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Background: Reverse shoulder arthroplasty (RSA) offers promising functional outcomes for young patients, yet challenges persist in restoring internal rotation (IR). This study aimed to assess the restoration of IR after RSA in patients younger than 60 years of age and analyze the factors affecting IR recovery., Methods: A retrospective multicenter study was conducted, examining the functional outcome of patients who underwent RSA, with a minimum follow-up period of 2 years. Two subgroups of patients who underwent primary RSA were analyzed separately with respect to active internal rotation with the elbow at the side (AIR1): "difficult AIR1" and "easy AIR1.", Results: The study included 136 patients (overall series) with a mean age of 51.6 years. The overall series showed statistically significant improvement in active range of motion (RoM), pain, and Constant scores, especially with active IR (p ​< ​0.01). According to etiology, statistically significant improvement (p ​< ​0.05) in active IR was observed for fracture sequelae, primary osteoarthritis, and rheumatoid arthritis, whereas no statistically significant improvement in IR was observed for tumor, revision, and cuff-tear arthropathy (p ​> ​0.05). In subgroup analysis, patients with easy AIR1 displayed a statistically significant lower body mass index and better Constant score mobility, as well as improved motion in forward elevation and active IR (p ​< ​0.05). No statistically significant associations were found between improved IR and prosthetic design or subscapularis repair. Scapular notch, lysis of the graft, and teres minor atrophy were significantly associated with better active IR (p ​< ​0.05)., Conclusion: RSA improves active RoM, pain, and functional outcomes in patients aged under 60. However, the degree of improvement in IR may vary depending on several factors and the underlying etiologies. These insights are crucial for patient selection and counseling, guiding RSA optimization efforts., Level of Evidence: IV., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest in relation to the research, authorship, and/or publication of this work., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

We report here a rare case of an acute peripheral nerve compression by pseudotumoral calcinosis (PCT) at the right elbow in a patient with severe tertiary hyperaparathyroidism. This complication required urgent multidisciplinary management. Surgical decompression by PCT resection enabled rapid motor and sensory recovery., Competing Interests: There are none., (© 2024 Published by Elsevier Inc.)

Background: Glenoid bone loss (GBL) calculation in patients with shoulder instability has a wide variability in methods and their reliability. The purpose of this study was to describe and validate a new semi-automated software developed to improve GBL calculation using a 3D imaging modeling (IODA-shoulder) and to compare the method to the PICO area method., Patients and Methods: A semi-automated software to assess GBL was preliminarily developed and validated on 7 fresh frozen specimens (scapulae with artificially created glenoid defect), using water displacement method. Afterwards, the software was retrospectively used on CT images of 20 patients affected by recurrent shoulder dislocation. Inclusion criteria were: unilateral dislocation, minimum 2 dislocation episodes. Exclusion criteria were bone reconstruction of the glenoid, failed shoulder stabilization, bilateral dislocation, shoulder arthritis. Three-dimensional computed tomography images of bilateral shoulder were retrieved for each patient. Two methods to determine GBL were compared. The PICO surface area method and the new IODA method. We assessed the intra- and inter-rater reliability of the two methods with the Intraclass Correlation Coefficient (ICC), the Bland-Alman analysis, and Lin's concordance correlation coefficient (CCC)., Results: We did not find a statistically significant difference between the mean volumes calculated with PICO and IODA methods, respectively 914 vs. 815 mm 3 , p=0.155. The analysis carried out by using the traditional PICO method showed a lower concordance rate among four observers than the higher concordance found using IODA method, regardless of the size and the location of the defect. The ICC agreement with PICO was significantly lower than with IODA (0.76 vs. 0.97). We found a poor CCC with PICO (from 0.65 to 0.81) and a substantial one with IODA (from 0.96 to 0.98)., Discussion: The intra- and inter-rater reliability using IODA method is significantly better than PICO method. The assessment of GBL using IODA method is time saving, avoiding significant inter- and intra-observer variation, mainly due to individual skill and experience in the method., Level of Evidence: IV, experimental study., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Neer's classification for proximal humerus fractures (PHFs) uses 10 mm and 45° thresholds to distinguish displaced fragments. While this system was originally developed referencing 2D X-rays, fracture displacements occur in three dimensions. Our work aimed to develop a standardized and reliable computerized method for measuring PHF 3D spatial displacements. CT scans of 77 PHFs were analyzed. A statistical shape model (SSM) was used to generate the pre-fracture humerus. This predicted proximal humerus was then used as a "layer" to manually reduce fragments to their native positions and quantify translation and rotation in three dimensions. 3D computerized measurements could be calculated for 96% of fractures and revealed that 47% of PHFs were displaced according to Neer's criteria. Valgus and varus head rotations in the coronal plane were present in 39% and 45% of cases; these were greater than 45° in 8% of cases and were always associated with axial and sagittal rotations. When compared to 3D measurements, 2D methods underestimated the displacement of tuberosity fragments and did not accurately assess rotational displacements. The use of 3D measurements of fracture displacement is feasible with a computerized method and may help further refine PHF analysis and surgical planning.

Introduction: The purpose of this study was to analyze the real range of motion (RoM) measured in patients operated on for reverse shoulder arthroplasty (RSA) and compare it to the virtual RoM provided by the preoperative planning software., Hypothesis: There was a difference between virtual and real RoM, which can be explained by different factors, specifically the scapula-thoracic (ST) joint., Methods: Twenty patients with RSA were assessed at a minimum follow-up of 18 months. Passive RoM in forward elevation abduction, without and with manually locking the ST joint, and in external rotation with arm at side were recorded. The humerus, scapula, and implants were manually segmented on post-operative CTs. Post-operative bony structures were registered to preoperative bony elements. From this registration, a post-operative plan corresponding to the real post-operative implant positioning was generated and the corresponding virtual RoM analysis was recorded. On the post-operative anteroposterior X-rays and 2D-CT coronal planning view, the glenoid horizontal line angle (GH), the metaphyseal horizontal line angle (MH), and the gleno-metaphyseal angle (GMA) were measured to assess the extrinsic glenoid inclination, as well as the relative position of the humeral and glenoid components., Results: There were some significant differences between virtual and post-operative passive abduction and forward elevation, with (55° and 50°, p < 0.0001) or without ST joint participation (15° and 27°, p < 0.002). For external rotation with arm at side, there was no significant difference between planning (24° ± 26°) and post-operative clinical observation (19° ± 12°) ( p = 0.38). For the angle measurements, the GMA was significantly higher (42.8° ± 15.2° vs. 29.1°± 18.2°, p < 0.0001), and the GH angle, significantly lower on the virtual planning (85.2° ± 8.8° vs. 99.5° ± 12.5°, p < 0.0001), while the MH was not different ( p = 0.33)., Conclusions: The virtual RoM given by the planning software used in this study differs from the real post-operative passive RoM, except for external rotation. This can be explained by the lack of ST joint and soft tissues simulation. However, in focusing on the virtual GH participation, the simulation looks informative. Some modifications between the glenoid and humerus starting positions before running the motion analysis could be provided for making it more realistic and predictive of the RSA functional results., Level of Evidence: III.

The aim of this study was to evaluate the variation in measured glenoid inclination measurements between each of the most used methods for measuring the scapular transverse axis with computed tomography (CT) scans, and to investigate the underlying causes that explain the differences., Methods: The glenoid center, trigonum and supraspinatus fossa were identified manually by four expert shoulder surgeons on 82 scapulae CT-scans. The transverse axis was generated either from the identified landmarks (Glenoid-Trigonum line (GT-line), Best-Fit Line Fossa (BFLF)) or by an automatic software ( Y -axis). An assessment of the interobserver reliability was performed. We compared the measured glenoid inclination when modifying the transverse axis to assess its impact., Results: Glenoid inclination remained stable between 6.3 and 8.5°. The variations occurred significantly when changing the method that determined the transverse axis with a mean biase from -1.7 (BFLF vs. Y -axis) to 0.6 (BFLF vs. GT-line). The Y -axis method showed higher stability to the inclination variation ( p = 0.030). 9% of cases presented more than 5° of discrepancies between the methods. The manual methods presented a lower ICC (BFLF = 0.96, GT-line = 0.87) with the widest dispersion., Conclusion: Methods that determine the scapular transverse axis could have a critical impact on the measurement of the glenoid inclination. Despite an overall good concordance, around 10% of cases may provide high discrepancies (≥5°) between the methods with a possible impact on surgeon clinical choice. Trigonum should be used with caution as its anatomy is highly variable and more than two single points provide a better interrater concordance. The Y -axis is the most stable referential for the glenoid inclination.

Background: The aim of our study was to evaluate the accuracy of manual determination of the three key points defining the anatomical plane of the scapula, which conditions the reliability of planning software programs based on manual method., Method: We included 82 scapula computed tomography scans (56 pathologic and 26 normal glenoid), excluding truncation and major three-dimensional artifact. Four observers independently picked the three key points for each case. Inter- and intra-observer agreement was calculated for each point, using the intraclass correlation method. The mean error (mm) between the observers was calculated as the diameter of the smallest sphere including the four chosen positions., Results: Lower inter-observer agreement was found for the trigonum superoinferior position and for the glenoid center anteroposterior position. The mean positioning error between the four observers was 6.9 mm for the trigonum point, and error greater than 10 mm was recorded in 25% of the cases. The mean positioning error was 3.5 mm for the glenoid center in altered glenoid, compared to 1.8 mm for normal glenoid., Discussion: Manual determination of an anatomical plane of the scapula suffers from inaccuracy especially due to the variability in trigonum picking, and in a lesser extent, to the variability of glenoid center picking in altered glenoid., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Adrien JACQUOT is consultant for Tornier-Wright Medical and receives consulting fees. Dr. Marc-Olivier GAUCI is consultant for Tornier-Wright Medical and receives consulting fees. Manuel URVOY is an Employee of Imascap (Wright Medical). François BOUX DE CASSON is an Employee of Tornier – Wright Medical. Dr. Julien BERHOUET is consultant for Tornier-Wright Medical, and receives consulting fees. Dr. Hoel LETISSIER has no conflict of interest., (© 2021 The British Elbow & Shoulder Society.)

Background: Early glenohumeral impingement leads to poor range of motion and notching in reverse shoulder arthroplasty. The aim was to find from planning software which implant configuration provides the best motions in reverse shoulder arthroplasty., Patients and Methods: Reverse shoulder arthroplasty planning (Glenosys) was made in 31 patients (12 men, 19 women, 76 ± 6 yo) and impingements were analyzed. Inlay (155°-inclined) and Onlay (145°-inclined) humeral designs were tested. Four configurations were tested for each shoulder: "INLAY": non-lateralized glenoid-inlay humerus, "BIO-INLAY": lateralized glenoid (BIO-RSA)-inlay humerus, "ONLAY": non-lateralized glenoid-onlay humerus, and "BIO-ONLAY": lateralized (BIO-RSA) glenoid-onlay humerus., Results: BIO-ONLAY and BIO-INLAY groups presented a significantly better result in all tested motion ( p  < 0.001 for all tests). BIO-ONLAY allowed a significantly better external rotation, extension and adduction than BIO-INLAY with decreased impingements with the pilar. BIO-INLAY presented a significantly better abduction. In abduction, an abutment of the greater tuberosity against the acromion was associated with a lower range of motion ( p  < 0.0001) and did not depend on the lateralization., Conclusion: Glenoid lateralization delays the glenohumeral impingement in reverse shoulder arthroplasty and gives the best rotations, adduction and extension when associated with neutral inclination and humeral 145° inclination. Greater tuberosity abutment has to be avoided in abduction and the Inlay design provides the best abduction., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Marc-Olivier Gauci, Julien Berhouet, Adrien Jacquot, Gilles Walch, and Pascal Boileau are consultants for Wright-Medical—Tornier Inc and Imascap and did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. Jean Chaoui is an employee of Wright Medical—Tornier Inc and Imascap., (© 2021 The British Elbow & Shoulder Society.)

Introduction: In the context of reverse shoulder arthroplasty, some parameters of glenoid baseplate placement follow established golden rules, while other parameters still have no consensus. The assessment of glenoid wear in the future location of the glenoid baseplate varies among surgeons. The objective of this study was to analyze the inter-observer reproducibility of glenoid baseplate 3D positioning during virtual pre-operative planning., Method: Four shoulder surgeons planned the glenoid baseplate position of a reverse arthroplasty in the CT scans of 30 degenerative shoulders. The position of the glenoid guide pin entry point and the glenoid baseplate center was compared between surgeons. The baseplate's version and inclination were also analyzed., Results: The 3D positioning of the pin entry point was achieved within ± 4 mm for nearly 100% of the shoulders. The superoinferior, anteroposterior and mediolateral positions of the baseplate center were achieved within ± 2 mm for 77.2%, 67.8% and 39.4% of the plans, respectively. The 3D orientation of the glenoid baseplate within ± 10° was inconsistent between the four surgeons (weak agreement, K=0.31, p=0.17)., Discussion: The placement of the glenoid guide pin was very consistent between surgeons. Conversely, there was little agreement on the lateralization, version and inclination criteria for positioning the glenoid baseplate between surgeons. These parameters need to be studied further in clinical practice to establish golden rules. Three-dimensional information from pre-operative planning is beneficial for assessing the glenoid deformity and for limiting its impact on the baseplate position achieved by different surgeons., Level of Evidence: III. Case control study., (Copyright © 2021. Published by Elsevier Masson SAS.)

Introduction: The arm change position (ACP) is a new parameter for evaluating the humerus' 3D displacement following reverse shoulder arthroplasty (RSA) during 3D pre operative planning. The purpose of this study was to analyze the relationship between ACP variations after RSA and simulated passive joint mobility. The assumption is that the ACP will to help optimize the passive joint mobility of a RSA implant., Methods: In 30 degenerative shoulders, four shoulder surgeons planned a RSA with virtual motion analysis. After this analysis, each plan was revised to optimize the range of motion. Relationships between the differences in movement amplitude and the differences in ACP were evaluated., Results: Arm lengthening and humerus lateralization were significantly associated with better joint mobility in all three planes (frontal, sagittal and axial). They were equally important for improving external rotation, extension, flexion and adduction. Anterior displacement of the humerus improved both internal and external rotation., Discussion: The ACP is a useful preoperative planning parameter for RSA. It could help with selecting the best implant combination, as well as determining their position, in order to optimize the simulated passive mobility relative to humerus displacement after RSA. To validate the value of the ACP in clinical practice, a prospective study is needed in which the postoperative joint mobility is measured in vivo as a function of the ACP., Level of Evidence: III, case control study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Clindamycin is an antibiotic with high bioavailability and appropriate bone diffusion, often proposed as an alternative in guidelines for C. acnes prosthetic joint infections. We aimed to evaluate the efficacy of clindamycin in the treatment of C. acnes shoulder implant joint infections (SIJI)., Methods: A retrospective analysis was conducted at the University Hospital of Nice (France) between 2010 and 2019. We included patients with one shoulder implant surgical procedure and at least one C. acnes positive sample. We selected the C. acnes SIJI according to French and international recommendations. The primary endpoint was favorable outcome of C. acnes SIJI treatment after at least 1-year follow-up in the clindamycin group compared to another therapeutic group., Results: Forty-eight SIJI were identified and 33 were treated with clindamycin, among which 25 were treated with monotherapy. The median duration of clindamycin antibiotherapy was 6 weeks. The average follow-up was 45 months; one patient was lost to follow-up. Twenty-seven patients out of 33 (82%) were cured with clindamycin, compared to 9/12 (75%) with other antibiotics. The rate of favorable outcomes increased to 27/31 (87%) with clindamycin and to 9/10 (90%) for other antibiotics when no septic revision strategies were excluded ( P = 1.00)., Conclusions: The therapeutic strategy based on one- or two-stage revision associated with 6 weeks of clindamycin seems to be effective.

Background: The Neer classification is among the most widely used systems to describe proximal humerus fractures (PHF) despite the poor interobserver agreement. The purpose of this study was to verify whether or not blinded shoulder surgeons and trainees agree with the authors of articles published in the highest impact-factor orthopedic journals., Methods: All articles regarding PHF published between 2017 and 2019 in the top 10 orthopedic journals as rated by impact factor were searched. Articles were included if the authors used the Neer classification to describe at least 1 PHF in the figures. Figures were extracted without the legend, and X-rays ± computed tomography scan images were included when available. An international survey was conducted among 138 shoulder surgeons who were asked to record the Neer classification for each de-identified radiograph in the publications. The type of fracture mentioned in the legend of the published figure was considered as the gold standard., Results: Survey participants agreed with the published article authors in 55% of cases overall (range 6%-96%, n = 35). The most common response disagreed with the article authors in 13 cases (37%), underestimating the number of parts in 11 of 13 cases. The interobserver agreement between the 138 responders was fair (k = 0.296). There was an association between the percentage of concordant answers and greater experience (number of years of shoulder surgery practice) of the responders ( P  = .0023). The number of parts, the number or type of available imaging modalities, and the geographic origin of participants did not influence the agreement between responders and authors., Discussion: In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of PHF in published manuscripts. Morphologic classification of PHF as the sole basis for treatment algorithms and surgical success should be scrutinized., (© 2022 The Author(s).)

The interest of patient-specific guides (PSGs) lies in reliable intraoperative achievement of preoperative planning goals. They are a form of instrumentation optimizing intraoperative precision and thus improving the safety and reproducibility of surgical procedures. Clinical superiority, however, has not been demonstrated. The various steps from design to implementation leave room for error, which needs to be known and controlled by the surgeon who is responsible for final outcome. Instituting large-scale patient-specific surgery requires management systems for guides and innovative implants which cannot be a simple extension of current practices. We shall approach the present state of knowledge regarding PSGs via 5 questions: (1) What is a PSG? Single-use instrumentation produced after preoperative planning, aiming exclusively to optimize procedural exactness. (2) How to use and assess PSGs in orthopedic surgery? Strict rules of use must be adhered to. Any deviation from the predefined objective is, necessarily, an error that must be identified as such. (3) Do PSGs provide greater surgical exactness? The contribution of PSGs varies greatly between procedures. Exactness is enhanced in the spine, in osteotomies around the knee and in bone-tumor surgery. In the shoulder, their contribution is seen only in complex cases. Data are sparse for hip replacement, and controversial for knee replacement. (4) What are the expected benefits of PSGs? As well as improving exactness, PSGs allow a lower radiation dose and shorter operating time. They also enable junior surgeons to train in techniques otherwise reserved to hyperspecialists. (5) How to include PSGs in everyday practice? As well as their potential clinical interest, PSGs involve deep changes in organization, equipment provision and economic model. LEVEL OF EVIDENCE: V; expert opinion., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Various implant designs have been proposed to increase active range of motion (ROM) and avoid notching in patients treated by reverse total shoulder arthroplasty (RSA). The purpose of this study was to investigate the efficacy and safety of an onlay prosthesis design combining a 135° humeral neck-shaft angle with the glenoid component lateralized and inferiorized., Methods: A retrospective descriptive study was conducted of the clinical and radiological outcomes at the final follow-up (≥24 months) of all RSAs performed by the same surgeon between September 2015 and December 2016 in the study center. At the last follow-up, patients were clinically assessed for ROM, Constant score, and subjective shoulder value and radiologically for scapular notching and glenoid radiolucent lines. Patients were followed up radiographically at 1 month and clinically at between 6 and 12 months (midterm) and again at between 24 and 48 months (final follow-up). Scapular notching was graded as per the Sirveaux classification at the last follow-up on anterior-posterior radiographs., Results: Seventy-nine RSAs were included with a mean follow-up time of 31 months. The mean Constant score at the final follow-up was 42 points higher than before surgery (69 vs. 27, P  < .001). There were also significant postoperative improvements in ROM (active anterior elevation, active external rotation, and active internal rotation). The final means for motions were 133° for active anterior elevation, 32° active external rotation, and level 7 for active internal rotation. The overall notching rate was 3% (2/67), and there were no cases of severe notching. Radiolucent lines were observed in 8 of 70 prostheses (11.5%) around the peg, and they were observed in 9 prostheses (13%) around the screws. Among the 79 RSAs included, there were 11 complications (13.9%) (two infections, two fractures, four cases of glenoid component loosening, and three cases of instability), 2 reoperations, and 4 prosthesis revisions., Conclusion: This study shows that an RSA design with a 135° humeral neck-shaft angle and an inferiorized and lateralized glenoid component is associated with significant improvements in active ROM, especially in rotation, and a low notching rate. However, rates of 3.8% for dislocation and 5% for glenoid loosening are certainly a concern at such a short follow-up of two years. Future studies with a larger population are needed to confirm these rates., (© 2022 The Author(s).)

Introduction: Outpatient surgery in France is defined by the national authority for health (HAS) as a scheduled surgery enabling same-day discharge without any increased risk to the patient. With the advent of enhanced recovery after surgery, outpatient lower limb arthroplasty has become a common procedure. However, only 1.1% of knee arthroplasties in France were performed on an outpatient basis in 2017., Objectives: 1) assess early morbidity and mortality after outpatient shoulder arthroplasties to validate eligibility and safety criteria; and 2) assess patient acceptance of outpatient surgery., Methods: A single-center study with the following inclusion criteria: primary shoulder arthroplasty, American Society of Anesthesiology (ASA) score I or II, no cognitive impairment, and no coronary artery or thromboembolic diseases. Analgesia was provided by bupivacaine via a peripheral nerve catheter in the first 72 hours followed by oral analgesics. Patients were discharged if the post-anesthetic discharge scoring system (PADSS) was>9/10 and the visual analog scale (VAS) was<5/10. Postoperative telephone interviews were carried out on D1, D2 and D3 to assess pain with the numerical rating scale and to collect data on their analgesic consumption. All patients were seen by an independent observer at one and six months for a clinical and radiologic follow-up and at 90 days during a consultation with the senior surgeon. The primary endpoint was the 90-day morbidity and mortality rate (readmissions, rehospitalizations, and minor and major complications). A satisfaction questionnaire was collected at one and six months., Results: Thirty-six patients were offered an outpatient shoulder arthroplasty between February 2016 and February 2018: 12 (33%) refused with no valid reasons and 24 patients agreed to the procedure (seven hemiarthroplasties, nine anatomic shoulder arthroplasties and eight reverse shoulder arthroplasties). The mean age at surgery was 70 years (55-82), mean body mass index (BMI) was 26 (21-32) and 14 patients were ASA II (66%). Three patients (12%) refused same-day discharge despite a PADSS score>9/10 and adequate pain management. Two patients (8%) were not discharged home on the same day as the surgery for medical reasons (one for pain and one for high blood pressure). No readmissions or complications were reported for the 19 outpatient arthroplasties. None of the outpatients used opioids. All patients were satisfied with their functional outcome, 84% were satisfied with the outpatient management and 17% felt they were insufficiently monitored and regretted that they were not hospitalized., Conclusions: 1) outpatient shoulder arthroplasty can be safely proposed to selected patients with low comorbidities, regardless of their age and type of implant; 2) the acceptance rate for outpatient shoulder arthroplasty remained low among our patient population. These results should incite us to better educate patients about outpatient surgery., Level of Evidence: IV; retrospective study., (Copyright © 2021. Published by Elsevier Masson SAS.)

Isolated pathology of the long head of the biceps is an indication for biceps tenotomy. To date, needle arthroscopy allows a direct diagnosis of shoulder lesion. We aimed to evaluate the technical feasibility of an in-office biceps isolated tenotomy by needle arthroscopy. Advantages were found in the fast-track process and the high rate of satisfaction in our selected patients. It was also a way to correct the diagnosis of torn biceps missed by the imaging. However, performing this procedure requires previous experience in conventional arthroscopy and should not be performed on anxious patients. Further studies will be necessary to confirm the reproducibility of this promising method, which could be a valuable alternative to heavy in-operating room process., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: Cuff tear arthropathy (CTA) is characterized by superior migration of the humeral head with superior erosion of the glenoid. Rarely, humeral head migration can be anteroinferior with associated anterior erosion of the glenoid, a pattern described by Favard as the type E4 glenoid. The purpose of this retrospective imaging study was to analyze the 2D and 3D characteristics of the E4 glenoid., Methods: A shoulder arthroplasty database of 258 cuff tear arthropathies was examined to identify patients with an E4 type deformity. This resulted in a study cohort of 15 females and 2 males with an average age of 75 years. All patients had radiographs and CT scans available for analysis. CT-scan DICOM (Digital Imaging and Communications in Medicine) data were uploaded to a validated three-dimensional (3D) imaging software. Muscle fatty infiltration, glenoid measurements (anteversion, inclination), and humeral head subluxation according to the scapular plane were determined., Results: The mean anteversion and inclination of the E4 cohort were 32° ± 14° and -5° ± 2, respectively. The mean anterior subluxation was 19% ± 16%. All cases had severe grade 3 or 4 fatty infiltration of the infraspinatus, whereas only 65% had grade 3 or 4 subscapularis fatty infiltration. A significant correlation existed between glenoid anteversion and humeral head subluxation ( p < 0.001), but no correlation was found with muscle fatty infiltration. The CT analysis demonstrated an acquired erosive biconcave morphology in 11 patients (65%) and monoconcavity in 6 patients (35%)., Conclusion: The E4 type glenoid deformity in cuff tear arthropathy is characterized by an anterior erosion and anteversion associated with anterior subluxation of the humeral head., Competing Interests: The authors declare no conflict of interest.

Introduction: Antegrade percutaneous intra-medullary nailing (IMN) has a poor reputation in the treatment of humerus fractures. The aim of the present study was to assess rotator cuff integrity and shoulder function after IMN in humerus fracture., Hypothesis: Third-generation humeral nails (straight, small diameter, with locked screws) conserve rotator cuff tendon integrity and avoid the shoulder stiffness and pain incurred by 1st generation (large diameter, without self-blocking screw) and 2nd generation nails (curved, penetrating the supraspinatus insertion on the greater tuberosity)., Methods: Forty patients (26 female, 14 male; mean age, 60 years (range, 20-89 years)) with displaced humeral fracture (23 proximal humerus, 17 humeral shaft) underwent IMN using a 3rd generation nail (34 Aequalis™ (Tornier-Wright), 6 MultiLoc™ (Depuy-Synthes)). Mean clinical, radiologic and ultrasound follow-up was 8 months (range, 6-18 months); 22 patients agreed to postoperative CT scan., Results: There were no revision surgeries for rotator cuff repair or secondary bone displacement. Mean Adjusted Constant Score (ACS) was 93±22% and the Subjective Shoulder Value (SSV) 77±18%. Elevation was 140±36°, external rotation 48±22° and internal rotation was to L3. Ultrasound found: 5 supraspinatus tendon lesions (12.5%) (2 full and 3 deep partial tears) without functional impact (ACS) 91% without vs. 107% with tear; (p=0.12); 2 of the deep partial tears involved excessively lateral and high nail positioning. Eight patients (20%) had painful tendinopathy of the long head of the biceps (LHB) tendon associated with significantly impaired functional scores (ACS 65% vs. 100%; p<0.001); and 4 cases of technical error: 3 of anterior LHB screwing in the groove, and 1 of LHB irritation due to an excessively long posterior screw., Conclusion: Supraspinatus tendon lesions following IMN with a 3 rd -generation humeral nail were rare (12.5%) and asymptomatic; prevalence was not higher than in the general population in the literature (16%). LHB tendinopathy was frequent (20%) and symptomatic, and due to technical error in half of the cases., Level of Evidence: IV, retrospective study., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Reverse shoulder arthroplasty (RSA) is offered to young patients with a failed previous arthroplasty or a cuff-deficient shoulder, but the overall results are still uncertain. We conducted a systematic review of the literature to report the midterm outcomes and complications of RSA in patients younger than 65 years., Methods: A search of the MEDLINE and Cochrane electronic databases identified clinical studies reporting the results, at a minimum 2-year follow-up, of patients younger than 65 years treated with an RSA. The methodologic quality was assessed with the Methodological Index for Non-Randomized Studies score by 2 independent reviewers. Complications, reoperations, range of motion, functional scores, and radiologic outcomes were analyzed., Results: Eight articles were included, with a total of 417 patients. The mean age at surgery was 56 years (range, 21-65 years). RSA was used as a primary arthroplasty in 79% of cases and revision of a failed arthroplasty in 21%. In primary cases, the indications were cuff tear arthropathy and/or massive irreparable cuff tear in 72% of cases. The overall complication rate was 17% (range, 7%-38%), with the most common complications being instability (5%) and infection (4%). The reintervention rate was 10% at 4 years, with implant revision in 7% of cases. The mean weighted American Shoulder and Elbow Surgeons score, active forward elevation, and external rotation were 64 points, 121°, and 29°, respectively., Conclusions: RSA provides reliable clinical improvements in patients younger than 65 years with a cuff-deficient shoulder or failed arthroplasty. The complication and revision rates are comparable to those in older patients., (© 2019 The Authors.)

Introduction: Surgical treatment of distal biceps tendon ruptures is recommended in an active population to avoid loss of strength, especially in supination and flexion., Hypothesis: A double incision repair technique with immediate postoperative mobilization for acute distal biceps tendon ruptures is safe and provides good results after 2 years in active patients., Material and Methods: Seventy-four men (47±7 years) with acute tears of the distal biceps tendon tears were included in this retrospective single-center study. All patients were operated using the double-incision repair technique described by Morrey. The tendon was inserted with transosseous sutures into the biceps tuberosity. Patients were allowed to perform immediate postoperative active mobilization. A minimum follow-up of two years was required including clinical and radiological evaluation., Results: Sixteen patients were lost to follow up leaving 58 (78%) patients for analysis with a mean follow-up of 53±19 months. At final follow-up, the mean evaluation for pain on the VAS scale was 0.22±0.7. Mean range of motion results included extension -1°±2°, flexion 138°±6°, pronation 72°±16° and supination 81°±10°. The strength ratio in flexion was 94±8% and in supination 90.5±12% compared to the contralateral limb. Subjective elbow value and DASH score were respectively 94±6% and 7.5±9%. All patients were satisfied or very satisfied and all except one returned to their previous sport. We noticed 2 heterotopic ossifications and one patient needed a reoperation for a radioulnar synostosis. Neither re-rupture nor nerve injury were observed., Discussion: A double incision technique for distal biceps tendon repair is a minimally invasive procedure with reliable results. Morrey's modification of the initial procedure associated with early mobilization is associated with a low rate of complications and limited the occurrence of synostosis or ossifications., Level of Evidence: IV, case series, with no comparison group., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

The need for modern patient evaluation tools continues to grow. A dependable and reproducible assessment provides objective follow-up and increases the validity of collected data. This is where mobile apps come into play, as they provide a link between surgeons and patients. They also open the possibility of interacting with other healthcare staff to exchange common scientific reference systems and databases. The CJOrtho app provides fast access to 65 classification systems in orthopedics or trauma surgery, 20 clinical outcome scores and a digital goniometer. The development of free mobile apps is an opportunity for education and better follow-up, while meeting the demands of patients., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)