Search

Resume Introduction De nombreuses techniques de reconstruction du ligament femoropatellaire medial (MPFL), utilisant differents types de transplants et moyens de fixation, ont ete decrites. La difficulte principale etant de retablir au mieux l’anisometrie du MPFL, nous proposons ici une technique percutanee de reconstruction du MPFL utilisant un transfert actif du gracilis sans fixation femorale. Methodes Un travail anatomique, sur 20 genoux cadaveriques, a ete entrepris pour evaluer la faisabilite et la fiabilite de la technique percutanee proposee. L’emplacement de la poulie femorale et la longueur des cicatrices ont ete analyses. Resultats Apres la dissection, l’emplacement de la poulie femorale permettait systematiquement de superposer le transplant au trajet du MPFL natif. La longueur cumulee des cicatrices etait de 6,5 cm (6–7,5). Discussion La technique percutanee de transfert actif du gracilis est facile, reproductible et permet de creer une poulie anatomiquement comparable au point d’insertion femoral du MPFL natif. Niveau de preuve IV ; etude retrospective.

Resume Introduction L’origine de l’osteolyse humerale proximale apres une prothese totale inversee de l’epaule (PTEI) reste controversee. Les objectifs etaient de comparer les resultats radiographiques des PTEI de type Grammont par methode de fixation cimentee par rapport au sans ciment et d’identifier la cause de ces changements radiographiques particulierement pour les tiges non cimentees. Hypothese La perte osseuse humerale proximale est plus importante pour les tiges humerales non cimentees. Methodes Avec un suivi minimum de 5 ans, deux cohortes appariees ont ete comparees de maniere retrospective : 70 PTEI avec tige cimentee et 70 PTEI avec tiges sans ciment. Sur les radiographies prises lors de la derniere visite de suivi, nous avons recherche la resorption des tuberosites, les signes de stress shielding, la presence de liseres periprothetiques et l’encoche scapulaire. Resultats A un suivi moyen de 9 ans (5,0–20,6), le taux de revision de la PTEI etait de 1,8 % dans le groupe cimente et de 3,6 % dans le groupe sans ciment (p = 1). La resorption tuberositaire etait deux fois plus frequente dans le groupe sans ciment : 59 % contre 30 % (p Discussion Pour les tiges sans ciment, l’osteolyse humerale proximale peut en partie etre attribuee au stress shielding. La relation entre l’encoche et la resorption tuberositaire dans les deux groupes suggere egalement une cause biologique secondaire. Niveau de preuve III ; etude comparative retrospective.

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.

Long head of the biceps (LHB) pathology is frequent but can be difficult to diagnose. Arthroscopy is the current diagnostic gold-standard. The aim of the present study was to assess inter- and intra-observer agreement in arthroscopic analysis of the LHB.Agreement in arthroscopic analysis of the LHB is good in the particular case of small rotator cuff tears.This prospective study included 49 patients operated on between November 1 and November 30, 2017. Seven surgeons were asked to record videos of arthroscopic LHB analysis for Patte-1 small supraspinatus tendon tears. One junior and 2 senior surgeons analyzed the videos independently, studying macroscopic intrinsic and extrinsic LHB aspect. Inter-observer agreement, and intra-observer agreement for the junior surgeon, were analyzed.Inter-observer agreement between the surgeons and intra-observer agreement for the junior surgeon were slight in describing the pathologic aspect of the LHB: respectively, κ=0.254, p0.038; and κ=0.319, p0.0019.Isolated arthroscopic LHB assessment without clinical or paraclinical input or precise surgical exploration protocol showed slight inter-observer agreement. Analysis and interpretation of LHB aspect should in practice be based on combined clinical, paraclinical and arthroscopic data.III.

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.

The long head of the biceps (LHB) tendon is a common locus of pain in rotator cuff tear and of residual pain after tendon repair. Therefore, systematic LHB tenotomy, with or without tenodesis, is usually recommended. However, the recent literature suggests that long-term functional results of supraspinatus tendon repair are comparable between conservation of a normal biceps and tenotomy. The study objective is to compare functional results between sectioning and sparing a normal LHB in treating isolated grade-1 supraspinatus tendon tear. The study hypothesis is that sparing the normal LHB is clinically preferable to sectioning in the particular case of distal supraspinatus tear.A French nationwide prospective single-blind randomized clinical study will include 194 patients undergoing arthroscopic repair of grade-1 supraspinatus tear with normal LHB. They will be randomized to 2 parallel groups: LHB sparing and sectioning. The main endpoint is Constant-Murley score, and secondary endpoints comprise ASES and SSV scores, clinical assessment of the biceps, pain on VAS, ultrasound assessment of cuff repair healing and conserved LHBs, impact on return to work and sport, pathologic assessment of sectioned LHBs, and analysis of risk factors for cuff repair failure.The protocol has been approved by the data protection committee (art.L.1122-1) and meets the criteria of the Declaration of Helsinki and of the SPIRIT statement defining standard protocol items for clinical trials. Results will be published in a peer-reviewed journal.not applicable.

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.

Resume Introduction L’objectif principal de cette etude etait de proposer une nouvelle methode d’assistance operatoire pour l’implantation d’une prothese totale d’epaule, avec l’utilisation de la realite augmentee. L’interet de cette approche etait de completer des informations, d’une part, preexistantes ou disparues suite a un processus pathologique, telles que l’etat de la glene avant l’usure arthrosique ou glene premorbide, et d’autre part, deja existantes mais non accessibles au chirurgien durant l’intervention, telles que la face dite « cachee » de la scapula. Materiel et methodes Plusieurs etapes de preparation de l’information ont ete necessaires. Une glene premorbide a d’abord ete generee a partir d’un nuage de points issus d’equations de regression prealablement etablies. Une bibliotheque de glenes generiques « saines » a en parallele ete creee par analyse ascendante hierarchique. A partir de cette base de donnees, une glene generique normale dite adequate etait fusionnee et appariee par morphing a la glene premorbide reconstruite. La glene finale normale reconstituee « la plus probable » etait alors obtenue. Une application experimentale de la realite augmentee a enfin ete mise au point. Elle reposait sur l’utilisation de lunettes connectees, qui permettaient l’affichage de l’information 3D implementee de la glene finale reconstituee. Resultats Une glene pathologique 3D a ete reconstruite et a ete utilisee pour l’application de la realite augmentee. L’affichage complet de la scene, glene reconstituee et scapula dans son entier, a pu etre obtenu. Un decalage par rapport au reel etait cependant observe. Les principales limites ont ete techniques, liees au support connecte utilise et au logiciel d’exploitation. Discussion/Conclusion Il s’agissait d’une etude de faisabilite des differentes etapes necessaires a l’application de la realite augmentee, de la preparation de l’information a sa visualisation. Un nouveau plan d’experience de croisement des parametres est necessaire pour optimiser chacune des etapes de ce processus. Niveau de preuve IV, etude scientifique de base.

Resume Introduction L’objectif de l’etude etait d’identifier des points de la scapula a partir desquels une prediction de l’anatomie glenoidienne pre-morbide normale pouvait etre obtenue. Materiels et methodes Quarante-trois scapulae normales reconstruites en 3D et positionnees dans un referentiel commun ont ete utilisees. Vingt points repartis entre l’ecaille de la scapula, partie consideree comme normale dans le temps et servant de reference, et la glene, partie consideree comme pathologique et a reconstruire, ont ete releves manuellement. Treize distances (X) entre 2 points ne se trouvant pas sur la glene, et 31 distances (Y) entre 2 points dont au moins un point etait localise sur la glene, ont ensuite ete calculees automatiquement. Une methode statistique de regression lineaire multiple a alors ete appliquee, avec pour objectif de calculer les distances Y a partir des distances X, et de ne retenir que les 4 meilleures equations selon leur coefficient de determination (R2) pouvant expliquer un point de la glene a reconstituer (p Resultats En cas de glene totalement detruite, l’erreur moyenne pour une distance choisie pour un point donne de la glene a ete calculee a 2,4 mm (4.e-3 mm ; 12,5 mm). En cas destruction partielle, l’erreur moyenne etait de 1,7 mm (4.e-3 mm ; 6,5 mm) pour la meme distance evaluee pour un point donne de la glene. Discussion – conclusion Le modele statistique propose a permis de predire l’anatomie pre-morbide de la glene avec un niveau de precision acceptable. Cette information nouvelle pour le chirurgien pourrait etre utilisee lors de la planification preoperatoire et en peroperatoire, via un nouveau support d’assistance chirurgicale.

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.

Although the use of short stem and stemless shoulder prosthesis is trending, the surgical outcome may vary due to varying biomechanics. Objectives were to evaluate and compare the short-term clinical results and radiological changes between anatomical total shoulder arthroplasty (TSA) and reverse TSA (rTSA) with a short-stem humeral design.There is no clinical and radiological difference between TSA and rTSA using a short-stem humeral design.This retrospective study included 66 patients who underwent TSA and rTSA (33 patients each) with a minimum 2-year follow-up. Radiographic findings, including preoperative Tingart cortical index (TCI), postoperative filling ratios of metaphysis (FRmet) and diaphysis (FRdia), bone adaptations, and osteolysis around the humeral stem at the immediate postoperative period, and the most recent follow-up were measured. Pre and postoperative Constant-Murley score, subjective shoulder value (SSV), and complications were noted.At a mean follow-up of 27 (range 24-50) months, FRmet was significantly higher in rTSA group than the TSA group (0.65 vs. 0.60, p=0.009). Bone resorption was similar in both groups (p=0.76) and was correlated to a lower TCI value of2.9mm (p=0.02). Despite significant clinical improvement in individual groups, the comparison between groups was non-significant (p0.05). Negative correlation was observed between TCI and total clinical score (p=0.045) in TSA group, active external rotation (p=0.019), activity (p=0.005), SSV (p=0.008) and total score (p=0.025) in rTSA group. Radiographic changes were not influenced by patient characteristics and clinical results (p0.05).Although no radiographic difference was observed between TSA and rTSA, better short-term clinical results observed with the usage of the short-stem humeral design prosthesis are encouraging.III; Retrospective cohort study.

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.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.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.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.III, case control study.

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.

Resume Introduction L’evaluation echographique de la longue portion du biceps (LPB) est difficile. Le but de cette etude etait d’analyser la reproductibilite inter et intra-observateur de deux coupes echographiques jusqu’a maintenant non evaluees : a l’apex de la tete humerale (coupe 1) et a l’entree de la gouttiere bicipitale (coupe 2). Hypothese Ces coupes echographiques seraient fiables et reproductibles pour l’analyse de la LPB dans sa portion intra-articulaire. Materiel et methodes Il s’agissait d’une etude prospective monocentrique. Une evaluation inter-observateur etait conduite par deux radiologues pour 20 epaules saines (groupe « asymptomatique ») et pour 35 epaules douloureuses (groupe « symptomatique »). Une evaluation intra-observateur etait realisee par un radiologue pour 10 epaules saines. Des mesures quantitatives : petit et grand axes, surface transversale, et des mesures qualitatives : echogenicite et position de la LPB etaient analysees. Resultats Pour les coupes 1 et 2, le niveau de concordance inter-observateur pour les 3 mesures quantitatives etait bon a excellent dans les 2 groupes de patients evalues (p Discussion Les deux niveaux de coupes intra-articulaires de la LPB sont fiables et reproductibles chez des patients avec une epaule saine ou douloureuse. L’interet d’un protocole echographique standardise pourrait permettre ainsi d’ameliorer la precision d’evaluation de la LPB ainsi que sa prise en charge. Les difficultes de mesures de la LPB, souvent associee a une situation pathologique de l’epaule peuvent cependant venir interferer l’interpretation echographique. Niveau de preuve III ; etude prospective intra et inter-observateur.

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.

Resume Introduction La creation des centres de reference pour les infections osteoarticulaires (CRIOA) a eu pour but d’optimiser la prise en charge de ce type d’infection, grâce a une concertation multidisciplinaire. L’objectif de cette etude etait d’etudier l’influence de la mise en place du Centre de reference des infections osteoarticulaires du Grand Ouest (CRIOGO) sur le traitement arthroscopique des arthrites septiques (AS) de l’epaule et du genou. L’objectif secondaire etait d’identifier d’autres facteurs d’echec de ce traitement. L’hypothese H0 etait l’absence de difference entre le groupe « succes » et le groupe « echec ». Materiel et methode Cette etude retrospective monocentrique a inclus 52 patients traites pour une AS entre le 01/01/2000 et le 31/12/2013 par lavage arthroscopique associe a une antibiotherapie d’au moins 4 semaines. Les criteres d’exclusion etaient un diagnostic retrospectif d’arthrite rhumatismale apres analyse bacteriologique negative, un arret precoce du traitement antibiotique et un suivi inferieur a 4 semaines. L’echec etait defini comme l’absence de guerison apres traitement de premiere intention. Le critere de jugement principal etait la date de la prise en charge par rapport a la date de mise en place du CRIOGO au premier trimestre 2010. L’influence de criteres pre- et peroperatoires, inherents au patient, au traitement realise et au germe identifie a ete recherchee. Resultats A la revision, 17 (32,9 %) patients etaient en echec de traitement de premiere intention et 5 (9,6 %) n’etaient pas gueris en fin de traitement, quel que soit le type de reprise. Le taux d’echec diminuait significativement apres la mise en place du CRIOGO : 42,9 % avant contre 11,8 % apres (p = 0,03). Dans le groupe echec, 70,6 % des patients etaient immunodeprimes contre 37,2 % dans le groupe succes (p = 0,01). Ni le delai de prise en charge (p = 1), ni le type de germe, ni un lavage antiseptique (p = 0,25) ou une synovectomie (p = 0,62) n’influencaient le resultat du traitement. Discussion La prise en charge multidisciplinaire des AS permet d’ameliorer le succes therapeutique. Niveau de preuve III, etude retrospective comparative.

Resume Introduction Les ruptures massives de la coiffe des rotateurs representent 10–40 % des ruptures de coiffe et plus de 80 % des ruptures iteratives. Le but de cette etude prospective etait d’evaluer a un an de recul les resultats fonctionnels des patients traites medicalement d’une rupture massive et irreparable de la coiffe des rotateurs et de rechercher les facteurs predictifs d’un bon resultat. Hypothese Le traitement medical vaut la peine d’etre tente car il ameliore l’etat des patients. Materiel et methodes Il s’agit d’une etude prospective, multicentrique (12 centres) entre mars 2015 et mars 2016, incluant tous les patients traites medicalement (reeducation et infiltrations sous-acromiales) d’une rupture de la coiffe des rotateurs touchant deux tendons ou plus dont au moins un avait une infiltration graisseuse > 2. Les resultats cliniques ont ete evalues a l’aide du score de Constant et du score SSV a 3, 6 et 12 mois. Resultats Soixante et onze patients ont ete inclus, 3 patients ont ete operes pendant le suivi et 68 ont ete analyses a un an. Le score de Constant (40,7 a l’inclusion versus 57,7 a 6 mois et 57,1 a un an) et chacun de ses items sauf la force ont ete significativement ameliores ainsi que le score SSV. Le score de Constant a un an ne differait pas significativement du score de Constant a 6 mois. Aucune difference significative n’a ete retrouvee entre les resultats fonctionnels et le type de rupture initiale. Conclusion Un traitement medical permet une amelioration fonctionnelle significative dans le cadre des ruptures massives et non reparables de la coiffe des rotateurs. Cette amelioration fonctionnelle est obtenue en 6 mois et a cette echeance, si le resultat n’est pas satisfaisant, un traitement chirurgical peut etre envisage. Niveau d’evidence III, etude prospective.

Resume Introduction Le choix du geste a realiser, tenotomie ou tenodese, sur la longue portion du biceps (LPB), ne fait actuellement l’objet d’aucun consensus lors des reparations d’une rupture de la coiffe des rotateurs (CDR). Le signe de Popeye (SP) est souvent cite en defaveur de la tenotomie. L’objectif principal de cette etude etait de determiner la frequence et le retentissement clinique du SP. Hypothese Le SP est rarement retrouve cliniquement, et de faible retentissement fonctionnel apres tenotomie. Materiels et methodes Une etude prospective, non randomisee, monocentrique, a ete realisee entre fevrier et octobre 2015 chez tous les patients ayant beneficie d’une chirurgie de la CDR. Les patients sans gestes sur la LPB ont ete exclus. Au sixieme mois postoperatoire, la frequence du SP a ete evaluee. Les patients ayant eu une tenotomie, avec ou sans SP, ont ensuite ete compares, avec pour criteres de jugement la presence d’une EVA inferieure ou egale a 3, le gain de mobilite articulaire, l’amelioration du SSV, la presence d’une gene ou de crampes et le gain de points du score de Constant. Resultats Parmi les 55 patients inclus, 7 (15,2 %) presentaient un SP en postoperatoire. Il n’existait aucune difference entre les deux groupes de patients, avec et sans SP, pour l’ensemble des criteres etudies. Seul le parametre mobilite du score de Constant etait significativement ameliore pour le groupe avec SP par rapport au groupe sans SP (respectivement gain de 13,8 points contre 3,8 points, p = 0,01). Discussion Le SP est d’observation clinique relativement rare. Son retentissement fonctionnel est faible, dans les limites de cette etude. La tenotomie de la LPB reste une option therapeutique legitime et non prejudiciable, lors d’une reparation associee d’une rupture de la CDR. Niveau de preuve IV. Type d’etude Etude prospective non randomisee.

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.

Resume Introduction La prothese d’epaule inversee (PTEI) a une place importante dans l’arsenal therapeutique de l’orthopediste traumatologue, notamment dans les fractures complexes de l’extremite superieure de l’humerus (FESH) du sujet âge. Dans cette indication, peu d’etudes se sont interessees au versant glenoidien de l’implant, implante sur une scapula generalement saine. Hypothese Les implants glenoidiens des PTEI traumatiques sont bien positionnes et peu sujets aux complications. Materiels et methode Etude retrospective multicentrique sur 513 patients operes d’une PTEI pour FESH, revus au recul moyen de 55 mois. L’analyse radiologique a evalue la position en hauteur et l’inclinaison de l’implant glenoidien, ainsi que l’apparition d’une encoche scapulaire ou d’un descellement. Le resultat clinique etait evalue par le score de Constant. Resultats Au dernier recul, 44 % d’encoche de la scapula, dont 7 % severes (stade 3–4) ; les encoches etaient evolutives, deux ont abouti a un descellement. Taux d’encoches severe plus important si position haute (62,5 % vs 42,3 %, p = 0,03) ou d’orientation superieure de la glenosphere (58,3 % vs 37,8 %, p = 0,02). Neuf patients presentaient un descellement avere et 63 un descellement potentiel. Ils etaient plus frequents en cas d’orientation superieure (9,3 % vs 0,4 %, p Discussion et conclusion Les descellements glenoidiens et les encoches severes de la scapula sont lies a un mauvais positionnement et/ou une mauvaise orientation de la glenosphere. Le choix des implants est important avec peu ou pas d’encoches pour les implants humeraux moins inclines et les implants glenoidiens lateralises. Niveau de preuve IV.

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.

Resume Introduction L’implantation du composant glenoidien d’une prothese totale d’epaule anatomique (PTE) peut etre assistee par l’utilisation de guides specifiques patients (GSP). Cette technologie repose sur une etape de planification preoperatoire precise du positionnement glenoidien. Le but de cette etude etait d’evaluer pour une premiere serie de 10 patients la fiabilite d’utilisation d’un GSP et sa precision de reproductibilite d’un planning preoperatoire. Materiel et methode Dix patients ont ete operes d’une PTEA avec l’utilisation d’un GSP pour le positionnement glenoidien, apres planification preoperatoire tridimensionnelle. Les parametres de version et d’inclinaison prothetique, habituellement evalues, ont ete mesures en postoperatoire et compares au planning prealablement realise. De nouveaux criteres de rotation et de positionnement global 3D de l’implant, ainsi que la precision du point d’entree 3D de la broche de preparation glenoidienne ont egalement ete evalues. Resultats L’erreur de positionnement glenoidien etait en moyenne de −1,7 ° ± 4,4 ° pour la version, de −0,4 ° ± 4,9 ° pour l’inclinaison, et de 6 ° ± 13,5 ° pour la rotation. L’orientation globale moyenne postoperatoire de la glene prothetique differait de 4,9 ° ± 2,5 ° par rapport au planning preoperatoire. Le decalage 3D du point d’entree de la broche guide etait en moyenne de 2,9 mm ± 0,5 mm, avec un decalage mediolateral plus important (1,9 mm ± 0,9 mm) que les decalages supero-inferieur (1,1 mm ± 1,2 mm) et antero-posterieur (0,8 mm ± 1,2 mm). Discussion-conclusion L’absence de controle en rotation et du fraisage par le GSP utilise peut expliquer la difference de positionnement glenoidien global observee. Une amelioration de la conception des GSP, integrant ces 2 parametres, pourrait etre envisagee a l’avenir.

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.

Resume Introduction Le positionnement du composant glenoidien lors de l’implantation d’une prothese d’epaule inversee reste techniquement difficile pour le chirurgien. L’instrumentation « guide specifique patient » (GSP) a ete preconisee pour en ameliorer la precision. Son utilisation repose elle-meme sur une planification preoperatoire precise. Le but de cette etude est de determiner et de comparer la precision de planification du placement glenoidien entre une situation ou seule la surface glenoidienne est visible, et une situation ou la totalite de la scapula est visible sur un modele tridimensionnel (3D). Materiel et methode Les tomodensitometries (TDM) de 30 epaules arthrosiques ont ete reconstruites en 3D. Deux chirurgiens ont virtuellement positionne le composant glenoidien en situation ou seule la surface glenoidienne 3D etait visible, simulant ainsi l’exposition classique intraoperatoire (chirurgie « 3D-aveugle »). Un seul des 2 chirurgiens a ensuite place le composant en situation de visualisation de la scapula 3D entiere (chirurgie « 3D-visible »). La precision de ces deux positionnements a alors ete evaluee et comparee sur les criteres de correction de la version et de l’inclinaison glenoidienne, ainsi que d’evitement de la perforation du cone glenoidien. Resultats Les versions et inclinaisons moyennes apres chirurgie « 3D-aveugle » etaient respectivement de +1,4° (SD 8,8°) et +7,6° (SD 6°). La perforation glenoidienne etait survenue pour 17 cas. Les versions et inclinaisons moyennes apres chirurgie « 3D-visible » etaient respectivement de +0,3° (SD 0,8°) et +0,1° (SD 0,5°), avec perforation glenoidienne survenue a 6 reprises. La chirurgie « 3D-visible » etait significativement plus precise que la chirurgie « 3D-aveugle » ( p Conclusion Lorsque la totalite de la scapula a ete utilisee comme reference, la precision de positionnement glenoidien et l’evitement de la perforation glenoidienne etaient ameliores. Ce type d’information est notamment disponible lors de l’etape du planning preoperatoire, prerequis necessaire a l’utilisation des GSP. Niveau de preuve Basic science study . Level III.

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.

Resume Introduction En 1985, Grammont a defini le concept de la prothese inversee pour les omarthroses avec une atteinte severe de la coiffe. Cependant, cette prothese ne permet pas toujours une bonne recuperation de la mobilite en rotation interne. Objectif L’objectif de cette etude a ete de rechercher les facteurs pre- et peroperatoires correles a la recuperation d’une bonne rotation interne. Notre hypothese est que le statut restant de la coiffe et la position de la sphere sont les deux facteurs les plus discriminants. Materiel et methode Cette etude prospective a ete menee, du 2/11/2015 au 10/01/2017, chez 36 patients operes d’une prothese totale inversee. Les criteres d’inclusion etaient : les ruptures massives de coiffe avec ou sans arthrose et les omarthroses avec usure asymetrique de la glene. En preoperatoire, les elements suivants ont ete analyses : le score de Constant, le SSV, les amplitudes articulaires passives et actives. Le bilan preoperatoire comportait des radiographies standard et un scanner. En postoperatoire, les patients ont tous ete revus a 6 mois et a chaque fois les memes parametres cliniques et radiographiques ont ete collectes. Resultats En postoperatoire, l’ensemble des mobilites a ete amelioree sauf la rotation interne coude au corps (RI1) consistant a mettre la main dans le dos. L’analyse montre que l’obtention d’une RI1 a hauteur de L3 ou plus haut etait significativement correlee a un IMC plus bas (p = 0,04), une bonne RI passive preoperatoire (p = 0,056), une inclinaison glenoidienne preoperatoire moins importante et un debord glenoidien de la sphere plus important (p = 0,03). L’etat du sub-scapulaire ainsi que sa reparation n’avait pas d’influence significative. La presence d’un teres minor fonctionnel limitait significativement la RI1. Conclusion Une RI1 active satisfaisante est correlee a une bonne RI1 passive. La RI1 est meilleure chez les sujets maigres presentant une omarthrose excentree associee. Par ailleurs, la RI est amelioree s’il existe un debord inferieur d’au moins 6 mm. Niveau d’evidence IV, etude prospective non randomisee.

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.

Resume Introduction La chirurgie du poignet rhumatoide repose sur la synovectomie articulaire associee a une stabilisation-reaxation du carpe. L’objectif de cette etude etait d’etudier les resultats obtenus par une technique conservatrice de stabilisation : le transfert tendineux du long extenseur radial du carpe (ECRL) sur l’extenseur ulnaire du carpe (ECU), et de redefinir ses indications therapeutiques. Hypothese Le transfert tendineux du long extenseur radial du carpe (ECRL) sur l’extenseur ulnaire du carpe (ECU) peut prevenir ou ralentir l’evolution des deformations du poignet rhumatoide. Materiels et methodes Il s’agissait d’une etude observationnelle retrospective. Seize poignets ont ete inclus. L’evaluation preoperatoire portait sur les criteres suivants : douleur, synovite, mobilites, hauteur du carpe, glissement ulnaire et deviation radiale du carpe, qualite des interlignes radio- et mediocarpien (Larsen). Une evaluation postoperatoire a ete conduite en consultation selon les memes criteres d’analyse. Resultats Au recul moyen de 42,5 mois, la douleur avait diminue dans 14 cas et la synovite disparue dans 10. Les gains en extension et flexion etaient respectivement de 19,7° et 5,7°. Sur le plan radiographique, on constatait une stabilite de la deviation radiale et du glissement ulnaire du carpe, mais une diminution de hauteur. L’atteinte radiographique des interlignes medio- et radiocarpiens etait stationnaire. Pour les 3 patients ayant eu un geste supplementaire d’arthrodese mediocarpienne pour atteinte preoperatoire avancee, l’interligne radiocarpien etait reste inchange. Le resultat pour ces 3 poignets etait identique a l’ensemble des cas de la serie. Discussion/Conclusion Le transfert tendineux de l’ECRL en association a la synovectomie est efficace sur la douleur et previent la destabilisation radiocarpienne. La principale indication reste le poignet avec deviation radiale et glissement ulnaire du carpe reductible. Le transfert de l’ECRL est aussi une bonne indication en association avec une arthrodese mediocarpienne dans les rares cas avec atteinte mediocarpienne predominante de Larsen > 2. Niveau de l’etude IV.

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.

Resume Introduction La luxation est une complication frequente des changements de protheses totales de hanche (PTH) encore plus en situation de revision. Les cupules double mobilite (CDM) diminuent le risque d’instabilite en chirurgie primaire mais leur utilite et leur survie ne sont pas encore etablies sur les reprises de PTH. Aussi nous avons mene une etude retrospective avec pour objectifs : (1) de verifier la stabilite des CDM dans cette indication, et (2) d’etudier leur survie avec un recul minimum de 5 ans. Hypothese Le taux de luxation des CDM pour les arthroplasties de revision est comparable a celui observe pour les arthroplasties primaires. Materiels et methodes Soixante et onze patients (74 hanches) ont eu un changement de cupule entre 2000 et 2007 avec mise en place d’une CDM, pour luxations iteratives (22 cas), descellement aseptique (38 cas), et changement pour infection (14 cas). Les cupules utilisees etaient cimentees (47 cas), ou non cimentees (27 cas). Les donnees cliniques (score de Postel-Merle d’Aubigne [PMA] et de Harris) et radiologiques de cette etude retrospective ont ete recueillies a partir du dossier et lors de la derniere consultation de revision. Resultats Sur 74 cas, 2 etaient perdus de vue. Le score PMA moyen au dernier recul etait de 15,2 (11–18) et le score de Harris etait de 80,4 (51–98). Il y avait 8 echecs dont 2 (2,7 %) pour cause mecanique (1 descellement aseptique, 1 luxation). Les echecs mecaniques n’etaient pas lies a une indication particuliere. Un lisere radiologique etait present dans 4 cas, sans correlation clinique. Le taux de survie, avec l’echec defini par toute reprise chirurgicale acetabulaire pour cause aseptique, etait de 99 % (IC 95 %, 93–100 %) a 5 ans. Discussion Par rapport aux arthroplasties primaires utilisant un CDM, le taux de luxation de cette serie (1,4 %) est legerement superieur, mais le taux de survie est comparable a 5 ans. Les CDM cimentees ne presentent pas un risque accru de descellement. Conclusion Les cupules double mobilite sont utiles pour prevenir le risque d’instabilite dans les changements de PTH, quelle que soit l’indication. Elles n’entrainent pas de contraintes elevees a l’interface os-implant comme en temoigne le faible taux de descellement. Niveau de preuve Niveau IV, etude retrospective.

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.