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Platelet-rich plasma (PRP) is a revolutionary treatment that harnesses the regenerative power of the body's own platelets to promote healing and tissue regeneration. While PRP therapy has emerged as a promising option for augmenting biologic healing in the shoulder, the complexity of shoulder disorders makes it difficult to draw definitive conclusions about the efficacy of PRP across different conditions and stages of disease. Our comprehensive review of twenty-four studies highlights the current state of PRP therapy in shoulder pathologies, revealing a wide variety of number of patients, control groups and results. Despite these challenges, the regenerative potential of PRP therapy is moderate in some conditions, with numerous studies demonstrating the positive effects. In conclusion, the authors of this study recommend the use of PRP therapy for adhesive capsulitis and rotator cuff repair of medium to large tears. However, they do not recommend the use of PRP for subacromial impingement or rotator cuff tears. It is up to the clinician's discretion to decide whether PRP therapy is appropriate for individual cases. However, there is still insufficient evidence to support the inclusion of PRP therapy in treatment protocols for other shoulder disorders. Therefore, further research is needed to fully explore the potential of PRP therapy in the treatment of various shoulder conditions.

Resume Introduction Le conflit postero-superieur est la premiere cause de douleurs chroniques d’epaule chez le sportif avec arme ou lancer. Lorsque le traitement chirurgical est preconise, il n’y a pas de consensus sur les techniques utilisees et les series publiees ont peu de patients et de recul. L’hypothese principale de l’etude etait que le traitement chirurgical permettait la reprise du sport au meme niveau ou superieur. L’hypothese secondaire etait que certains facteurs epidemiologiques, anatomiques pre- et peroperatoires et certains gestes chirurgicaux permettaient un meilleur resultat sur la reprise du sport au meme niveau ou superieur. Methodologie Cent trente-cinq patients operes de l’epaule pour conflit postero-superieur sous arthroscopie avec l’un des gestes suivants : capsuloraphie anterieure, capsulotomie/ectomie posterieure, debridement du bourrelet postero-superieur, glenoidoplastie posterieure, debridement ou reparation d’une lesion des tendons de la coiffe des rotateurs, ont ete inclus de maniere retrospective dans l’etude avec un minimum de un an de recul. Ils ont ete separes en deux groupes : groupe A : reprise du meme sport au meme niveau ou superieur ; groupe B : reprise du meme sport a un niveau inferieur, changement de sport, arret du sport. Deux scores (KJOC et Constant) ont ete utilises pour l’analyse subjective et objective de la fonction de l’epaule. Resultats Le recul moyen etait de 7,9 ans. Quatre-vingt-dix pour cent des patients ont repris le sport dont 52 % a un niveau identique ou superieur. Les facteurs favorisant la reprise du sport au meme niveau etaient en analyse univariee et multivariee : le sexe masculin, l’existence d’une lesion de coiffe en peroperatoire et’l'absence de geode trochiterienne a l’imagerie preoperatore. Lee debridement de la lesion de coiffe etait un facteur favorisant uniquement en analyse univariee. La capsuloraphie anterieure etait associee a plus de douleurs postoperatoires. Discussion Le taux de retour au sport au niveau anterieur est peu comparable a celui des series de la litterature du fait de sports pratiques differents et de techniques chirurgicales tres variables. Le caractere favorisant de la presence d’une lesion de la coiffe des rotateurs est une notion qui va a l’encontre de la plupart des series publiees. Les differences entre les sports pratiques en Europe continentale et dans les pays de culture anglo-saxons pourraient expliquer certaines des differences retrouvees. Niveau de preuve IV.

Internal impingement of the shoulder (IIS) is a specific disorder of young overhead-throwing athletes that was first described in 1991. The many non-operative and surgical treatments suggested to date have produced mixed outcomes. The objective of this study was to compare the practices of surgeons in France versus other countries regarding the diagnosis and treatment of IIS.Diagnostic and therapeutic practices regarding IIS differ between surgeons in France and in other countries.A 21-item questionnaire in French and English was emailed to the 1300 members of the French Arthroscopy Society and to surgeons from countries other than France. The questionnaire collected information on knowledge about IIS (2 items), the frequency of IIS in clinical practice (2 items), the diagnosis of IIS (6 items), the non-operative and surgical treatment of IIS (3 and 5 items, respectively), and return-to-sports rates after treatment for IIS (3 items).The completed questionnaire was sent back by 261 surgeons, 206 in France and 55 in other countries, including 42 in Japan. Among the respondents, 90% knew about IIS. Experience with IIS in terms of number of patients seen or surgical treatments performed was greater in the international group (45% vs. 19% in France, p0.001). Posterior shoulder pain in the arm cocking position was the most widely recognised symptom (99% in France, 74% internationally, p0.001), followed by excessive external rotation during arm abduction (55% vs. 65%, p=0.23). The most commonly sought lesions were those of the postero-superior labrum and articular surface of the rotator cuff. Rotator cuff debridement was among the surgical options according to most respondents (74% vs. 70%). In contrast, postero-superior glenoidplasty was cited almost only by surgeons in France (67% vs. 4%, p0.001). The proportion of patients who are able to return to sports was estimated at 50% to 75% by most respondents.Most respondents had theoretical knowledge about IIS, but surgery was rarely performed in France. Only very few athletes in France play baseball, which is responsible for most sports injuries of the shoulder seen in Japan. This fact, combined with differences in the lesions or even the diagnoses, may have contributed to the differences in the responses to the survey items between the French and international groups.

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Cadaveric joint simulators are commonly used to explore native and pathological joint function as well as to test medical devices. Recently, robotic manipulators have been proposed as a new gold standard for in vitro biomechanical testing as they offer higher possibilities than Universal Testing Machines in terms of degrees of freedom (DOF). However, current protocols remain conducted in extra-corporal conditions by fixing one segment of a diarthrodial joint while mobilising the other segment. Moreover, induced motions are commonly not specimen-specific and do not respect related joint kinematic constraints and physiologic boundaries. In this study, using a 7 DOF redundant robotic manipulator, an intra-corporal condition protocol was defined. This protocol allows 1) the analysis of the shoulder girdle full kinematic chain, 2) the replication of specimen-specific humerus motions initially induced by an operator. On the 10 shoulders tested, the robotic manipulator was able to perform requested end-effector motions with a reliability of 0.28 ± 0.57 mm and 0.15 ± 0.25°, and a fidelity of 0.27 ± 0.56 mm and 0.22 ± 0.28°. This protocol will be used in the future to explore joint function as well as to test medical devices, on the shoulder girdle and potentially other joints.

Proximal humerus fracture (PHF) is the 3rd most common fracture over age 65, and its incidence increases with age. The combination of an aging population and a high incidence in geriatric patients constitute a serious potential public health concern. The treatment of PHF is debated. Recent publications report similar results of conservative versus surgical treatment in several types of fractures. Therapeutic decision based on a multiparametric analysis is recommended, there is yet no consensus on the parameters to be analyzed. A recent study suggests taking into consideration individual parameters in deciding the therapeutic strategy and provides a pragmatic treatment algorithm. We propose here a simplified version of this algorithm, guiding therapeutic decision between conservative treatment, osteosynthesis and arthroplasty.La fracture de l’humérus proximal (FHP) est la troisième fracture la plus fréquente au-delà de 65 ans, et son incidence augmente avec l’âge. Avec le vieillissement de la population, l’incidence des FHP devrait augmenter ces prochaines années, en en faisant un véritable problème de santé publique. Leur traitement est un débat d’actualité. Des publications récentes rapportent des résultats similaires entre traitement conservateur et traitement chirurgical dans plusieurs types de FHP. Concernant le choix de traitement, une décision basée sur une analyse multiparamétrique est recommandée mais les paramètres à considérer ne font actuellement pas l’objet d’un consensus. Nous proposons ici un algorithme basé sur celui d’une étude récente, permettant de guider la décision thérapeutique entre traitement conservateur, ostéosynthèse et arthroplastie.

The elbow joint is highly congruent and subject to less stress than other joints. This contributes to a rather low incidence of pathologies in the general population. However, in athletes who perform repeated movements with supraphysiological forces, diverse pathologies may appear. The objective of this article is to develop an anatomopathological approach to elbow pain in order to identify its origin. A rapid and precise diagnosis allows initiating an adequate treatment and minimizing time of sporting activity arrest.L’articulation du coude est soumise à des contraintes mécaniques moindres que d’autres articulations et présente une importante congruence. Ces éléments contribuent à la faible incidence des pathologies qui l’affectent dans l’ensemble de la population. Toutefois, chez le sportif qui effectue des mouvements répétés et avec des forces supraphysiologiques, de multiples lésions peuvent survenir. L’objectif de cet article est de développer une démarche anatomopathologique pour le diagnostic des douleurs de coude. Un diagnostic rapide et précis permet la mise en place d’un traitement adéquat ainsi que de minimiser le temps d’arrêt de l’activité sportive.

Resume Introduction Le conflit postero-superieur de l’epaule correspond par definition a un contact de la face profonde de la jonction des tendons des muscles supra-epineux et infra-epineux avec le labrum postero-superieur, en position d’abduction et de rotation laterale maximales. Il en resulte le plus souvent une lesion significative ou non de ce tendon et un delabrement labral postero-superieur en miroir. Hypothese L’objectif primaire etait de definir si ce contact etait observe de facon systematique chez les patients ne presentant pas de lesion de la coiffe des rotateurs. Methodologie Cent epaules chez 100 patients ont ete inclues dans cette etude. Tous les patients ont ete operes en position semi-assise. Apres introduction de l’arthroscope par voie posterieure, la presence ou non d’un contact entre la face articulaire de la coiffe et le labrum postero-superieur etait notee lors de la realisation d’un mouvement d’arme du bras a 90° d’abduction et 90° de rotation laterale (arme 90/90) puis d’un mouvement d’arme du bras a 140° d’abduction et une rotation laterale maximale (arme 140/Max). Resultats Un contact a ete observe dans 69 % des cas pour l’arme 90/90, et dans 94 % des cas en position d’arme 140/Max. Nous avons retrouve une correlation entre l’existence de lesions de la coiffe et/ou du labrum et la realisation d’un mouvement d’arme du bras regulier chez le patient concerne (p = 0,035). Discussion Le contact entre la face profonde du tendon du muscle supra-epineux et le labrum postero-superieur est physiologique. Le fait de repeter un mouvement d’arme du bras peut etre responsable de lesions macroscopiques de la face profonde de la coiffe et du labrum postero-superieur. Niveau de preuve IV, etude fondamentale.

Preoperative computed tomography (CT) measurements of glenoid version and inclination are recommended for planning glenoid implantation in shoulder arthroplasty. However, current manual or semi-automated 2-dimensional (2D) and 3-dimensional (3D) methods are user-dependent and time-consuming. We assessed whether the use of a 3D automated method is accurate and reliable to measure glenoid version and inclination in osteoarthritic shoulders.CT scans of osteoarthritic shoulders of 60 patients scheduled for shoulder arthroplasty were obtained. Automated, surgeon-operated, image analysis software (Glenosys; Imascap) was developed to measure glenoid version and inclination. The anatomic scapular reference planes were defined as the mean of the peripheral points of the scapular body as well as the plane perpendicular to it, passing along the supraspinatus fossa line. Measurements were compared with those obtained using previously described manual or semi-automated methods, including the Friedman version angle on 2D CTs, Friedman method on 3D multiplanar reconstructions (corrected Friedman method), Ganapathi-Iannotti and Lewis-Armstrong methods on 3D volumetric reconstructions (for glenoid version), and Maurer method (for glenoid inclination).The mean differences (and standard deviation) and the concordance correlation coefficients (CCCs) were calculated. Two orthopaedic surgeons independently examined the images for the interobserver analysis, with one of them measuring them twice more for the intraobserver analysis; interobserver and intraobserver reliability was calculated using the intraclass correlation coefficients (ICCs).The mean difference in the Glenosys glenoid version measurement was 2.0° ± 4.5° (CCC = 0.93) compared with the Friedman method, 2.5° ± 3.2° (CCC = 0.95) compared with the corrected Friedman method, 1.5° ± 4.5° (CCC = 0.94) compared with the Ganapathi-Iannotti method, and 1.8° ± 3.8° (CCC = 0.95) compared with the Lewis-Armstrong method. There was a mean difference of 0.2° ± 4.7° (CCC = 0.78) between the inclination measurements made with the Glenosys and Maurer methods. The difference between the overall average 2D and 3D measurements was not significant (p = 0.45).Use of fully automated software for 3D measurement of glenoid version and inclination in arthritic shoulders is reliable and accurate, showing excellent correlation with previously described manual or semi-automated methods.The use of automated surgeon-operated image analysis software to evaluate 3D glenoid anatomy eliminates interobserver and intraobserver discrepancies, improves the accuracy of preoperative planning for shoulder replacement, and offers a potential gain of time for the surgeon.

Resume Contexte Le conflit postero-superieur (CPS) est une pathologie specifique des jeunes sportifs avec lancer en arme, decrite en 1991. De nombreux traitements medicaux et chirurgicaux ont ete proposes avec des resultats mitiges. Objectif Comparer les pratiques diagnostiques et therapeutiques d’un groupe de chirurgiens francais avec un groupe de chirurgiens etrangers concernant le CPS. Methodes Un questionnaire comprenant 21 questions a ete produit en francais et en anglais et envoye par courrier electronique aux 1300 membres de la SFA (groupe France) et a des chirurgiens non francais (groupe Monde). Le sondage interrogeait sur la connaissance de la pathologie (2 questions), sa frequence en pratique clinique (2), son diagnostic (6), son traitement medical (3) et chirurgical (5), et les resultats du traitement sur la reprise du sport (3). Resultats Deux cent soixante et un chirurgiens (206 France, 55 Monde dont 42 du Japon) ont repondu au questionnaire. Quatre-vingt-dix pour cent d’entre eux avaient connaissance de la pathologie. Les chirurgiens nonfrancais sondes avaient une experience plus importante de la pathologie par le nombre de cas vus en consultation ou pour la pratique chirurgicale (19 % vs 45 %, p Discussion Le CPS est une pathologie connue sur le plan theorique par la majorite des interroges mais la chirurgie reste rare en France. La pratique du base-ball, tres rare en France mais responsable de la majorite de la pathologie sportive de l’epaule au Japon, ainsi que la presence de lesions voire de diagnostics differents pourraient expliquer certaines differences mises en evidence par ce sondage.

Arthroscopic management of elbow stiffness offers several potential advantages over conventional open procedures. Projected increased joint visualization, decreased tissue disruption and faster recovery have yielded growing interest for this procedure. Elbow arthroscopy remains a challenging procedure and reported complication rate is higher than in other joints. Sound local anatomy knowledge is required to ensure a safe procedure. We report here our indications techniques and postsurgical care protocols for arthroscopic management of osseous, soft tissue and neurological lesions associated with elbow stiffness.La prise en charge arthroscopique des raideurs articulaires de coude présente plusieurs avantages potentiels par rapport aux techniques conventionnelles ouvertes. La perspective d’une meilleure visualisation de l’articulation ainsi que la minimisation des perturbations tissulaires et la recherche d’une accélération de la convalescence ont généré un intérêt croissant pour cette technique. L’arthroscopie de coude est cependant une procédure techniquement exigeante, dont le taux de complications rapporté est plus important que pour d’autres articulations. Une connaissance approfondie de l’anatomie locale est nécessaire pour assurer la sécurité de la procédure. Nous rapportons ici nos indications, techniques et protocoles postopératoires pour la prise en charge des lésions osseuses, tissulaires et neurologiques constitutives de la raideur de coude.

BACKGROUND: Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies.METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement.RESULTS: Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue).CONCLUSION: A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Background Internal impingement of the shoulder (IIS) is the leading cause of chronic shoulder pain in overhead throwing athletes. No consensus exists about which techniques are optimal when surgery is in order. The available studies are limited by small sample sizes and short follow-ups. The primary objective of this study was to assess return-to-sports (RtS) outcomes after surgical treatment for IIS. A favourable RtS outcome (RtS +) was defined as returning to the previous sport at the same or a higher level. Hypothesis The main hypothesis was that surgical treatment resulted in an RtS + outcome. The secondary hypothesis was that epidemiological factors, pre- and intra-operative anatomical factors, and specific surgical procedures were associated with higher RtS + rates. Material and methods A retrospective multicentre design was used. We included 135 patients with IIS managed arthroscopically using any of the following procedures: anterior capsulorrhaphy, posterior capsulotomy/capsulectomy, postero-superior labral debridement, posterior glenoidplasty, and rotator cuff tear debridement or repair. Follow-up was at least 1 year. The patients were divided into two groups based on whether they had an RtS + outcome as defined above or an RtS − outcome defined as a return to the previous sport at a lower level, a switch to another sport, or an inability to engage in any sport. The Kerlan-Jobe Orthopaedic Clinic (KJOC) and Constant's score were used to evaluate subjective and objective shoulder function. Results Mean follow-up was 7.9 years. Of the 135 patients, 120 (90%) returned to sports after surgery including 70 (52%) to the previous sport at the same level (RtS + outcome). By univariate analysis, the following factors were associated with an RtS + outcome: male sex, rotator cuff tear documented intra-operatively, absence of a greater tuberosity cyst on pre-operative imaging studies, and cuff tear debridement. Anterior capsulorrhaphy was associated with worse post-operative pain. Discussion The RtS + rate in this study differed from previously reported values, due to differences in the sports practiced by the patients and to considerable variability in the surgical techniques used. The positive association between presence of a rotator cuff tear and an RtS + outcome is at variance with most of the previously published data. Some of the apparent discrepancies between our results and those from other countries may be ascribable to differences in the most popular sports. Level of evidence IV.

Posterosuperior (or internal) impingement at the shoulder is defined as contact between the underside of the supraspinatus or infraspinatus tendons with the posterosuperior labrum during extreme external rotation and abduction. In many cases, this contact damages the tendon and causes mirror posterosuperior labrum deterioration. The primary aim of this study was to define whether this contact occurs normally in patients who do not have a rotator cuff tear. Methods We evaluated 100 shoulders in 100 patients. All patients were operated on in the beach chair position. After introducing the scope through the posterior portal, contact between the articular side of the rotator cuff and the posterosuperior labrum was noted as being present or absent when the arm was cocked in 90° abduction and 90° external rotation (90/90) then the arm was cocked in 140° abduction and maximum external rotation (140/Max). Results Contact was observed in 69% of patients in the 90/90 cocked position and in 94% of patients in the 140/Max cocked position. We found a correlation between the presence of rotator cuff and/or labrum lesions and the patient regularly performing arm-cock movements (p = 0.035). Discussion Contact between the underside of the supraspinatus tendon and the posterosuperior labrum occurs physiologically. Repetitive arm-cock movements may contribute to macroscopic lesions of the underside of the rotator cuff and posterosuperior labrum. Level of evidence IV, basic science study

Management of a first-time dislocation in the athlete patient is challenging. This patient population has important requirements with high expectations and deadlines to meet, especially if the trauma occurs during high season. As initial management is usually conservative with immobilization followed by rehabilitation, some authors support the role of primary surgical treatment in high risk athletes. Indication for surgery and choice of surgical technique is based on an algorithm incorporating risk factors for recurrence and the presence of concomitant bony lesions on the humeral and glenoid sides. Return to sport varies from 3 to 6 months depending on the type of sport practiced.La luxation gléno-humérale chez l’athlète présente un challenge particulier dans la prise en charge. Cette population de patients a des exigences importantes avec des échéances à respecter dans son programme, surtout si le traumatisme a lieu en pleine saison. Si la prise en charge initiale consiste en un traitement conservateur comprenant une immobilisation suivie d’une réédu-cation musculaire, certains auteurs préconisent une stabilisation chirurgicale d’emblée chez les patients à haut risque de récidive. Le choix de la chirurgie et de sa technique se fait en fonction d’un algorithme basé sur les facteurs de risque de récidive ainsi que la présence de lésions concomitantes. Le retour au sport varie de 3 à 6 mois selon le type de sport pratiqué.

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The implication of scapular morphology in rotator cuff tears has been extensively studied. However, the role of the greater tuberosity (GT) should be of equal importance. The aim of this study was to propose a new radiographic marker, the GT angle (GTA), which measures the position of the GT in relation to the center of rotation of the humeral head. The hypothesis was that a higher angle value would be associated with a higher likelihood in detecting a rotator cuff tear.During 1 year, patients were prospectively recruited from a single institution specialized shoulder clinic in 2 different groups. The patient group consisted of individuals with a degenerative rotator cuff tear involving at least the supraspinatus. The control group consisted of individuals with no rotator cuff pathology. Individuals in both groups with congenital, post-traumatic, or degenerative alterations of the proximal humerus were excluded. The GTA was measured on an anteroposterior shoulder x-ray image with the arm in neutral rotation by 3 observers at 2 different times.The study recruited 71 patients (33 patients, 38 controls). Mean GTA value was 72.5° (range, 67.6°-79.2°) in patients and 65.2° (range, 55.8°-70.5°) for controls (P .001). A value above 70° resulted in 93-fold higher odds of detecting a rotator cuff tear (P .001). Interobserver and intraobserver reliability were high.GT morphology is implicated in rotator cuff tears. The GTA is a reliable radiographic marker, with more than 70° being highly predictive in detecting such lesions.

Indications for arthroscopic management of elbow stiffness and pain associated with elbow osteoarthritis have steadily increased in the last few years. Although technically demanding, the potential advantages, comprising increased joint visualization, decreased tissue disruption, and faster recovery have yielded growing interest into this technique. The reported complication rates are higher than in other joints and sound knowledge of the local anatomy is required to ensure a safe procedure. The technique and indications for arthroscopic management of osteophytes, soft tissue contracture, and associated ulnar nerve neuropathy as well as postsurgical care, as given by the senior author, have been described in this article.

Glenoid deficiency and erosion (excessive retroversion/inclination) must be corrected in reverse shoulder arthroplasty (RSA) to avoid prosthetic notching or instability and to maximize function, range of motion, and prosthesis longevity. This study reports the results of RSA with an angled, autologous glenoid graft harvested from the humerus (angled BIO-RSA).A trapezoidal bone graft, harvested from the humeral head and fixed with a long-post baseplate and screws, was used to compensate for residual glenoid bone loss/erosion. For simple to moderate (25°) glenoid defects, standardized instrumentation combined with some eccentric reaming (15°) was used to reconstruct the glenoid and obtain neutral implant alignment. For severe (25°) and complex (multiplanar) glenoid bone defects, patient-specific grafts and guides were used after 3-dimensional planning. Patients were reviewed with minimum 2 years of follow-up. Mean follow-up was 36 months (range, 24-81 months). Preoperative and postoperative measurements of inclination and version were performed in the plane of the scapula on computed tomography images.The study included 54 patients (41 women, 13 men; mean 73 years old). Fifteen patients had combined vertical and horizontal glenoid bone deficiency. Among E2/E3 glenoids, inclination improved from 37° (range, 14° to 84°) to 10.2° (range -28° to 36°, P .001). Among B2/C glenoids, retroversion improved from -21° (range, -49° to 0°) to -10.6° (-32° to 4°, P = .06). Complete radiographic incorporation of the graft occurred in 94% (51 of 54). Complications included infection in 1 and clinical aseptic baseplate loosening in 2. Mild notching occurred in 25% (13 of 51) of patients. Constant-Murley and Subjective Shoulder Value assessments increased from 31 to 68 and from 30% to 83%, respectively (P .001).Angled BIO-RSA predictably corrects glenoid deficiency, including severe (25°) multiplanar deformity. Graft incorporation is predictable. Advantages of using an autograftharvested in situ include bone stock augmentation, lateralization, low donor-site morbidity, low relative cost, and flexibility needed to simultaneously correct posterior and superior glenoid defects.

Purpose: Long-term studies evaluating risk factors for development of ankle osteoarthritis (OA) following malleolar fractures are sparse. Methods: We conducted a retrospective cohort study including consecutive patients treated by open reduction and internal fixation for malleolar fracture between January 1988 and December 1997. Perioperative information was obtained retrospectively. Patients were evaluated clinically and radiographically 12-22years postoperatively. Radiographic ankle OA was determined on standardised radiographs using the Kellgren and Lawrence scale (grade 3-4 = advanced OA). Uni- and multivariate regression analyses were performed to determine risk factors for OA. Results: During the inclusion period, 373 fractures (372 patients; 9% Weber A, 58% Weber B, 33% Weber C) were operated upon. The mean age at operation was 42.9years. There were 102 patients seen at follow-up (mean follow-up 17.9years). Those not available did not differ in demographics and fracture type from those seen. Advanced radiographic OA was present in 37 patients (36.3%). Significant risk factors were: Weber C fracture, associated medial malleolar fracture, fracture-dislocation, increasing body mass index, age 30years or more and length of time since surgery. Conclusions: Advanced radiographic OA was common 12-22years after malleolar fracture. The probability of developing post-traumatic OA among patients having three or more risk factors was 60-70%

It is widely thought that myogenin is one of the earliest detectable markers of skeletal muscle differentiation. Here we show that, during human myoblast differentiation, an inward rectifier K(+) channel (Kir2.1) and its associated hyperpolarization trigger expression and activity of the myogenic transcription factors, myogenin and myocyte enhancer factor-2 (MEF2). Furthermore, Kir2.1 current precedes and is required for the developmental increase in expression/activity of myogenin and MEF2. Drugs or antisense reducing Kir2.1 current diminished or suppressed fusion as well as expression/activity of myogenin and MEF2. In contrast, LY294002, an inhibitor of phosphatidylinositol 3-kinase (a pathway controlling initiation of the myogenic program) that inhibited both myogenin/MEF2 expression and fusion, did not affect Kir2.1 current. This non-blockade by LY294002 indicates that Kir2.1 acts upstream of myogenin and MEF2. We propose that Kir2.1 channel activation is a required key early event that initiates myogenesis by turning on myogenin and MEF2 transcription factors via a hyperpolarization-activated Ca(2+)-dependent pathway.

Contexte La disjonction acromio-claviculaire (AC) aigue perturbe le controle de rotation et de translation de l’omoplate par les complexes ligamentaires acromio-claviculaires et coraco-claciculaires. Les donnees restent tres limitees, quant a l’efficacite des techniques de stabilisation acromio-claviculaire chirurgicale existante pour resister aux forces de rotation et de translation. Objectifs Evaluation de l’impact de 4 constructions differentes sur la stabilite en rotation et translation de l’articulation AC. Methodes Deux modeles osseux synthetiques ont ete equipes de dispositifs de reparation coraco-claviculaires de maniere standardisee. Des tunnels horizontaux ont ete fores aux marges de l’articulation AC sur le premier modele et des tunnels verticaux ont ete fores sur le deuxieme. Les modeles osseux etaient equipes de dispositifs de navigation sur la clavicule et l’acromion. La stabilite rotationnelle et translationnelle des constructions a ete testee avec des tests de traction quasi-statique non destructifs. Les forces de deplacement ont ete appliquees a l’aide d’un transducteur de force. Les mesures ont ete effectuees avec le dispositif coraco-claviculaire seul (CC), avec un (O) cerclage horizontal seul, une (8) figure horizontale de huit seul, un cerclage horizontal (O8) renforce avec une figure de huit, et (V) cerclage vertical seul. Le deplacement total entre les dispositifs de suivi claviculaire et acromial a ete enregistre dans un laboratoire de kinesiologie. Resultats Le deplacement total (moyenne ± SD mm/N) etait de 9,67 ± 12,56 pour la reparation CC seule etait de 1,3 ± 0,64 pour le cerclage horizontal, 1,6 ± 1,58 pour le cerclage de huit ; 0,95 ± 0,79 pour le cerclage horizontal associe a la figure 8 et 3,31 ± 3,04 pour le cerclage vertical. Le deplacement total etait significativement inferieur pour les constructions O8 que pour toutes les autres constructions (p > 0,000–0,014). Aucune difference statistique n’a ete trouvee entre les constructions O et 8 (p = 0,09) ainsi que le cerclage vertical et le cerclage coraco-claviculaire seul (p = 0,06). Conclusion Le cerclage horizontal associe a la figure huit permet une augmentation significative de la resistance aux forces de deplacement en rotation et en translation par rapport a d’autres constructions testees. Une etude plus approfondie est necessaire pour evaluer la resistance des constructions au chargement cyclique. Pertinence clinique L’optimisation de la stabilite des constructions acromio-claviculaires peut permettre des protocoles de reeducation postoperatoires plus rapides et une diminution du risque de detente apres stabilisation chirurgicale.

Rehabilitation post surgical repair of the rotator cuff is an important determinant of the quality of the healing process, and of the clinical and functional results. Techniques used have been reported to favor certain of those parameters at the expense of others. Several approaches have been proposed; none has reached a consensus yet. The level of evidence in the literature does not allow for definitive recommendations and elaborating a protocol relies on clinical experience as well as expert opinion, incorporating scientific data. An initial period of rest with limited passive motion emerges though as an approach suited to the treatment of most clinical situations.

The recent progress in oncologic management of patients with metastatic disease has permitted a significant improvement of their life expectancy. Many of these patients will suffer from complications related to bone metastasis. Unfortunately an orthopaedic treatment is seldom offered to them, mainly because of the misconception that this would not bring them any benefice. However these patients are often good candidates for an orthopaedic management, which objectives are to relieve pain and to re-establish their quality of life. The available surgical techniques are well described and the management protocols are clearly defined, as are the expectable complications and the errors that must not be done.

Background Shoulder strength training exercises represent a major component of rehabilitation protocols designed for conservative or post-surgical management of shoulder pathologies. Numerous methods are described for exercising each shoulder muscle or muscle group. Limited information is available to assess potential deleterious effects of individual methods in respect to specific shoulder pathologies. Objectives To use a patient specific 3D motion capture system for evaluation of a set of shoulder strength training exercises regarding glenohumeral, labral and subacromial compression as well as elongation of individual rotator cuff muscles. Methods One healthy right-handed male volunteer (28 years old, 180 cm, 80 kg) participated to the study. The outcome of interest was the impact of a set of common shoulder rehabilitation exercises on articular cartilages and labrum compression, subacromial space height, and rotator cuff elongation. After 3D reconstruction, a kinematic evaluation according to a previously validated protocol was used. Results According to the type of strengthening exercise, important variations in glenoid cartilage and labrum compression, subacromial space height and tendons elongation were observed, as indicated by the calculated P-values below the significance level at P > 0.05. Glenoid cartilage compression varied up to 1.98 mm and labral compression up to 1.80 mm, with maximal average penetration depths obtained during the strengthening of middle/inferior trapezius, deltoid, supraspinatus, infraspinatus and teres minor. Exercises performed with TheraBand™ had the lowest impact on cartilages compression, whereas exercises executed with the body weight induced the greatest penetration depths. Contacts were all located between the antero- and postero-superior sectors of the glenoid. Minimal subacromial height ranged between 0.15 mm to 3.60 mm in average for targeted muscles exercises according to the training technique used. Least favorable target muscles training with respect to subacromial space height were serratus, biceps brachii, pectoralis major and supraspinatus. Overhead strength training resulted in significant decrease (P = 0.001) of subacromial space height. Conclusion To our knowledge, this study represents the first screening of shoulder strengthening exercises to identify potential deleterious effects on the shoulder joint Motion capture allows for reliable assessment of glenohumeral, labral and subacromial compression as well as tendon muscle elongation during shoulder strength training exercises. Data may be used to design rehabilitation protocols specific to shoulder pathological states.

Introduction Les mesures scanner preoperatoires de l’inclinaison et de la version glenoidienne sont couramment recommandees avant d’implanter une prothese totale d’epaule (PTE) pour omarthrose. Cependant les methodes 2-D et 3-D existantes sont manuelles ou semi-automatiques- de ce fait, elles dependent de l’expertise des utilisateurs (les chirurgiens) et sont chronophages. Objectif Evaluer si l’utilisation d’une methode 3-D, entierement automatisee, permettrait d’obtenir des mesures aussi precises et reproductibles de la version et de l’inclinaison glenoidiennes dans des epaules arthrosiques. Methodes Soixante scanners d’epaules arthrosiques ont ete obtenus chez des patients programmes pour une PTE. Un logiciel a ete developpe (Glenosys™) pour fournir aux chirurgiens, de maniere automatisee, la version et l’inclinaison 3-D de la glene. Les mesures obtenues avec la methode automatisee ont ete comparees a celles des methodes manuelles ou semi-manuelles deja existantes- methode I (angle de version, selon Friedman) appliquee a des scanners 2-D ; methodes II (IIa inclinaison, IIb version) appliquees a des reconstructions multiPlanes (MPR 3-D) ; methode III (selon Iannotti) et methode IV (selon Armstrong) appliquees a des reconstructions 3-D. Les differences de moyennes (+ deviations standards) et les coefficients de concordance de correlation (CCC) ont etaient calcules. Trois chirurgiens orthopedistes ont examine independamment les images a deux reprises. La fiabilite des mesures intra-observateurs et interobservateurs a ete calculee grâce aux correlations intraclasses (ICC). Resultats La difference des mesures obtenues avec Glenosys™ pour la methode I etait 2,0° ± 4,5° (CCC = 0,9301). Elle etait 2,5° ± 3,2° (CCC = 0,9483) pour la methode IIa + 0,2° ± 4,7° (CCC = 0,7754) pour la methode IIb + 1,5° ± 4,5° (CCC = 0,9427) pour la methode III et 1,8 ± 3,8 (CCC = 0,9517) pour la methode IV. La difference entre les mesures globales moyennes 2-D and 3-D n’etait pas statistiquement significative (p = .45). Conclusion Les mesures 3-D de l’inclinaison et de la version glenoidiennes d’epaules arthrosiques, obtenues grâce a un logiciel entierement automatise, sont precises et reproductibles, montrant une excellente correlation par rapport a celles obtenues avec les methodes manuelles ou semi-automatiques existantes. La methode automatisee elimine les erreurs inter et intra-observateurs et offre un gain de temps lors de la planification scanners des PTE. La limite de la methode est d’obtenir des images scanners du corps entier de la scapula.

Introduction Les tendons de la coiffe des rotateurs sont frequemment delamines en 2 feuillets. L’impact de cette delamination sur la cicatrisation tendineuse est mal connu. Le but de notre etude etait d’evaluer l’impact de cette delamination sur la reparation arthroscopique des tendons de la coiffe des rotateurs. Methode Cent dix-sept patients presentant une lesion transfixiante des tendons de la coiffe des rotateurs, operes par simple rangee (haubanage lateral), ont ete suivis cliniquement et radiologiquement. La retraction tendineuse et la delamination en 2 feuillets etaient evalues en peroperatoire - 80 patients presentaient des tendons non delamines (groupe A), 37 une delamination (groupe B). Les 2 groupes etaient comparables en termes d’âge, de sexe, d’IMC, de SSV, de force et de score de Constant ajuste. En postoperatoire, la cicatrisation tendineuse etait analysee par ultrasons et les resultats cliniques etaient exprimes utilisant le score de Constant ajuste. Resultats Le taux de cicatrisation etait de 78 % dans le groupe A et de 57 % dans le groupe B, avec une difference statistiquement significative (p = 0,0287). L’analyse en sous-groupe ne retrouvait pas de difference pour les lesions retractees stade 1 (77 % versus 75 %), retrouvait une difference non significative pour les lesions de stade 2 (75 % versus 60 %), et une difference significative pour les lesions de stade 3 (83 % versus 45 % + p Conclusion cette etude montre que la delamination tendineuse de la coiffe des rotateurs, dans les lesions larges a massives, est associee a un faible taux de cicatrisation apres reparation en simple rangee par hauban lateral. Ceci suggere que ces lesions devraient etre reparees avec une technique en double feuillet O. A contrario, les resultats de cette etude nous encourage a utiliser une reparation en simple rangee par haubanage tendineux pour les lesions non delaminees et peu retractees.

Objective: To assess reliability and construct validity of the Kellgren-Lawrence (K&L) scale in posttraumatic ankle osteoarthritis (OA); additionally evaluate the validity of including tibiotalar tilting in the scale. Method: One-hundred and fifty ankle radiographs (75 patients, unilateral malleolar fractures) evaluated at average of 18 years after surgery. American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot (HF) score and pain (visual analog scale) were recorded. Grading of OA according to K&L criteria and identification of OA features was performed on standardized radiographs by four physicians. Minimal joint space width, sclerosis, and talar tilt angle were quantified by digital measurements. A modified K&L scale including talar tilting is presented. Validity of original and modified scale was evaluated and expressed as ability to (1) Identify those with clinical symptoms of ankle OA; and (2) Distinguish between different degrees of fracture severity. Results: Inter- and intra-observer reliability of OA assessment according to K&L were good (ICC 0.61 and 0.75). Original and modified K&L grades significantly increased with decreasing AOFAS ankle-HF scores and greater pain. A talar-tilt angle >2° compared with ≤2° in grade 3 was associated with significantly higher pain levels (VAS pain 4.2 vs1.4, respectively; mean difference 2.8, 95% CI 0.5-5.1). More severe fracture patterns at time of surgery were more often in patients with the highest K&L grades. Conclusions: The K&L scale is a valid and reliable radiographic grading system for assessment of ankle OA. Inclusion of the talar tilt angle might allow for better differentiation with respect to clinical outcomes.

Increases in cytoplasmic Ca(2+) are crucial for inducing the initial steps of myoblast differentiation that ultimately lead to fusion; yet the mechanisms that produce this elevated Ca(2+) have not been fully resolved. For example, it is still unclear whether the increase comes exclusively from membrane Ca(2+) influx or also from Ca(2+) release from internal stores. To address this, we investigated early differentiation of myoblast clones each derived from single post-natal human satellite cells. Initial differentiation was assayed by immunostaining myonuclei for the transcription factor MEF2. When Ca(2+) influx was eliminated by using low external Ca(2+) media, we found that approximately half the clones could still differentiate. Of the clones that required influx of external Ca(2+), most clones used T-type Ca(2+) channels, but others used store-operated channels as influx-generating mechanisms. On the other hand, clones that differentiated in low external Ca(2+) relied on Ca(2+) release from internal stores through IP(3) receptors. Interestingly, by following clones over time, we observed that some switched their preferred Ca(2+) source: clones that initially used calcium release from internal stores to differentiate later required Ca(2+) influx and inversely. In conclusion, we show that human myoblasts can use three alternative mechanisms to increase cytoplasmic Ca(2+) at the onset of the differentiation process: influx through T-types Ca(2+) channels, influx through store operated channels and release from internal stores through IP(3) receptors. In addition, we suggest that, probably because Ca(2+) elevation is essential during initial differentiation, myoblasts may be able to select between these alternate Ca(2+) pathways.

Myoblast transplantation is a potential therapy for severe muscle trauma, myopathies and heart infarct. Success with this therapy relies on the ability to obtain cell preparations enriched in myogenic precursor cells and on their survival after transplantation. To define myoblast transplantation strategies applicable to patients, we used a large animal model, the pig. Muscle dissociation procedures adapted to porcine tissue gave high yields of cells containing at least 80% myogenic precursor cells. Autologous transplantation of 3[H]-thymidine labeled porcine myogenic precursor cells indicated 60% survival at day 1 followed by a decay to 10% at day 5 post-injection. Nuclei of myogenic precursor cells transduced with a lentivirus encoding the nls-lacZ reporter gene were present in host myotubes 8 days post-transplantation, indicating that injected myogenic precursor cells contribute to muscle regeneration. This work suggests that pig is an adequate large animal model for exploring myogenic precursor cells transplantation strategies applicable in patients.

Objectif Evaluer les resultats a moyen terme du Hill-Sachs remplissage associe a la reparation de Bankart chez une serie consecutive de patients. Methode Etude retrospective monocentrique (133 patients) presentant une instabilite anterieure recidivante d’epaule avec un defect osseux de la tete humerale, profond et engageant. Tous les patients ont eu une evaluation clinique (score de Walch-Duplay, score de Rowe, SSV, mobilites, douleur residuelle), fonctionnelle (auto-questionnaire) et radiographique (IRM ou arthro-TDM). Resultats Au recul moyen de 50 mois, 9 patients (7 %) ont presente une recidive traumatique d’instabilite anterieure, et 7 ont du etre reoperes. Dans tous les echecs (9/9), nous avons trouve une erosion glenoidienne anterieure sur l’imagerie preoperatoire. Le taux d’echec etait de 5 % pour le chirurgien senior (6/110 interventions) contre 13 % d’echec pour les chirurgiens juniors (3/23). Au total, 92 % des patients (123/133) etaient satisfaits ou tres satisfaits de l’intervention. Une limitation des mobilites a ete retrouvee, principalement en rotation externe active (environ 10°), mais sans retentissement ou presque dans la vie de tous les jours ou dans la pratique sportive ; 78 % des patients (80/103) ont pu reprendre le sport au meme niveau. Le remplissage de l’encoche humerale avec les tissus mous etait superieur a 75 % dans 70 des 87 imageries postoperatoires realisees (80 %). Conclusion Le « Hill-Sachs remplissage » associe a la reparation de Bankart est une indication fiable pour les patients avec une encoche humerale profonde et engageante. Deux facteurs ont ete associes aux echecs de l’intervention : – l’experience du chirurgien ; – presence d’une erosion glenoidienne anterieure. L’erosion glenoidienne, qui est souvent sous-estimee, est une contre-indication formelle a la realisation d’un Hill-Sachs remplissage, car elle conduit a la recidive d’instabilite anterieure.

Objectif Evaluer les causes et les resultats des re-interventions revisions des protheses totales d’epaule anatomique (PTEA) realisees sur une periode de 20 ans, dans un meme centre. Methodes Etude monocentrique retrospective de 82 reprises de PTEA consecutives effectuees par un meme chirurgien senior de 1993 a 2012. La PTEA initiale avaient ete implantee pour omarthrose primitive (46 cas), sequelle de fracture (14), omarthrose post-instabilite (10), polyarthrite rhumatoide (5), autres (4). Les patients ont ete revus cliniquement et radiologiquement avec un recul de un an minimum. Soixante-dix neuf reprises de PTEA (79 patients) ont pu etre analysees avec un recul moyen de 52 mois (12–173). Resultats Le delai moyen entre la PTEA et la re-intervention etait de 6 ans. L’âge moyen au moment de la re-intervention etait de 66 ans (26–90). Les indications de reprise etaient variees et souvent associees – descellement glenoidien (43), rupture du subscapularis (34), instabilite anterieure (19), infection (14), rupture de coiffe postero-superieure (8), raideur (4), autres (6). Trente-sept patients (47 %) ont ete repris par a une prothese totale inversee (PTEI), 20 (25 %) ont eu une modification de la PTEA, 8 (10 %) une ablation de l’implant glenoidien avec ou sans greffe osseuse (conversion en hemiarthroplastie [HA]), 10 (13 %) un geste sur les tissus mous (suture du subscapularis, transfert musculo-tendineux, tenodese du long biceps) sans changement de l’implant et 4 un autre geste. Treize patients (16 %) ont du etre reoperes ensuite. Au final, 39 (49 %) patients etaient porteurs d’une PTEI, 33 (42 %) d’une PTEA, 4 (5 %) d’une HA et 3 (4 %) etaient en resection–arthroplastique ou porteur d’un spacer. Au dernier recul, le score de Constant ajuste etaient respectivement de 72 % (21–123) pour les PTEI, 80 % (22–127) pour les PTEA et 96 % pour les HA. Un geste sur les parties molles permettait d’obtenir en moyenne un score de 65 % (24–96). Conclusion Les principales causes d’echec ou de complications apres PTEA sont le descellement glenoidien (54 %), la rupture du subscapularis (43 %), l’instabilite (24 %) et ou l’infection (18 %). Une reprise chirurgicale de PTEA se solde dans la moitie des cas par une conversion en PTEI.