Purpose of the study: For patients aged less than 65 years who have a large rotator cuff tear, potential solutions include anatomic repair, palliative treatment, non-anatomic repair with flaps or cuff prosthesis, and reversed prosthesis. The later solution is not recommended at this age and anatomic repair is not always possible. In this situation, what is best, palliative treatment or flap or prosthesis repair?

Material and method: This retrospective multicentric study included 142 patients, 74 men and 68 women with a large or massive cuff tear. Palliative treatment (group A) involved acromioplasty (n=48) associated as needed with a biceps procedure and partial repair (n=41). Non-anatomic repair (group B) included supra-spinatous translation (n=16), deltoid flaps (n=22), and cuff prostheses (n=15). Preoperatively, the two groups were not statistically different for acromiohumeral height (AH, 6 mm in group A versus 7.5 mm in group B) and percent of fatty infiltration of the infraspinatus > II (55% in group A versus 26% in group B). The Constant score, active and passive range of motion, gain in elevation and external rotation were noted.

Results: Mean follow-up was 74 months in group A and 90 months in group B; the Constant score was 64 and 65, active elevation 145 and 147 and external rotation 17 and 26 respectively. The two groups were not significantly different. For patients with deficient elevation (n=46), the gain was 62 without any difference between the two groups. For patients with deficient external rotation (n=37), the gain was nil in both groups.

Discussion: Although group A had a more severe condition than group B (narrower AH and more advanced fatty degeneration, the final outcome as assessed by the Constant score and range of motion was similar. Both groups recovered active elevation well, but not external rotation. Nevertheless, there were no cases of latissimus dorsi transfer in this series. Repair with a deltoid flap, supraspinatus translation, or cuff prosthesis does not appear to add any supplementary benefit despite the more aggressive surgery.

Purpose of the study: Covering cutaneous tissue loss of the distal quarter of the leg and ankle remains a difficult surgical challenge. We report our experience with a new lateral hemisoleus island flap with a fibular pedicle specifically adapted for large-sized defects.

Material and method: Preliminary anatomic work on 15 injected legs demonstrated that:

the dimensions of the muscular part of the lateral head of the soleus measures on average 218 mm (range 160–270) in length and 73 mm (range 58–95) in width, sufficient for large “tailored” flaps;

Results: Three patients treated with success are presented. The advantages of the technique are large muscle volume, safe vascular supply and significant mobility. Drawbacks include sacrifice of the fibular artery and difficult dissection of the fibular pedicle. Preoperative precautions are indispensable: arteriography, exclusion of contusion cases affecting the muscle masses or compartment syndrome.

Discussion: The lateral hemi-soleus flap can be a useful therapeutic option for major tissue loss on the distal quarter of the leg, the ankle, or even the foot. It is an attractive alternative to free flaps, the only other solution for large defects.

The purpose of this study is to report the results of arthroscopic Bankart repair following failed open treatment of anterior instability.

We performed a retrospective review of twenty-two patients with recurrent anterior shoulder instability (i.e. subluxations or dislocations, with or without pain) after open surgical stabilization. There were seventeen men and five women with an average age of thirty-one years (range, 15–65). The most recent interventions consisted of sixteen osseous transfers (twelve Latarjet and four Eden-Hybinette), three open Bankart repairs and three capsular shifts. The causes of failure were additional trauma in twelve patients and complications related to the bone-block in thirteen (poor position, fracture, pseudarthrosis or lysis). All patients were noted to have distension of the anterior-inferior capsular structures. Labral re-attachment and capsulo-ligamentous re-tensioning with suture anchors was performed in all cases with an additional rotator interval closure in four patients and an inferior capsular plication in twelve patients; the bone block screws were removed in eight patients.

At an average follow-up of forty-three months (range, twenty-four to seventy-two months), nineteen patients were evaluated by two independent observers. One patient had recurrent subluxation, and two patients had persistent apprehension. Anterior elevation was unchanged, and loss of external rotation (RE1) was 6°. Nine patients returned to sport at the same level; all patients returned to their previous occupations, including the six cases of work-related injury. Eighty-nine percent were satisfied or very satisfied; the subjective shoulder value (SSV) was 83% ± 23%; the Walch-Duplay, Rowe and UCLA scores were 85 ± 21, 81 ± 23 and 30 ± 7 points respectively. The number of previous interventions did not influence the results. Eight patients (42%) were still painful (six with light pain and two with moderate pain).

Arthroscopic revision of open anterior shoulder stabilization gives satisfactory results. The shoulders are both stable and functional. While the stability obtained with this approach is encouraging, our enthusiasm is tempered by some cases of persistent pain.