Arthroscopic osteochondral autograft transfer for juvenile osteochondritis dissecans of the humeral head

CASE: Osteochondritis dissecans (OCD) rarely affects the humeral head. We describe a 14-year-old adolescent who, despite conservative treatment, had persistent pain in the left shoulder as well as limited function. Radiographs and a computed tomography (CT) arthrogram revealed an osteochondral defect of the humeral head. He was managed with an arthroscopic osteochondral autograft transfer from the knee, which provided a satisfactory outcome. CONCLUSION: Arthroscopic osteochondral autograft transfer is an effective option for the treatment of OCD of the humeral head

Mini invasive axillary approach and arthroscopic humeral head interference screw !xation for latissimus dorsi transfer in massive and irreparable posterosuperior rotator cuff tears.

Abstract: As the number of shoulder surgeries is increasing, the challenges of treating the massive and irreparable rotator cuff tears pose an operative challenge for the shoulder surgeons. The purpose of this study is to propose a new mini invasive axillary incision (5 cm) for harvesting latissimus dorsi (LD) tendon and arthroscopic-assisted interference screw fixation of the transfer on the humeral head for the treatment of massive and irreparable posterosuperior rotator cuff tears. We describe our technique. The incision is minimized with the help of ultrasound Doppler-guided identification of the LD pedicle preoperatively. This study also makes clear how to maintain the tension on the pedicle of the LD uniform before and after the fixation of the transfer. During our experience of 17 cases from November 2007 to July 2009, we had good-to-excellent results in patient satisfaction. The clinical outcomes were not indifferent from the other methods of fixation. Key Words: latissimus dorsi transfer, massive irreparable posterosuperior cuff tear, iterative cuff tear, interferrence screw latissimus dorsi fixation, arthroscopic latissimus dorsi fixation, mini invasive axillary approach (Tech Should Surg 2010;11: 8--14) T he incidence of the challenges for massive and irreparable rotator cuff tears is on the raise in the patients attending shoulder specialty centers for surgery. Some of these patients have already been operated by open or arthroscopic technique even before the age of 50 years. Gerber et al 1 is the first to publish the latissimus dorsi (LD) tendon transfer for the treatment of these massive irreparable rotator cuff tears. The LD flap is well known and widely used in other specialties such as breast reconstructions and paralytic shoulder owing to birth palsy in pediatric orthopedics. 2 Gerber 3 and Gerber et al 4 discussed in detail regarding the indications and contraindications for the LD transfer. He concluded that when posterosuperior rotator cuff tears were associated with subscapularis tears, the LD transfer is contraindicated. Other authors 5-10 also confirmed bad results in case of subscapularis tears, deltoid anterior deficit, proximal migration of the humeral head, preoperative poor function of the shoulder, and as a salvage procedure. Whereas the patient selection plays an important role in success of this transfer, it remains a viable and effective option for younger patients with massive and irreparable rotator cuff tears. Moreover, constantly great tuberosity is fragile owing to earlier surgery or lack of mechanical stimulus chronically by the absence of rotator cuff musculature. The technical difficulties of fixation of the LD transfer on to osteoporotic bone need to be studied in detail. Gerber et al 1 fixed the transfer to the subscapularis with transosseous sutures. Warner and Parson 6 fixed the transfer on to the greater tuberosity by transosseous sutures. Habermeyer et al, We hypothesized that the reasons for failures of this transfer were not only owing to invasive and open surgery (new deltoid injury), but also owing to lack of adequate strong and stable fixation of the LD tendon on to the greater tuberosity. From the experience of the anterior cruciate ligament (ACL) reconstruction of the knee and from the work of Boileau et al 14 in the tenodesis of long head of biceps into the humeral head, we describe a new mini invasive technique for harvesting the LD tendon, new technique of fixation by tubularization, and interference screw (IFS) fixation into a bone tunnel made in the humeral head. This fixation initially carried out by open procedure now switched to arthroscopically assisted procedure as our experience increased and it was more advantageous. This procedure is a viable alternative to the existing techniques in the hands of surgeon who is skilled in arthroscopic management of shoulder pathology. The specific biomechanical study conducted under the guidance of Jean Grimberg (personal communication) has concluded that the IFS fixation of the LD transfer on the humeral head is equal or slightly better than the multiple anchor fixation technique. Various studies OPERATIVE TECHNIQUE The patient is in lateral position with shoulder in 30 degrees abduction, slightly tilted toward the back, and a 3 kg traction. The operative position allows free wide access to the shoulder, entire scapula, and its apex as this transfer needs free movement of shoulder and arm. This position also allows easy shifting over from open axillary approach for LD tendon harvesting to shoulder arthroscopic fixation of the transfer. It is important at this point to mention that the LD muscle neurovascular pedicle enters from the medial and under surface of the muscle from about 10 cm from humeral insertion of the LD tendon and 2 cm from the lateral scapular border. The exac

A subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of shoulder in Erb's palsy (SPARC procedure)

The purpose of this study was to evaluate a minimally invasive subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of the shoulder due to Erb's palsy. We performed our procedure (subscapularis-preserving arthroscopic release of capsule) in 10 paediatric shoulders with an average age of 20.2 months and followed them for an average period of 41.5 months. All the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used for analysing the results. The average gain in passive external rotation was 508. The active internal rotation was preserved in all the cases. With the mid-term follow-up, there was no loss of the gained external rotation or the recurrence of internal rotation contracture of the shoulder. Our hypothesis has achieved its goal in preserving subscapularis, active internal rotation and treatment of internal rotation contracture of the shoulder. The success of this procedure lies in the early identification of starting of internal rotation contracture and early surgical intervention to prevent progressive permanent glenohumeral osseocartilaginous deformity

Management of massive rotator cuff tears: prospective study in 218 patients

BACKGROUND: No consensus exists about the management of massive and symptomatic rotator cuff tears (RCTs). The objective of this study was to compare the 12-month clinical outcomes of various treatment options for massive RCTs. HYPOTHESIS: Arthroscopic surgery has a role to play in the treatment of massive and apparently irreparable RCTs. MATERIAL AND METHODS: A prospective multicentre non-randomised study was performed in patients with massive RCTs managed non-operatively (NONOP) or by arthroscopic tenotomy/tenodesis of the long head of biceps (aTLB), arthroscopic partial tendon repair (aPTR), arthroscopic latissimus dorsi transfer (aLDT), or reverse shoulder arthroplasty (RSA). Clinical outcomes were evaluated based on the Constant score, Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) score after 3, 6, and 12 months. RESULTS: The 218 included patients (mean age, 69 years) were distributed as follows: NONOP, n=71; aTLB, n=26; aPTR, n=61; aLDT, n=25; and RSA, n=35. After 12 months, the mean Constant score, SSV, and ASES score values were 70, 68%, and 73, respectively, and had improved significantly versus the preoperative values in all treatment groups. RSA was the only treatment followed by improvements in all Constant score items. Active forwards elevation improved significantly in the NONOP (+25°), aPTR (+26°), and RSA (+66°) groups. An improvement in active external rotation was seen only in the RSA group, where it was small (+10°, p=0.046). Significant increases in internal rotation were seen in the NONOP (+1.6 points) and aPTR (+1.7 points) groups. CONCLUSION: Arthroscopic techniques (aTLB, aPTR, and aLDT) for managing massive irreparable RCTs produce significant functional gains. Partial tendon repair (aPTR) and RSA may provide better outcomes than isolated aTLB or aLDT

Amélioration de productivité d'un atelier de conditionnement sur le site du laboratoire Merck-Serono de Semoy

Cette thèse porte sur l'amélioration de la productivité du département de conditionnement du Laboratoire de Semoy. Cette thèse aborde l'importance de l'application de l'amélioration continue pour les laboratoires pharmaceutiques puis dans un second temps, quelques uns des outils de l'amélioration continue sont présentés (TPM, 5S, 6 Sigma, SMED, Lean Manufacturing). La dernière partie est consacrée à différents exemples d'application dans les laboratoires Merck Serono avec la description d'un projet de diminution du nombre des lignes, la mise en place de l'amélioration des lignes hautes cadences et la mise en place d'un atelier 5S dans le local des pièces détachées. Cette thèse comporte 35 références bibliographiques.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF

Combined Fully Arthroscopic Transfer of Latissimus Dorsi and Teres Major for Treatment of Irreparable Posterosuperior Rotator Cuff Tears

Many treatment options have been proposed for treatment of irreparable posterosuperior rotator cuff tears. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before development of glenohumeral arthritic changes, aiming at rebalancing the shoulder with a functioning subscapularis muscle and restoring both active external rotation and elevation with the aid of a properly functioning deltoid muscle. The technique was recently adapted from open to arthroscopically assisted with numerous advantages. We propose a combined fully arthroscopic technique for transfer of latissimus dorsi and teres major in which the tendons are fixed in a flat manner at the junction of supraspinatus and infraspinatus to decrease failure rate

Arthroscopic Coracoacromial Ligament Transfer Augmented With Suspensory V-Shaped Fixation System for Chronic Acromioclavicular Joint Dislocation

Chronic acromioclavicular joint dislocations (ACJDs) develop when there is failure of conservative treatment, failed surgical treatment of acute ACJD, or simply missing the treatment in the acute healing phase. There is wide agreement that mechanical fixation alone in chronic ACJD is not sufficient and biological augmentation is necessary. Various arthroscopic techniques for reconstruction of the coracoclavicular ligament have been described, but allografts are expensive, are not available in all centers, carry the risk of disease transmission, and are “dead tissue” with a poor capacity for healing. Autografts are associated with donor-site morbidity and avascular structures. Moreover, these grafts are associated with a high risk of clavicular or coracoid fractures owing to large tunnels. We present an arthroscopic technique to transfer the coracoacromial ligament to the inferior surface of the lateral part of the clavicle in chronic ACJD, augmented with 2 clavicular buttons and a single coracoid button in a V-shaped configuration. The technique has various advantages including better stabilization, anatomic reconstruction, and a minimal risk of fracture of the coracoid and clavicle with small tunnels, using a vascularized graft with arthroscopic control of reduction

Optimisation préopératoire afin de prévenir les infections de prothèses articulaires

International audienceAu cours des dernières décennies, des progrès significatifs ont été réalisés dans la prévention de l’infection des prothèses articulaires, notamment dans la gestion de l’environnement et de l’antibioprophylaxie. Toutefois, une part significative du risque est liée au profil du patient, avec des facteurs de risque modifiables ou non. Basé sur la littérature récente, nous proposons les attitudes suivantes pour « optimiser » le patient avant la chirurgie et réduire le risque d’infection : (1) la réalisation d’un examen cytobactériologique des urines préopératoires n’est pas nécessaire en l’absence de symptômes, en revanche le traitement d’une infection urinaire symptomatique est indispensable ; (2) les patients avec des foyers dentaires patents doivent être identifiés et pris en charge, car plus à risque d’infection de prothèse ; (3) une prise en charge nutritionnelle/endocrinologique doit être proposée aux patients obèses (indice de masse corporel > 40 kg/m2), dénutris (albumine 7,5–8 %) ; (4) une prise en charge de l’anémie doit être évoquée, mais la supplémentation en fer n’est pas toujours efficace, et l’administration d’érythropoïétine est coûteuse ; (5) les biothérapies pour rhumatisme inflammatoire doivent être suspendues, avec un délai dernière injection – prothèse qui est spécifique à chaque molécule ; (6) l’arrêt du tabac est préconisé au moins quatre semaines avant la chirurgie ; (7) la recherche d’un portage nasal à Staphylocoque aureus ne doit pas être systématique, mais peut être proposée dans une stratégie de dépistage-décolonisation en cas de prothèse de révision, de tabagisme ou d’obésité ; (8) une décolonisation d’un portage nasal à S. aureus est à proposer systématiquement si le patient est connu porteur de S. aureus résistant à la méticilline, ou si un portage est authentifié ; (9) une recherche systématique d’un portage rectal à bactérie multirésistante (BMR) n’est pas nécessaire, mais l’application de précautions complémentaires d’hygiène de type contact lors du séjour chirurgical est à envisager pour les patients connus porteurs de BMR. Niveau de preuve : V, avis d’expert