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The objective of this study was to evaluate the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) associated with two techniques: L'Episcopo procedure (combined teres major and latissimus dorsi transfer) and modified L'Episcopo procedure (isolated latissimus dorsi transfer).A retrospective review of 36 RSAs (mean age 69.8 years; SD 8.9) associated with either L'Episcopo procedure (Group 1, 21 cases) or modified L'Episcopo procedure (Group 2, 15 cases) was performed between 2007 and 2020. Clinical outcome measures consisted of range of motion (ROM), SSV, VAS, and Constant-Murley scores. These scores were compared between the two groups. Radiographs were assessed for transfer site bony lesions.With a mean follow-up of 40.8 months (6-98; SD 28.8), no significant differences were revealed in the clinical outcomes: Constant score, SSV, VAS, ROM. The entire study group demonstrated a significant improvement in post-operative functional outcome scores and ROM parameters compared to their pre-operative state, IR measures being the only exception (p = 0.26). Radiographs demonstrated transfer site bony lesions in 60% of the patients (18/30). Three complications (8.3%) were noted in the study.At the short-term follow-up, RSA combined with either latissimus dorsi (LD) transfer in isolation or in association with teres major proved to be equally effective in restoring external rotation in the settings of an irreparable postero-superior cuff tear treated with RSA. Although the LD transfer group displayed a tendency towards superior ROM, this was not supported statistically. Post-operative radiographs confirmed the presence of bony lesions at the transfer fixation sites in both groups of patients (52% vs. 72%).

To report clinical and radiologic outcomes of arthroscopic Eden-Hybinette using 2 cortical suture buttons in a series of patients with previous failed Latarjet and persistent glenoid bone loss.Between 2015 and 2019, patients with recurrent anterior instability after failed Latarjet underwent arthroscopic Eden-Hybinette procedure using 2 cortical buttons for graft fixation. Exclusion criteria were open and primary Eden-Hybinette and less than one year follow-up. Functional assessment was performed using Rowe and Walch-Duplay scores, subjective shoulder value, visual analog scale, and degree of satisfaction. Iliac crest bone graft placement and healing were assessed postoperatively with computed tomography imaging.A total of 17 patients with a mean age of 28 years (range, 21-43 years) at time of revision were included. The mean glenoid bone loss was 23% (range, 18%-42%). Medium or deep Hill-Sachs lesion (Calandra 2 and 3) was present in 65% of cases. At a mean follow-up of 3 ± 1.6 years, all but 1 patient (94%) considered their shoulder stable, and 15 patients (88%) were satisfied or very satisfied. The subjective shoulder value increased from 51% to 87% (P.05), the Walch-Duplay increased from 23 to 86 points (P.05), and Rowe scores improved from 30 to 92 points (P.05). Apprehension was still positive in 3 patients (17.6%), with this percentage being greater in the presence of Hill-Sachs Calandra 3 (P = .02). Postoperative computed tomography scans showed optimal bone autograft position in all patients (below the glenoid equator and flush to the glenoid rim). Iliac crest bone graft healed to the anterior glenoid neck in 16 shoulders (94%). The rate of recurrent instability was 11.7% but only 1 patient required revision surgery (5.8%).Arthroscopic Eden-Hybinette using 2 cortical buttons leads to satisfactory clinical outcomes and a low recurrence rate after failed Latarjet, allowing successful reconstruction of the anterior glenoid rim and simultaneous treatment of capsular deficiency and humeral bone loss.Therapeutic, level IV, retrospective case series.

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation.From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29 years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6 months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3 years (range 4-11).At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p 0.00001).Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

PURPOSE The aim of this study was to describe the results of an arthroscopic Trillat procedure utilized to treat patients with symptomatic antero-inferior shoulder instability associated with hyperlaxity. METHODS A retrospective review was performed on 19 consecutive shoulders (17 patients, 2 bilateral) who underwent a Trillat procedure combined with anterio-inferior capsulolabral plasty from 2016 to 2019. Patients included in the study presented with shoulder instability combined with shoulder hyperlaxity and no glenoid or humeral bone loss. Clinical assessment included range of motion, apprehension, and instability tests. Outcome measures Constant-Murley score (CMS) scale, Walch-Duplay, ROWE, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS). Post-operatively, healing of the coracoid osteoclasy was evaluated by CT scan. RESULTS The mean follow-up was 24.8 months (range, 12-51). Post-operatively, none of the patients experienced a recurrent dislocation or subluxation and the anterior apprehension test was negative in all shoulders. Post-operative motion deficits of 22.1° ± 15.8 [p

Anterior glenohumeral instability (AGI) is a challenging condition that requires close attention to osseous and soft-tissue abnormalities. The morphometric variance of the periarticular scapular anatomy may be involved in the pathogenesis of recurrent traumatic anterior instability.The Trillat procedure repositions the coracoid medially and downward by a partial wedge osteotomy, mimicking the sling effect of the Latarjet procedure by moving the conjoint tendon closer to the joint line in throwing position. The Trillat procedure decreases the coracohumeral distance without affecting the integrity of the subscapularis muscle and tendon.Joint preservation methods, such as the Trillat procedure, may be explored in older patients to treat AGI with simultaneous irreparable rotator cuff tears (RCTs) with a static centered head and a functional subscapularis.Shoulder hyperlaxity and instability can be challenging to treat with isolated soft-tissue procedures. In cases without glenoid bone loss, free bone block techniques are ineffective because of the subsequent potential graft resorption, apprehension, or recurrence. The Trillat surgery, in conjunction with an anteroinferior capsuloplasty, seems to be helpful in preventing recurrent instability and in reducing shoulder apprehension.Recently, several variations of the original technique have been described. In the future, anatomical, biomechanical, and clinical studies need to be conducted to further evaluate the morphometric characterization of the procedure, enhance the technical features, improve indications, and avoid coracoid impingement and other potential complications with the Trillat procedure.

The goal of this study was to assess the clinical outcomes associated with anatomic healing of the greater tuberosity in patients treated for proximal humerus fractures with reverse shoulder arthroplasty. Our hypothesis was that anatomic healing of the greater tuberosity leads to less complications and better functional outcomes.RESULTS: Patients from the GT+ group presented better functional outcomes than the GT- group in all evaluated outcomes. Mean constant score was 61 ± 14 versus 56 ± 15, and the subjective shoulder value (SSV) was 77 ± 14 versus 64 ± 21 (p 0.001). Forward elevation was 128° ± 28° versus 107° ± 30° and external rotation was 23° ± 17° versus 14° ± 17° (p 0.001). Twenty patients presented with at least one prosthetic dislocation (7 GT+ vs 13 GT-) while nine patients were revised for humeral loosening (1 GT+ vs 8 GT-). The use of a fracture specific humeral stem was associated with a higher rate of greater tuberosity healing.Non-anatomic healing of the greater tuberosity was associated with a higher dislocation and humeral loosening rate. Anatomic healing of the greater tuberosity lead to better functional outcomes, less humeral-sided complications, and fewer re-operations.

Therapeutic management of recurrent anterior shoulder instability with an anterior glenoid defect and a Hill-Sachs lesion requires a bone graft to restore the width of the glenoid. The Latarjet procedure is the most popular technique but an iliac crest bone graft is preferred when the coracoid process is dysplastic or too short or after failure of Latarjet or Bristow-Latarjet. The purpose of this manuscript is to describe a full arthroscopic Eden-Hybinette-guided technique with 2 cortical suture buttons for bone graft fixation. This procedure allows reconstruction of severe glenoid bone defects and treatment of concomitant capsulolabral lesions and humeral bone loss, while preserving the subscapularis muscle. In addition, the use of 2 cortical buttons for bone graft fixation simplify graft transport and positioning, provides good control of the rotation, improving healing of the iliac crest bone graft to the anterior glenoid rim.

Management of irreparable posterosuperior rotator cuff tears (RCTs) presents a significant challenge to shoulder surgeons. Previous studies on latissimus dorsi transfer (LDT) have demonstrated good to excellent outcomes in younger patients, but this indication is debatable in the elderly. The main objective of this study was to compare the results of LDT in a group of patients aged ≤55 years vs. one of patients aged ≥75 years. We hypothesized that LDT could give equally good results in the elderly as in the younger population.Between 2014 and 2017, a total of 153 patients who underwent LDT either for irreparable posterosuperior RCT or for failed prior repair were enrolled. All LDTs were performed by a single surgeon, were arthroscopically assisted, and fixed onto the humeral head with 2 anchors. A retrospective comparative clinical study was conducted. Patients with a minimum of 24 months of follow-up were divided into 2 groups: group A (≤55 years old at surgery) and group B (≥75 years old at surgery). The age-adjusted Constant-Murley score (aCMS), Subjective Score Value (SSV), Simple Shoulder Test (SST), Activities of Daily Living requiring active External Rotation (ADLER) score, visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient's satisfaction, and rate of LD tendon rupture at last follow-up were compared.A total of 66 patients met inclusion criteria. Four in 66 patients (6%) were lost to follow-up. There were 31 patients in group A and 31 patients in group B. The mean age was 52 and 77 years for the respective groups. Preoperatively, the 2 groups were comparable with respect to other characteristics like the mean number of ruptured tendons, mean preoperative Hamada stage, mean SST, and mean aCMS. The mean follow-up was 33 and 31 months, respectively. At last follow-up, there was no significant difference in the scores evaluated between groups A and B with SSV (61 vs. 66.7 points), ADLER (23 vs. 26.4 points), VAS (2.8 vs. 2.2 points), and ASES (64.4 vs. 72.4 points), respectively, except for the aCMS (75 vs. 96.3; ±001) and the SST (6.2 vs. 8.3; P.001). Patient's satisfaction was not significantly different in both groups (81% of either satisfied or very satisfied patients in both groups). The rate of LD tendon rupture was higher in group A: 10 (33%) vs. 8 (26%).Posterior transfer of latissimus dorsi tendon could be an effective surgical option for the treatment of massive irreparable posterosuperior cuff tears in patients ≥75 years of age.

Resume Introduction L’omarthrose avant l’âge de 50 ans est rare et sa prise en charge delicate. Si le traitement choisi est une prothese d’epaule, les risques evolutifs a long terme, plutot frequents avec un fort taux de revision, rendent l’indication discutable chez un patient jeune et actif. Le but de cette etude etait de connaitre les caracteristiques epidemiologiques des arthroses du patient de moins de 50 ans et d’evaluer les resultats cliniques des alternatives therapeutiques proposees. Hypothese L’hypothese principale etait qu’un traitement non chirurgical bien conduit pouvait retarder la mise en place d’une prothese. L’hypothese secondaire etait qu’une prothese totale anatomique restait le traitement a privilegier en cas d’echec des autres traitements. Materiels et methodes Il s’agit d’une etude multicentrique retrospective incluant les arthroses primitives (AP) ou post-instabilite (API) chez les patients âges de 50 ans ou moins au debut des symptomes. Ont ete exclues les arthroses post-traumatiques, les polyarthrites rhumatoides et les necroses. Ont ete inclus 266 patients (273 epaules) issus de 13 centres specialises dans la chirurgie de l’epaule. Deux traitements non chirurgicaux (28 PRP et 88 viscosupplementations), 73 arthroscopies et 150 protheses dont 62 hemiarthroplasties humerales (10 « hemi-metal », 24 « hemi-pyrocarbones », 28 hemi-resurfacages), 77 protheses totales anatomiques et 11 protheses inversees ont ete analyses. Le recul minimum etait de 12 mois pour le traitement non chirurgical, et de 24 mois pour les patients ayant beneficie d’une arthroplastie, certains ayant eu deux types de traitements. Les criteres d’evaluation suivants etaient analyses : score de Constant, Subjective Shoulder Value (SSV) et le nombre de complications/revisions. Resultats L’âge moyen au moment de la prise en charge etait de 43 ans (23–65), avec une predominance masculine (75 %). Le debut des symptomes etait plus precoce pour les API que pour les AP : 36 vs. 39 ans (20–50). PRP et viscosupplementation permettaient de retarder de 3,5 ans la pose d’un implant dans 86 % des cas et l’arthroscopie dans 56 %. La limitation de la RE1 etait le facteur le plus pejoratif. Au recul moyen de 74 mois pour les hemiarthroplasties et de 95 mois pour les protheses totales anatomiques, le score de Constant moyen etait significativement inferieur pour les hemiprotheses (56 vs. 67 ; p = 0,004), avec un taux plus eleve de complications (31 % vs. 11 % respectivement) et de changements de protheses (13 % vs. 9 % respectivement). Discussion/Conclusion PRP, viscosupplementation et arthroscopie peuvent retarder la mise en place d’une prothese avant que l’epaule ne devienne raide et douloureuse. En cas d’echec, la prothese totale anatomique reste la solution la plus efficace a moyen terme. Niveau d’evidence IV a, Therapeutic Studies - Investigating the Results of Treatment.

The objective of this study was to describe the outcome of reverse shoulder arthroplasty (RSA) combined with modified L’Episcopo procedure at long-term follow-up (5 to 12 years). A retrospective review of 17 RSAs (mean age 67.2 years) with the modified L’Episcopo procedure conducted between 2006 and 2016 was performed. All patients had a combined loss of active elevation and external rotation with an irreparable posterosuperior rotator cuff tear. Clinical assessment was performed with a minimum follow-up of five years (mean 97.3 months). Outcome measures included range of motion, subjective shoulder value (SSV), visual analogue scale (VAS), and Constant-Murley scores. All patients (16) demonstrated a significant improvement in all clinical and functional parameters. VAS pain scores improved from 6 ± 2.6 to 1 ± 1; SSV improved from 35 ± 14 to 72 ± 10; active forward elevation increased from 66° ± 34 to 125° ± 29; and active external rotation arm at the body increased from −11° ± 22 to 21° ±11 and in 90° of abduction from −10° ± 17 to 37° ± 24. The mean Constant score improved from 25 ± 11 to 59 ± 8. Active internal rotation did not significantly change (p = 0.332). At long-term follow-up, RSA combined with modified L’Episcopo procedure resulted in significant improvements in pain, range of motion, and functional scores for patients with shoulder pseudoparalysis and a lack of active external rotation caused by a massive posterosuperior cuff tear with a teres minor deficiency.

Background To compare latissimus dorsi tendon rupture rates after arthroscopic transfer for posterior superior rotator cuff tear using 3 different humeral head fixation techniques. Methods One-hundred fifty consecutive latissimus dorsi transfers were included. Inclusion criteria were massive irreparable posterosuperior rotator cuff tear with advanced fatty infiltration associated with persistent pain and limited range of motion after failed conservative treatments or surgery. All transfers were arthroscopically assisted and fixed in a transosseous tunnel with a cortical button (group 1, n = 59), “over the top” onto the footprint of the supraspinatus (group 2, n = 47), or posteriorly onto the footprint of the infraspinatus (group 3, n = 44) with 2 suture anchors. The tendons were marked with 3 metallic clips placed intraoperatively at a fixed distance of 2, 4, and 6 cm from the tip. Immediate postoperative standard anteroposterior radiographs were performed to confirm the position of the clips and to determine whether the clips displaced on subsequent radiographs during follow-up, indicating tendon rupture. Results Repeat radiographs at 3-month follow-up showed higher risk of latissimus dorsi transfer rupture rate in 27/59 patients in group 1 (46%), 11/47 in group 2 (24%), and 7/44 in group 3 (15%). Conclusion Posterior anchor fixation of the latissimus dorsi tendon onto the infraspinatus footprint had the lowest rupture rate.

The footprint medialization allows a tension free repair in severely retracted rotator cuff tears (RCT), thereby de-creasing the rate of retear. The purpose of the study was to evaluate the clinical and radiological results in a cohort of chronic RCT treated with medialized repair. Secondary purpose was to analyze the impact of medialization length on shoulder function and tendon healing.It was hypothesized that the medialization length would have an impact on clinical and radiological outcome.A consecutive series of thirty patients that underwent arthroscopic repair of a massive posterosuperior RCT at a single institution were retrospectively studied at mean follow-up 18.4months (SD 15.3; range 9-58). The medialization of the medial footprint was measured intraoperatively. Preoperative and postoperative examination included active range of motion, abduction strength, pain assessment, and functional scores. The postoperative rotator cuff integrity was evaluated according to the Sugaya's classification. Types IV-V were categorized as absence of healing.At final follow-up the clinical outcomes were significantly improved in all patients (p≤0.001) with the exception of external rotation that displayed no significant improvement (p=0.05). In group 1 (n=8) medialization length was≤10mm (mean 8, SD 1.9) and in group 2 (n=14)10mm (mean 12.6, SD 1.7). There were no significant differences regarding preoperative and postoperative clinical outcomes (p0.05) between two groups. Group 2 demonstrated moderate correlation between length of medialization and Sugaya stage of tendon healing (r=0.53, p=0.049). Absence of healing was noted in 4/22 patients, 1/8 in group 1 and 3/14 in group 2.Medialized repair is an effective technique for treating chronic, massive and retracted posterosuperior RCT. A medialization of the footprint less than or equal to 10mm is recommended, as it was associated with good clinical and radiological results. The rate of tendon healing decreases when medialization exceeds 10mm.III.

Reverse total shoulder arthroplasty (RSA) associated with modified L'Episcopo (isolated LD) or L'Episcopo (combined TM and LD) procedures had been confirmed to effectively overcome the expected external rotation deficit in patient with postero-superior massive cuff tear and teres minor deficiency. The objective of this study was to evaluate the radiological bony lesions of the lateral proximal humerus following RSA combined with tendon transfer, and to determine whether these bony lesions affect the clinical outcome.A retrospective review of 24 RSAs (mean age 68.71 years, range 52-83) associated with modified L'Episcopo procedure (9) and L'Episcopo procedure (15) was performed. X-rays were assessed for lateral cortex lesions and were categorized into either intact, irregular or complete lytic appearances. In addition, signs of stem loosening were assessed. Clinical outcome measures included range of motion, SSV, VAS, and Constant-Murley scores.With a mean follow-up of 44.71 months (12-97; SD 27.42), eight (33.3%) patients demonstrated intact lateral cortex, eight (33.3%) irregular and eight (33.3%) lytic lesions. 40% of cemented stems demonstrated a deformed cortex compared to 74% of cementless stems. Radiolucent lines were detected in one cemented stem (p=0.046). GT resorption (p=0.147), condensations lines (p=0.449) and spot weld (p=0.342), appeared exclusively in non-cemented stem. Postoperatively all patients (24) demonstrated significant improvements in all clinical and functional parameters. A comparison between patient with (Group 2, 16 patients) and without bony lesions (Group 1, 8 patients) revealed no significant differences in functional scores and range of motion: Constant (p=0,61), VAS (p=0,61), SSV (p=0,66) and external rotation (p=0,34).At short-term follow-up, RSA combined with L'Episcopo or modified l'Episcopo procedure resulted in high incidence (67%) of lateral proximal humerus lesions. Radiolucent lines were noted in cemented stems whereas, signs of stress shielding and GT resorption appeared in non-cemented stems. Yet, no case of humeral loosening was detected and these lesions did not seem to affect the clinical outcome. The use of cemented straight standard-length humeral stems should be positively considered in RSA associated with LD\TM tendon transfer.IV; retrospective study.

Background: The preoperative number of dislocations has been previously proved to be a major factor influencing the results after Bankart repair with more preoperative dislocations correlated with higher recurrence rates and more reoperations. This could possibly be because of the lower quality of the tissue repaired during the procedure after multiple dislocations. On the other hand, the Latarjet procedure does not “repair” but rather reconstructs and augments the anterior glenoid. Purpose/Hypothesis: The main objective was to report the clinical outcomes of patients undergoing a Latarjet procedure after 1 dislocation versus multiple (≥2) dislocations. The hypothesis was that the preoperative number of dislocations would not influence clinical results. Study Design: Cohort study; Level of evidence, 3. Methods: Patients older than 18 years who had undergone a primary Latarjet procedure for shoulder instability with at least 2 years of follow-up were included. Three different techniques were used: a mini-open technique using 2 screws, an arthroscopic technique using 2 screws, and an arthroscopic technique using 2 cortical buttons. Patients were evaluated and answered a questionnaire to assess the number of episodes of dislocation before surgery, the time between the first dislocation and surgery, recurrence of the dislocation, revision surgery, the Walch-Duplay score, the Simple Shoulder Test score, and the visual analog scale (VAS) score for pain. Results: A total of 308 patients were included for analysis with a mean follow-up of 3.4 ± 0.8 years. Of that, 83 patients were included in the first-time dislocation group and 225 in the recurrent dislocation group. At last follow-up, the rates of recurrence and reoperation were not significantly different between groups: 4.8% in the first-time dislocation group versus 3.65% in the recurrent dislocation group and 6.1% versus 4.0%, respectively. The overall Walch-Duplay scores at last follow-up were also comparable between the 2 groups, 67.3 ± 24.85 and 71.8 ± 25.1, even though the first-time dislocation group showed a lower pain subscore (15.0 ± 8.6 vs 18.0 ± 7.5; P = .003). The VAS for pain was also significantly higher in the first-time dislocation group compared with the recurrent dislocation group (1.8 ± 2.3 vs 1.2 ± 1.7; P = .03). Conclusion: The number of episodes of dislocation before surgery does not affect postoperative instability rates and reoperation rates after the Latarjet procedure. However, patients with first-time dislocations had more postoperative pain compared with patients with recurrent dislocations before surgery.

Resume Introduction Avec le vieillissement de la population, le nombre de fractures deplacees de l’extremite superieure de l’humerus du sujet âge est en constante augmentation. Depuis une dizaine d’annees, la part de traitement par hemiarthroplastie (HA) tend a diminuer au profit de la prothese totale d’epaule inversee (PTEI). L’objectif de cette etude retrospective multicentrique etait d’evaluer les resultats de la PTEI fracture a court et long terme, sur une large cohorte de patients âges. Materiel et methode Au total, 898 patients d’âge moyen 79 ans ont ete inclus et 422 ont ete revus au recul minimum de 1 an, par un examen radio-clinique standardise. Certains patients ont ete revus 2 fois a des temps differents, ce qui a permis de constituer 2 groupes : 420 patients a moins de 5 ans de recul moyen (G1) et 119 a plus de 5 ans de recul moyen (G2). Resultats En moyenne, l’elevation anterieure active etait de 115° (± 29), la rotation externe 1 de 17° (± 19), la rotation interne dos de 4,3 points (± 2,5), le score de Constant absolu de 57 (± 15) et le score subjectif SSV de 70 % (± 18). La reinsertion des tuberosites aboutissant a leur consolidation en position anatomique permettait une amelioration significative de tous les resultats, en particulier sur les rotations. En cas d’echec de consolidation anatomique, le resultat clinique restait significativement meilleur qu’en cas d’excision des tuberosites. Les resultats cliniques a court terme (G1) et long terme (G2) etaient statistiquement identiques. Le taux de descellement humeral etait de 3,5 % et etait favorise par l’excision des tuberosites. Le taux de descellement glenoidien etait de 3,5 % et etait favorise par la position en tilt superieur de la glenosphere. La principale complication etait l’instabilite prothetique (2,5 %) et etait favorisee par l’excision des tuberosites. Le taux de survie post-operatoire des patients n’etait pas different de la population generale. Le taux de survie prothetique etait de 91 % a 20 ans. Conclusion Les resultats cliniques d’une PTEI pour fracture sont globalement satisfaisants mais surtout reproductibles et stables dans le temps. La reinsertion des tuberosites autour de la PTEI est l’element clef de l’intervention, permettant d’ameliorer le resultat fonctionnel, notamment par la restauration des rotations et la diminution du taux de complications (instabilite prothetique et descellement humeral). Niveau de preuve IV, etude retrospective.

Since its first description, the concept of reverse shoulder arthroplasty (RSA) has evolved. The term lateralization remains unclear and is used to describe implants that lateralize on the glenoid side, the humeral side, or both. The objective of this study was to provide a clear definition of lateralization and to measure the lateralization achieved by the most commonly used implants. Twenty-eight different configurations with 22 different implants were analyzed. Glenoid, humeral, and global lateralization was measured on digitized templates. Implant lateralization was normalized to the lateral offset of the Delta III. Each implant was defined as a combination of one of two glenoid categories (medialized glenoid (MG), lateralized glenoid (LG), and one of four humeral categories (medialized humerus (MH), minimally lateralized humerus (LH), lateralized humerus (LH+). In addition, implants were separated in categories of 5-mm increments for global offset (medialized RSA (M-RSA), minimally lateralized RSA (ML-RSA), lateralized RSA (L-RSA), highly lateralized RSA (HL-RSA), and very highly lateralized RSA (VHL-RSA). The global lateral offset of the Delta III was 13.1 mm; global lateral offset of all designs in this study varied between 13.1 and 35.8 mm. Regarding their global lateral offset, five implants are M-RSA (lateral offset

The Trillat procedure has been proposed to treat chronic anterior shoulder instability by performing a closing wedge osteotomy of the coracoid process fixed with a coracoscapular screw above the subscapularis. The goal of this osteotomy is to distalize and medialize the coracoid tip to place the conjoint tendon in front of the glenohumeral joint. This in turn distalizes and reinforces the subscapularis in abduction and allows the conjoint tendon to act as a sling and push the humeral head posteriorly. It is commonly accepted to perform this surgery for patients with chronic shoulder anterior instability associated with massive irreparable rotator cuff tear (to preserve and retension the residual subscapularis muscle) or in patients with anterior instability and hyperlaxity. We present a less invasive arthroscopic technique for this procedure. This arthroscopic technique allows assessment and treatment of associated lesions and allows for intraoperative assessment of the subscapularis after the coracoid process is moved to prevent subcoracoid impingement and loss of external rotation.

Background Previously reported outcomes after tendon transfers to reconstruct the subscapularis are unpredictable and often unsatisfactory, especially in the presence of anterior humeral head subluxation. We studied the anatomic feasibility of the lower trapezius and the rhomboid minor transfer to reconstruct irreparable tendon tears of the subscapularis. The aim of this study was to determine the feasibility of lower trapezius and rhomboid minor transfer to reconstruct irreparable subscapularis tendon tears. Materials and methods We measured the tendons dimensions, muscles excursions, distances to pedicles, and dissection needed to complete a successful lower trapezius and/or rhomboid minor transfer to the subscapularis footprint in 10 cadaveric shoulders. The transferred muscles were detached distally, augmented with a semitendinosus and gracilis autograft, and passed anteriorly between the scapula and the subscapularis remnant through a small serratus window to reach the lesser tuberosity. The risk of pedicle compression was subjectively assessed in all cases. Results The trapezius and rhomboid tendons were asymmetric with an average length of 37.6 mm and 21.7 mm, an average width of 63 mm and 33.4 mm, respectively. The mean distances from each distal insertion to the lesser tuberosity were 109 mm for the trapezius and 144 mm for the rhomboid. Mean distances from tendon to pedicle were 57.9 mm and 33.1 mm, respectively. The mean size of the necessary serratus window was 49.4 mm, which was measured at maximal excursion achieved at maximal external rotation 90° representing two digitations. All of the tendon transfers were feasible, and the risk of pedicle compression was 20% for the trapezius and 10% for the rhomboid. Superior migration of the transfer was observed during passive external rotation if the insertion point was too high. Conclusions Transfer of the lower trapezius and rhomboid minor to the lesser tuberosity to reconstruct an irreparable subscapularis tear is feasible without extensive dissection and with a low risk of nerve compression. We recommend not to transfer the rhomboid minor routinely, owing to the risk of tendon luxation after external rotation of the shoulder.

The therapeutic management of the paralytic shoulder after an obstetric brachial plexus injury is complex. When nerve repair or neurotization fail, or if the biological times for nerve reconstruction is over, tendon transfer to restore active external rotation of the shoulder becomes the main surgical alternative. The purpose of this manuscript is to describe the surgical technique of the lower trapezius muscle transfer to the infraspinatus muscle, to restore active shoulder external rotation in the child with paralytic shoulder, step by step with details and pearls.

SummaryBackgroundRecent genome-wide studies of many species reveal the existence of a myriad of RNAs differing in size, coding potential and function. Among these are the long non-coding RNAs, some of them producing functional small peptides via the translation of short ORFs. It now appears that any kind of RNA presumably has a potential to encode small peptides. Accordingly, our team recently discovered that plant primary transcripts of microRNAs (pri-miRNAs) produce small regulatory peptides (miPEPs) involved in auto-regulatory feedback loops enhancing their cognate microRNA expression which in turn controls plant development. Here we investigate whether this regulatory feedback loop is present in Drosophila melanogaster.ResultsWe perform a survey of ribosome profiling data and reveal that many pri-miRNAs exhibit ribosome translation marks. Focusing on miR-8, we show that pri-miR-8 can produce a miPEP-8. Functional assays performed in Drosophila reveal that miPEP-8 affects development when overexpressed or knocked down. Combining genetic and molecular approaches as well as genome-wide transcriptomic analyses, we show that miR-8 expression is independent of miPEP-8 activity and that miPEP-8 acts in parallel to miR-8 to regulate the expression of hundreds of genes.ConclusionTaken together, these results reveal that several Drosophila pri-miRNAs exhibit translation potential. Contrasting with the mechanism described in plants, these data shed light on the function of yet un-described pri-microRNA encoded peptides in Drosophila and their regulatory potential on genome expression.

CASE REPORT We present a case of a 30-year-old man with proximal humerus osteosarcoma and periarticular soft-tissue involvement. Severe humeral and glenoid bone loss was observed, with nonfunctional deltoid after limb-sparing resection and a failed attempt of stabilization. The shoulder was reconstructed using a reverse allograft-prosthesis composite, with deltoid reconstruction by pectoralis major transfer. CONCLUSIONS To the best of our knowledge, this is the first time that this reconstruction technique has been reported in an oncological patient. Favorable clinical and radiological results were achieved at the 24-month follow-up.

We analyzed the clinical and functional results of patients with irreparable posterosuperior rotator cuff tears treated with arthroscopic-assisted latissimus dorsi transfer and the clinical relevance of the addition of partial repair of the remaining cuff to the transfer. This was a prospective cohort study that included patients diagnosed with irreparable massive rotator cuff tears treated by arthroscopic-assisted latissimus dorsi transfer between 2015 and 2018. Demographic characteristics, clinical and functional outcomes (Constant-Murley (CS) score and subjective shoulder value (SSV)), and the incidence of complications were evaluated. Clinical outcomes were compared between patients treated with transfer alone and transfer with partial cuff repair. Fifteen patients were included, with an average follow-up of 37 ± 16 months. The median duration of symptoms before surgery was 66 weeks (24–208). A significant increase in forward elevation of 52° (p

Lower trapezius (LT) transfer using Achilles tendon allograft or semitendinosus autograft is effective in restoring external rotation in massive irreparable posterosuperior rotator cuff tears (RCT). The purpose of this study was to evaluate if the infraspinatus fascia (IF) could be used in LT transfer to extend the LT tendon. Eight fresh-frozen whole-body cadavers were dissected using both shoulders, beach chair position. A 2.5–3 cm wide bundle of the IF was dissected, from the inferior angle of the scapula up to the insertion of the LT which was then detached subperiosteally in continuity with the fascia. The extended tendon was reinforced with sutures and brought to the center of the footprint of the supraspinatus on the humerus. We measured: (a) the distance between the insertion of the LT on the scapula and the inferior angle of the scapula, estimating the length of the IF that can be harvested, (b) the distance between the insertion of the LT on the scapula and the center of footprint of the infrastinatus on the humerus, estimating the distance needed to be covered by the graft (c) the length of the extended tendon between the center of footprint of the infrastinatus on the humerus (fixation point) and its free end, estimating the length available for fixation. The mean length of the fascia that can be harvested is 125.56 mm. The mean distance that needs to be covered by the graft is 100 mm. The extended tendon is long enough leaving 24.69 mm for fixation. The transfer of the LT extended with the IF on the footprint of the infraspinatus is feasible. It could be a viable alternative to the currently used grafts in LT transfer in irreparable posterosuperior RCT.

Background Loss of active shoulder internal rotation can be very disabling. Several tendon transfers have been described for the management of an irreparable subscapularis (SSC) tear. The purpose of this study was to determine and compare the internal rotation moment arm (IRMA) of the sternal head of the pectoralis major (PM), latissimus dorsi (LD), and teres major (TM) when transferred to different insertion sites to restore shoulder internal rotation with and without reverse shoulder arthroplasty (RSA). Methods Six fresh-frozen right hemithoraces were prepared and evaluated using a custom tendon transfer model to determine the IRMA of different tendon transfers using the tendon and joint displacement method. Five tendon-transfer pairs were modeled using a single suture and tested before and after implantation of an RSA (Comprehensive; Zimmer-Biomet, Warsaw, IN, USA): PM to the insertion site of the SSC, LD to the anterior insertion site of the supraspinatus (SSP) tendon on the greater tuberosity, LD to SSC, TM to SSP, and TM to SSC. The SSC was not repaired at the end of the RSA procedure to simulate an SSC deficiency. The PM transfer was passed under the conjoined tendon when tested on the intact shoulder and above the conjoined tendon when tested with an RSA. Results Tendon transfers were shown to have a significant effect on IRMA. The effect of transferred tendons was significantly affected by the position of the humerus. With the humerus adducted, the IRMA of the TM-SSP (14.1 mm ± 3.1 mm) was significantly greater than the other transfers. With the humerus abducted to 90°, the IRMAs of the LD-SSP (30.0 mm ± 5.4 mm) and TM-SSP (28.4 mm ± 6.6 mm) were significantly greater than the IRMAs of other transfer options. The IRMA of the native shoulder differed significantly from that of the RSA state for all tendon transfers. With the humerus adducted to the side of the body, the IRMA of the RSA PM-SSC transfer was significantly greater than that without an RSA (19.0 mm ± 6.4 mm vs. 7.1 mm ± 0.9 mm), demonstrating increased efficiency for internal rotation in the RSA state. Conclusion Tendon transfers to restore shoulder internal rotation differ in effectiveness and may be affected by arm position and by implantation of a lateralized humerus/lateralized glenoid RSA. The LD potentially results in superior restoration of shoulder internal rotation in a native shoulder (given the risk of nerve compression with the TM transfer) compared with PM and should be considered as a potential tendon transfer to restore internal rotation in selected patients. In combination with a lateralized humerus/lateralized glenoid RSA, the fulcrum provided by the biomechanics of the semiconstrained implant allows the PM transfer to become a more efficient tendon transfer to restore active internal rotation.

The purpose of the study is to report the results of reverse shoulder arthroplasty (RSA) after three types of initial treatment performed for complex proximal humeral fracture (PHF): conservative, reduction and internal fixation (RIF), or hemiarthroplasty. This is a retrospective study of 63 patients separated into three groups with a minimum follow-up of two years. Group I included 25 patients with an initial conservative fracture treatment, group II included 25 patients treated by RIF, and group III included 13 patients initially treated by hemiarthroplasty. Patients were assessed using the absolute Constant-Murley score, functional parameters, complications rate, and radiological follow-up. One patient died and five were lost to follow-up. All functional outcomes improved significantly post-operatively for the three groups (p < 0.005). The mean Constant-Murley score increased from 13.7 to 54.1 (group I); 16.6 to 48.5 (group II); and 22.6 to 48.2 (group III) (p < 0.001). The gain of Constant-Murley and SST scores was better for group I (p = 0.049 and 0.028, respectively), while post-operative pain was better in group III (p = 0.033). The complication rate was 38% in group III, 30% in group II, and 14.3% in group I. Reverse shoulder arthroplasty represents a good surgical option in complex proximal humeral fracture sequelae. Whatever the initial treatment, function and motion of the shoulder are improved. The final result is better if the initial treatment was conservative. The group initially treated with hemiarthroplasty had the most complications.

BACKGROUND: Our purpose was to evaluate the clinical and radiologic outcomes of reverse shoulder arthroplasty for proximal humeral fractures in a large cohort of elderly patients and compare the results in the case of tuberosity excision, failed fixation, or anatomic healing. METHODS: In this retrospective multicenter study, 420 patients underwent review and radiography with a minimum follow-up period of 12 months. The patients were divided into 3 groups according to the status of the greater tuberosity (GT) on the last anteroposterior radiographs: anatomic GT healing (group A, n = 169); GT resorption, malunion, or nonunion (group B, n = 131); and GT excision (group C, n = 120). Complications were recorded; shoulder function, active mobility, and subjective results were assessed. RESULTS: At a mean follow-up of 28 months, the mean Simple Shoulder Value in group A (75%) outperformed the results found in groups B (69%, P

Severe glenoid bone loss remains a surgical challenge. This condition is known to be associated with high rates of glenoid component failure. The objective of this study was to evaluate clinical and radiological outcomes of a lateralized metal-backed 15.2-mm keeled baseplate prolonged by a thin 24.8-mm metallic post fixed directly in the subscapularis fossa in primary cases of reverse shoulder arthroplasty (RSA) for severe glenoid bone loss and in revision cases. Between January 2011 and December 2014, 51 shoulders (50 patients) underwent primary or revision RSA using this baseplate. Forty-five shoulders in 44 patients were followed for a minimum of two years (mean, 33 months; range, 24–60 months). The mean age of the patients was 76 years (range, 55–93 years). Outcome measures included pain, range of motion, Constant Score, and complications. The complication rate was 12% in primary cases and 25% in revision cases. One glenoid implant (4%) failed in primary cases and one glenoid implant (5%) failed in revision cases. Pain and range of motion were significantly improved in both groups. The mean Constant Score improved from 24 (± 7) to 62 (± 9) in primary cases and from 24 (± 10) to 58 (± 12) in revision cases. A lateralized metal-backed 15.2-mm keeled baseplate prolonged by a thin 24.8-mm metallic post fixed directly in the subscapularis fossa may provide satisfactory mid-term outcomes in patients with large glenoid bone defects where initial press-fit of a regular baseplate is impossible to obtain.

Lower trapezius transfer can restore external rotation in brachial plexus palsies. In some cuff tear arthropathies, there is lack of active external rotation with a preservation of forward elevation. We evaluated the clinical outcomes of a lower trapezius transfer extended with a semitendinosus tendon and fixed to the insertion of the infraspinatus via arthroscopy.Between 2013 and 2016, we operated on 14 patients (8 men, 6 women; mean age of 62 years, range: 50-70) to reconstruct irreparable posterosuperior rotator cuff tear. A vertical incision of 6 cm following the medial border of the spine was made to harvest the lower trapezius in extension with the semitendinosus tendon. The extension band of the lower trapezius was fixed laterally via arthroscopy on the great tuberosity at the level of the insertion of the infraspinatus. The proximal stump of this extension band was then fixed medially into the muscle of the lower trapezius with the arm in maximum external rotation. Outcomes were evaluated with the Constant-Murley score, simple shoulder test (SST), and subjective shoulder value (SSV).Over a mean follow-up of 24 months (range: 12-36 months), the gain in external rotation with the arm at the side was 24° and 40° in 90° of abduction. The Constant-Murley score improved from 35 to 60 points, the SST from 3.5 to 7.5, the SSV from 30 to 60%, and the pain decreased from 7 to 2 (visual analogue scale, 0-10). Both the lag sign and hornblower sign were negative after this transfer. There were two cases of hematomas, and one was revised because of infection.Lower trapezius transfer is a therapeutic option for irreparable posterosuperior cuff tears with a lack of active external rotation and a good subscapularis. Patients can expect improvements in pain and in active external rotation without any loss of active anterior elevation.Bei brachialen Plexuslähmungen kann ein Transfer des unteren Anteils des M. trapezius die Außenrotation wiederherstellen. Bei einigen manschettenrupturbedingten Arthropathien fehlt es an aktiver Außenrotation, während die Vorwärtshebung erhalten ist. Evaluiert wurden die klinischen Ergebnisse nach Transfer des mit einer Semitendinosus-Sehne verlängerten und arthroskopisch an den Ansatz des M. infraspinatus fixierten unteren Trapeziusanteils.Zwischen 2013 und 2016 wurden 14 Patienten (8 Männer, 6 Frauen; Durchschnittsalter 62 [50–70] Jahre) mit irreparabler posterosuperiorer Rotatorenmanschettenruptur rekonstruktiv operiert. Über einen 6 cm langen Schnitt am medialen Wirbelsäulenrand wurde der untere Anteil des M. trapezius in Verlängerung mit der Semitendinosussehne mobilisiert. Das „Verlängerungsband“ des unteren M. trapezius wurde arthroskopisch seitlich an der Tuberositas maior in Höhe des Ansatzes des M. infraspinatus fixiert. Der proximale Stumpf dieses Bandes wurde dann medial in den unteren Trapeziusanteil fixiert mit dem Arm in maximaler Außenrotation. Anhand des Constant-Murley-Scores, des SST („simple shoulder test“) und des SSV („subjective shoulder value“) wurde das Outcome evaluiert.Nach einer durchschnittlichen Follow-up-Zeit von 24 (12–36) Monaten betrug der Funktionszuwachs hinsichtlich der Außenrotation bei an der Seite gehaltenem Arm in 90°-Abduktion 24° und 40°. Der Constant-Murley-Score hatte sich von 35 auf 60 Punkte verändert, der SST von 3,5 auf 7,5, der SSV von 30 auf 60 % und die Schmerzen von 7 auf 2 (visuelle Analogskala, 0–10). Nach dem Transfer waren sowohl das Lag- als auch das Hornblower-Zeichen negativ. Bei 2 Patienten kam es zu Hämatomen, bei einem zu einer infektionsbedingen Revision.Ein unterer Trapezius-Transfer ist eine therapeutische Option bei posterosuperiorer Rotatorenmanschettenruptur mit eingeschränkter aktiver Außenrotation und einer guten Subscapularis-Situation. Zu erwarten sind eine Schmerzlinderung und eine verbesserte aktive Außenrotation bei unveränderter aktiver Vorwärtshebung.

Resume Introduction Depuis une dizaine d’annees, les indications du traitement chirurgical des fractures deplacees de l’humerus proximal du sujet âge se modifient progressivement : la part de l’hemiarthroplastie (HA) diminue au profit de celle de la prothese totale d’epaule inversee (PTEI). L’objectif de cette etude est d’evaluer les resultats radio-cliniques, les complications, les reoperations/revision des PTEI et de les comparer a ceux des HA. Materiel et methode Une analyse systematique de la litterature, publiee entre janvier 2006 et fevrier 2016, a permis d’identifier les etudes rapportant ou comparant les resultats des PTEI et des HA implantees pour fracture deplacee de l’humerus proximal chez les patients âges de plus de 65 ans. Ces etudes ont ete classees selon un score de qualite et leur niveau de preuve. Sur les 67 etudes identifiees et analysees, 22 ont finalement ete retenues. Resultats Le resultat fonctionnel (score de Constant) obtenu apres PTEI est significativement meilleur et plus reproductible que celui obtenu apres HA. La PTEI donne une mobilite active significativement meilleure en elevation anterieure et abduction que l’HA. En revanche, les mobilites actives en rotation apres PTEI sont inferieures a celles obtenues apres HA. La reinsertion des tuberosites autour de la PTEI permet d’ameliorer les rotations. En l’absence de consolidation des tuberosites, le resultat fonctionnel reste satisfaisant apres PTEI alors qu’on observe un deficit fonctionnel majeur apres HA. Le taux de consolidation des tuberosites autour de la PTEI ne diminue pas avec l’âge, contrairement aux HA ou l’âge est un facteur pejoratif. Le taux global de complications est superieur apres PTEI, mais le taux de reoperations est equivalent. Le taux de revision avec changement prothetique est superieur apres HA. Conclusion Comparee a l’HA, la PTEI permet d’obtenir un resultat fonctionnel plus reproductible avec recuperation d’une meilleure mobilite active en elevation/abduction, meme en l’absence de reinsertion ou de consolidation des tuberosites. La moindre mobilite en rotation peut etre amelioree par la reinsertion des tuberosites. Meme si le taux de complications apres PTEI est plus important, le taux de reoperations est equivalent et le taux de revision est moindre. Niveau de preuve IV, revue systematique de la litterature.