Jusqu’à l’utilisation de l’arthroscopie dans la chirurgie de la coiffe des rotateurs, la fréquence des lésions du subscapulaire est restée longtemps sous-estimée. Par ailleurs, leur traitement même sous contrôle arthroscopique reste difficile. L’absence de classification réellement spécifique des lésions du subscapulaire a rendu difficile la communication en matière de traitement et de pronostic pour les différents types de rupture du sous-scapulaire. Le but de cette étude prospective multicentrique était de valider la pertinence du traitement arthroscopique des lésions du subscapulaire en analysant les résultats à court terme, en fonction de l’importance initiale des lésions anatomiques. Il s’agit d’une étude prospective multicentrique menée sous l’égide de la Société française d’arthroscopie de mars 2010 à janvier 2011. Deux cent-huit cas de lésions isolées du subscapulaire où associées à une d’atteinte antéro-supérieure limitée. Une évaluation des résultats cliniques (Score de Constant et University of California Los Angeles rating scale [UCLA]), anatomiques et du pronostic tenant compte de l’examen clinique, de l’imagerie pré- et postopératoire et des lésions anatomiques mises en évidence a été possible pour les données cliniques, sur un groupe de 103 patients ayant un recul d’un an et pour les données radiologiques, sur un groupe de 129 patients ayant au moins six mois de recul. Les résultats cliniques préliminaires portent sur 103 patients revus au recul minimal d’un an. Il existait une amélioration globale, statistiquement significative des scores de Constant et UCLA, avec dans ces cas une disparition des signes cliniques. Cette amélioration semblait augmenter avec le recul. Après, classification en quatre groupes lésionnels des patients, en fonction des lésions anatomiques observées, il existait également une différence significative des résultats cliniques entre les différents types lésionnels. Les résultats anatomiques, appréciés par une imagerie postopératoire chez tous les patients ayant au moins six mois de recul (n = 129) comportaient 92 % de cicatrisation tendineuse, mais associée dans 18,6 % à une amyotrophie de la partie supérieur du subscapulaire et une majoration de l’infiltration graisseuse du corps musculaire. Notre étude confirme les bons résultats cliniques et radiologiques déjà publiés dans la littérature. L’utilisation d’une classification des lésions en quatre groupes a montré qu’elle était utilisable dès le bilan d’imagerie. Cette classification permettait surtout de différencier les résultats entre les types II et III. La tendance à l’amélioration des résultats avec le recul doit être confirmée par une évaluation à plus long terme, de même que l’absence de caractère péjoratif de l’aggravation de l’amyotrophie supérieure du subscapulaire et de l’infiltration graisseuse. 3.

Hypothesis: Clinically, subscapularis tendon tears are suggested by the presence of increased passive external rotation compared to the opposite side, resisted internal rotation manoeuvres (Lift-Off test [LOT], Belly-Press test [BPT], Napoleon test and Bear-Hug test [BHT] and positive Internal Rotation Lag Sign and/or Belly-Off Signs). Associated bicipital involvement is frequent with subscapularis tendon tears, because it participates in the formation of the biceps pulley. The Palm-Up test (PUT) is used for the biceps, and the Jobe test for the supraspinatus.Material and methods: In this multicenter study, we evaluated the positive diagnostic value of the clinical tests, LOT, BPT, BHT, PUT, and the Jobe test for subscapularis tears as well astheir anatomical value. The relationships of the different parameters studied were compared statistically by analysis of variance (ANOVA). This prospective multicenter study was performed from January 2009 to February 2010 and included 208 cases of subscapularis tendon tears, isolated or associated with partial (Ellman 1, 2 or 3) or full thickness (SFA stage 1) supraspinatus tears.Results: The severity of the subscapularis tear was quantified according to the SFA classification into four stages and according to the level of injury (the lower 1/3 and upper 2/3). The three tests LOT, BPT and BHT were correlated to the severity of observed tears (P < 0.05). The more deficient the test results were, the more severe the anatomical damage. The LOT is the test that cannot be performed most often (18%) but when it is positive, it is predictive of very severe tears. The BHT is the most sensitive of all tests (82%). The frequency of biceps involvement was correlated to the severity of subscapularis damage. There was no significant correlation between biceps involvement and subscapularis tests, or between supraspinatus involvement and subscapularis tests. There was no correlation between the Palm-Up test and subscapularis tears with associated supraspinatus involvement however, it was significantly correlated to biceps involvement (P < 0.05). The Jobe test was disappointing because it was often positive even for isolated subscapularis tears.Conclusion: Even though all three tests were performed (LOT, BPT, BHT), 24% of the subscapularis tears were only diagnosed during surgery. The role of the Internal Rotation Lag Sign and Belly-Off Sign in improving the diagnosis of tears was not studied in this work. Level of evidence: II. (C) 2012 Elsevier Masson SAS. All rights reserved.

Background: The absence of a coherent classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tendon lesions. In addition, a reliable classification system allows comparisons of epidemiological and therapeutic data. The classification systems used until now fail to incorporate the radiological and intraoperative abnormalities of the bicipital sling, and they do not consider the degree of subscapularis tendon cleavage. Here, we describe a new arthroscopy-based classification system intended for therapeutic and prognostic purposes.Methods: A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 150 isolated subscapularis lesions with or without limited anterosuperior involvement. The bicipital sling and insertion of the deep subscapularis layer were routinely investigated by arthroscopy with video recording. Each lesion was classified after a consensus was reached among four surgeons.Results: We identified four lesion types based on the bicipital sling findings. Type I was defined as partial separation of the subscapularis tendon fibres from the lesser tuberosity with a normal bicipital sling. Type II consisted of a partial subscapularis tear at the lesser tuberosity attachment combined with partial injury to the anterior wall of the bicipital sling, without injury to the superior glenohumeral ligament. Type III was complete separation of the subscapularis fibres from the lesser tuberosity with extensive cleavage of the bicipital sling. Finally, in Type IV, all the subscapularis fibres were detached and, in some cases, conjunction of the subscapularis and supraspinatus fibres produced the comma sign. Nearly all the lesions identified intraoperatively during the study fit one of these four types.Discussion: A reproducible classification system that allows different surgeons to establish comparable homogeneous patient groups is useful for both therapeutic and prognostic purposes. We defined four types of subscapularis lesions that are easy to identify as either isolated lesions or combined with anterosuperior rotator cuff tears. Long head of biceps tendon abnormalities and fatty degeneration of the shoulder muscles can be added to our classification system. Studies of intraobserver and interobserver reproducibility are needed to complete the process of validating the diagnostic and/or prognostic usefulness of this new classification scheme. Level of evidence: II. (C) 2012 Elsevier Masson SAS. All rights reserved.

Background: Until the introduction of arthroscopic-assisted surgery for rotator cuff repair, the frequency of subscapularis tears was underestimated. These tears remain challenging to treat even with arthroscopy. The absence of a specific classification system has hampered communication about the treatment and outcomes of the various types of subscapularis tears. The objective of this prospective multicentre study was to validate the relevance of arthroscopic subscapularis tendon repair based on an assessment of short-term outcomes according to the initial extent of the anatomic lesions.Methods: A prospective multicentre study sponsored by the French Society for Arthroscopy was conducted from March 2010 to January 2011 in 208 patients with subscapularis lesions that were either isolated or associated with limited anterosuperior tears. The Constant and UCLA scores were used to assess clinical outcomes. Anatomic and prognostic results were evaluated based on the physical examination, preoperative and postoperative imaging study findings, and anatomic lesions. Clinical data were available for 103 patients after at least 1 year of follow-up and radiological data for 129 patients after at least 6 months.Results: The preliminary clinical results in 103 patients with at least 1 year of follow-up showed overall statistically significant improvements in the Constant and UCLA scores, with resolution of the clinical manifestations. The degree of improvement seemed to increase over time. The clinical results varied significantly across patient groups based on a classification system distinguishing four lesion types. Postoperative imaging studies to assess the anatomic results in all patients with at least 6 months of follow-up (n = 129) showed tendon healing in 92% of cases but also indicated muscle wasting of the upper subscapularis muscle in 18.6% of cases and increased fatty degeneration of the muscle belly.Discussion: Our study confirms the good clinical and radiological results reported in the literature. Our classification system distinguishing four lesion patterns was applicable during the imaging workup. The main finding from this classification system was the difference in results between Type 2 and Type 3 lesions. The trend towards improvements over time requires confirmation by longer-term studies, which will also have to establish that the increased wasting of the upper subscapularis muscle and fatty degeneration of the muscle belly have no adverse effects. Level of evidence: Level 3. (C) 2012 Elsevier Masson SAS. All rights reserved.

Les ruptures du subscapulaire peuvent être évoquées cliniquement devant une rotation externe passive augmentée en comparatif par rapport au côté opposé, des manœuvres de rotation interne contrariée (Lift-Off test [LOT], Belly-Press test [BPT], Napoléon test et Bear-Hug test [BHT]) et des signes de rappel automatique positifs (Internal Rotation Lag Sign et Belly-Off Sign). Le biceps est fréquemment associé aux lésions du subscapulaire car ce dernier participe à la formation de la poulie médiale. Le Palm-Up test [PUT] est utilisé pour le biceps comme le test de Jobe pour le supraépineux. Dans le cadre d'une étude multicentrique, nous avons souhaité évaluer la valeur diagnostique positive des tests cliniques LOT, BPT, BHT, PUT et de Jobe, pour les lésions du subscapulaire et leur importance anatomique. Les relations entre les différents paramètres étudiés ont été comparées statistiquement en utilisant une analyse de la variance. Cette étude prospective multicentrique de janvier 2009 à février 2010 comprenait 208 cas de lésions du subscapulaire isolées ou associées à une atteinte partielle (Ellman 1, 2, 3) ou transfixiante (stade 1 de la SFA) du supraépineux. La sévérité de l'atteinte du subscapulaire a été quantifiée selon la classification de la SFA (en quatre stades) et selon la hauteur de l'atteinte (tiers proximal et tiers supérieur). Les trois tests LOT, BPT et BHT étaient corrélés à sévérité des lésions observées (p < 0,05). Plus le test était déficitaire, plus l'atteinte était anatomiquement sévère. Le LOT est le test le moins réalisable (18 %) mais quand il est présent, il préjuge de lésions très sévères. Le BHT était le test le plus sensible de tous les tests (82 %). L'atteinte du biceps était d'autant plus fréquente que la sévérité de la lésion du subscapulaire était importante. Il n'y avait pas de corrélation significative entre les lésions du biceps et les tests du subscapulaire, ni entre les lésions du supraépineux et les tests du subscapulaire. Le PUT n'avait aucune corrélation avec les lésions du subscapulaire des lésions associées du supraépineux, en revanche, il était significativement corrélé aux lésions du biceps (p < 0,05). Le test de Jobe quant à lui était décevant car il était souvent positif même pour des lésions isolées du subscapulaire. Malgré la réalisation des trois tests (LOT, BPT, BHT), 24 % des lésions du subscapulaire n'étaient diagnostiquées qu'en peropératoire. L'apport des signes de rappel automatique dans l'amélioration du diagnostic lésionnel n'a pas été étudié dans ce travail. II.

L’absence d’un système cohérent de classification des lésions du sub-scapularis a rendu difficile la communication en matière de traitement et de pronostic pour les différents types de rupture du sub-scapularis. En outre, une classification fiable fournit un moyen de comparaison des données épidémiologique et thérapeutiques. Les classifications jusqu’alors proposées n’intégraient pas les constatations radiologiques et peropératoires de la coulisse du biceps et le degré de clivage du tendon du sub-scapulaire. Cette étude propose une nouvelle classification basée sur les constatations arthroscopiques à visée thérapeutique et pronostic.

Purpose: We assessed mid-term outcome of mobile cup shoulder prostheses for the treatment of degenerative shoulders with a destroyed cuff. Material and methods: Forty-four biopolar prostheses were assessed with a mean follow-up of 32 months (range 13 – 50 months). The SOFCOT scoring chart was used. The morphological features of the different forms of shoulder degeneration with cuff destruction were analysed on standard x-rays to define anatomic conditions favourable for his type of implant. Results: At last follow-up 86% of the shoulders exhibited little or no pain. Mean active anterior elevation was 59.6° – 82.84°, external rotation in position 1 was 8.86° to 301.68°, and internal rotation was 3.13 points to 5.68 points. The mean Constant score was 48.86 points (weighed score 69.13%). Seventy-seven percent of the patients were satisfied and had resumed their former activities. We had one anterior displacement of a shoulder with deltoid palsy and three complications requiring revision: one polyethylene insert which slipped out of the mobile cup, one conflict between the tendon of the long head of the biceps and the cup, and one anterioposterior conflict because of an oversized cup. One non-cemented prosthesis exhibited mobility at 33 months follow-up. One case of excessive lateralisation of the humerus, one mediocre joint congruency, and atrophy of the deltoid were also recorded. The best outcomes were observed in joints with “centred” degeneration and cuff destruction. Preservation of a satisfactory centring of the cup avoided pain and enabled a mean anterior elevation of 1112.3° with a weighted Constant score of 90.5%. For early excentred degeneration, preservation of the glenoid bone stock prevented perfect joint congruency leading to excessive lateralisation of the humerus: 20% of the shoulders remained painful and anterior elevation reached 68° with a weighted Constant score of 56%. Paradoxically, results were better in patients with severely excentered degeneration. “Acetabulation” of the shoulder preserved joint congruency and lengthened the lever arm of the deltoid by medialisation and lowering of the centre of rotation. Full pain relief was achieved in all such cases, with anterior elevation at 86° and a weighted Constant score at 78%. Discussion: Biopolar arthroplasty is effective in shoulders with centred degeneration and cuff destruction. It is an interesting salvage solution for advanced-stage excentric degenerated shoulders beyond the limits of other implants. We propose a decisional tree based on an anatomic classification of the shoulder degeneration with cuff destruction.

An original method of CT measurement of the lateralization of the humeral intertubercular groove is described based on geometric construction following Thales theorem. A study of intra- and interobserver reproducibility was done of this measurement and humeral retroversion on 32 healthy volunteers. The results show good reproducibility of these measurements. The average value of humeral retroversion was lower than the average values found in the literature: 11.71° on average on the dominant side and 7.03° on average on the non-dominant side with a large spread of values. The reasons for these differences are discussed. The average values of lateralization of the intertubercular groove were 114.97° on the dominant side and 121.9° on the non-dominant side. These CT measurements are important to consider in the pathophysiology of chronic anterior instability of the shoulder.

Purpose: The purpose of this work was to study the biomechanical properties of mobile cup shoulder prostheses and factors affecting their kinetics. Material and methods: Bipolar shoulder prostheses were implanted in 39 patients with degenerative shoulders and a destroyed cuff. Radiocinematic recordings of anterior elevation and active rotation were made at a mean 32 months follow-up (13 months–550 months). Results: Three types of biomechanical behaviour were observed for elevation movements. “Normal” behaviour was observed in 17 prostheses with preservation of the scapulohumeral rhythm and chronological participation of the three articular interfaces [intraprosthetic (head/cup), extra-prosthetic (cup/glenoid), scapulothoracic]. Mean anterior elevation was 114.7° for these shoulders. A “paradoxical” behaviour was observed in ten prostheses. Anterior elevation depended entirely on the scapulorthoracic joint, and was limited on the average to 42.5°. An “intermediate” behaviour was observed in 12 prostheses with inversion of the scapulohumearl rhythm. The glenohumeral mobility was decreased due to the absence of extraprosthetic mobility (eight cases) or intraprosthetic mobility (four cases). Mean anterior elevation in these shoulders was 80.83°. When the elevation behaviour was “normal”, the Constant score at last follow-up was significantly better compared with “intermediate” (p = 0.008) or “paradoxical” (p = 0.0001) behaviour. Three types of biomechanical behaviour were also observed for rotation movements: a “chronological “ behaviour was observed for 15 prostheses, via extraprosthetic mobility in all. Mean external rotation was 37.33° and mean internal rotation was 6.53 points. An “anarchic” behaviour was observed in 16 prostheses with a random proportion of intra- and extraprosthetic mobility. Mean external rotation was 8.75° and mean internal rotation was 4.25 points. For shoulders with “chronological” or “anarchic” behaviour, the mean external rotation (p = 0.002) and the mean internal rotation (0.04) were statistically better than shoulders with “truncated” behaviour. Discussion: An atrophic deltoid, mediocre joint congruency, and early-stage excentred scapular degeneration with preserved glenoid bone stock are factors favouring “paradoxical” elevation. Deltoid atrophy alone favours “truncated” rotation. This study was helpful in identifying conditions most appropriate for implanting this type of prosthesis and factors predicting postoperative outcome.

Purpose of the study Management of patients with massive irreparable rotator cuff tears associated with severe glenohumeral joint degeneration presents a difficult clinical challenge. The present study reports on 24 patients with disabling shoulder pain due to relator cuff arthropathy treated using a bipolar arthroplasty. Material and methods Between 1995 and 1997, a bipolar shoulder arthroplasty (Biomet, Warsaw, In) was used in 24 patients (25 shoulders) with rotator cuff arthropathy. Patients were monitored for an average of 14.5 months (range 12 to 24 months). The coracoacromial ligament was maintened in all patients to provide anterosuperior stability. The rotator cuff was irreparable and no attempt was made to cover the superior defect. Postoperative results were reviewed with the Constant score and the Swanson score. In order to verify the head-shell motion and to analyze the dynamic comportement of bipolar arthroplasties, we recorded anterior active elevation and active rotations with video-fluoroscopy. Results At final the follow-up, 21 shoulders had no or slight pain. Average active flexion improved to 84.8 degrees after operation from 62.4 degrees beforehand. 13 patients achieved more than 90 degrees of active flexion after operation. Active external rotation improved from a mean 3 to 28.8 degrees. Before surgery the average Constant score was 17.62. Postoperatively, the average Constant score was 46.97 and the average Swanson score was 23.13. Complications requiring reoperation occurred in 2 cases: 1 component dislocation (Head-shell), 1 subluxation of the long head of the biceps. Radiographic evaluation at follow up demonstrated no humeral stem loosening or component migration and no bony erosion of the coracoacromial arch. Rupture of the infraspinatus tendon (absolute Constant score: p=0.04, adjusted Constant score: p=0.02, Swanson score: p=0.03, Functional score: p=0.04), preoperative anterior subluxation of the humeral head (absolute Constant score: p=0.03, adjusted Constant score: p=0.05, anterior elevation: p=0.01, functional score: p=0.04), preoperative narrowing of the acromio-humeral interval (adjusted Constant score: p=0.02, overall mobility: p=0.02, anterior elevation: p=0.03) may jeopardize the subsequent success of bipolar shoulder arthroplasty. The results of this study suggest that the radius curvature of the shell must match that of the bony surface of the glenoid and the coracoacromial arch (absolute Constant score: p=0.003, adjusted Constant score: p=0.005, overall mobility: p=0.002, anterior elevation: p=0.0008, functional score: p=0.002). Recording of anterior active elevation with video-fluoroscopy allowed to identify 3 different types of movements after bipolar shoulder arthroplasty. Recording of internal and external rotation allowed to distinguish 2 differents types of movements. Motion appeared to occur between the bipolar shell and the head. The amount of motion was variable and depended on the biomechanics. Discussion and conclusion Bipolar shoulder arthroplasty is an effective surgical option for patients with massive irreparable tears of the rotator cuff with concomitant glenohumeral arthritis. Satisfactory pain relief and modest gains in motion result in significant functional improvement in this "low functional demand" population. Predictive factors have been identified and should be discussed before surgery.

De nombreuses publications ont fait etat des resultats a long terme des implants glenoidiens dans les protheses totales d'epaule. Le but de notre travail etait d'evaluer a moyen terme le comportement des tiges humerales et d'en deduire les facteurs pouvant etre a l'origine d'un echec de fixation. Quarante tiges humerales ont ete revues au recul minimum de un an. Vingt neuf protheses etaient implantees sans ciment et 11 etaient scellees. L'evaluation clinique et radiologique utilisait la fiche de revision concue pour le symposium de la SO.F.C.O.T en 1994. Vingt tiges humerales (50%) presentaient un lisere, evolutif dans 12 cas. Deux descellements etaient notes dont un d'origine septique. Seule l'absence de scellement etait statistiquement liee a l'existence d'un lisere. L'etiologie, le type d'implant ou l'association a un resurfacage glenoidien n'etaient pas correles a la presence d'un lisere. Devant le mediocre comportement a long terme des tiges humerales lisses non cimentees, les auteurs defendent la necessite du scellement des tiges sans traitement de surface, et le benefice escompte par l'utilisation de tiges revetues sans ciment dont les avantages a long terme restent a demontrer.

PURPOSE OF THE STUDY:Management of patients with massive irreparable rotator cuff tears associated with severe glenohumeral joint degeneration presents a difficult clinical challenge. The present study reports on 24 patients with disabling shoulder pain due to rotator cuff arthropathy treated using a bipolar arthroplasty.MATERIAL AND METHODS:Between 1995 and 1997, a bipolar shoulder arthroplasty (Biomet, Warsaw, In) was used in 24 patients (25 shoulders) with rotator cuff arthropathy. Patients were monitored for an average of 14.5 months (range 12 to 24 months). The coracoacromial ligament was maintained in all patients to provide anterosuperior stability. The rotator cuff was irreparable and no attempt was made to cover the superior defect. Postoperative results were reviewed with the Constant score and the Swanson score. In order to verify the head-shell motion and to analyze the dynamic comportement of bipolar arthroplasties, we recorded anterior active elevation and active rotations with video-fluoroscopy.RESULTS:At final the follow-up, 21 shoulders had no or slight pain. Average active flexion improved to 84.8 degrees after operation from 62.4 degrees beforehand. 13 patients achieved more than 90 degrees of active flexion after operation. Active external rotation improved from a mean 3 to 28.8 degrees. Before surgery the average Constant score was 17.62. Postoperatively, the average Constant score was 46.97 and the average Swanson score was 23.13. Complications requiring reoperation occurred in 2 cases: 1 component dislocation (Head-shell), 1 subluxation of the long head of the biceps. Radiographic evaluation at follow up demonstrated no humeral stem loosening or component migration and no bony erosion of the coracoacromial arch. Rupture of the infraspinatus tendon (absolute Constant score: p = 0.04, adjusted Constant score: p = 0.02, Swanson score: p = 0.03, Functional score: p = 0.04), preoperative anterior subluxation of the humeral head (absolute Constant score: p = 0.03, adjusted Constant score: p = 0.05, anterior elevation: p = 0.01, functional score: p = 0.04), preoperative narrowing of the acromio-humeral interval (adjusted Constant score: p = 0.02, overall mobility: p = 0.02, anterior elevation: p = 0.03) may jeopardize the subsequent success of bipolar shoulder arthroplasty. The results of this study suggest that the radius curvature of the shell must match that of the bony surface of the glenoid and the coracoacromial arch (absolute Constant score: p = 0.003, adjusted Constant score: p = 0.005, overall mobility: p = 0.002, anterior elevation: p = 0.0008, functional score: p = 0.002). Recording of anterior active elevation with video-fluoroscopy allowed to identify 3 different types of movements after bipolar shoulder arthroplasty. Recording of internal and external rotation allowed to distinguish 2 differents types of movements. Motion appeared to occur between the bipolar shell and the head. The amount of motion was variable and depended on the biomechanics.DISCUSSION AND CONCLUSION:Bipolar shoulder arthroplasty is an effective surgical option for patients with massive irreparable tears of the rotator cuff with concomitant glenohumeral arthritis. Satisfactory pain relief and modest gains in motion result in significant functional improvement in this "low functional demand" population. Predictive factors have been identified and should be discussed before surgery.

The clinical and radiological evolution of the glenoid socket in total shoulder arthroplasty is well documented, whereas evaluation of the humeral component has received much less attention. The outcome of 40 humeral replacements performed in 39 patients was studied with a minimum follow-up of one year. There were 26 Neer prostheses, 9 Modular Shoulder prostheses and 5 Aequalis prostheses. Twenty-nine prostheses were implanted with cement and 11 were cementless. The clinical and radiological results were assessed according to the scoring system used for the 1994 symposium of SO.F.C.O.T. X rays in the coronal plane were used to assess the position of the stem, radiolucencies around the humeral component and the percentage of the cross-section of the diaphysis filled by the humeral stem. The average follow-up period was respectively 55.6 months for the Neer prostheses, 17.9 months for the Modular Shoulder prostheses and 12.4 months for the Aequalis prostheses. Radiolucent lines were noted in 20 cases, all with uncemented humeral components. Two prostheses were loose; however, none required revision. The underlying pathology, surgical approach, position of the humeral component, implant design or association with glenoid resurfacing were not correlated with the presence of radiolucent lines or with a loose implant. Cementless fixation was the only parameter statistically related with the presence of radiolucent lines. This report confirms the good results obtained with cemented humeral prostheses. Radiological evaluation of the smooth cementless humeral implant showed many progressive radiolucent lines, without clinical expression. The authors analyze the various studies in the literature and discuss the interest of cementless implants with ingrowth surface.

PURPOSE OF THE STUDY:The authors report their experience of Zadek's wedge osteotomy in the treatment of posterior talalgia in adults and evaluate the various radiographical measurements for calcaneus deformity measurement....MATERIAL:This procedure was performed in 27 patients with a total of 36 calcanea treated between 1985 and 1996. The sex ratio was 20 women for 7 men with an average age of 27 years. Prior to this osteotomy nine feet were operated by resection of the postero-superior tuberosity with recurrence of pain and disability, and two patients presented an inflammatory arthritis.METHOD:For the surgical procedure, the patient was placed in lateral position. Skin incision was five to six centimeters long, curvilinear along the lateral side of the tendo achillis. Two dorsal pins were inserted, creating a triangle so that the apex pointed plantarly and the base dorsally. The sagittal saw was then used to create a wedge osteotomy with a dorsal base of seven to ten millimeters. A screw was then driven across the osteotomy site for ultimate fixation.RESULTS:Eighty per cent (29 osteotomies) of patients had been examined clinically and radiologically with a mean follow-up of 29 months. Considering pain, daily activity and discomfort with footwear, results were excellent in 12 cases, good in 10, fair in 5 and poor in two cases. No radiological criteria used for the diagnosis of Haglund's disease were absolutely reliable. The "total angle" of Ruch, the "c.l angle" of Chauveaux and the "parallel pitch lines" of Heneghan reflect the amount of deformation most accurately, but especially, the calcaneal inclination angle was always increased (16 cases between 18 degrees and 30 degrees, 6 cases > 30 degrees). All patients had a weight-bearing calcaneal talus, either alone or in the context of posterior pes cavus.CONCLUSION:This study confirms the responsibility of rearfoot morphostatic disorders in posterior talalgia and the goods results obtained by Zadek osteotomy.

Five patients with a large defect in the articular cartilage at the knee joint were treated by transplantation of an autogenic osteochondral fragment. The graft was harvested from the posterior portion of the ipsilateral femoral condyle in 4 cases of osteochondritis dissecans, and from the lateral third of the patella pedicled on the patellar ligament in one case of posttraumatic necrotic collapse of the lateral tibial plateau. One patient underwent concomitant high tibial osteotomy. Two months postoperatively bony union was achieved in all cases but in one case, the grafted articular cartilage did not survive after weight bearing because of an overlooked varus deformity. At the follow-up examination (8 to 20 years) all 5 patients were asymptomatic ; the range of flexion was somewhat restricted (120 degrees) ; roentgenogram revealed slight narrowing of the articular space or at least flattening of the grafted zone and subchondral osteosclerosis. At arthroscopic exploration, the grafted zones were recognizable from the surrounding cartilage, and histologic examination of their border revealed fibrocartilage and proliferating vessels; late gonarthrosis might ensue over time. Therefore the procedure should be performed only in large osteochondral defects where neither reattachment of a loose body, nor hemiarthroplasty, nor isolated osteotomy are suitable and before degenerative changes have developed. Morever any associated varus deformity requires concomitant correction by high tibial osteotomy to relieve stress from the graft.