioplasty of the meso-acromion can result in a situation equivalent to an acromionectomy. This procedure, proposed in the past for rotator cuff disease treatment, has negative consequences on shoulder function, which have been described by Neer and Marberry. 4 Bosley R.C. Total acromionectomy: a twenty-year review. J Bone Joint Surg Am. 1991; 73: 961-968 PubMed Google Scholar , 7 Hammond G. Complete acromionectomy in the treatment of chronic tendinitis of the shoulder. J Bone Joint Surg Am. 1971; 53: 173-180 PubMed Google Scholar , 8 Harris J.D. Griesser M.J. Jones G.L. Systematic review of the surgical treatment for symptomatic os acromiale. Int J Shoulder Surg. 2011; 5: 9-16https://doi.org/10.4103/0973-6042.80461 Crossref PubMed Scopus (31) Google Scholar , 14 Neer II, C.S. Marberry T.A. On the disadvantages of radical acromionectomy. J Bone Joint Surg Am. 1981; 63: 416-419 PubMed Google Scholar , 17 Rockwood Jr., C.A. Total acromionectomy. A twenty-year review. J Bone Joint Surg Am. 1992; 74: 792-793 PubMed Google Scholar The clinical consequences (pain and loss of strength and function) are related to the insufficiency of the anterior and lateral portions of the deltoid.

Les ruptures du tendon moyen fessier représentent une cause sous diagnostiquée de tendino-bursite trochantérienne rebelle au traitement médical. Les résultats cliniques après réparation endoscopique de ces lésions ont rarement été rapportés. Le but de cette étude était de rapporter les résultats précoces des ruptures partielles ou transfixiantes du moyen fessier réparé par une technique endoscopique. Entre septembre 2011 et décembre 2013, les données concernant les patients opérés par une technique endoscopique d'une rupture partielle ou transfixiante du tendon du moyen fessier ont été collectée de façon prospective. Les critères d'inclusion comprenaient les ruptures partielles de haut grade ou transfixiante des tendons du moyen et du petit fessier en échec du traitement médical bien conduit depuis plus de 6 mois. Une technique simple ou double rang de réparation et par abord trans-tendineux en cas de rupture partielle de la face profonde a été utilisé. Les patients ont tous étés revus cliniquement et avec une échographie ou une IRM de contrôle et les scores fonctionnels de hanche ont été complétés (scores modifié de Harris et Non arthritic hip score) à 3 mois, 6 mois, 1 an et au dernier recul. Treize hanches (12 patients) au total remplissaient les critères d'inclusion. Il s'agissait de neuf femmes et de trois hommes d'âge moyen 68 ans (l'extrême : 59–82). Lors de l'exploration endoscopiques, il existait trois cas de rupture transfixiante et 10 cas de rupture partielles. Une patiente a présenté une rupture itérative suite d'une chute ayant nécessité une reprise chirurgicale a été considéré comme un échec. À 14 mois de recul moyen (extrêmes : 6–28 mois), les patients ont rapporté une amélioration des scores fonctionnels de hanche, avec une amélioration moyenne de plus de 20 points sur les deux scores utilisés. Six patients présentaient cependant des douleurs résiduelles de la région péri-trochantérienne au dernier recul en rapport avec une bursite persistante. Les réparations endoscopiques des ruptures partielles ou transfixiantes des tendons des fessiers semblent donner des résultats encourageants, comparables aux séries à ciel ouvert. Des études avec un plus grand effectif et un recul supérieur sont nécessaires pour confirmer cette impression.

Les lésions non transfixiantes du moyen et du petit glutéal ont été récemment reconnues comme une source de douleurs trochantériennes chroniques résistantes au traitement médical. Le but de cet article était de détailler une technique endoscopique originale permettant de reconnaître et réparer ces lésions. Nous utilisons un arthroscope standard à 30°, patient positionné en décubitus latéral sans aide d’un amplificateur de brillance. En cas de lésion partielle de la face profonde du tendon, la palpation minutieuse au crochet suivie d’une exploration de la bourse permet de détecter le tendon pathologique. Un abord transtendineux permet ensuite de réaliser le débridement de la lésion, de réséquer de façon systématique les structures osseuses responsables du conflit et de réaliser une suture bord-à-bord du tendon.