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Purpose Systematic reviews report return to play (RTP) within 5.8 months (range, 3–8) following the Latarjet procedure, but the factors that influence RTP remain unknown. The present study aimed to report the rate and time of return to play (RTP) during the first 8 months following the Latarjet procedure, and to determine the influence of sport type or patient characteristics. Methods The authors retrospectively collected the records of patients that underwent Latarjet procedures for anterior shoulder instability between 2015 and 2017. Patients were excluded if they had any concomitant rotator cuff tendon lesions, or previous ipsilateral shoulder surgery. The authors retrieved patient demographics, time from injury to surgery, type of sport practiced (overhead/non-overhead, contact/non-contact), as well as pre- and postoperative Western Ontario Shoulder Instability index (WOSI), Shoulder Instability-Return to Sport After Injury index (SIRSI), and Rowe score. Results A total of 217 patients (217 shoulders) were eligible for inclusion, comprising 184 males and 33 females, aged 26.8 ± 7.3 years at index surgery. The main sport practiced prior to surgery involved overhead (n = 173, 80%) and/or contact (n = 152, 70%) activities. By 8 month follow-up, 158 patients (73%) resumed their main sport, at a mean of 5.1 ± 1.5 months. Multivariable analysis revealed that RTP was more likely in patients with higher preoperative Rowe score (OR, 1.02; p = 0.024) and SIRSI score (OR, 1.02; p = 0.008). Conclusions By 8 months following the Latarjet procedure, 73% of patients had resumed their main sport. The likelihood of RTP was significantly associated with preoperative Rowe and SIRSI scores, but not with sport type. Level of evidence IV.

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 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.

Background In reverse shoulder arthroplasties (RSA), osseous in-growth is promoted if glenoid micromotion does not exceed 150 μm. The purpose of this study was to determine whether the configuration of central fixation for RSA glenoid baseplates reduces implant micromotion or changes scapula bone stresses. Methods Using finite element analysis, glenoid baseplate fixation was tested in a cohort of 3 male and 2 female patients who were to undergo RSA. Computer models were created for 3 different RSA glenoid baseplate and 84 glenosphere designs, a central threaded peg (1 variant, D-TP), a central unthreaded peg (2 variants, I- 85 P(15) and I-P(25)), and a central peg with a screw (2 variants, A-PS and I-PS). A compressive and shear force of 756 N was distributed across the glenosphere with the scapula anchored. Results Displacement was within 20-130 μm at the glenosphere baseplate-bone interface for all baseplates. The glenospheres with unthreaded pegs had intermediate displacement values (I-P(15): median, 89 μm; range, 32-112 μm; and I-P(25): median, 93 μm; range, 31-109 μm). The von Mises stresses were 1.8-7.0 MPa within cortical bone and 0.6-1.6 MPa within trabecular bone. Cortical bone stresses were similar with unthreaded pegs (I-P(15): median, 4.2 MPa; range, 1.8-6.0 MPa; and I-P(25): median, 4.2 MPa; range, 1.8-6.1 MPa), whereas mean trabecular stresses were similar for all configurations. Conclusions All configurations yielded adequate stability, with micromotions being below 150 μm. The unthreaded pegged designs provided a valid alternative to the stable threaded pegged convex baseplates in terms of micromotions and bone stresses.

Background In patients with rheumatoid arthritis, the surgical treatment of wrist lesions relies on synovectomy combined with stabilisation and realignment of the carpal bones. The objective of this study was to evaluate the outcomes and define the indications of extensor carpi radialis longus (ECRL) transfer to the extensor carpi ulnaris (ECU) as described by Clayton and Ferlic. Hypothesis ECRL-to-ECU transfer combined with synovectomy can prevent the development and/or progression of rheumatoid deformities at the wrist. Material and methods A retrospective observational study was performed in 16 wrists. The following data were collected before and after surgery: pain, synovitis, range of motion, carpal height, ulnar translocation and radial deviation of the carpal bones, and Larsen's grade of the radio-carpal and mid-carpal joints. Results After a mean follow-up of 42.5 months after surgery, pain relief was noted in 14 cases and synovitis resolution in 10 cases. Mean mobility gains were 19.7° in extension and 5.7° in flexion. The radiographs showed a decrease in carpal height, whereas radial deviation and ulnar translocation were unchanged. No change was seen in the radio-carpal and mid-carpal joint lines. In the 3 wrists that required mid-carpal arthrodesis due to advanced disease before surgery, the radio-carpal joint line was unchanged and outcomes were the same as in the overall population. Discussion ECRL-to-ECU transfer combined with synovectomy provides pain relief and prevents radio-carpal destabilisation. The main indication of ECRL transfer is reducible radial deviation and ulnar translocation. ECRL is also indicated in combination with mid-carpal arthrodesis in the small minority of patients who have predominant mid-carpal involvement with a Larsen grade greater than 2. Level of evidence IV, retrospective observational study.

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.

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.

Because it medializes the centre of rotation, one of the drawbacks of reverse shoulder arthroplasty (RSA) is the risk of impingement between the humerus and lateral border of the scapula resulting in scapular notching. The long-term impact of this notching is not well known, either on function or the risk of glenoid loosening. The aim of this longitudinal study was to analyze the drawbacks of this notching. Between 1993 and 2006, 81 patients (91 shoulders) underwent RSA for primary glenohumeral osteoarthritis or massive cuff tear with or without osteoarthritis. This cohort was followed longitudinally with post-operative assessments done at one to two years (T1), three to eight years (T2), and nine+ years (T3). Before T3, 25 patients had died, nine were lost to follow-up, five had the implants changed, and seven had incomplete records. Thus, 45 shoulders were available for follow-up beyond nine years (mean follow-up of 12 years) and were used to determine the long-term impact of notching. Survival curves were generated using the occurrence of Sirveaux grade 3 or 4 notching and the presence of aseptic glenoid loosening as endpoints. The survivorship before grade 3 or 4 notching developed was 83% at five years, 60% at 10 years, and 43% at 15 years. In the end, aseptic glenoid loosening occurred in four shoulders, all of which had developed grade 4 notching. No glenoid loosening occurred in the population with grade 0, 1, 2, or 3 notching (p = 0.02). The Constant score significantly decreased between T2 and T3, although it was not different between shoulders with and without advanced notching. Beyond the second year post-RSA, the number of shoulders with grade 3 or 4 notching increases steadily up to the longest follow-up. Grade 4 notching always preceded the occurrence of late glenoid loosening. The functional outcomes become significantly worse after the 9th year post-RSA, although they were not correlated to the presence of high-grade scapular notching.

Ultrasound assessment of the long head of the biceps (LHB) is difficult. The aim of the present study was to analyze the inter- and intra-observer reproducibility of 2 ultrasound cross-sections not previously assessed: humeral head apex (image 1) and bicipital groove entrance (image 2).These ultrasound cross-sectional images allow reliable and reproducible analysis of the intra-articular LHB.A single-center prospective study was conducted. Inter-observer reproducibility was assessed between 2 radiologists in 20 healthy shoulders (asymptomatic group) and 35 painful shoulders (symptomatic group); intra-observer reproducibility was assessed for 1 observer in 10 healthy shoulders. Quantitative parameters comprised short and long axes and transverse area, and qualitative parameters comprise echogenicity and LHB position.On images 1 and 2, inter-observer agreement on the 3 quantitative parameters was good to excellent in both subject groups (p0.05), and more precise and highly reproducible for image 1. Agreement on the 2 qualitative parameters was excellent (p0.001). Intra-observer reproducibility results were non-significant on all parameters.The 2 intra-articular LHB cross-sections proved reliable and reproducible in painful and in healthy shoulders. A standardized ultrasound protocol could thus enhance the precision of LHB assessment and treatment. The difficulties of LHB measurement, often related to shoulder pathology, may, however, hinder interpretation.III, prospective intra- and inter-observer study.

Background Many techniques have been described for reconstructing the medial patello-femoral ligament (MPFL), using a variety of transplants and fixation methods to treat patello-femoral dislocation. The main challenge with static transfers is to position the femoral fixation point at the site that best restores MPFL anisometry. The objective of this cadaveric study was to propose a version of the initially described dynamic gracilis transfer technique that can be performed percutaneously. Hypothesis Our working hypothesis was that using a minimally invasive approach would provide better cosmesis without altering the biomechanical efficacy of the procedure. Methods 20 cadaveric knees were used to evaluate the feasibility and reliability of our percutaneous technique. We analysed femoral pulley location and scar length. Results After dissection, the position of the femoral pulley allowed superimposition of the transplant along the trajectory of the native MPFL in all 20 knees. Cumulative scar length was 6.5 cm (range, 6-7.5 cm). Discussion Percutaneous dynamic gracilis transfer is easy to perform, reproducible, and capable of creating a pulley that anatomically replicates the femoral insertion point of the native MPFL. Level of evidence IV; retrospective study.

Reverse shoulder arthroplasty (RSA) is a reliable, long-term treatment option for degenerative shoulder pathology. However, the functional outcomes degrade around the fifth year postoperation, particularly for internal and external rotation. Long-term radiographic changes have been reported around the humeral stem, depending on the fixation method.The primary objective was to compare the clinical outcomes of RSAs by fixation method-cemented vs. press-fit-after a minimum follow-up of 5 years. We hypothesized that proximal humeral osteolysis impacts the functional outcomes.Our study compared 2 matched cohorts: 56 RSAs with cemented stems and 56 RSAs with press-fit stems. We evaluated all the patients using the Constant-Murley score (CMS) and range of motion (ROM), which we measured preoperatively and at the final follow-up visit. We evaluated radiographs from the final follow-up visit to look for proximal humeral osteolysis with tuberosity resorption, signs of stress shielding, periprosthetic radiolucent lines, and scapular notching.At a mean follow-up of 9.5 years (5-21), regardless of the fixation method, the RSA procedure helped to improve the CMS and active joint ROM postoperatively, except for internal and external rotation with elbow at side in the press-fit group. Shoulder ROM was significantly better in the group with cemented stems for anterior elevation (P.001), abduction (P = .006), and external (P = .02) and internal rotation with elbow at side (P = .02). The CMS did not differ between groups. The presence of tuberosity resorption or scapular notching had no effect on the CMS and active ROM in either group. Osteopenia, which was more prevalent in the press-fit group, had no impact on the functional outcome.There was no significant difference between groups in the CMS, although the active shoulder ROM was significantly worse in the press-fit group. This difference could be attributed to more frequent tuberosity resorption in this group.

Background Massive rotator cuff tears (RCTs) account for 10% to 40% of all RCTs and over 80% of re-tears. The objectives of this prospective study were to assess functional outcomes 6 and 12 months after starting non-operative therapy for an irreparable massive RCT and to identify predictors of good outcomes of non-operative treatment. Hypothesis Non-operative treatment deserves to be tried because it can produce improvements in patients with irreparable massive RCTs. Material and methods A prospective multicenter (12 centres) study was conducted between March 2015 and March 2016. Consecutive patients managed non-operatively for RCTs involving two or more tendons including one with a fatty infiltration score greater than 2 were included. Non-operative treatment consisted in rehabilitation and sub-acromial corticosteroid injections. Functional outcomes were assessed based on the Constant score and Subjective Shoulder Value (SSV) after 3, 6, and 12 months. Results Of 71 included patients, 3 underwent surgery during the study year, leaving 68 patients for the analysis of 12-month outcomes. Significant improvements were noted after 12 months in the Constant score (from 40.7 at baseline to 57.7 after 6 months and 57.1 after 12 months), in each of its items except force, and in the SSV. Constant score values after 6 and 12 months were not significantly different. No significant differences in functional outcomes were found across initial tear type. Conclusion Non-operative treatment produces significant functional gains in patients with irreparable massive RCTs. These gains are obtained after 6 months. Surgery can therefore be considered if the outcome is unsatisfactory after 6 months. Level of evidence III, prospective study.

Introduction There is currently no consensus on the choice between tenotomy and tenodesis of the long head of the biceps tendon in rotator cuff repair. The Popeye sign is often seen as a drawback of tenotomy. The main objective of the present study was to determine the frequency and clinical impact of the Popeye sign. Hypothesis The Popeye sign is rarely found clinically, and shows little functional impact following tenotomy. Materials and Methods A single-center non-randomized prospective study was conducted between February and October 2015 in all patients undergoing rotator cuff surgery. Patients without surgery on the long head of the biceps tendon were excluded. The rate of Popeye sign was assessed 6 months postoperatively. Tenotomy patients with and without Popeye sign were compared in terms of pain on visual analog scale ≤ 3, gain in range of motion, improvement in subjective shoulder value, discomfort or cramps and gain in Constant score. Results Seven of the 55 patients included (15.2%) showed postoperative Popeye sign. There were no differences between the groups with and without Popeye sign on any of the assessment criteria except for a significantly greater improvement in mean Constant range of motion score in the Popeye group: gain of 13.8 versus 3.8 points; p = 0.01. Discussion The Popeye sign was relatively rarely observed. Functional impact in the present study was slight. Longhead of the biceps tenotomy is a justifiable treatment option in case of associated rotator cuff tear repair. Level of evidence IV, prospective non-randomized.

Background Implantation of the glenoid component of a total shoulder prosthesis can be facilitated by using a patient-specific guide (PSG) designed to ensure replication of the preoperatively planned position. The objective of this study was to assess the reliability and accuracy of a PSG in replicating the planned glenoid component position during total shoulder arthroplasty (TSA). Hypothesis Additional criteria should be used for 3D preoperative planning and PSG design to further improve the accuracy of glenoid component positioning. Material and methods We studied 10 patients who underwent TSA with use of a PSG to position the glenoid component after preoperative 3D planning. Postoperative glenoid version and tilt were measured and compared to the planned values. We also used new criteria to assess implant rotation and global 3D position, as well as accuracy of the 3D pilot hole for the glenoid guide-pin. Results Mean errors in glenoid position were −1.7° ± 4.4° for version, −0.4° ± 4.9° for tilt, and 6.0° ± 13.5° for rotation. Mean difference in global orientation of the glenoid implant versus the planned value was 4.9° ± 2.5°. Mean 3D discrepancy in glenoid pilot hole position was 2.9 ± 0.5 mm; the discrepancy was greater in the mediolateral direction (1.9 ± 0.9 mm) than in the supero-inferior (1.1 ± 1.2 mm) and antero-posterior (0.8 ± 1.2 mm) directions. Discussion The poor performance of the PSG in controlling rotation and reaming may explain the difference in global glenoid position compared to the planned value. Improvements in PSG design to incorporate these two parameters deserve consideration. Level of evidence II, prospective cohort study.

Version correction via eccentric reaming reduces clinically important retroversion in Walch type B2 glenoids (those with substantial glenoid retroversion and a second, sclerotic neoglenoid cavity) before total shoulder arthroplasty (TSA). Clinically, an increased risk of glenoid component loosening in B2 glenoids was hypothesized to be the result of compromised glenoid bone quality attributable to eccentric reaming. However, no established guidelines exist regarding how much version correction can be applied without compromising the quality of glenoid bone. (1) How does version correction correlate to the reaming depth and the volume of resected bone during eccentric reaming of B2 glenoids? (2) How does version correction affect the density of the remaining glenoid bone? (3) How does version correction affect the spatial distribution of high-quality bone in the remaining glenoid? CT scans of 25 patients identified with Walch type B2 glenoids (age, 68 ± 9 years; 14 males, 11 females) were selected from a cohort of 111 patients (age, 69 ± 10 years; 50 males, 61 females) with primary shoulder osteoarthritis who underwent TSA. Virtual TSA with version corrections of 0°, 5°, 10°, and 15° was performed on 25 CT-reconstructed three-dimensional models of B2 scapulae. After simulated eccentric reaming at each version correction angle, bone density (Hounsfield units [HUs]) was analyzed in five adjacent 1-mm layers under the reamed glenoid surface. Remaining high-quality bone (> 650 HUs) distribution in each 1-mm layer at different version corrections was observed on spatial distribution maps. Larger version corrections required more bone resection, especially from the anterior glenoid. Mean bone densities in the first 1-mm bone bed under the reamed surface were lower with 10° (523.3 ± 79.9 HUs) and 15° (479.5 ± 81.0 HUs) version corrections relative to 0° (0°, 609.0 ± 103.9 HUs; mean difference between 0° and 15°, 129.5 HUs [95% CI, 46.3–212.8 HUs], p < 0.001; mean difference between 0° and 10°, 85.7 HUs [95% CI, 8.6–162.9 HUs], p = 0.021) version correction. Similar results were observed for the second 1-mm bone bed. Spatial distribution maps qualitatively showed a decreased frequency of high-quality bone in the anterior glenoid as version correction increased. A version correction as low as 10° was shown to reduce the density of the glenoid bone bed for TSA glenoid fixation in our computational study that simulated reaming on CT-reconstructed B2 glenoid models. Increased version correction resulted in gradual depletion of high-quality bone from the anterior region of B2 glenoids. This computational study of eccentric reaming of the glenoid before TSA quantitatively showed glenoid bone quality is sensitive to version correction via simulated eccentric reaming. The bone density results of our study may benefit surgeons to better plan TSA on B2 glenoids needing durable bone support, and help to clarify goals for development of precision surgical tools.

Background Glenoid component positioning in reverse shoulder arthroplasty (RSA) is challenging. Patient-specific instrumentation (PSI) has been advocated to improve accuracy, and is based on precise preoperative planning. The purpose of this study was to determine the accuracy of glenoid component positioning when only the glenoid surface is visible, compared to when the entire scapula is visible on a 3D virtual model. Methods CT scans of 30 arthritic shoulders were reconstructed in 3D models. Two surgeons then virtually placed a glenosphere component in the model while visualizing only the glenoid surface, in order to simulate typical intraoperative exposure (“blind 3D” surgery). One surgeon then placed the component in an ideal position while visualizing the entire scapula (“visible 3D” surgery). These two positions were then compared, and the accuracy of glenoid component positioning was assessed in terms of correction of native glenoid version and tilt, and avoidance of glenoid vault perforation. Results Mean version and tilt after “blind 3D” surgery were +1.4° (SD 8.8°) and +7.6° (SD 6°), respectively; glenoid vault perforation occurred in 17 specimens. Mean version and tilt after “visible 3D” surgery were +0.3° (SD 0.8°) and +0.1° (SD 0.5°), respectively, with glenoid vault perforation in 6 cases. “Visible 3D” surgery provided significantly better accuracy than “blind 3D” surgery (P Conclusion When the entire scapula is used as reference, accuracy is improved and glenoid vault perforation is less frequent. This type of visualization is only possible with pre-operative 3D CT planning, and may be augmented by PSI. Level of evidence Basic science study. Level III.

Background To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire. Methods The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was “reported hypersensitivity to metals,” comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips. Results A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals. Conclusions This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.

To compare the clinical outcomes of self-locking T-tenotomy called “tomydesis” to three different techniques of tenodesis for lesions of the long head of the biceps tendon (LHBT) associated with rotator cuff tears. Tomydesis could provide similar clinical outcomes than the other LHBT tenodesis techniques. This prospective multicentre study included 77 patients who underwent rotator cuff repair concomitant with one of four surgical techniques on the LHBT. All patients had a minimum of 6-month follow-up post-operatively. Outcomes were evaluated based on the Constant score, SSV, pain on visual analogue scale, biceps-specific pain and Popeye deformity on photographs. There was no difference for the pain at the biceps muscle belly (p = 0.58), the bicipital groove (p = 0.69) and during resisted supination (p = 0.53), as well as for muscle cramps (p = 0.09), VAS for pain (p = 0.12) and Popeye deformity (p = 0.18). There was more pain in resisted flexion in the tomydesis group (p = 0.032), and significantly better Constant scores and SSV (

Introduction The main goal of this study was to propose a new method of surgical assistance for the implantation of a total shoulder prosthesis, with the use of augmented reality (AR). The advantage of this approach is that it supplements information, on the one hand pre-existing or disappeared due to a pathological process, such as the premorbid glenoid, and on the other hand already existing but not accessible to the surgeon during the procedure, such as the so-called “hidden” face of the scapula. Material and methods Several information preparation steps were needed. The first consisted in the three-dimensional (3D) rendering of the pathological glenoid, from a point cloud corresponding to the premorbid glenoid based on previously developed regression equations. A library of “healthy” generic glenoids was then created by hierarchical bottom-up analysis. From this database, a so-called adequate normal generic glenoid was fused and matched to the pathological glenoid reconstructed using a morphing technique. An experimental AR application was constructed. Smart glasses were used to display the prepared 3D information. Results A pathological 3D glenoid was reconstructed and used for the AR application. A complete display of the scene, reconstructed glenoid and full scapula was obtained. However, an offset from reality was observed. The main limitations were technical, related to the connected tool itself and the operating software. Discussion/Conclusion This was a feasibility study of the different steps required to apply AR, from information preparation to its visualization. A new parameter crossing experiment is needed to optimize each step of this process. Level of evidence IV, Basic science study.

The cause of proximal humeral osteolysis after reverse shoulder arthroplasty (RSA) remains controversial. The primary objective of our study was to compare the radiographic outcomes of Grammont-type RSA when a cemented stem is used versus when a cementless stem is used. The secondary objective was to identify the cause of these radiographic changes, especially for the cementless stems.More proximal humerus bone loss occurs when a cementless humeral stem is used.With a minimum follow-up of 5 years, two paired cohorts were compared retrospectively: 70 RSA with cemented stem and 70 RSA with cementless stem. Using the radiographs made at the final follow-up visit, we looked for tuberosity resorption, signs of stress shielding, the presence of periprosthetic radiolucent lines and scapular notching.At a mean follow-up of 9 years (5.0-20.6), the RSA revision rate was 1.8% in the cemented group and 3.6% in the cementless group (p=1). Tuberosity resorption was twice as common in the cementless group: 59% versus 30% (p0.001). Signs of stress shielding such as osteopenia were only present in the cementless group. In both groups, tuberosity resorption was often associated with scapular notching. In the shoulders with tuberosity resorption, stage≥3 scapular notching was more common in the cementless group (p=0.001).For the cementless stems, proximal humeral osteolysis can in part be attributed to stress shielding. The relationship between notching and tuberosity resorption in the two groups also suggests a secondary biological cause.III; Comparative retrospective study.

Background Reverse shoulder arthroplasty (RSA) was introduced in 1985 by Grammont for patients with gleno-humeral osteoarthritis and severe rotator cuff damage. Internal rotation (IR) is limited in some patients after RSA. The objective of this study was to identify pre- and intra-operative factors associated with good IR outcomes 6 months after RSA. Hypothesis The condition of the residual cuff (usually the sub-scapularis and teres minor) and inferior glenosphere overhang are the main factors associated with IR outcomes after RSA. Material and Method A total of 36 patients who underwent RSA between 2 November 2015 and 10 January 2017 were enrolled prospectively. The inclusion criterion was massive rotator cuff tear with or without osteoarthritis and gleno-humeral osteoarthritis with asymmetrical glenoid wear. The pre-operative work-up included determination of the Constant score, Subjective Shoulder Value (SSV), and passive and active motion ranges; standard radiographs; and computed tomography. The same clinical and radiological parameters were recorded in all patients during a visit 6 months after surgery. Results After surgery, all motion ranges were improved except IR with the elbow by the side (IR1, ability to place the hand on the back). IR1 to or above L3 was significantly associated with a lower body mass index (p = 0.04), good passive IR before surgery (p = 0.056), a smaller pre-operative glenoid inclination angle, and greater glenosphere overhang (p = 0.03). Neither the condition of the sub-scapularis nor sub-scapularis repair were significantly associated with post-operative IR1. IR1 was significantly more limited in patients whose teres minor was normal. Conclusion Satisfactory active IR1 correlated with good passive IR1. IR1 was better in thin individuals who had non-concentric gleno-humeral osteoarthritis. Inferior glenosphere overhang of 6 mm or more was associated with a greater range of IR. Level of evidence IV, prospective observational cohort study.

Introduction The aim of this study was to identify points on the scapula that can be used to predict the anatomy of the native premorbid glenoid. Material and methods Forty-three normal scapulas reconstructed in 3D and positioned in a common coordinate system were used. Twenty points distributed over the blade of the scapula (portion considered normal and used as a reference) and the glenoid (portion considered pathological and needing to be reconstructed) were captured manually. Thirteen distances (X) between two points not on the glenoid and 31 distances (Y) between two points of which at least one was on the glenoid were then calculated automatically. A multiple linear regression model was applied to calculate the Y distances from the X distances. The best four equations were retained based on their coefficient of determination (R2) to explain a point on the glenoid being reconstructed (p Results For a completely destroyed glenoid, the mean error for a chosen distance for a given point on the glenoid was 2.4 mm (4.e-3 mm; 12.5 mm). For a partially damaged glenoid, the mean error was 1.7 mm (4.e-3 mm; 6.5 mm) for the same distance evaluated for a given point on the glenoid. Discussion/Conclusion The proposed statistical model was used to predict the premorbid anatomy of the glenoid with an acceptable level of accuracy. A surgeon could use this information during the preoperative planning stage and during the actual surgery by using a new surgical assistance method.

Introduction Referral Centers for Bone and Joint Infection (BJI) were set up to optimize BJI management thanks to multidisciplinary teamwork. The main aim of the present study was to assess the impact of setting up the Western France Bone and Joint Infection Referral Center on arthroscopic treatment of septic arthritis of the shoulder and knee. The secondary aim was to identify other risk factors for failure of this treatment. The null hypothesis was that there was no difference between the “success group” and the “failure group”. Material and methods This single-center retrospective study included 52 patients treated for septic arthritis between January 1, 2000 and December 31, 2013 by arthroscopic joint lavage associated to at least 4 weeks’ antibiotic therapy. Exclusion criteria comprised: retrospective diagnosis of rheumatoid arthritis after negative bacteriological analysis, early cessation of antibiotic treatment, and follow-up less than 4 weeks. Failure was defined as non-healing after first-line treatment. The primary endpoint was date of treatment compared to the launch date of the Center in the first quarter of 2010. The influence of pre- and intraoperative criteria related to patient, treatment and microorganism was assessed. Results At follow-up, 17 patients (32.9%) showed failure of first-line treatment and 5 (9.6%) were non-healed at end of treatment, whatever the re-intervention. The failure rate significantly decreased after setting up the Center, from 42.9% to 11.8% (p = 0.03). In the failure group, 70.6% of patients showed immunosuppression, versus 37.2% in the success group (p = 0.01). Neither time to surgery (p = 1), type of microorganism, or performance of antiseptic lavage (p = 0.25) or synovectomy (p = 0.62) influenced outcome. Conclusion Multidisciplinary management of septic arthritis improved treatment success. Level of evidence III, Retrospective comparative study.

Background Dislocation is a common complication of total hip arthroplasty (THA), particularly when performed as revision surgery. Dual mobility cups (DMCs) minimize the risk of instability when implanted during primary THA. However, their usefulness and survival in revision THA remain unclear. We therefore conducted a retrospective study to assess DMC stability and survival at a minimal follow-up period of 5 years after revision THA. Hypothesis The dislocation rate associated with DMCs for revision THA is similar to that seen after primary THA. Materials and methods Cup exchange with implantation of a DMC was performed in 71 patients (74 hips) between 2000 and 2007, for the following reasons: recurrent dislocation ( n = 22), aseptic loosening ( n = 38), and infection ( n = 14). The DMCs were cemented in 47 cases and cementless in 27 cases. The clinical variables (Merle d’Aubigne-Postel score and Harris Hip Score) and radiological findings were collected retrospectively from the medical records and compared with those obtained at the last follow-up visit. Results Of the 74 cases, 2 were lost to follow-up. At last follow-up, the mean Merle d’Aubigne-Postel score was 15.2 (11–18) and the mean Harris Hip Score was 80.4 (51–98). Of the 8 failures, 2 (2/72, 2.7%) were related to mechanical factors (1 case each of aseptic loosening and dislocation) and 6 were changed because of infection (recurrent infection, n = 4). Mechanical failure was not linked to a specific reason for revision THA. A radiolucent line was visible in 4 cases but this finding was not associated with clinical manifestations. When failure was defined as cup revision for any non-infectious complication, 5-year implant survival was 99% (95% confidence interval, 93–100%). Discussion Use of a DMC in revision THA was associated with a slightly higher dislocation rate (1/72, 1.4%) than in primary THA, whereas 5-year survival was comparable. Cemented DMCs were not associated with a greater risk of loosening. Conclusion DMCs are useful to decrease the risk of dislocation in revision THA performed for any reason. The low rate of loosening indicates that DMCs do not result in high stresses at the bone-implant interface. Level of evidence IV, retrospective study.

Background Recent shoulder prostheses have introduced a concept of a universal humeral stem component platform that has an onlay humeral tray for the reverse total shoulder arthroplasty (RTSA). No studies have reported how humeral tray positioning can affect the biomechanics of RTSA. Materials and methods The Newcastle Shoulder Model was used to investigate the biomechanical effect of humeral tray positioning in the Biomet Comprehensive Total Shoulder System (Biomet, Warsaw, IN, USA) RTSA. Five humeral tray configuration positions were tested: no offset, and 5 mm offset in the anterior, posterior, medial, and lateral positions. Superior and inferior impingement were evaluated for abduction, scapular plane elevation, forward flexion, and external/internal rotation with the elbow at the side (adduction) and at 90° of shoulder abduction. Muscle lengths and moment arms (elevating and rotational) were calculated for the deltoid, the infraspinatus, the teres minor, and the subscapularis. Results Inferior impingement was not affected by the humeral tray position. There was less superior impingement during abduction, scapular plane elevation, and rotation with the shoulder when the tray was placed laterally or posteriorly. The subscapularis rotational moment arm was increased with a posterior offset, whereas infraspinatus and teres minor rotational moment arms were increased with an anterior offset. Very little change was observed for the deltoid elevating moment arm or for its muscle length. Conclusion Positioning the humeral tray with posterior offset offers a biomechanical advantage for patients needing RTSA by decreasing superior impingement and increasing the internal rotational moment arm of the subscapularis, without creating inferior impingement.

The deltopectoral approach is a common surgical procedure for shoulder arthroplasty. Many surgeons are familiar with this procedure, but certain steps are still controversial. This is the case for the management of subscapularis, where surgeons must choose between tenotomy and the lesser tuberosity osteotomy.This article is conceived as a toolkit for the inexperienced surgeons, describing our tips and tricks to facilitate final exposure of the glenoid. For experienced surgeons, we analysed the tricky portions of the deltopectoral approach, comparing them with what is classically reported in the literature.We describe an original technic for subscapularis reattachment after lesser tuberosity osteotomy in order to improve its stability. The medial part of the fragment is secondarily sculpted to obtain a step shape, which will be applied against the base of the prosthetic cup in a sort of "corner buttress".Our work, based on our personal experience, confirms that there is no preferred single deltopectoral approach but, rather, multiple options. When embarking on this "shoulder highway", we encourage surgeons to respect the successive anatomic planes, which we believe is the only way to ensure easy and atraumatic dissection.- The safe plane for going around the humeral head and positioning retractors is the plane of the subacromial deltoid bursa. - Always stay close to the bone during capsule release, whether on the humeral or glenoid side. - Never go medially to the conjoint tendon or its deep face.

Reverse shoulder arthroplasty (RSA) is a key tool in the orthopedic trauma surgeon's arsenal, especially when faced with a proximal humerus fracture in older patients. However, few studies have focused on the glenoid side of RSA in this indication as the implant is placed in a generally healthy scapula.Glenoid implants for RSA after trauma are well positioned and do not often cause complications.Retrospective multicenter study of 513 patients who underwent RSA because of a proximal humerus fracture. The mean follow-up was 55 months. Radiographs were used to assess the height and tilt of the glenoid implant, along with the development of scapular notching or loosening. The clinical outcomes were determined based on the Constant score.At the last follow-up, 44% of shoulders had scapular notching, 7% of which were severe (stages 3-4). This notching was progressive, with two resulting in loosening. The rate of severe notching was higher in patients with a high glenoid implant (62.5% vs. 42.3%, p=0.03) or glenosphere with superior tilt (58.3% vs. 37.8%, p=0.02). Nine patients had confirmed loosening and 63 had potential loosening. This was more common in cases with superior tilt (9.3% vs. 0.4%, p0.001). Patients with a high glenoid implant had a lower Constant score (57 vs. 45, p0.001). There fewer cases of severe notching when a lateralized glenoid implant was used (0% vs. 7%, p0.05) and/or the humeral implant had a smaller neck-shaft angle (implants155°: 3% vs. implants at 155°: 8.5%, p=0.03).Glenoid loosening and severe scapular notching are related to poor positioning and/or incorrect orientation of the glenosphere. Implant selection is important, as there is little to no notching when less-angled humeral implants and lateralized glenoid implants are used.IV.

Reverse Shoulder Arthroplasty (RSA) has gained popularity over the recent years, but impingement concerns are still present. Surgeons aim to correct pre-operative glenoid deformities to reduce impingement but it can be challenging without assistance like patient specific guides. However, it is unclear how accurate glenoid correction affects the impingement. The main objective of this study was to determine whether accurate glenoid correction to neutral version and tilt can reduce the risk of impingement. Two types of virtual surgeries were performed on 22 pre-operative arthritic shoulders: (i) "Interactive," the glenoid baseplate could be placed with accuracy, and (ii) "Blind," surgeons placed the RSA baseplate while they could only visualize the glenoid. The virtual models were then used in an RSA biomechanical model which recorded impingement for (i) four Range of Motion (ROM) tasks, (ii) ten Activities of Daily Living (ADL). The "Blind" method resulted in more variable glenoid placement (version and tilt) than the "Interactive" method (p = 0.001). However, both methods showed similar ROM and impingement occurrence in ADLs. The results suggest it is challenging for surgeons to accurately correct version and tilt on arthritic glenoids when only referencing off of the face of the glenoid. However, the variable glenosphere placement observed in the "Blind" method did not result in worse impingement compared to the accurate "Interactive" method. This was because both methods had similar inferior baseplate positioning which is more important than correcting version or tilt. Implantation accuracy remains important in RSA, but pre-operative planning should not just target at correcting version and tilt. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1213-1219, 2018.

Although good short-term and mid-term outcomes are reported for rotator cuff repair, few studies have investigated long-term outcome with clinical and MRI evaluation. The hypothesis was that 10 years following repair of rotator cuff tear, the clinical and anatomic results depend on the extension of the tear.The records of all 965 patients who underwent repair of rotator cuff tears in 2003 were retrieved. The patients were reviewed in 2014 for evaluation at a minimum follow-up of 10 years. A total of 511 patients were evaluated clinically, of whom 397 were also evaluated using MRI. There were 289 isolated supraspinatus tears (SS), 94 tears with posterior extension (P), 92 with anterior extension (A) and 36 with anteroposterior (AP) extension.The Constant score had significantly improved from 53.8 ± 14.7 preoperatively to 77.7 ± 12.1 (P 0.0001) at 10 years, with no significant difference between the four groups. The rate of retear (Sugaya IV, V) was lower in the SS group (19%) and higher in the P (32%) and AP groups (31%). At review, infraspinatus fatty degeneration was significantly greater (Fuchs 2) in the P (P 0.001) and AP (P 0.001) groups and subscapularis fatty degeneration was significantly greater (Fuchs 2) in the A (P 0.001) and AP (P 0.001) groups. The rate of osteoarthritis (Samilson 2) was significantly higher at 11% (P = 0.001) in the A group. The failure rate was significantly lower (P = 0.044) in the SS group (25%) than the massive rotator cuff tear groups (A, P and AP groups) (35%). Complications occurred in 51 shoulders (10%) and repeat surgery was required in 62 shoulders (12%), with no difference between the four groups.The long follow-up period of this study, large series of patients and MRI evaluation of tendon repair allowed us to demonstrate that 10 years following rotator cuff tear repair, between 68 and 81% of tendons had healed. These findings are of value in predicting response to surgical treatment. Tears with posterior extension had a higher risk of retear. However, surgical repair appeared to give a good functional outcome whatever the type of tear, despite the overall rate of complications and repeat surgery.IV.

Glenoid component loosening is a commonly encountered complication of total shoulder replacements. Therefore, focus has been placed on glenoid fixation. Porous metal implants, which promote biological fixation through osteointegration, have provided an uncemented alternative to the traditional cemented implant. In this explantation study, the authors examined the bone ingrowth and ongrowth of a specific porous titanium glenoid peg. Six explanted polyethylene glenoid components with porous titanium-coated central pegs were identified in the authors' implant retrieval program via retrospective review. The retrieved implants were sectioned into thirds with a precision saw and underwent scanning electron microscopy for analysis of bone ingrowth and ongrowth. Bone ingrowth was calculated as bone volume fraction, or the fraction of available pore space filled with bone, whereas ongrowth was the percentage of the perimeter of the implant covered with bone. The 6 total shoulders included in the study were revised at an average of 16.3 months (range, 5–48 months) for instability secondary to subscapularis rupture, subscapularis rupture plus infection, or other rotator cuff tear. All glenoid components were grossly stable on retrieval and had an average of 23% bone ingrowth and 54% ongrowth. The preliminary results show that osteointegration into a porous titanium ingrowth glenoid component is possible in the short-term, even in the presence of an unfavorable biomechanical environment, such as instability and rotator cuff dysfunction, as well as infection. [ Orthopedics. 2017; 40(4):e703–e707.]

BackgroundNotching of the scapular pillar is the main radiographic complication seen during follow-up of reverse shoulder arthroplasties. Several recommendations pertaining to the implantation technique and glenoid component design have been suggested. No studies have investigated potential anatomic risk factors for inferior scapular impingement.HypothesisA specific anatomic shape of the scapular pillar promotes the development of notching.Materials and methodsThe Aequalis Reversed® (Tornier Inc., Edina, MN, USA) prosthesis was implanted into 40 cadaver scapulae. We measured maximal range-of-motion (ROM) in internal rotation, external rotation, and adduction. The anatomic specimens were then imaged using two-dimensional computed tomography (CT) and the scapular neck angle, surface area under the scapular pillar, and distance from the central glenosphere peg to the inferior glenoid rim were measured. Associations between these CT parameters and ROM values were assessed using statistical independence tests.ResultsROM values were greatest when the surface area under the scapular pillar was above 0.8cm2 (P

Background A common disadvantage of reverse shoulder arthroplasty is limitation of the range of arm rotation. Several changes to the prosthesis design and implantation technique have been suggested to improve rotation range of motion (ROM). Hypothesis Glenoid component design and degree of humeral component retroversion influence rotation ROM after reverse shoulder arthroplasty. Material and methods The Aequalis Reversed™ shoulder prosthesis (Tornier Inc., Edina, MN, USA) was implanted into 40 cadaver shoulders. Eight glenoid component combinations were tested, five with the 36-mm sphere (centred seating, eccentric seating, inferior tilt, centred with a 5-mm thick lateralised spacer, and centred with a 7-mm thick lateralised spacer) and three with the 42-mm sphere (centred with no spacer or with a 7-mm or 10-mm spacer). Humeral component position was evaluated with 0°, 10°, 20°, 30°, and 40° of retroversion. External and internal rotation ROMs to posterior and anterior impingement on the scapular neck were measured with the arm in 20° of abduction. Results The large glenosphere (42 mm) was associated with significantly (P

Summary Introduction When performing meniscus transplantation, allograft size must be carefully matched to the host knee anatomy. The radiographic method devised by Pollard et al. is the current reference standard for meniscus size matching. The primary objective of this study was to compare the accuracy of radiographic measurement according to Pollard, direct anatomic measurement, and photographic measurement. Hypothesis Anatomic and photographic allograft size measurement is as reliable as radiographic host-knee sizing according to Pollard et al. Materials and methods Three methods for measuring meniscal width and length based on reliable landmarks were assessed in 10 cadaver knees: direct measurement of anatomic specimens, measurement of photographs, and the radiographic method described by Pollard et al. Results No significant differences were found between the anatomic and radiographic methods, whereas the anatomic and photographic methods produced significantly different results. Compared to the anatomic method, mean overall measurement error was 7.9% for the radiographic method and 24.1% for the photographic method. Discussion The photographic method used in everyday practice during allograft harvesting is not reliable. Correcting for magnification bias might improve the performance of the photographic method. The radiographic method described by Pollard et al. is acceptable, with a margin of error of about 10%, which is considered tolerable. In practice, however, the radiographic method is burdensome to use. Conclusion The best measurement method is direct measurement of the specimen during allograft harvesting. Level of evidence Level IV.

Background Fatty infiltration (FI) compromises outcomes of rotator cuff repairs. Most clinicians consider FI of the infraspinatus, whether it is torn or intact, because it is most rapidly affected. The purpose of this study was to report long-term outcomes of isolated supraspinatus repairs and to determine their associations with FI of the infraspinatus and supraspinatus. Methods The records of 182 patients who underwent repair of isolated supraspinatus tears and had preoperative magnetic resonance imaging were retrieved. Of these, 147 patients were evaluated at 10 years' follow-up using the Constant score and magnetic resonance imaging scans. Results Preoperative FI was greater in the supraspinatus (52% stage ≥1) than in the infraspinatus (29% stage ≥1). The 10-year Constant scores were influenced by FI of the supraspinatus ( P = .006) but not of the infraspinatus ( P = .422). Multivariable regression confirmed that Constant scores were significantly lower for female patients, repetitive work, and stage 1 and stage 2 FI of the supraspinatus in addition to open surgery. Retear rates (Sugaya types IV-V) were also influenced by FI of the supraspinatus ( P = .001) but not of the infraspinatus ( P = .979). Shoulders with supraspinatus FI at stages 0, 1, and 2 had retear rates of 10%, 22%, and 31%, respectively. Multivariable regression affirmed that the odds of retears are significantly increased by both stage 1 and stage 2 FI of the supraspinatus. Conclusions The Constant scores and retear rates were significantly associated with FI of the torn supraspinatus (stage ≥1) but not of the intact infraspinatus. The authors recommend that rapid surgical intervention be considered, before accumulation of fat, especially for young, active patients.

Background Impingement after reverse shoulder arthroplasty (RSA) has been correlated with implant design and surgical techniques. Previous studies suggested that humeral retroversion can reduce impingement and increase external rotation range of motion (ROM). The purpose of this study was to determine how humeral version affects impingement in activities of daily living (ADLs). Materials and methods A single surgeon performed virtual RSA on 30 arthritic shoulders that were reconstructed from preoperative computed tomography scans. For each subject, the humeral component was placed into 5 versions: −40°,−20°, 0°, +20°, and +40° (– indicates retroversion, + indicates anteversion). Intra-articular and extra-articular impingement was calculated for 10 ADLs. Impingement-free ROM was also calculated for abduction, forward flexion, scapula plane elevation, and internal/external rotation (standardized tests). Risk of impingement for ADLs was assessed as the collective duration and frequency of impingement across all motions. Frequent impingement sites were identified. Results For the ADLs, 0° version showed the least amount of impingement. In contrast, 40° retroversion resulted in the largest ROM for the standardized tests (118° ± 19° abduction, 109° ± 16° forward flexion, 111° ± 10° scapula plane elevation, 140° ± 15° internal/external rotation). The site of impingement changed with version: retroversion increased the extra-articular impingement, and anteversion increased the contact between the inferior glenoid and the humeral cup. Conclusions Humeral version can significantly affect impingement in RSA. Maximizing ROM in standardized tests may not reduce the risk of impingement during ADLs. Our results showed that an average 0° of version should be preferred, but the large variability among subjects suggested that optimum version may vary among individuals.

Summary Introduction Various surgical techniques have been described to set the rotational alignment of the tibial baseplate during total knee arthroplasty. The self-positioning method (“self-adjustment”) aligns the tibial implant according to the rotational alignment of the femoral component which is used as a reference after performing repeated knee flexion/extension cycles. Postoperative computed tomography scanning produces accurate measurements of the tibial baseplate rotational alignment with respect to the femoral component. Hypothesis The rotational positioning of the tibial baseplate matches the rotation of the femoral component with parallel alignment to the prosthetic posterior bicondylar axis. Patients and methods A 3-month follow-up CT scan was carried out after primary total knee arthroplasty implanted in osteoarthritic patients with a mean 7.8° varus deformity of the knee in 50 cases and a mean 8.7° valgus deformity of the knee in 44 cases. The NexGen LPS Flex (Zimmer) fixed-bearing knee prosthesis was used in all cases. An independant examiner (not part of the operating team) measured different variables: the angle between the anatomic transepicondylar axis and the posterior bicondylar axis of the femoral prosthesis (prosthetic posterior condylar angle), the angle between the posterior bicondylar axis and the posterior marginal axis of the tibial prosthesis, the angle between the posterior marginal axis of the tibial prosthesis and the posterior marginal axis of the tibial bone and finally the angle between the anatomic transepicondylar axis and the posterior marginal axis of the tibial prosthesis. Results For the genu varum and genu valgum subgroups, the mean posterior condylar axis of the femoral prosthesis was 3.1° (SD: 1.91; extremes 0° to 17.5°) and 4.7° (SD: 2.7; extremes 0° to 11°) respectively. The tibial baseplate was placed in external rotation with respect to the femoral component: 0.7° (SD : 4.45; extremes –9.5° to 9.8°) and 0.9° (SD: 4.53; extremes –10.8° to 9.5°), but also to the native tibia: 6.1° (SD: 5.85; extremes –4.6° to 22.5°) and 12.5° (SD: 8.6; extremes –10° to 28.9°). The tibial component was placed in internal rotation relative to the anatomic transepicondylar axis: 1.9° (SD : 4.93; extremes –13.6° to 7°) and 3° (SD : 4.38; extremes –16.2° to 4.8°). Discussion The tibial component is aligned parallel to the femoral component whatever the initial frontal deformity ( P ≅ 0.7). However, a difference was observed between the rotational alignment of the tibial baseplate and the native tibia depending on the initial deformity and could be attributed to the morphological variations of the bony tibial plateau in case of genu valgum. Conclusion The self-positioning method is a reproducible option when using this type of implant since it allows the tibial component to be positioned parallel to the posterior border of the femur. Level of evidence Level III. Observational prospective study.

SummaryCurrently, there is little information on the clinical, radiographic and electric profile of patients younger than 65 years of age with large rotator cuff tear. According to our hypothesis, massive rotator cuff tear, when discovered after recent traumatism, do not provide typical radiographic findings and suprascapular nerve impairment in large rotator cuff tears is uncommon. This is a prospective, descriptive, multicenter study of a series of 112 patients younger than 65 years, including 66 males and 46 females with extensive or massive cuff tear. Duration of symptoms was less than 6 months in 28 cases and secondary to trauma in 57 cases. Patients had loss of elevation or external rotation or both in 57 cases. An electromyogram (EMG) of suprascapular nerve was performed in 50 cases. A higher incidence of advanced fatty infiltration of the infraspinatus muscle (>stage 2 according to Goutallier) was observed in case of long-term symptomatology or in the absence of known trauma. Traumatic status was commonly found in patients with functional deficit in shoulder elevation, thus reporting a significantly lower Constant score (p

Rotator cuff surgery is developing at a fast pace, with progress in arthroscopic techniques driving much of its advance. Overall, functional outcomes are satisfactory. Tendon healing, however, is inconsistently obtained. Tendon healing correlates with better outcomes, most notably greater strength. Therefore, the best candidates for surgery are patients with lesions that are likely to heal. Factors associated with healing are age younger than 65 years, recent tear, no history of smoking, acromiohumeral distance greater than 6 mm, and Goutallier fatty degeneration grade of the infraspinatus or subscapularis muscle smaller than 2. Open, mini-open, or arthroscopic rotator cuff repair should comply with a number of principles. The bony reattachment site should be decorticated, because healing proceeds largely from the bone. The cuff should be released to enable reattachment without tension when the elbow is by the side. The suture should ensure permanent bone-to-tendon contact until healing is complete. The arm should be kept in abduction after the procedure, and rehabilitation therapy should be gentle and chiefly passive. When an intact cuff cannot be achieved, partial repair may be appropriate in some cases. The goal is to restore muscular balance with sufficient glenohumeral stability to promote good shoulder function. In patients with factors that predict poor healing, medical treatment or palliative surgery should be considered.

Resume Nous rapportons un cas de PECome de localisation inhabituelle, intra-articulaire chez un jeune garcon de 13 ans. La tumeur, de 4 cm, mal limitee, etait composee de cellules epithelioides et fusiformes, claires ou granuleuses eosinophiles, et d’un contingent de cellules plurinucleees. Des atypies cyto-nucleaires etaient focalement observees. L’index mitotique etait evalue a 2 mitoses/50 champs au fort grandissement. Aucune necrose tumorale n’etait decelee. L’etude immunohistochimique montrait une positivite pour l’HMB45 et l’actine-muscle-lisse (AML). L’etude ultrastructurale montrait l’existence de premelanosomes. De rares cas de PEComes ont ete rapportes dans les tissus mous. Leur diagnostic repose sur la positivite des marqueurs melanocytaires (en particulier l’HMB45) et parfois de l’AML. Les criteres de malignite de ces tumeurs sont mal definis et pourraient inclure la mauvaise limitation, la taille tumorale, la presence d’atypies cytologiques et le compte mitotique. Nous discutons ici les diagnostics differentiels de cette tumeur, notamment le sarcome a cellules claires.

The Biomet Comprehensive® Reverse Shoulder Arthroplasty (RSA) is newer designed third-generation reverse prosthesis. Based on the concept originally developed by Grammont, the Biomet Comprehensive® RSA utilizes initial design of the reverse ball-and-socket implant while adding some newly developed technologic changes in order to avoid specific complications such as scapular notching or baseplate failure. One of these important advances in design, the Versa-Dial® glenosphere, allows for an infinite number of offset combinations in all direction on the glenoid side. When this technology is used in combination with two available sized baseplates, which have improved fixation features, it allows the surgeon to place the implant in the best bone stock and in the best possible position to prevent complications. In addition, the Biomet Comprehensive® Shoulder is based upon the concept of an universal humeral stem component platform system, which allows any humeral stem type or size to be used in this RSA system. It also makes conversion of an anatomic shoulder arthroplasty or fracture hemiarthroplasty (HA) to RSA much easier. This chapter will present the design considerations and biomechanical rationales of the Biomet Comprehensive® RSA. The surgical procedure is presented in details in order to clearly define the different technical steps for successful prosthesis implantation. Finally, newer concepts of implant placement and fixation will be discussed as our efforts to improve this technology continue.

The rotational profile of the lower limb, in particular tibial torsion and knee rotation, should be carefully assessed to achieve a successful total knee replacement (TKR) and to prevent rotational malalignment of the tibial component. Various surgical techniques have been described to determine the rotational alignment of the tibial baseplate during TKR. The self-positioning method aligns the tibial implant according to the rotational alignment of the femoral component which is used as a reference after performing repeated knee flexion/extension cycles. Preoperative CT scan may provide more useful insight into the exact and precise rotational orientation of the tibial component. The purpose of this chapter was to review the rotational differences among knees, the surgical and radiological landmarks commonly used, and the methods to allow an optimal placement of the tibial component.

Introduction Recent studies reported the use of patient-specific guides in aim to improve accuracy in glenoid component positioning for RSA. Most of the guides assessed in the literature have shown promising results on following preoperative plans. However, there are no direct comparisons for glenoid placement and functional outcomes of a standard RSA surgery to a guided RSA surgery. Methods This study was designed to perform RSA surgery from a single surgeon in 20 cadaveric specimens with two methodologies for glenoid baseplate placement: – traditional procedure in using a standard surgical instrumentation; – assisted procedure with a specific-guide according to a preoperative plan. The Biomet Comprehensive RSA was used. In both methods, the surgeon aimed to achieve glenoid baseplate version and tilt placement to anatomical values (0 to 5°). For the guided surgeries, a preoperative plan was performed using an interactive shoulder model (Newcastle Shoulder Model). The plan aimed to maximize impingement free range of motion (abduction, internal and external rotation). Specific guides were manufactured based on these plans by a 3D printer. Pre- and postoperative CTs were used to assess the glenoid orientation as well as the position of the baseplate. The impingement free range of motion was evaluated with a motion analysis system postoperatively. Results In average both standard and guided RSA surgeries changed the postoperative glenoid version and tilt, but none of the changes were statistically significant ( P > 0.05). The guided surgery had a significant impact on the placement of the glenoid baseplate, which was in average 4.2 mm (SD 4.0) more inferiorly compared to the standard procedure ( P P P Discussion The specific guides allowed to achieve a more inferior glenoid placement compared to the standard instrumentation. The latter translated in a better functional outcome with a larger free impingement range of motion. The guided surgeries had no effect on the postoperative glenoid alignment but this was expected since the cadaveric specimens had no arthritis or abnormal glenoid deformities.

Introduction Glenoid component positioning during reverse shoulder arthroplasty (RSA) remains challenging. Patient-specific instrumentation (PSI) has been advocated to manage this technical pitfall. The purpose of this study was to determine the accuracy of glenoid placement when only the face of the glenoid is visible, and compare it to the accuracy when the entire scapula is visible on a 3D virtual model. Materials and methods Computed tomographies (CT's) of 30 pathologic shoulders were reconstructed into 3D models. Two surgeons then virtually placed a glenosphere component into the model while only visualizing the face of the glenoid in order to simulate the exposure typically seen intraoperatively (“blinded-3D” surgery). One surgeon then placed the component in an ideal position while visualizing the entire scapula (“full-3D visible” surgery). These two positions were then compared, and the accuracy of glenoid component positioning was determined by correction of the native glenoid version and tilt, as well as by the avoidance of glenoid vault perforation. Results The mean preoperative glenoid version and tilt were +5.4° A 9.9° and +10.7° A 9.5°, respectively. The mean version and tilt after “blinded-3D” surgery were +1.4° A 8.8° and +7.6° A 6°. Glenoid vault violation occurred in 17 specimens. The mean version and tilt after “full-3D-visible” surgery were +0.3° A 0.8° and +0.1° A 0.5°, with glenoid vault perforation in 6 cases. Results between the both surgeries were significantly different ( P P > 0.05). Discussion/conclusion Surgical accuracy of the glenoid component in RSA is compromised when only the face of the glenoid is available for reference as is typical during surgery. When the entire scapula is used as a reference, accuracy is improved and glenoid vault perforation is limited. This type of visualization is only possible with preoperative 3D-CT planning and may be augmented with PSI.

Introduction A previous study by our group suggested that surgeons were not able to achieve the same accuracy in computer surgeries without full vision of scapulae. However, it is unknown whether planned prosthetic position for correcting alignment would result in better functional outcomes. The aim of this study is to analyze the effect of glenoid component positioning on the postoperative impingement free range of motion during standard glenohumeral kinematics. Materials and methods Thirty 3D-CT scapulas with highly eroded glenoid were involved. Two surgeons (A and B) performed blind RSA in Mimics software, when only the glenoid was visible. Surgeon A performed full 3D structure assisted virtual surgery on the same group of scapulae, and achieved high accuracy in correcting tilt and version. For each subject, the center of the frontal surface of glenoid metaglene from 3D assisted surgeries was defined as the planned position for baseplate. Translation of baseplate was measured in sagittal plane (anterior-posterior and superior-inferior directions) as the distance from the planned position to the center of baseplate from blind surgeries. For three postoperative situations, four standard glenohumeral kinematics (abduction, forward flexion, and internal external rotation) were simulated. Impingements between the humeral prosthesis, humerus and scapula during motion were recorded. Results Relative to the planned position from 3D assisted surgeries, no statistical difference was found on positioning by different surgeons for the anterior-posterior and superior-inferior translations of the baseplate. No statistical difference was found in impingement free range of motion among three operative conditions for each activity. Compared to the planned positions, more inferiorly translated baseplates resulted in increased impingement free range of motion in forward flexion ( P P P P P Discussion Without the guidance of the full 3D structure, the location deviation of baseplate positioning for both surgeons were similar, but showed significant variability. However, surgical plans focusing only on alignment accuracy in RSA may not result in better positioning of glenoid component, therefore may not improve impingement free range of motion for patients. A more inferior and posterior position may be advantageous for a better functional outcome. Future studies should integrate better designs for both alignment and positioning accuracy.

Management of massive rotator cuff tears is a therapeutic challenge in patients younger than 65 years, particularly if still working. According to our hypothesis, choice of the most appropriate treatment option mainly depends on the patient's functional status and on two predictive factors: height of the subacromial space and fatty muscle infiltration. This is a retrospective, multicenter study of a series of 296 patients younger than 65 years, including 176 males and 120 females with extensive or massive cuff tear. Patients had loss of elevation or external rotation or both in 162 cases. Four types of management of massive rotator cuff tear were performed in this study: anatomical watertight repairs, palliative treatments and partial repairs, watertight repairs using flaps or cuff prostheses and reverse shoulder prostheses. At follow-up, the Constant score (65.6+/-3.4) and active elevation (147.7 degrees +/-32 degrees) had significantly improved. Active external rotation with elbow at the side, and acromiohumeral interval (AHI) were unchanged. Work-related injuries, previous surgeries and complications were correlated with a poorer Constant score. At follow-up, the anatomical repair sub-group had a significantly better Constant score than the three other treatment groups but involved patients with unchanged AHI and a low degree of fatty infiltration of the infraspinatus muscle. The reverse shoulder prostheses sub-group showed better outcomes in terms of function benefits. The presence of a long biceps was correlated with the use of a palliative treatment. In the light of the results and literature, an approach to treatment is suggested related to the functional capacity of patients, the AHI and the degree of fatty infiltration of the infraspinatus and subscapularis muscles.