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The surgical management of a degenerative or traumatic lesion of the shoulder joint is based on anatomical, clinical, and radiologic criteria. To optimize the diagnostic and therapeutic management of patients, the use of radiological imaging must be accompanied by meticulous clinical examination first. Conventional radiography is an effective complementary exam to assess the nature of shoulder joints injuries. Many conventional radiographic markers have been described, mainly for degenerative rotator cuff lesions, and are routinely used by clinicians as a screening tool. The aim of this review was to describe these different markers and define their reliability and usefulness in avoiding more expensive imaging modalities.La prise en charge chirurgicale d’une lésion dégénérative ou traumatique de l’épaule repose sur des critères anatomiques, cliniques et radiologiques. Afin d’optimiser la prise en charge diagnostique et thérapeutique des patients, le recours à l’imagerie est essentiel et doit être accompagné d’un examen clinique méticuleux. La radiographie conventionnelle est un examen efficace de dépistage pour apporter un diagnostic de présomption. Plusieurs marqueurs radiologiques ont été décrits, surtout dans les pathologies de la coiffe des rotateurs, et sont couramment utilisés dans la pratique clinique. Le but de cet article est d’effectuer une revue critique de ces différents marqueurs et de définir leurs fiabilité et utilité clinique pour éviter de recourir à une imagerie plus coûteuse.

Les luxations traumatiques de l'articulation de l'épaule sont généralement décrites comme des luxations antéro-inférieures. Les luxations antéro-supérieures sont extrêmement rares. Nous rapportons un cas rare de luxation traumatique de l´épaule antéro-supérieure chez un patient âgé de 45 ans où l´examen physique trouve une saillie antéro-supérieure de la tête humérale en sous-cutanée avec comblement de l´espace sous acromiale, le diagnostic était confirmé radiologiquement avec la découverte d´une rupture totale des tendons supra-épineux et sous scapulaire à l´imagerie par résonance magnétique. L´épaule était jugée instable après réduction de la luxation. Une arthrorise gléno-humérale provisoire était réalisée par la suite avec des bons résultats fonctionnels.

Total shoulder arthroplasty has become an effective treatment option, for both pain relief and restoration of shoulder range of motion. The key factor limiting long-term prosthetic survival remains glenoid implant loosening. Proper glenoid implant positioning and orientation during surgery was shown to significantly reduce complication rates. The emergence of new technologies now allows for three-dimensional (3D) surgical planning, patient-specific instrumentation and augmented-reality-based intraoperative navigation. Such novel tools have been developed to aid and improve the surgeon's performance. The future will tell whether the gains in term of surgical precision will also translate into better functional outcomes for patients and prolonged survival of glenoid implants.La prothèse totale d’épaule permet de nos jours d’obtenir des résultats fiables tant sur le plan de l’antalgie que de la récupération des amplitudes articulaires. Le facteur clé limitant la survie de la prothèse reste le descellement de l’implant glénoïdien. Une orientation correcte de celui-ci permet une diminution du risque de complications. L’essor des nouvelles technologies permet la planification en trois dimensions (3D), la création d’instrumentation spécifique au patient ou encore la navigation peropératoire à l’aide de la réalité augmentée. Ces nouveaux outils ont été développés dans le but d’aider et d’améliorer la performance des chirurgiens. L’avenir devra déterminer si le gain en termes de précision chirurgicale pourra également se traduire par un bénéfice fonctionnel pour le patient et une survie augmentée des implants, notamment glénoïdiens.

This article aims to present the principles of rehabilitation following anatomical and reverse total shoulder arthroplasties. The rehabilitation consist of three phases: wound healing and movement initiation (weeks 0-6), movement recovery (7-12), strengthening and return to activity (13-18). At 6 to 12 months follow-up, most patients report a substantial decrease in pain and a return to light to moderate activity level. The rehabilitation of the reverse arthroplasty specifically requires deltoid muscle strengthening and dislocation prevention. The functional outcome is slightly inferior for reverse arthroplasty, which is indicated when musculotendinous lesions are associated to bone lesions, but satisfaction rates are comparable between the two types of implants. The durability of total shoulder arthroplasties is globally satisfying, though shorter in young active patients.Cet article présente la rééducation après prothèses totales d’épaule anatomique (PTEa) et inversée (PTEi), qui se découpe en 3 phases : cicatrisation et initiation du mouvement (semaines 0-6), récupération du mouvement (7-12), renforcement et retour à l’activité (13-18). Après 6-12 mois, la plupart des patients rapportent une nette diminution des douleurs et une reprise des activités légères à modérées. La rééducation de la PTEi implique spécifiquement de renforcer le muscle deltoïde et de prévenir la luxation. Le résultat fonctionnel est légèrement inférieur pour la PTEi, qui est posée lorsque des lésions musculo-tendineuses sont associées à des lésions osseuses, mais la satisfaction est comparable entre les deux types d’implants. La longévité de ces prothèses, bien que plus courte chez le patient actif jeune, est généralement bonne.

Management of shoulder instability. Shoulder instability is a commonly encountered problem in young active athletes. Instability is most often due to a traumatic gleno-humeral dislocation. The diagnosis is based on clinical apprehension tests and on diagnostic imaging. Most frequent lesions are Bankart lesion and Hill-Sachs injury. Shoulder instability could be managed conservatively with rehabilitation or surgically. The therapeutic indication should be discussed taking into account several criteria such as: traumatic versus atraumatic mechanisms, hyperlaxity, age, number of dislocations, type of work and sports activities and the presence of associated lesions.Prise en charge de l’instabilité de l’épaule. L’instabilité de l’épaule est une pathologie fréquente qui touche le plus souvent des hommes jeunes et sportifs. Il s’agit le plus souvent d’une instabilité post-traumatique au décours d’une luxation gléno-humérale complète. Le diagnostic positif repose sur les tests cliniques d’appréhension ainsi que sur la réalisation d’examens d’imagerie. Les lésions les plus fréquentes sont la lésion de Bankart et l’encoche de Malgaigne. Cette instabilité peut faire l’objet d’un traitement conservateur avec rééducation ou d’un traitement chirurgical. La stratégie thérapeutique est définie en fonction du caractère traumatique ou atraumatique de l’instabilité, de la présence d’une hyperlaxité ligamentaire généralisée, de l’âge, du nombre d’épisodes de luxation, de l’activité professionnelle et sportive du patient et de la présence de lésions associées.

A century and a half after its first description, adhesive capsulitis (frozen shoulder) has revealed only part of its secrets. Its definition remains clinical since the imaging technology we have at our dis-posal is insufficiently sensitive and specific. Next to its idiopathic form, the most frequent and the most characteristic, there are numerous situations inducing a functional limitation of the glenohumeral joint and of its environment. The clinical course inexorably takes place in one to two years, and develops in 3 phases where successively pain, retraction, and then recovery, as a rule complete recovery, dominate. No treatment is likely to shorten it. In the absence of clearly established proof, our therapeutic approach must be prudent and conservative.Un siècle et demi après sa première description, la capsulite rétractile de l’épaule n’a dévoilé qu’une partie de ses secrets. Sa définition reste clinique puisqu’on ne dispose d’aucune méthode d’imagerie suffisamment sensible et spécifique. A côté de la forme idiopathique, la plus fréquente et la mieux caractérisée, il existe une multitude de situations induisant une limitation fonctionnelle de l’articulation gléno-humérale et de son environnement. L’évolution se déroule inexorablement sur un à deux ans et comporte trois phases où dominent successivement la douleur, la rétraction puis la récupération en principe complète. Aucun traitement n’est susceptible de l’écourter. En l’absence de preuve clairement établie, l’approche thérapeutique doit être prudente et conservatrice.

L’enclouage centromédullaire antérograde s’est imposé comme un des traitements de référence des fractures céphalotubérositaires à deux, trois et quatre fragments. Nous présentons une étude rétrospective de 06 patients ayant bénéficié d’un enclouage centromédullaire depuis janvier 2012. Le Recul moyen est de 12 mois, l’âge moyen était de 57 ans. Evaluation clinique se basait sur le score de Constant et Murley, en brut et pondéré en fonction de l’âge et du sexe, avec un comparatif avec le coté sain. Le bilan radiologique nous a permis d’évaluer la consolidation osseuse, l’apparition d’Ostéonécrose de la tête ou arthrose post traumatique. Surveille aussi l’Etat des tubérosités avec l’existence ou non d’ostéolyse du trochiter. Elle recherche aussi les critères de bonne réduction à savoir l’angle calotte céphalique et l’axe diaphysaire (αF) sur les clichés de face. Tous les patients ont été traités selon la même technique chirurgicale. Le score de Constant et Murley sur l’ensemble des patients était de 64.13 points. Le score pondéré en fonction de l’age et du sexe était de 73%. Les mobilités articulaires étaient en moyenne sur l’ensemble des patients 116° en élévation antérieure, 99.9° en élévation latérale, et 42° en rotation externe. Angle αF moyen s’élève à 42°. Tous les patients présentaient des critères de bonne réduction à savoir αF. L’enclouage centromédullaire permet une synthèse osseuse simple et au prix d’un abord limité avec des résultats fonctionnels très prometteurs. La comminution fracturaire et l’ostéoporose peuvent limiter ces indications.

Shoulder pain is a common problem for general practitioners. The objectives of a shoulder arthroplasty are to improve the articular function and to provide pain relief. Anatomic shoulder arthroplasty is not the treatment of choice if a rotator cuff deficiency is associated with arthritis. In some circumstances (muscle or tendon deficiency) rotator cuff repair is technically impossible. Reverse shoulder arthroplasty (RSA) has opened new opportunities for patients suffering with shoulder conditions such as shoulder pseudoparalysis and revision surgery. RSA is rarely proposed to patients below the age of 60 but thereafter there is no age limit. With this procedure, the functional improvement can be achieved after days or weeks. A new surgical approach allows for early active mobilization without a specific rehabilitation period.

Entre 2005 et 2014, 73patients (77 épaules) ont bénéficié d’une intervention de Latarjet pour instabilité antérieure de l’épaule. Nous avons, rétrospectivement, évalué les résultats cliniques et radiologiques de cette technique opératoire. L’intervention a été réalisée pour le traitement d’une luxation récidivante dans 69 cas, subluxation récidivante douloureuse dans 5 cas et 3 épaules douloureuses Tous les patients ont eu une évaluation radiographique avant l’intervention et lors du contrôle le plus récent. Selon le score de Rowe, 73 (94.8 %) des 77 épaules ont obtenu un résultat bon ou excellent. Au plus grand recul, 74 épaules étaient indemnes d’arthrose glénohumérale.

Evolution of shoulder arthroplasty has led to mainly three types of implants: hemiarthroplasty, total shoulder arthroplasty and reverse shoulder arthroplasty. There is yet no clear consensus about indications for the different existing types of prothesis. The aim of this article is therefore to bring together and clarify the indications found in the current literature. Hemiarthroplasty, historically the first widely used implant, has lost much ground to total shoulder arthroplasty, and keeps its place only for specific situations. Total shoulder arthroplasty is mainly used for centered glenohumeral osteoarthritis, whereas reverse shoulder arthroplasty is indicated for most situations in which the rotator cuff or tuberoties are deficient.

Omarthrose bilatérale de l’épaule sur ostéonécrose est une pathologie rarement traitée dans la littérature. La présence de cette pathologie chez deux sœurs gémellaires n'est jamais décrite. Sa prise en charge chirurgicale représente un défi et nécessite un chirurgien orthopédique expérimenté en chirurgie du membre supérieur. Nous présentent deux sœurs gémellaires qui avaient une omarthrose bilatérale de l’épaule sur ostéonécrose, qui ont été traités dans notre département par prothèse inversée. La planification préopératoire a été réalisée par une équipe de chirurgiennes entrainées. Globalement nos résultats (cliniques et radiologiques) immédiats, moyen terme et au dernier recul étaient satisfaisants. Le but de notre travail est d'attirer l'attention sur cette association rare et de discuter sa prise en charge thérapeutique.

Scapula and proximal humerus are the most frequent site of primary bone tumors of upper limb. Surgical reconstruction after resection, aimed to obtain a stable painful limb and active motion of the shoulder. Three major key-points can affect functional results: intra- or extra-articular resection, ability to offer a strength fixation of rotator cuff tendons, and remaining function of the deltoid muscle after resection. When most of the deltoid muscle is active associated with an intra-articular resection, recent results of reversed prosthesis are very promising in terms of active motion. For other cases, conventional or tumor prosthesis can be proposed, but inefficience of rotator cuff tendons fixation on a prosthesis leads to very poor restoration of active motion. Arthrodesis is an attractive option in this situation for young patients. In all cases, impairment of the shoulder function is the rule after resection, complication rate is high, and long-term deterioration of the reconstruction is frequent. Moreover, cosmetic results are always poor.

Shoulder pain is a common cause of consultation in primary care medicine. A detailed history and a carefully carried out physical exam allow to orientate the diagnosis towards an intrinsic or extrinsic cause and to the differential diagnosis. Rotator cuff injury is the most frequent affection. Plain radiography will often be done in first intention since it identifies direct or indirect signs associated with certain pathologies. Ultrasonography is an excellent way of evaluating soft tissue injury and allows a diagnosis in most cases (rotator cuff injury, tendinopathy of the long head of the biceps, bursitis, effusion, calcifications). Other imaging studies may be carried out depending on the pathology suspected.

Evaluate the technique of Bristow-Latarjet in the treatment of the recurrent dislocation of the shoulder.It was a continuous retrospective study on 46 cases selected in the CHU of Dakar over 11 years. From our criteria of inclusion, 41 patients were retained. There were 37 men for 4 women, whose average age at the time of the intervention was 29 years (extreme: 20 - 44 years). The management of the first episode was unsuited in 25 times. The average time of the first repetition was 10 months and its number varied between 5 and 36 episodes. The treatment of the recurrences was also misfit in 23 times. All our patients were treated according to the technique of Bristow-Latarjet. A standard immobilization Mayo clinic during 3 weeks was made with a systematic rehabilitation. The evaluation was done according to the scale of Constant with 45,6 months an average retreat.We found: 7 excellent cases (17%); 14 very good cases (34%); 9 good cases (22%); 6 average cases (15%); 5 bad cases (12%). Five cases of omarthrosis (3 types II and 2 types III of Samilson-Prieto) were found like two surface cases of sepsis. There was neither post-operative recurrence nor iatrogenic nervous attack.The recurrent anterior dislocation of the shoulder represents a frequent complication of primary dislocations of the shoulder touching especially young subjects. Stabilization by the anterior coracoid abutment according to the technique of Bristow-Latarjet led well represents one of the best techniques for its treatment.

Posterior glenohumeral dislocation is rare, accounting for less than 3% of all shoulder dislocations. Main etiologies are direct or indirect trauma, seizure and electrocution. The diagnosis is missed in 50 to 80% of the cases on initial presentation because of the rather subtle clinical signs compared to anterior dislocation and inadequate imaging. An unreduced posterior dislocation can lead to severely impairing complications such as recurrent instability, arthritis or avascular necrosis, requiring open reduction and complex surgery with a lower rate of success. The purpose of this article is to highlight and clarify the challenges when confronted with posterior dislocation in order to avoid misdiagnosis. Furthermore it aims to propose an adequate and comprehensible management from the initial diagnosis to the treatment.

The authors report three cases in which cerebral ischemia occurred during arthroscopic shoulder surgery performed in beach chair position under general anaesthesia and interscalene plexus block. Several similar cases have been published in the literature. This rare but extremely severe complication is related to the decrease in cerebral perfusion pressure (CPP). Monitoring of CPP in the beach chair position using the measurement of arterial pressure and taking into account the hydrostatic gradient is essential. Prevention includes correction of preoperative hypovolaemia, treatment of postural arterial hypotension, adequate installation of the patient's head, aggressive treatment of perioperative arterial hypotension (whatever the cause) and avoidance of deliberate perioperative arterial hypotension. Routine use of non-invasive monitoring of cerebral oxygenation has been advocated to avoid this accident but its usefulness has to be confirmed by clinical studies.

We report the first case of glenohumeral Salmonella arthritis in an immunocompetent 86-year-old woman. There was no entry point. An empirical antibiotherapy was started then adapted according to culture results. Given the persistence of symptoms, an arthroscopy was performed at 72 hours for a joint lavage and synovectomy. Postoperative course was good. Apyrexia was obtained by 72 hours and inflammatory syndrome was normalized in 12 days. The patient was reviewed regularly until the 3rd month. She has no clinical sequelae. Her osteoarthritis remained stable throughout follow-up.

The reverse shoulder arthroplasty indications are cuff tears arthropaty, revision of anatomic prosthesis and traumatology. The reverse shoulder arthroplasty doesn't need a rotator cuff integrity to be functional. However, complications are not rare (dislocation, descellement, infection...). The patient selection has to be rigorous. In any case, patient must be older than seventy years.

Clinical history and patient examination are mandatory to correctly order shoulder imaging. The choice of the imaging modality will depend on different factors. Is the shoulder stable or instable? Was there a traumatic history or simply repetitive microtraumas? Is the A-C joint electively tender? Generally, plain X-rays is the first step in the shoulder imaging. However different views will be adapted to the clinical examination. Double oblique standard view in neutral position and rotations with associated profile is the basis of the examination. In the case of a painful stable shoulder, ultrasound is usually the second step. MRI is only necessary in case of deficient ultrasound. If surgery is an option, CT-scan or MRI without any contrast media are useful because ultrasound cannot correctly predict the eventual fatty degeneration of the muscles that contra-indicates the surgical treatment. In the case of shoulder instabilities, there is no place for ultrasound. The best choice is always an intra-articular injection of contrast medium followed by CT-scan or MRI. Only these examinations are able to depict labrum lesions or bicipital desinsertion. Finally, the AC joint must be evaluated separately from the rest of the shoulder with special radiological and ultrasound incidences. Stress or dynamic maneuvers can be added either with X-rays or ultrasound.

The purpose of this article is to: 1) describe the main plain film, ultrasound and MR imaging features of peripheral involvement in psoriatic arthritis, 2) describe the advantages of ultrasound and MRI at the early stages of the disease; 3) describe how to use MRI and ultrasound in order to assess response to tumor necrosis factor-alpha blocker therapy.

The patients besides 50 years represented 58% with a sex ratio of 1.22 in favor of the women. A limited painful of the movements of shoulder has been noted in 75% of cases of the right shoulder (90%). The sonography was abnormal in 95% of patients, the recovered lesions were : calcifications 58%, ruptures 23.6%, extrusion 15.7%. The supraspinatus muscle and the m.biceps brachii (caput longum) were the more involved in respectively 55.3% and 26.3% . A comparison made between the results of the clinical tests and those of the sonography study show that there is not a homology. Summarise The sonography is a good means diagnosis of the degenerative pathology of the shoulder especially in the beginning where classic x ray examination is less contributive.

We report the case of a fracture of the glenoid, Goss-Ideberg type II, associated with an inferior dislocation of the shoulder, a combination that has not to our knowledge been previously reported. The injury had occurred after a fall of three metres. The radiological assessment included an anteroposterior view and a CT scan that guided the surgical approach by indicating that the fragment of the glenoid cavity was especially dorsal. We carried out a preoperative MRI to eliminate the possibility of a rotator cuff tear being present. The surgical treatment was carried out with the patient in lateral decubitus position and restored normal function to the shoulder.

The purposes of this paper are: 1) to review the different radiographic projections commonly used to explore shoulder pathology; 2) to propose a practical approach for radiographic evaluation of the shoulder, adapted to the main clinical situations; 3) to recognize the different imaging features of the most frequent shoulder diseases.

Whether post-traumatic focal fixed dystonia has a physiological or psychologically-mediated mechanism is discussed.We report the case of an active 22-year-old soldier with shoulder-fixed dystonia, eight months after a fall with minor right-acromioclavicular sprain.Psychiatric examination and search of complex regional pain syndrome, radicular or accessory nerve damage, and genetic predisposition to dystonia are necessary for selecting a difficult treatment in these patients.

To describe osseous, chondral and tendinous lesions associated with fissures of the posterior labrum. To better understand the pathological processes leading to fissure of the posterior labrum. Materials and methods. Retrospective study of 43 CT arthrograms performed in 43 patients that showed a fissure of the posterior labrum. The following associated lesions were noted: osseous and chondral remodeling of the humeral head and/or glenoid and articular surface fissures of the rotator cuff. Based on type of associated lesions, patients were separated into one of four pathological subgroups: posterior instability, posterosuperior or internal impingement, anterior instability and isolated fissure of the posterior labrum.Sixteen patients (37.2%) of patients showed posterior instability, 12 (27.9%) showed lesions of internal impingement, and 11 (25.6%) showed lesions of anterior instability. Only 4 patients (9.3%) had an isolated fissure of the posterior labrum.Posterior instability, internal impingement and anterior instability are the main pathologies leading to fissure of the posterior labrum, which seldom occurs in isolation. Evaluation of these associated lesions allows understanding of the underlying pathological processes leading to fissure of the posterior labrum.

To describe the epidemiological and clinical features of patients with primitive adhesive capsulitis of the shoulder treated by capsular distension and then rehabilitation; to evaluate the short-, mid- and long-term efficiency of this therapeutic protocol and compare it with rehabilitation alone.This was a two-year prospective study. Sixty patients were included and divided into populations P1 (capsular distension and rehabilitation) and P2 (rehabilitation only). Assessment of the treatments' efficacy was based on the following parameters: pain on a visual analogue scale (VAS), joint motion in several axes, a simplified Constant score (functional ability) and the SF-36 quality of life score.Thirty patients (mean age: 56) underwent capsular distension. The Constant score was judged to be poor in over half of the patients. All the quality of life parameters were modified. When compared with P2, the P1 group showed a statistically significant improvement in terms of the pain score (p=0.005), anterior elevation (p=0.001), lateral elevation (p=0.005), external rotation (p=0.006) and the Constant score (p0.001) one week after capsular distension. One year after capsular distension, this gain persisted in a statistically significant manner for all functional parameters and all SF-36 dimensions (p0.001 for PF, RP, BP, SF and RE; p=0.01 for GH and VT and p=0.002 for MH).Our results show that capsular distension and subsequent intensive rehabilitation have a beneficial effect. This combination enables rapid, significant improvement from the first week onwards. The improvement phase lasts for one month and may hold steady for up to 12 months.

Bilateral anterior shoulder dislocation is a very rare clinical entity. We report another case of traumatic bilateral anterior dislocation of shoulders. We discuss the mechanism of the dislocation which is unusual and the treatment.

Recurrent anterior dislocations associated with full thickness rotator cuff tear (RCT) carry a difficult therapeutic problem: should we treat instability and rotator cuff tear at the same time or only one of both pathologies? The goal of this study was to analyse a retrospective series of patients operated on to try to answer this question.Twenty-eight shoulders (27 patients) were operated on between 1988 and 2002. The mean age at first dislocation was 47 years (16-65), the average delay between first dislocation and operation was 6.1 years. Twenty-four shoulders presented with recurrent dislocations and four shoulders with recurrent subluxations; the average number of dislocations was 2.6 (1-20). Preoperatively, Hill-Sachs lesion was present in 96%, anterior glenoid rim fracture in 53.5% and glenohumeral osteoarthritis was observed in 37.5%. All the cases had full thickness rotator cuff tears: isolated supraspinatus in 43%,, Supra- plus infraspinatus in 35%, supraspinatus plus subscapularis in 4% and rupture of the three tendons in 18%. An isolated open stabilization with the technique of Trillat was performed in 19 cases when the cuff was not repairable or when the patient was not willing to accept rotator cuff (RC) repair (age and motivation); the mean age of the patients was 59.3 years in this group. Whereas an open anterior stabilization (Latarjet procedure) associated with RC repair was done in nine cases (average age at operation: 40 years). All the patients were followed up and had clinical-radiographic examinations more than two years after the operation.With a mean follow-up of 73.5 months (24-178), the average Constant score progressed from 63.1 to 78.1 points (p0.05). Three patients who had isolated anterior stabilization had recurrence of instability (16%) whereas none of the patients with both anterior stabilization and RC repair had recurrence. Subjectively, 96% of the patients were satisfied with their operation. Postoperatively, the rate of osteoarthritis progressed to 64.3%.The decision not to repair the RCT in 19 cases was justified by the size of the tear, the muscular fatty infiltration of the RC muscles and the age-motivation of the patients. This decision lead to a greater rate of recurrence (16%) and less satisfactory functional results but the age at FU was 20 years higher in this group than in the group with cuff repair. No patient had an isolated RC repair because 92.5% of the patients in this series had either a bony Bankart (53.5%) or a Bankart type lesion (39%). The recurrent instability in this series was clearly under the dependence of the "anterior mechanism" and not under the dependence of the "posterior mechanism". Therefore, isolated repair of the cuff has never been performed because of the fear of higher rate of postoperative instability leading to RC re-tear.In case of recurrent dislocations associated with rotator cuff tear, treatment of instability should be proposed whereas the concomitant repair of the cuff depends upon the possibility to perform it: size of the rupture, fatty infiltration, age and motivation of the patients.

Mac Lauglhin defects of the right humeral head developed in a 44-year-old woman with drug-resistant epileptic seizures, subsequent to recurrent posterior dislocations. The preoperative work-up demonstrated a large anterior defect corresponding to more than 50% loss of the osterochondral tissue. The humeral head lodged on the posterior rim of the scapular glenoid, like an inveterate posterior dislocation, causing major pain and joint dysfunction. After adjustment of the antiepilepsy treatment, the patient underwent joint reconstruction with a chondrocostal autograft harvested from the ninth homolateral rib combined with transfer of the lesser tubercle. At three years follow-up, the patient has a stable pain-free shoulder with a satisfactory range of motion. The graft was integrated.

We report the case of a 47-year-old female patient who developed predominantly anterior multidirectional glenohumeral instability. After rehabilitation, this patient was treated surgically with an anterior coracoid bone block using the Latarjet technique. The second postoperative day, the control scan revealed posterior glenohumeral dislocation. The patient underwent a second operation for a posterior iliac block. At last clinical follow-up (six years), the patient had normal shoulder motion; shoulder function was considered excellent using the clinical scores. We recall the pathogenic hypotheses explaining multidirectional shoulder instability and discuss the proposed treatments. This case illustrates the difficult diagnosis and therapeutic management of multidirectional instability. Under general anesthesia, examination showed that posterior laxity predominated while paradoxically, the patient presented predominantly anteromedial dislocations. This case is also exceptional by the development of posterior dislocation, an unusual postoperative complication after an anterior bone block; we describe the therapeutic options. In the event of multidirectional instability with bone injuries, we recommend a block in the direction of the instability. Preoperative examination under general anesthesia can be helpful in understanding the mechanism of residual postoperative instability, which would require complementary surgical stabilization.

Scapula alata resulting from a deficient musculus serratus anterior leads to shoulder instability, pain and loss of elevation. Etiologies include fascioscapulohumeral dystrophy and lesion of the thoracicus longus nerve. Dynamic (muscle transfer) or static (scapulopexia or scapulothoracic arthrodesis) stabilization methods can be proposed. The purpose of this study was to assess fusion and function after eight scapulothoracic arthrodeses performed in five patients. We used cerclage with compression after intercostal avivement to increase the contact surface.This retrospective study included four men and one woman. Three patients had fascioscapulohumeral dystrophy who underwent bilateral arthrodeses and two patients with post-traumatic injury to one thoracicus longus nerve. All scapulothoracic joints were unstable; six were painful. There was a cosmetic prejudice in all cases. Preoperative function was 71+/-6 degrees antepulsion (range: 60-80 degrees ) and 71+/-7 degrees abduction (range: 60-80 degrees ). Postoperative assessment included: reduction of the scapula alata, gain in motion, Constant score (raw and weighed), subjective assessment of daily activity, complications, respiratory function in patients with double arthrodesis and bone fusion on the CT scan.Patient follow-up was 21.5 months on average. The scapula alata was reduced in all cases. Mean gain in motion was 39+/-21 degrees antepulsion and 41+/-26 degrees abduction. The raw Constant score was 77.75+/-11.4/100 and the weighted score was 81.5+/-9.1/100. Daily activity was scored 100% in four of five patients. Complications were transient intercostal dysesthesia, mild exercise-induced pain, one pneumothorax which did not require drainage. There was no evidence of an impact on respiratory function. The control scans revealed fusion in five shoulders and nonunion in three.Scapulothoracic arthrodesis enabled reduction of the scapula alata and improved shoulder function for elevation and daily activities. The gain in motion and Constant score were satisfactory and similar to other results in the literature. The main drawback was deficient external rotation. Pain was mild and resulted from the deafferentation. It resolved six months postoperatively. Secondary exercise-related pain was mild with little impact. Technically, authors have proposed using different ribs for the fusion, depending on the patient's morphology and searching for a good position for the scapula for external rotation. There have been few postoperative complications: we had one pneumothorax and no neurological, vascular or pulmonary complications. Our results are the first reporting CT fusion findings. Indirect signs of nonunion on plain x-rays reported in earlier studies are not fully reliable, since our CT scans demonstrated nonunion in three shoulders. The lack of fusion does not mean poor function, as was also noted by others, since function was improved (mean gain 27 degrees flexion and 25 degrees abduction).

In rugby players, 9 to 11% of injuries involve shoulder trauma. Anterior dislocation is one of the most severe accidents affecting the upper limb; recurrent dislocation, observed in more than 60%, appears to be related to the characteristic mechanism of injury in this sport (tackling). Surgical treatment for this instability is a bone block or capsulolabral repair. The purpose of this work was to evaluate outcome with minimum five-years follow-up after treatment by selective capsule repair in a homogeneous series of rugby players.Between 1995 and 2001, 31 rugby players were reviewed at mean 82 months (range: 60 to 120 months) follow-up. Sixty-one percent were regional-level players. A tackle was involved in the instability accidents for half of the players. Age at surgery was 21 years (range: 16 to 34), on average 4.44 years (range: 2 to 20) after the instability accident. Signs of capsule hyperlaxity were noted in 16 shoulders (46%). Dislocation was noted in 27 shoulders, subluxation in five. Chronic pain and instability were noted for three shoulders. Disinsertion of the anteroinferior labrum was noted in 23 shoulders (65%) and was repaired with two, three or four anchors. Isolated capsule distension was observed in twelve shoulders. Neer capsuloplasty was performed on 33 shoulders, with complementary labral reinsertion for 21 of them.Ninety-seven percent of the patients were playing rugby again after surgery, the longest delay being one year after the operation. A new episode of instability after major trauma was observed in six shoulders (17%), on average 3.8 years (range: 0.5 to 6) after the operation. Isolated capsule repair had the poorest prognosis (p=0.04). Compared with the contralateral side, external rotation decreased on average 6.2 degrees (elbow to chest) and 3.4 degrees at 90 degrees abduction. Subscapular muscle force decreased on average 2.05 kg. The Rowe and Duplay-Walch scores were good or excellent for 86% and 80% of shoulders, respectively. Patient satisfaction was 88%. According to Samilson, radiographic degeneration was noted in 32% of shoulders, with stage 1 osteoarthritis in 45% and stage 2 in 23%.Young age appears to be a major factor, predictive of recurrence after a first instability accident; the type of sport would only be indirectly involved. Nevertheless, for patients playing this type of contact sports, the appropriateness of surgical stabilization can be debated; arthroscopic anatomic methods have not yet yielded results equivalent to open surgery. The results in this series are similar to those found elsewhere in the literature, but with a follow-up longer than generally reported. Anatomic reconstruction of anterior stability elements enables these patients to resume their contact sport at an equivalent level with restored joint motion.

To analyze the shoulder joint complex in high level swimmers. We formulated the assumption that high level swimming weakens this complex, resulting in laxity of the anterior-inferior capsuloligamentous structures with atraumatic anterior instability, impingement with rotator cuff tendonitis and muscle imbalance of the rotator cuff muscles.Two 20-subject groups took part in this study (a group of high level swimmers and a group of sedentary people). The swimmers were all national-level front crawl specialists. The evaluations included clinical examination and isokinetic testing of the shoulder.Isokinetic testing (at 60 degrees /s) revealed that the swimmers have an external rotation/internal rotation ratio that is unbalanced (right shoulder: 0.52) and significantly lower than that seen in sedentary subjects (right shoulder: 0.75). Even though swimming is a symmetrical sport, our data confirm that intensive front crawl swimming involves asymmetry, with a stronger shoulder (right shoulder: 61.2+/-10.2 Nm; left shoulder: 52.8+/-9.8 Nm). The results of the clinical examination showed that 55% of the swimmers presented scapular protraction and that 35% were positive for mechanical impingement. These clinical elements were not observed in the control group. Laxity of the anterior-inferior capsuloligamentous structures was also noted in 67% of the swimmers.high level swimming ineluctably weakens the shoulder joint complex.

The aim of our study is to evaluate the efficacy of joint distension during arthrography followed by an intra articular corticosteroid injection.This procedure associated to a physical therapy started immediately after joint distension and performed during 3 months in the treatment of 20 patients suffering from adhesive capsulitis of the shoulder were assessed.Patients were evaluated on D 90:90 % of them have regression of pain, 70 % have an improvement of deficiency and ranges of motion of the shoulder. Adhesive capsulitis of the shoulder is a disabling pathology but, generally, with good evolution. It is a clinical diagnosis.Joint distension associated to physical therapy has an interest in treatment because of therapeutic and antalgic effect and also restoration of range of movement.

We searched for factors present preoperatively which could be used to predict the intensity of postoperative pain.We undertook a prospective study among all patients aged over 18 years who underwent shoulder surgery from January to September 2004 in our unit. The study included 86 patients for which the following data were noted preoperatively: past history of pain, intensity and duration of prior pain, triggering factors, localization, psychological context. The intensity of the postoperative pain was measured on a visual analog scale (VAS); measurements were noted up to 24 hours postop then at one month. Data processing was performed with Statview5.5.Significant postoperative pain was correlated with a prior history of surgical pain, with duration of prior pain, with intensity of preoperative pain, and with depression.Significant sustained preoperative pain can favor memory of pain leading to postoperative sensitivization of nociception neurons. Intense postoperative pain can favor the development of refractory chronic pain.Significant postoperative pain can be expected in the following situations: pain after prior surgery, presence of chronic pain sustained for more than six months, intense preoperative pain, state of depression.

The rotator interval corresponds to a defined triangular shaped anatomical region at the anterosuperior portion of the shoulder where specific pathological processes may occur. First, the morphological and functional anatomy of the region will be reviewed. Then, the role of different imaging modalities will be described along with pathological imaging features. Normal structures of the rotator interval may be imaged with modern techniques, including MR and CT arthrography. On the other hand, clinical evaluation of rotator interval pathology remains difficult; and no consensus exists concerning their management. Imaging characterization of rotator interval pathology could be a key factor for pre-therapeutic work-up.

The aim of this work was to compare the anatomic and functional effect on the subscapularis muscle of two ways of sectioning its tendon during Latarjet procedure: complete vertical section and Weaver section (partial section of the lower third preserving the upper part of the tendon).We compared two series (eight-year interval) of patients comparable for age, gender, form of instability, type and level of sports activity. Twenty-nine patients underwent complete vertical section (group 1) and 30 Weaver section (group 2). All were reviewed with minimum four year follow-up. The clinical analysis involved strength of internal rotation, the maximal hand-back distance, and the Constant and Duplay scores. The radiographic analysis was coupled with computed tomography in 46 patients (23 in each group). Loss of subscapularis muscle thickness compared with the non-operated side was noted as was the Bernageau fatty infiltration stage.No recurrent dislocation was noted in either group. There were six cases of nonynion in group 1 and seven in group 2. The Gerber was positive in five patients in group 1 and zero in group 2 (P=0.01). Loss of internal rotation strength between the operated and healthy side, expressed in percentage, was 48.4% for group 1 and 17.9% for group 2 (P0.0006). In group 1, the fatty infiltration stage of the subscapularis muscle was: stage 0 (n=3), stage 1 (n=11), stage 2 (n=3), stages 3 and 4 (n=6). In group 2, these stages were: stage 0 (n=21), stage 1 (n=1), stage 1 (n=2) and zero stage 3 and 4 (P0.0001).The Latarjet operation remains the reference procedure for anterior stabilization of the shoulder joint. The choice of the incision technique for the subscapularis muscle tendon remains a subject of debate. Recent studies have demonstrated the importance of subscapularis muscle trophicity to obtain a good mid- and long-term clinical outcome. We have ourselves demonstrated elsewhere that complete section of the subscapularis tendon leads to secondary tears and subsequent fatty degeneration.Our study demonstrates that Weaver section in the Latarjet procedure enables placing the bone block in conditions equivalent to those achieved with total section while preserving better trophicity of the subscapularis muscle.

Rupture of the brachial artery associated with radial nerve palsy in a context of exostosis of the proximal humerus has not been described to date in the literature. Our patient was a fourteen-year-old girl with a history of violent pain occurring suddenly with no prodrome or triggering factor. The pain was localized at the level of the proximal left humerus. Physical examination revealed the presence of a hematoma and complete motor radial nerve palsy. The diagnosis was not confirmed by computed tomography with contrast injection but was confirmed by magnetic resonance imaging which eliminated malignant transformation of the exostosis. After checking the neurovascular bundles and evacuating the hematoma, treatment consisted in resection of the exostosis and arterial repair with an autologous venous graft. We discuss the diagnostic and therapeutic challenges which present vascular complications due to exostosis.