The days of the Shoulder of the Holy Hospital Antoine of Paris made it possible this school to give a progress report on several of its therapeutic options. The Instructor André who chaired them particularly put forward the experiment of his service as regards repair of the lesions of the cap of the rotators. He entrusts to us his vision of the pathology of the shoulder.

 

 

. : It was much question of the broad ruptures of cap lasting this congress; which are your therapeutic guidelines?

A.A.: Currently in the broad ruptures of cap, when the rupture only interests known and under thorn-bush, our essential indication is the scrap of deltoid which makes it possible in the best cases to have a negotiable instrument of centring of the humeral head and in the usual cases to have at least a mattress of interposition living between the head and the roof. On the other hand when the ruptures extend beyond known and from under thorn-bush, i.e. when it reached there under scapular ahead and of the small round behind, it seems in our experiment that the scrap of deltoid is exceeded. In these cases there, currently, we do not have an ideal solution and it is probably necessary to wait more the possible for a long time by considering prosthesis of an intermediate type in the long term. It is not however very logical since one will try to solve a muscular problem of insufficiency by a prosthetic replacement.

. : What do you understand by rupture of known and of under thorn-bush?

A.A.: It is not really a rupture it is rather a trophic disappearance of known and under thorn-bush. I.e. one observes not only one disappearance of the tendons (which for the are known thorny one retracted with , and for under thorn-bushes stuck under the roof), but especially a lubricating atrophy of the fleshy bodies. Thus in fact, one is vis-a-vis an impossibility of direct repair by any other method that a scrap of deltoid (or another muscular scrap).

. : Which solution did you adopt before the scraps?

A.A.: Before the scraps we made . It is the technique which the Americans borrowed us, by calling it “debridement”. In practice we made a resection of the tendon of the long biceps if there existed still, a regularization of the banks of the rupture, a resection of the ligament and a with minima.

. : Did that give which result?

A.A.: That gave in the 2/3 of the cases a frank improvement on the pain but an functional improvement which was minor on mobility with a shoulder very . Especially in practically half of the cases, that evolved to an experimental osteoarthritis offset in the 10 years.

. : Was deterioration slow or fast?

A.A.: In general slow; apart from the industrial accidents we had a good impression but as from the third year the results were degraded gradually.

. : With is the scrap that degraded less quickly?

A.A.: Certainly, if there is an isolated rupture known/under thorn-bush with a good subscapular ahead.

. : It would seem that you wide the indications of scrap to average ruptures?

A.A.: Yes and we call that of the minicomputer-scraps. Where we formerly made on ruptures which make three centimetres in diameter and which expose the long biceps, and to avoid of the , we practice now a minicomputer-scrap . The aforementioned brings a trophic “” on the cap and allows a cicatrization of the rupture. It is very simple of realization because in these cases there is no offsetting of the head and the rupture being relatively limited, the joinings are done without voltage.

. : Don't you think that by making a plastic surgeon of update of the cap you could obtain the same thing?

A.A.: Yes but in this case, one decreases the articular capacity of the glenohumeral one, one decreases rotations and I think that they are not good.

. : Is needed the banks of the rupture?

A.A.: One needs but while being rather sparing. In practice the banks should simply be revived, to remove all that is sclerous and to arrive not out of tissue frankly bleeding because one does not arrive there always but out of tissue of good .

. : How are you explained that the relatively old technique of the scrap proposed by remains so confidential?

A.A.: Several mailmen can explain disappointments of those which took this route. Initially the technique of realization is not always precise, then the postoperative treatment were not led according to the sequence which we recommended. Moreover, some attacked very broad ruptures which largely exceeded known and under thorn-bush, had failures as we had of it besides on this type of patients. I thus think that the bad realization either of the technique or of the postoperative treatment associated with an indication pushed a little towards very broad ruptures beyond any resource discredited this technique a little. In addition, the deltoid was always regarded as the Master muscle of the shoulder and touch to the deltoid plank the heresy for many surgeons.

. : Precisely, which are the important technical details?

A.A.: It is necessary well to take the former beam of the average chief; it is important, and not to shift ahead or behind. The deltoid should not too much be dissociated ahead because there are branches of acromio-thoracic which the former party of the scrap. It is necessary well to individualize the banks of the cap on which one will suture: it is not always very easy especially behind between under round thorn-bush and small where it is rather difficult to make the distinction between the small round only one makes go up starting from his insertion on the and under thorn-bush which is in a different plan and which is installed under the ; the dissection is a little difficult to arrive at following the bank of the perforation well behind. It is necessary to pass all the stitches before tying wire, like one does it for a digestive joining, and then to tie all the points the ones after the others by distributing tractions well on the scrap.

. : How to explain frequent the good tolerance of the great ruptures of cap?

A.A.: It is conventional to say that for a long time there is no parallelism anatomo-private clinic. I.e. there are very small ruptures very badly tolerated on tight shoulders and very broad ruptures which are very well tolerated on relatively cowardly shoulders. That depends on the quality of the flexibility of the capsule. A quite mobile shoulder without any will tolerate large lesions of cap, whereas a a little tight shoulder with a lower very very badly will tolerate a small lesion. This is why, for a long time, certain broad ruptures are relatively well tolerated. And then one day, either for lack of use, or by immobilization at the time of an intercurrent traumatism, the shoulder and the rupture will become very badly tolerated.

. : What do you propose in the small ruptures?

A.A.: In the small ruptures, when they are badly tolerated, we make if the long biceps is not discovered. If the long biceps is exposed, there are the choice between two solutions: either the if it is really very pathological or, if it seems preservable, to make a mini scrap.

. : One can also close the cap?

A.A.: One can also close the cap but on the condition of being able to make a longitudinal joining, but it is rare.

. : Why not make a conventional joining?

A.A.: Because the reintegrations bone-tendon go badly. Moreover, if you reintegrate the area broken of the cap on the you create a shift between the proximal part of the rupture and the healthy party of the cap which remains inserted on the . To be logical it is necessary to dissociate the broken portion of the cap of the healthy portion ahead and behind so as to mobilize only the pathological portion for then reintegrating it on the ; in any event, an area of the cap will be under voltage, beside the other muscles which will keep a physiological voltage: in my opinion that cannot function in a physiological way.

. : How do you carry out the subacromial before?

A.A.: We in fact only the ligament , by carrying its area of insertion what led us to literally peel the antéro-lower face of the . We did it by delto-pectoral channel, and we were nevertheless less better for will seek this insertion; it was primarily a resection of the ligament .

. : What do you think of the ?

A.A.: The isolated , I do not conceive it; it is only a associated with the resection of the ligament . That belonged to the release of a mechanical conflict by enlarging the procession under .

. : You extended your indications of scrap to the joint replacements…

A.A.: We carry out our arthroplasties by supéro-external channel in routine, by raising the known thorny one; also, when we have a perforation of the cap we finish the intervention by a scrap of deltoid which enables us to seal off the cap. When we leave on a prosthesis where we know that there is a lesion of the cap, the channel initially is done everything, and we make our joint replacement through the perforation of the cap. Then we finish by sealing off the hinge by a scrap of deltoid. But there still the limits of this technique of not more forced arthroplasty scrap are the limits of the scrap. I.e. one can make this intervention only if there is a perforation either limited to the know-thorn-bush but there it is simply a complement to finish suturing the cap, or a rupture of known and under thorn-bush but not reaching under scapular ahead nor the small round behind. The ideal is to even have a small blade of under thorn-bush behind which stabilizes the small round. At this time there the scrap goes very well and there are results which are comparable with those of a prosthesis not forced without scrap on healthy cap. But as soon as one has a rupture which leaves ahead on under scapular (more of the third party of under scapular), or when one has a lesion which leaves behind and which involves a lesion of the small round, at this time there the scrap is exceeded, the prosthesis will migrate in top, will offset and give a poor performance.

. : And if one exploits the size of the head and that one tries to close the cap longitudinally…

A.A.: Not, because one will decrease the articular capacity considerably and that at this time there one will have a difficult rehabilitation, and a prosthesis which will not recover mobility. A poor result will be obtained because one will automatically have a with a higher solicitation and the joinings of cap will release. A joining of cap can hold only on flexible shoulder. If there exists a or if one reduces the articular capacity by making scraps of capsular rotation what returns to same one will have problems on the level of the cap because there will be no possibility of abduction free.

. : Does that say the scrap carries out primarily only one interposition?

A.A.: Completely. But one obtains an active negotiable instrument of centring about in 1/4 of the cases. It is difficult to appreciate because one cannot impose on operated who are well, of the imageries constraining and repeated during years.

. : What do you think, when one gave up any repair, of humeral prostheses of famous person?

A.A.: We prefer the intermediate prostheses which we currently develop. It is a solution for offset osteoarthritides stage II because in these cases there is already a thus a which is done everything and which only requires to accept a floating cup of intermediate prosthesis. But it is also certainly the indication in the great ruptures of nonreparable cap by a scrap of deltoid. As soon as the rupture overflows on more of the higher third party of under scapular ahead and the small round behind, any prosthesis not forced with scrap is exceeded and at this time there one can propose prosthesis of an intermediate type.

. : But it is necessary that it is fixed…

A.A.: It is necessary to be able to fix it and thus adhere to the totality of the roof absolutely, i.e. not only the ligament but all the osteophytes of the : one should not touch with the . It is thus necessary: firstly, to respect the totality of the roof strictly what is not easy, and secondly to create a if required if the spontaneous is not good by cutting down the upper pole of for centering well and fixing well the cup under the roof . It is necessary to give a little more retroversion to the prosthesis for stabilizing the under the well so that it does not leave in top and ahead, which is the shelf of this type of prosthesis. But obviously they are prostheses with small scores: they will give you an abduction to 80-90° and good rotations.

. : Do you think that there remains still a place for the total prosthesis of shoulder?

A.A.: I think that the best clinical results are obtained with the total prostheses insofar as the indications are well posed. One can make the impasse on the replacement , but the indolence, which is nevertheless the main element that one seeks, is obtained with the total prostheses. It is certain that the fact of putting simple humeral prostheses solves the problem of unsealings of but indolence is never also good. Practically all the statistics, in all the series are concordant on this point.

. : How do you explain the failures of the parts standard ?

A.A.: Because anchoring is very bad in the neck of the scapula. There is in fact only one vertical aileron in a neck of the extremely thin scapula and one is far from the possibilities of anchoring of a or one really has of a hemisphere full and a hemisphere hollow with a distribution with the pressures and stresses very favorable. With there is always a negotiable instrument of rocker which it is very difficult to compensate, and there will all the more be this solicitation which the shoulder will be less mobile. If the operated shoulders are very mobile the loosen little, or there are nonevolutionary edgings which are well tolerated, whereas in the case the reverses is very requested with a negotiable instrument breaks nut at the upper part of the implant: when the bottom of lower bag of the capsule does not open in abduction, it occurs a higher on the which tends to tilt and to loosen itself.

. : You developed your own shoulder prosthese; it is a prosthesis of moreover?

A.A.: Not it was conceived completely differently. I reproached much thing , initially to be very , therefore to be aggressive for the cap with a horse negotiable instrument which was required besides at the beginning by to try to increase the effectiveness of the cap but which in fact was practically balanced by a rupture of cap in a case on three. We thus actually developed a prosthesis in the concern essential to spare the cap. It and corresponds more to the normal anatomy of the higher of the humerus.

. : Does that want to say what, little ?

A.A.: 135°. In addition the head has a variable radius of curvature i.e. a radius of curvature which is larger with the upper pole with the aim of gum the upper pole of the prosthesis literally and to make it not very aggressive for the cap. It was wanted that the upper pole of the prosthesis is practically on the level of the , does not exceed it especially and that the cap with the top of this prosthesis is really without voltage. Incidentally one also wanted to make a prosthesis which supported association bearing update. Indeed, the presence of joint surfaces far from congruent with the level of the shoulder with a surface of humeral head much larger than that of implies obligatorily the association of bearing and update to lead to the physiological articular amplitudes. Prosthesis AP is in fact a compromise with a hinge of the condylar type, as on the level of the knee, or there is typically a negotiable instrument bearing update of a condyle on a more or less plane surface.

. : Didn't this rolling-gliding negotiable instrument exist with hemispherical prostheses?

A.A.: If, but it were not sought. In fact, if there are completely congruent surfaces, as soon as the overall amplitude permitted by joint surface is reached, one stops mobility in the glenohumeral one.

. : Do you think that this subtle biomechanical innovation results in a clinical advantage?

A.A.: It is difficult for me to answer objectively. What I know, it is that with these prostheses we have incomparable results compared to those which we obtained with the other prostheses.

. : With a technique which was identical?

A.A.: To tell the truth, the supéro-external channel certainly also influences the results. The respect of under scapular is, I think, fundamental in prosthetic surgery of the shoulder. Thus the fact of not cutting the subscapular, and of keeping this essential stabilizing brake of the shoulder, plays a very important part; in the same way the form of joint surfaces spares the cap and supports its share. I believe that one has results, on mobility in particular, which are really very good.

. : Your approach is paradoxical. The common pathway passes through under scapular and with much of precautions to adhere to the known thorny one. You recommend in fact the reverse!

A.A.: Absolutely. But it is an experience gained as a practitioner the surgery of the degenerative cap. Paul had said a long ago that the know-thorn-bush was not at all the essential muscle of the shoulder; it is not the “choke” of abduction as it at the time was said. We observed good number of shoulders without know-thorn-bushes, (some is the etiology) and which, while remaining flexible, tolerated their rupture perfectly by keeping a rigorously normal abduction. It is on the basis of this official report, and with the purpose of being able to carry out channel consequently initially a scrap of deltoid in the event of difficulties of repair of cap that we came from there to pose the prostheses by supéro-external channel, channel of the scrap at the beginning. I do not have a scruple to cut one known thorny; I cut it in the area known as , about with m of insertion; in this area the internal bank is vascularized by the muscular body, and the external area is vascularized by osseous insertion: there are all the chances to have a good cicatrization, whereas the reintegrations tendon-bone are always random.

. : One can to you the same thing for the subscapular…

A.A.: Yes but the experiment proves that any subscapular which was cut recovers very badly. It is a observation almost of rule in repeating luxations. When one re-examines the subjects of the years after an intervention by delto-pectoral channel for instability and if the subscapular were cut, one realizes that the muscle is not worth anything; one leads to antéro-posterior destabilizations and if one asks a or for MRI one realizes that there is not practically more subscapular. When one by delto-pectoral channel one does not find large any more thing ahead.

. : From which does the tradition come from the shoulder surgery to Saint-Anthony?

A.A.: I think that it is Jean who is interested there the first, especially with instabilities of the shoulder since it is him which had described the technique of the armed costal stop. That goes back to beginning of the year 50.

. : How this general surgeon did come from there to the shoulder?

A.A.: It was always interested in traumatology and the bone surgery inter alia. That corresponded to its spirit: he liked mechanics, manual work, all that was a little “do-it-yourself”. He had manufactured acrylic resin hip prosthese besides at the same time as . It was interested much in the tibial plateau fractures, with repeating luxations of the shoulder. In parallel its assistant Paul was interested in the degenerative shoulders, the ruptures of cap and directed himself towards the channel of the whereas everyone was repairing on the caps. became the “liberator” of conflict and the tradition of the shoulder at the Saint-Anthony hospital gradually continued.

. : Jean left the memory of a strong personality…

A.A.: Yes, it is the least which one can say. But it was a man who had many ideas, which was very innovator, excel operator and who was interested much in surgeries as different as the hand surgery, shoulder, stomach, of the colonist and uterus. It described many techniques. The abdomino-perineal amputation of the rectum with double team it was also a technique of Jean . It was a very open spirit, very curious, very humanistic and which learned to me much.

. : also had a strong personality. How it was between them…

A.A.: It was a muscular if not permanent competition at least frequent between two personalities which could all at the same time only run up, to appreciate itself much and to push back itself possibly much. They had also a different ethics, since the owner catholic was convinced and Protestant . The “divorce”, let us say the relative separation of the paths, was done after . At the time, was extremely against all this agitation and ran up there of face whereas Jean rather tried to understand it.

. : on the side of the Command?

A.A.: It is true that was anticonformist in its design of the surgery and that it questioned all the generally accepted ideas. But it had a certain vision of hospital medicine and hierarchy of a service. He thought that agitation would lead to an opposite result of what the students wished. I think that it was not entirely wrong.