Search

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

Background: We aim to predict a clinical difference in the postoperative range of motion (RoM) between 2 reverse shoulder arthroplasty (RSA) stem designs (Inlay-155° and Onlay-145°) using preoperative planning software. We hypothesized that preoperative 3D planning could anticipate the differences in postoperative clinical RoM between 2 humeral stem designs and by keeping the same glenoid implant., Methods: Thirty-seven patients (14 men and 23 women, 76 ± 7 years) underwent a BIO-RSA (bony increased offset-RSA) with the use of preoperative planning and an intraoperative 3-dimensional-printed patient-specific guide for glenoid component implantation between January 2014 and September 2019 with a minimum follow-up of 2 years. Two types of humeral implants were used: Inlay with a 155° inclination (Inlay-155°) and Onlay with a 145°inclination (Onlay-145°). Glenoid implants remained unchanged. The postoperative RSA angle (inclination of the area in which the glenoid component of the RSA is implanted) and the lateralization shoulder angle were measured to confirm the good positioning of the glenoid implant and the global lateralization on postoperative X-rays. A correlation between simulated and clinical RoM was studied. Simulated and last follow-up active forward flexion (AFE), abduction, and external rotation (ER) were compared between the 2 types of implants., Results: No significant difference in RSA and lateralization shoulder angle was found between planned and postoperative radiological implants' position. Clinical RoM at the last follow-up was always significantly different from simulated preoperative RoM. A low-to-moderate but significant correlation existed for AFE, abduction, and ER (r = 0.45, r = 0.47, and r = 0.57, respectively; P < .01). AFE and abduction were systematically underestimated (126° ± 16° and 95° ± 13° simulated vs. 150° ± 24° and 114° ± 13° postoperatively; P < .001), whereas ER was systematically overestimated (50° ± 19° simulated vs. 36° ± 19° postoperatively; P < .001). Simulated abduction and ER highlighted a significant difference between Inlay-155° and Onlay-145° (12° ± 2°, P = .01, and 23° ± 3°, P < .001), and this was also retrieved clinically at the last follow-up (23° ± 2°, P = .02, and 22° ± 2°, P < .001)., Conclusions: This study is the first to evaluate the clinical relevance of predicted RoM for RSA preoperative planning. Motion that involves the scapulothoracic joint (AFE and abduction) is underestimated, while ER is overestimated. However, preoperative planning provides clinically relevant RoM prediction with a significant correlation between both and brings reliable data when comparing 2 different types of humeral implants (Inlay-155° and Onlay-145°) for abduction and ER. Thus, RoM simulation is a valuable tool to optimize implant selection and choose RSA implants to reach the optimal RoM., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively., Material: We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70 ± 9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence., Results: The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ = 0.58) and strong at final follow-up (ρ = 0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P < .05) and retroversion (20° vs. 10° respectively, P < .05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P < .05)., Conclusion: Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The use of isolated soft tissue repair versus bone block stabilization for the treatment of recurrent anterior shoulder instability in adolescents has no scientific evidence., Purpose: To compare the clinical outcomes of adolescent patients who underwent isolated arthroscopic Bankart (iB) repair with those who underwent the arthroscopic Bristow-Latarjet procedure in addition to Bankart (BLB) repair., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 60 shoulders in adolescents (aged 13-18 years) were reviewed with a minimum 2 years' follow-up: iB repair (n = 36) and arthroscopic Bankart repair with an additional Bristow-Latarjet procedure (BLB; n = 24). The characteristics of the patients in each group in terms of age at the first instability episode, age at surgery, hyperlaxity, participation in at-risk sports, and Instability Severity Index Score were comparable. The mean follow-up was longer in the iB group (7.7 vs 4.1 years, respectively), whereas the rates of patients engaged in competition and those with glenoid lesions were higher in the BLB group. The primary outcome measures were failure, defined as the recurrence of instability (clinical dislocation or subluxation), and return to sports. The mean follow-up was 6.2 years (range, 2-16 years)., Results: At the last follow-up, the rate of recurrence was significantly higher in the iB group, with 22% (8/36) failures, than in the BLB group, with 8% (2/24) instability recurrences ( P < .05). The rate of return to sports at the same level was significantly higher after the BLB repair than after iB repair (79% vs 47%, respectively; P < .001). No statistical difference was found in patient-reported outcome scores between treatment groups ( P > .05). Although failures occurred early after the BLB repair, 88% of failures after iB repair occurred after 2 years. On multivariate analysis, adolescents in the iB group with >3 episodes of preoperative dislocation and shoulder hyperlaxity (external rotation >90°) had a 60% recurrence rate ( P < .005)., Conclusion: Adolescent patients undergoing the BLB repair had a lower rate of recurrent instability and higher rates of return to sports and competition than those undergoing iB repair. Patients with shoulder hyperlaxity (external rotation >90°) and >3 dislocations had an unacceptable failure rate of 60% after iB repair., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: P.B. has received consulting fees from Smith & Nephew and support to develop the specific instruments and implants used to perform the discussed procedure. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

A major limitation of Patient-Reported Outcomes Measures (PROMs) postoperatively is the ceiling effect, where patients report the maximum score, making it difficult to differentiate between different conditions. Our findings regarding the SSV-Sport reveal a significant ceiling effect post-surgery, indicating the need for improvements in PROMs, including the Single Assessment Numerical Evaluation (SANE). One of the problems with SANE is scoring a 'normal' joint as the maximum. Patients might tolerate some subtle imperfections in their recovery and still consider their joint 'normal'. Proposing the concept of a 'forgotten' joint into the SANE could be a more accurate assessment tool and c which could diminish the ceiling effect. We suggest a shift from 'normal joint' to 'forgotten joint' as a standard for evaluating postoperative recovery and function in SANE., Competing Interests: Disclosures The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Lateralization and distalization in reverse shoulder arthroplasty (RSA) can be measured on anteroposterior (AP) radiographs using 2 previously described angles: lateralization shoulder angle (LSA) and distalization shoulder angle (DSA). However, these 2 angles measure global lateralization and distalization but do not allow to differentiate how much lateralization or distalization are attributable to the glenoid and the humerus. We hypothesized that new angles could allow us to separately measure glenoid vs. humeral lateralization and distalization. A more precise understanding of independent glenoid and humeral contributions to lateralization and distalization may be beneficial in subsequent clinical research., Method: Retrospective analysis of postoperative AP radiographs of 100 patients who underwent primary RSA for cuff-tear arthropathy, massive cuff tear, or glenohumeral osteoarthritis were analyzed. The new angles that we proposed use well-known bony landmarks (the acromion, glenoid, and humerus) and the most lateral point of the glenosphere, which we termed the "glenoid pivot point" (GPP). For lateralization, we used the GPP to split LSA into 2 new angles: glenoid lateralization angle (GLA) and humeral lateralization angle (HLA). For distalization, we introduced the modified distalization shoulder angle (mDSA) that can also be split into 2 new angles: glenoid distalization angle (GDA) and humeral distalization angle (HDA). Three orthopedic surgeons measured the new angles, using the online tool Tyche. Mean values with overall and individual standard deviations as well as intraclass correlation coefficients (ICCs) were calculated., Results: Because the angles form a triangle, the following equations can be made: LSA = GLA + HLA, and mDSA = GDA + HDA. All angles showed excellent inter- and intraobserver reliability (ICC = 0.92-0.97) with low means of individual standard deviations that indicate a precision of 2° for each angle., Conclusion: Use of the most lateral part of the glenosphere (termed glenoid pivot point) allows us to separately measure glenoid vs. humeral lateralization and distalization. The 4 new angles (HLA, GLA, GDA, HDA) described in the present study can be used on true AP radiographs, routinely obtained after shoulder replacement, and the measured angles may be used with all types of reverse prostheses available., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To validate the subjective shoulder value for sport (SSV-Sport) by measuring its correlation with existing patient-reported outcome measures (PROMs) and defining its psychometric properties., Methods: Between May 2021 and May 2022, we established 2 patient groups. Group 1 included those (1) aged 18 years or older, who were (2) consulting for the first time for any shoulder condition, (3) regularly participated in sports, and were capable of accessing a questionnaire independently. There were asked to rate their SSV and SSV-Sport at admission and 2 weeks later; they also were asked to answer a questionnaire including other PROMS. Group 2 comprised patients who had (1) undergone shoulder stabilization surgery and had (2) a minimum follow-up period of 6 months., Results: For the shoulder disability patients (group 1, n = 62), there was a strong and significant correlation between SSV-Sport and other PROMs: Quick Disabilities of the Arm, Shoulder and Hand Sport (r = 0.84), Walch-Duplay (r = 0.65), Rowe (r = 0.74), Western Ontario Shoulder Instability (r = 0.78), and SSV (r = 0.75) (P = .0001). The SSV-Sport was reliable at baseline and 2 weeks after (0.91, 95% confidence interval 0.85-0.94), and was responsive to change (P < .001). For the anterior instability patients (group 2, n = 83), SSV was on average 50 points greater than SSV-Sport (29.2 vs 79.4, P < .001) for preoperative values. In both groups, the values of SSV were constantly and significantly higher than the values of SSV-Sport (81.9 ± 21.3 vs 54.8 ± 30.9; P < .001)., Conclusions: The SSV-Sport is an easily administered, reliable, responsive, and valid measure of shoulder function in athletes that is highly correlated with other PROMs. SSV-Sport is better adapted than SSV to quantify pre- and postoperative shoulder deficiency in athletes., Level of Evidence: Level III, cohort study (diagnosis)., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high., Methods: A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders., Results: There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction., Conclusions: One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Objective: Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI., Methods: In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point., Results: Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed., Conclusion: The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone-from which even patients with prior unsatisfactory results after conventional physical therapy can benefit., Impact: Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association.)

Purpose: Reverse shoulder arthroplasty (RSA) has shown improvement in clinical outcomes for various conditions, although some authors expressed concern about the restoration of active internal rotation (AIR). The current study assesses preoperative and intraoperative predictive factors of AIR in patients having a Grammont-style RSA with a minimum five year follow-up., Methods: We conducted a retrospective multicentric study, including patients operated on with a 155° Grammont-style RSA for cuff-related pathology or primary osteoarthritis with posterior subluxation or an associated cuff tear. Patients were clinically evaluated at a minimum of five year follow-up. Patients with previous surgery or those who had a tendon transfer with the RSA were excluded. Demographic parameters, BMI, preoperative notes, and operative reports were obtained from medical records. AIR was graded according to the constant score system from 0 to 10., Results: A total of 280 shoulders in 269 patients (mean age at surgery, 74.9 ± 5.9 years) met the inclusion criteria and were analyzed. The average follow-up was 8.1 years (range, 5-16 years). Overall, AIR increased from 4.2 (SD 2.5, range 0 to 10) preoperatively to 5.9 (SD 2.6, range 0 to 10) at final follow-up. At the last follow-up, AIR increased in 56% of cases, was unchanged in 26% and decreased in 18%. In 188 shoulders (67%), internal rotation was functional and allowed patients to reach the level of L3 or higher. Multivariable linear regression found the following preoperative clinical factors predictive of worse AIR after RSA: male gender (ß = -1.25 [-2.10; -0.40]; p = 0.0042) and higher values of BMI (ß = -0.085 [-0.17; -0.0065]; p = 0.048). Two surgical factors were associated with better AIR after RSA: glenoid lateralization with BIO-RSA technique (ß = 0.80 [0.043; 1.56]; p = 0.039) and subscapularis repair (ß = 1.16 [0.29; 2.02]; p = 0.0092)., Conclusions: With a mean of eight year follow-up (5 to 16 years), internal rotation was functional (≥ L3 level) in 67% of operated shoulders after Grammont-style RSA; however, two patients out of ten had decreased AIR after surgery. Male patients and those with higher BMIs had worse AIR, with glenoid lateralization (using the BIO-RSA technique) and subscapularis repair, as they are predictive of increased AIR after RSA., Level of Evidence: Case series, Level IV., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: The purpose of this study is to report the outcomes of the all-arthroscopic Trillat procedure, combined with capsular plication, for the treatment of recurrent anterior instability in young athletes with shoulder hyperlaxity (external rotation >90°)., Methods: We performed a retrospective evaluation of patients with recurrent anterior instability and shoulder hyperlaxity who underwent an arthroscopic Trillat between 2009 and 2019. Patients with concomitant rotator cuff lesions or voluntary or multidirectional instability were excluded. The osteotomized coracoid was fixed above the subscapularis with a cannulated screw or a suture button; a capsular plication was systematically associated. We followed patients with x-rays, computed tomography scans, and Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. Mean follow-up was 56 months (24-145)., Results: Twenty-eight consecutive patients (30 shoulders) with a mean age of 25 years were identified, and all met criteria. The main finding under arthroscopy was a "loose shoulder" with anteroinferior capsular redundancy and no or few (10%) labrum tears, glenoid erosion (13%), or Hill-Sachs lesions (10%). At last follow-up, 90% of the shoulders (27/30) were stable, and 79% (19/24) of the patients practicing sports returned to their preinjury activity level. The Walch-Duplay and Rowe scores improved from 54 (38-68) to 81 (4-100) and 55 (30-71) to 84 (45-100), respectively, P < .001., Conclusions: The arthroscopic Trillat is an effective procedure for the treatment of recurrent anterior instability in young athletes with shoulder hyperlaxity but no substantial humeral or glenoid bone loss, allowing return to overhead/contact sports., Level of Evidence: Level IV, retrospective study., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: The purpose of the present study is to report the mid- and long-term clinical and radiologic outcomes of the arthroscopic Trillat for the treatment of recurrent anterior instability in patients with chronic massive irreparable rotator cuff tears (MIRCTs) and maintained active shoulder motion where reverse shoulder arthroplasty (RSA) is not indicated., Methods: Twenty-one consecutive patients (mean age 61 years) were identified and retrospectively reviewed. All patients had recurrent anterior dislocations and conserved active forward elevation and active external rotation. The MIRCTs included a retracted (stage 3) supraspinatus tear in 14%, a supra- and infraspinatus tear in 76.5%, and a 3-tendon tear in 14%. A closed-wedge osteotomy of the coracoid was performed, and the coracoid was fixed above the subscapularis with a cannulated screw (10 cases) or suture buttons (11 cases). We followed patients with x-rays and computed tomography scan at 6 months, along with Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. The mean clinical and radiographic follow-up was 58 months (24-145 months)., Results: Overall, 96% (20/21) of the patients had a stable and functional shoulder and were satisfied with the procedure; no patient lost active shoulder motion. The Subjective Shoulder Value increased from 44% (10%-75%) to 94% (80%-100%), P < .001. The Constant and Rowe scores improved from 60 (25-81) to 81 (66-96) and from 54 (35 to 65) to 92 (70-100), respectively (P < .001). Among the 13 patients practicing sports before surgery, 10 (77%) went back to sports. At last follow-up, only 1 patient was revised to RSA., Conclusions: The arthroscopic Trillat procedure is a valuable and durable option for the treatment of recurrent anterior dislocations in older patients with chronic MIRCTs and conserved active shoulder motion., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2022. Published by Elsevier Inc.)

Background: Glenoid bone loss is one of the main challenges in revision of failed shoulder arthroplasties. The concept of a hemi-reverse procedure is to implant a glenoid baseplate and glenosphere to protect the glenoid reconstruction to allow it to heal and to preserve the joint space for a potential second-stage humeral component implantation. The purpose of this study was to report the results of hemi-reverse procedures., Methods: Revision to a hemi-reverse procedure was performed in 15 patients: 8 with a failed anatomic total shoulder arthroplasty, 3 with a failed reverse shoulder arthroplasty, 3 with a failed humeral hemiarthroplasty, and 1 with placement of a cement spacer owing to sepsis after a total shoulder arthroplasty. After complete removal of the initial prosthesis, all patients underwent glenoid reconstruction with bone grafting and implantation of a reverse arthroplasty baseplate and glenosphere. A humeral implant was not placed in any case. The patients were prospectively followed up and underwent complete clinical and radiologic studies preoperatively and postoperatively at a minimum of 2 years after the surgical procedure., Results: Thirteen hemi-reverse implants and glenoid bone grafts healed (86%) and remained radiographically stable. One hemi-reverse construct migrated and became mechanically loose, which was attributed to absent fixation of the central post in the native glenoid bone. In 1 patient, an implant-related infection developed; irrigation and debridement were performed, in addition to revision to a resection arthroplasty. After documented radiographic healing of the hemi-reverse glenoid reconstruction, 5 patients underwent a second-stage revision to a reverse procedure with insertion of a humeral component at a median of 6 months (interquartile range [IQR], 6-8 months). In this group, the median follow-up period was 73 months (IQR, 45-153 months), the median Constant score was 48 (IQR, 41-56), median active forward elevation was 135° (IQR, 100°-150°), and the median Subjective Shoulder Value was 50% (IQR, 50%-60%). In the group of 9 patients with remaining hemi-reverse implants, the median follow-up period was 38 months (IQR, 29-60 months), the median Constant score was 41 (IQR, 38-46), median active forward elevation was 100° (IQR, 80°-100°), and the median Subjective Shoulder Value was 50% (IQR, 40%-60%)., Conclusion: The hemi-reverse procedure is an effective revision procedure to reconstruct a severely deficient glenoid. The hemi-reverse procedure may function as the definitive procedure, with satisfactory outcomes. Additionally, in patients who undergo the hemi-reverse procedure, second-stage revision to a total reverse procedure can be performed once imaging confirms bone graft and construct stability., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Background: There is growing interest in using suture buttons for coracoid fixation to avoid the complications associated with screws during the Latarjet procedure. However, achieving bone block healing is critical for successful shoulder stabilization and return to sport. The purpose of this study was to assess and compare the healing rates and positioning of the coracoid bone block fixed with cortical suture buttons that were either manually tensioned (using a knot pusher) or mechanically tensioned (using a tensioning device) during arthroscopic Latarjet procedures., Methods: This prospective, nonrandomized, comparative study enrolled 69 consecutive patients (mean age, 27 years) who underwent an arthroscopic guided Latarjet procedure with suture-button fixation. Hand tensioning was performed in the first 34 shoulders, whereas the next 35 shoulders underwent mechanical tensioning. Twelve patients (17%) had a history of failed Bankart stabilization. The characteristics of the patients in each group in terms of age, sex, type of sport, bone loss, number of previous failed surgical procedures, smoking, and length of follow-up were comparable. Intraoperatively, the tensioning device was set at 100 N successively 3 times until complete immobilization of the bone block was confirmed, as assessed with a probe. The primary outcome measure was coracoid bone block union and position on computed tomography scan images at 6 months' follow-up. Secondary outcome measures included functional outcome scores, shoulder stability, return to sports, and complications at last follow-up., Results: Overall, the rate of bone block healing was 74% (25 of 34 patients) in the hand-tensioning group and 94% (33 of 35 patients) in the mechanical tensioning group (P = .043). Smoking was an independent risk factor associated with nonunion (P < .001) in each group. Patient age, size of the preoperative glenoid bone defect (<20% or >20%), and a history of surgery were not found to have any influence. The tensioning modality did not affect the bone block position, which was subequatorial in 92% of the cases and flush with the glenoid rim in 92%. At a mean of 34 months of follow-up (range, 24-62 months), 96% of the patients (65 of 69) had a stable shoulder and 87% returned to sports. At final follow-up, no significant difference in clinical scores was noted between the groups; no neurologic or hardware complications were observed., Conclusion: Mechanical tensioning achieves significantly higher healing rates than hand tensioning during the arthroscopic Latarjet procedure with suture-button fixation. The use of a suture-tensioning device is a key step to the suture-button fixation technique during arthroscopic Latarjet procedures. By making the suture-button construct rigid, the tensioning device transforms the initially flexible suture into a "rigid fixation", similar to a bolt (or a rivet)., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

➤: Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency., ➤: The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle., ➤: When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications., ➤: For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes., ➤: Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes., ➤: The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty., ➤: The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G956)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons., Purpose: To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation., Study Design: Cohort study; Level of evidence, 3., Methods: A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months)., Results: The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B ( P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B ( P ≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B ( P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009)., Conclusion: A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).

Hypothesis: The purpose was to report the short-term outcomes and survival of hemiarthroplasty with a pyrocarbon head (HA-PYC) for the treatment of shoulder osteoarthritis in patients aged ≤ 60 years. We hypothesized that HA-PYC could be an alternative to hemi-metal (avoiding the risk of rapid glenoid erosion) and total shoulder arthroplasty (TSA) (avoiding the risk of rapid glenoid loosening) in an active patient population., Methods: Sixty-four consecutive patients (mean age, 53 years) who underwent HA-PYC for glenohumeral osteoarthritis were included. The primary outcome was revision to TSA or reverse shoulder arthroplasty. Secondary outcome measures included functional outcome scores; return to work and sports; and radiographic evaluation of humeral reconstruction quality using the "circle method" of Mears, as well as glenoid erosion severity and progression using the Sperling classification. Patients were reviewed and underwent radiography at an average follow-up of 33 months (range, 24-60 months)., Results: At last follow-up, the rate of survival of the HA-PYC prosthesis was 92%. Revision was performed in 5 patients, with a mean delay of 24 months (range, 15-37 months): 1 conversion to TSA and 4 conversions to reverse shoulder arthroplasty. The Constant score and Subjective Shoulder Value increased from 36 points (range, 26-50 points) to 75 points (range, 69-81 points) and from 35% (range, 20%-50%) to 80% (range, 75%-90%), respectively (P < .001). Postoperatively, 91% of the patients (42 of 46) returned to work and 88% (15 of 17) returned to sport. The severity of preoperative and postoperative glenoid wear (Sperling grade 3 or 4) had no influence on the functional results. Patients who underwent associated concentric glenoid reaming (n = 23) had similar Constant scores and Subjective Shoulder Values (P = .95) to other patients and did not show more progression of glenoid wear. Nonanatomic reconstruction of the proximal humerus (center of rotation of the prosthesis > 3 mm from the anatomic center) occurred in 29% (18 of 62 patients) and was associated with significantly lower functional and subjective results, more complications (subscapularis insufficiency and/or symptomatic glenoid erosion), and a higher risk of revision. The additional 1.5-mm thickness of the metal disc under the pyrocarbon head was found to be the main reason for oversizing of the prosthetic head., Conclusion: HA-PYC is a reliable procedure to treat shoulder osteoarthritis and allows return to work and sports in a young (≤60 years) and active patient population. The severity of glenoid bone erosion or the association with glenoid reaming does not affect functional outcomes and failure risk. By contrast, nonanatomic reconstruction of the proximal humerus after HA-PYC (because of humeral head oversizing) occurred in one-third of the cases and is associated with lower functional outcomes, as well as higher risks of complications and revision., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Recurrence of anterior instability after arthroscopic Bankart prevents return to sports and remains a surgical challenge. We aim to assess clinical and radiologic outcomes after coracoid bone-block performed either open or under arthroscopy, for the management of failed arthroscopic Bankart PATIENTS AND METHODS: Fifty-nine consecutive patients with anterior instability recurrence after arthroscopic Bankart were revised with a Bristow or Latarjet procedure performed either open (25 cases) or under arthroscopy (34 cases). Patients were reviewed for clinical and radiologic examination at a minimum 2-year follow-up. Glenohumeral bony lesions were evaluated preoperatively with computed tomographic scans. Postoperative bone-block position, union, and postinstability arthritis were also evaluated., Results: The mean follow-up was 89 months (24-193). The epidemiologic analysis showed that patients with failed arthroscopic Bankart were young (age <23 years), 58 (98%) were practicing sports, with contact/forced overhead sports (53%), often in competition (53%), had hyperlaxity (71%), and for the most part of them glenohumeral bone loss (88%). Their mean preoperative Instability Severity Index Score was 5.4 ± 2.2 points. After revision with Bristow-Latarjet procedure, 53 patients (91%) returned to sports, 37 (70%) to their previous sports activity, and 17 (46%) to their previous level. No patient suffered recurrent dislocation. Four patients (7%) had recurrent subluxations, all after open procedure; 8 patients (14.5%) had persistent anterior apprehension. A large and deep Hill-Sachs lesion was a risk factor for persistent anterior apprehension (P = .002) and lower level when returned to sports (P = .04). Ninety-two percent of bone-blocks were positioned flush with the glenoid anterior rim, with 84% of bone union. At last follow-up, 5% of patients had severe postinstability osteoarthritis (Samilson 4)., Conclusion: The Bristow-Latarjet, performed either open or under arthroscopy, is an efficient procedure to restore shoulder stability and allow returning to sports in patients with failed arthroscopic Bankart and glenoid bone loss. Patients with a large and deep Hill-Sachs lesion had more persistent anterior apprehension and a lower sports level., (Copyright © 2021. Published by Elsevier Inc.)

Background: Despite its potential biomechanical advantages, reverse shoulder arthroplasty (RSA) is still considered to be particularly high risk in rheumatoid patients who are osteoporotic and immunodeficient. Our purpose was to report prosthesis survival, complications, and outcomes of RSA in patients with rheumatoid arthritis (RA) at minimum 5-year follow-up., Methods: We conducted a retrospective multicenter study including 65 consecutive primary RSAs performed in 59 patients with RA between 1991 and 2010. We excluded rheumatoid patients with previous failed anatomic shoulder arthroplasty. Age at surgery averaged 69 years (range, 46-86 years). A structural bone grafting was performed in 18 cases (45%), using the humeral head in 15 cases (BIO-RSA technique), the iliac crest in 2 cases (Norris technique), and an allograft in 1 case. The mean follow-up was 92 months (range, 60-147 months) or until revision surgery., Results: Revision-free survivorship, using Kaplan-Meier curves, was 96% at 7 years. Two patients had revision surgeries for infections, with associated glenoid loosening in 1 case. No humeral loosening was recorded. The mean adjusted Constant score improved from 36% ± 23% preoperatively to 90% ± 26% postoperatively, and mean Subjective Shoulder Value improved from 21% ± 13% to 85% ± 12%, respectively (P < .001). Active anterior elevation increased from 65° ± 43° to 132° ± 27°, active external rotation increased from 10° ± 26° to 22° ± 27°, and internal rotation improved from buttocks to waist (P < .001). Stable fixation of the baseplate was achieved in all cases (including the 6 patients with end-stage RA), and we did not observe bone graft nonunion or resorption. Preoperative radiologic pattern (centered, ascending, or destructive), presence of acromial fractures or tilt (4 cases, 10%), and scapular notching (55%) on final radiographs were not found to influence outcomes or complication rate. Patients with absent/atrophied teres minor had lower functional results. Overall, 95% of the patients were satisfied with the procedure., Conclusion: RSA is a safe and effective procedure for the treatment of RA patients, with a low risk of complications and low rate of revision, regardless of the radiologic presentation and stage of the disease. Rheumatoid patients undergoing primary RSA, with or without glenoid bone grafting, can expect a revision-free survival rate of 96% at 7-year follow-up. RSA offers the benefit of solving 2 key problems encountered in rheumatoid shoulders: glenoid bone destruction and rotator cuff deficiency., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: An assessment of the pathoanatomic parameters of the arthritic glenohumeral joint (GHJ) has the potential to identify discriminating metrics to differentiate glenoid types in shoulders with primary glenohumeral osteoarthritis (PGHOA). The aim was to identify the morphometric differences and threshold values between glenoid types including normal and arthritic glenoids with the various types in the Walch classification. We hypothesized that there would be clear morphometric discriminators between the various glenoid types and that specific numeric threshold values would allow identification of each glenoid type., Methods: The computed tomography scans of 707 shoulders were analyzed: 585 obtained from shoulders with PGHOA and 122 from shoulders without glenohumeral pathology. Glenoid morphology was classified according to the Walch classification. All computed tomography scans were imported in a dedicated automatic 3D-software program that referenced measurements to the scapular body plane. Glenoid and humeral modeling was performed using the best-fit sphere method, and the root-mean-square error was calculated. The direction and orientation of the glenoid and humerus described glenohumeral relationships., Results: Among shoulders with PGHOA, 90% of the glenoids and 85% of the humeral heads were directed posteriorly in reference to the scapular body plane. Several discriminatory pathoanatomic parameters were identified: GHJ narrowing < 3 mm was a discriminatory metric for type A glenoids. Posterior humeral subluxation > 70% discriminated type B1 from normal GHJs. The root-mean-square error was a discriminatory metric to distinguish type B2 from type A, type B3, and normal GHJs. Type B3 glenoids differed from type A2 by greater retroversion (>13°) and subluxation (>71%). The type C glenoid retroversion inferior limit was 21°, whereas normal glenoids never presented with retroversion > 16°., Conclusion: Pathoanatomic metrics with the identified threshold values can be used to discriminate glenoid types in shoulders with PGHOA., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aim: To demonstrate how reverse shoulder arthroplasty (RSA) planning software could be used to improve how the trainees position glenoid and humeral implants and obtain optimal simulated range of motion (ROM)., Methods: We selected four groups of five various level participants: medical student (MS), junior resident (JR), senior resident (SR), and shoulder expert (SE). Thereafter, the 20 participants planned five cases of arthritic shoulders for a RSA on a validated planning software following three phases: (1) no guidelines and no ROM feedback, (2) guidelines but no ROM feedback, and (3) guidelines and ROM feedback. We evaluated the final simulated impingement-free ROM, the choice of the implant (baseplate size, graft, glenosphere), and the glenoid implant positioning., Results: MS planning were significantly improved by the ROM feedback only. JR took the best advantage of both guidelines and ROM in final results. SR planning were less performant than SE into phase 1 regarding flexion, external rotation, and adduction (respectively - 10°, p = 0.03; - 11°, p = 0.003; and - 3°, p = 0,03), but reached similar results into phase 3 (respectively - 2°, p = 0.329; - 4°, p = 0.44; - 2°, p = 0.319). For MS, JR, and SR, we observed a systematic improvement in the agreement over the study course. The glenoid diameter remained highly variable even for SE. Comparing glenoid implant position to SE, the distance error decreased with advancing phases., Conclusion: Planning software can be used as a simulation training tool to improve implant positioning in shoulder arthroplasty procedures., (© 2021. SICOT aisbl.)

Purpose: 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., Methods: 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., Conclusions: 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.

Introduction: The cause of proximal humeral osteolysis after reverse shoulder arthroplasty (RSA) remains controversial. The primary objective of our study was to compare the radiographic outcomes of Grammont-type RSA when a cemented stem is used versus when a cementless stem is used. The secondary objective was to identify the cause of these radiographic changes, especially for the cementless stems., Hypothesis: More proximal humerus bone loss occurs when a cementless humeral stem is used., Methods: With a minimum follow-up of 5 years, two paired cohorts were compared retrospectively: 70 RSA with cemented stem and 70 RSA with cementless stem. Using the radiographs made at the final follow-up visit, we looked for tuberosity resorption, signs of stress shielding, the presence of periprosthetic radiolucent lines and scapular notching., Results: At a mean follow-up of 9 years (5.0-20.6), the RSA revision rate was 1.8% in the cemented group and 3.6% in the cementless group (p=1). Tuberosity resorption was twice as common in the cementless group: 59% versus 30% (p<0.001). Signs of stress shielding such as osteopenia were only present in the cementless group. In both groups, tuberosity resorption was often associated with scapular notching. In the shoulders with tuberosity resorption, stage≥3 scapular notching was more common in the cementless group (p=0.001)., Discussion: For the cementless stems, proximal humeral osteolysis can in part be attributed to stress shielding. The relationship between notching and tuberosity resorption in the two groups also suggests a secondary biological cause., Level of Evidence: III; Comparative retrospective study., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

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

Purpose: To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss., Methods: A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus., Results: After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out., Conclusions: The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed., Level of Evidence: Level V, consensus statement., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Reverse shoulder arthroplasty (RSA) is a reliable, long-term treatment option for degenerative shoulder pathology. However, the functional outcomes degrade around the fifth year postoperation, particularly for internal and external rotation. Long-term radiographic changes have been reported around the humeral stem, depending on the fixation method., Objectives: The primary objective was to compare the clinical outcomes of RSAs by fixation method-cemented vs. press-fit-after a minimum follow-up of 5 years. We hypothesized that proximal humeral osteolysis impacts the functional outcomes., Design and Methods: Our study compared 2 matched cohorts: 56 RSAs with cemented stems and 56 RSAs with press-fit stems. We evaluated all the patients using the Constant-Murley score (CMS) and range of motion (ROM), which we measured preoperatively and at the final follow-up visit. We evaluated radiographs from the final follow-up visit to look for proximal humeral osteolysis with tuberosity resorption, signs of stress shielding, periprosthetic radiolucent lines, and scapular notching., Results: At a mean follow-up of 9.5 years (5-21), regardless of the fixation method, the RSA procedure helped to improve the CMS and active joint ROM postoperatively, except for internal and external rotation with elbow at side in the press-fit group. Shoulder ROM was significantly better in the group with cemented stems for anterior elevation (P < .001), abduction (P = .006), and external (P = .02) and internal rotation with elbow at side (P = .02). The CMS did not differ between groups. The presence of tuberosity resorption or scapular notching had no effect on the CMS and active ROM in either group. Osteopenia, which was more prevalent in the press-fit group, had no impact on the functional outcome., Conclusion: There was no significant difference between groups in the CMS, although the active shoulder ROM was significantly worse in the press-fit group. This difference could be attributed to more frequent tuberosity resorption in this group., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Three-dimensional (3D) geometry of the normal glenohumeral bone anatomy and relations is poorly documented. Our aims were (1) to determine the 3D geometry of the normal glenohumeral joint (GHJ) with reference to the scapular body plane and (2) to identify spatial correlations between the orientation and direction of the humeral head and the glenoid., Methods: Computed tomographies (CTs) of the normal, noninjured GHJ were collected from patients who had undergone CTs in the setting of (1) polytrauma, (2) traumatic head injury, (3) chronic acromioclavicular joint dislocations, and (4) unilateral trauma with a contralateral normal shoulder. We performed 3D segmentation and measurements with a fully automatic software (Glenosys; Imascap). Measurements were made in reference to the scapular body plane and its transverse axis. Geometric measurements included version, inclination, direction, orientation, best-fit sphere radius (BFSR), humeral subluxation, critical shoulder angle, reverse shoulder angle, glenoid area, and glenohumeral distance. Statistical correlations were sought between glenoid and humeral 3D measurements (Pearson correlation)., Results: A total of 122 normal GHJs (64 men, 58 women, age: 52 ± 17 years) were studied. The glenoid BFSR was always larger than the humerus BFSR (constant factor of 1.5, standard deviation = 0.2). The mean glenoid version and inclination were -6° ± 4° and 7° ± 5°, respectively. Men and women were found to have significantly different values for inclination (6° vs. 9°, P = .02), but not for version. Humeral subluxation was 59% ± 7%, with a linear correlation with glenoid retroversion (r = -0.70, P < .001) regardless of age. There was a significant and linear correlation between glenoid and humeral orientation and direction (r = 0.72 and r = 0.70, P < .001)., Conclusion: The 3D geometry of the glenoid and humeral head present distinct limits in normal shoulders that can be set as references in daily practice: version and inclination are -6° and 7°, respectively, and humeral posterior subluxation is 59%; interindividual variations, regardless of the size, are relative to the scapular plane. There exists a strong correlation between the position of the humeral head and the glenoid orientation and direction., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Aims: We aimed to address the question on whether there is a place for shoulder stabilization surgery in patients who had voluntary posterior instability starting in childhood and adolescence, and later becoming involuntary and uncontrollable., Methods: Consecutive patients who had an operation for recurrent posterior instability before the age of 18 years were studied retrospectively. All patients had failed conservative treatment for at least six months prior to surgery; and no patients had psychiatric disorders. Two groups were identified and compared: voluntary posterior instability starting in childhood which became uncontrollable and involuntary (group VBI); and involuntary posterior instability (group I). Patients were reviewed and assessed at least two years after surgery by two examiners., Results: In all 38 patients (40 shoulders) were included: group I (20 shoulders), with involuntary posterior instability (onset at 14 years of age (SD 2.3), and group VBI (20 shoulders), with initially voluntary posterior instability (onset at 9 years of age (SD 2.6) later becoming involuntary (16 years of age (SD 3.5). Mean age at surgery was 20 years (SD 4.6 years; 12 to 35). A posterior bone block was performed in 18 patients and a posterior capsular shift in 22. The mean follow-up was 7.7 years (2 to 18). Recurrence of posterior instability was seen in nine patients, 30% in group VBI (6/20 shoulders) and 15% in group I (3/20 shoulders) (p > 0.050). At final follow-up, the shoulder's of two patients in each group had been revised. No differences between either group were found for functional outcomes, return to sport, subjective, and radiological results., Conclusion: Although achieving stability in patients with so-called voluntary instability, which evolves into an involuntary condition, is difficult, shoulder stabilization may be undertaken with similar outcomes to those patients treated surgically for involuntary instability. Cite this article: Bone Joint J 2020;102-B(12):1760-1766.

Hypothesis: The aim was to evaluate risk factors for complications, revision, and mid- to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS)., Methods: The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years)., Results: The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P = .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P = .003), and a higher revision rate (15% vs. 2%, P = .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P = .026) and with higher rates of postoperative complications (27% vs. 13%, P = .099) and reinterventions (17% vs. 2%, P = .018)., Conclusion: The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor., (Copyright © 2020. Published by Elsevier Inc.)

Background: The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer., Methods: An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years)., Results: Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045)., Conclusions: (1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion., (Copyright © 2020. Published by Elsevier Inc.)

Background: Glenoid lateralization has been shown to be the most imortant factor in maximizing passive range of motion and shoulder stability while preventing scapular impingement and notching. We aimed to evaluate mid- to long-term functional and radiologic outcomes after bony increased-offset-reverse shoulder arthroplasty (BIO-RSA) using a Grammont-style (medialized) humeral implant., Methods: The study included 143 consecutive shoulders (140 patients; mean age, 72 years) treated with a BIO-RSA for rotator cuff deficiency. A cylinder of autologous cancellous bone graft, harvested from the humeral head, was placed between the reamed glenoid surface and baseplate; fixation was achieved using a long central peg (25 mm) and 4 screws. A large baseplate (29 mm) with a small baseplate sphere (36 mm) was used in 77% of cases, and a Grammont-style (medialized) humeral implant with 155° of inclination was used in all cases. All patients underwent clinical and radiographic assessment at a minimum of 5 years after surgery; in addition, 86 cases (60%) underwent computed tomography scan assessment., Results: At a mean follow-up of 75 months (range, 60-126 months), the survivorship of the BIO-RSA using revision as an endpoint was 96%. No cases of dislocation or humeral loosening were observed. Overall, 118 patients (83%) were either very satisfied (61%) or satisfied (22%). The adjusted Constant score improved from 40% ± 18% to 93% ± 23%, and the Subjective Shoulder Value improved from 31% ± 15% to 77% ± 18% (P < .001). The humeral bone graft incorporated completely in 96% of cases (137 of 143). Severe inferior scapular notching (grade 3 or 4) occurred in 18% (24 of 136). The risk of postoperative notching correlated to a lower body mass index (P < .05), superior glenosphere inclination (P = .02), and high or flush glenosphere positioning (P = .035)., Conclusions: BIO-RSA is a safe and effective technique to lateralize the glenoid, providing consistent bone graft healing, excellent functional outcomes, a low revision rate, and a high rate of patient satisfaction. Thin patients (with a low body mass index) and glenosphere malposition (with persistent superior inclination and/or insufficient lowering of the baseplate and sphere) are associated with higher risk of scapular notching.Our data confirm the importance of implanting the baseplate with a neutral inclination (reverse shoulder arthroplasty angle < 5°) and with sufficient glenosphere inferior overhang (>5 mm) in preventing scapular notching. The use of a less medialized humeral implant (135° or 145° inclined) and smaller (25-mm) baseplate (when using a small, 36-mm sphere) should allow reduction in the incidence of scapular notching., (Copyright © 2020. Published by Elsevier Inc.)

Background: Recent studies have shown variations in glenoid bone density in asymmetric wear patterns but have yet to analyze non-arthritic or concentrically worn glenoids., Questions/purposes: The purpose of this study is to characterize and compare subchondral glenoid bone densities in both non-arthritic and A1, A2, B1, B2 and B3 osteoarthritic glenoids, as well as to assess uniformity in symmetric and asymmetric erosion wear patterns., Methods: In all, 150 computerized tomography (CT) scans containing equal numbers of non-arthritic (N), A1, A2, B1, B2 and B3 glenoids were segmented semi-automatically. Each reconstructed glenoid was divided first into anterior and posterior quadrants, and then further subdivided into four quadrants. Volumes of interest (VOI) were defined at depths of 0-2.5mm (Zone A), 2.5-5mm (Zone B) and 5-7.5mm (Zone C). Average bone densities were measured at each VOI depth and in each quadrant., Results: Osteoarthritic glenoids had higher mean bone densities than N glenoids. Mean bone densities were uniform amongst all quadrants for N glenoids, but not for osteoarthritic glenoids. In A1 glenoids, the antero-superior quadrant was less dense in Zone C. A2 glenoids had increased bone density measured posteriorly in Zones B and C. In B1 and B2 glenoids, Zones B and C demonstrated increased bone densities of posterior quadrants compared to anterior quadrants. B3 glenoids presented similar results as A1 and A2 glenoids. Cystic changes were more pronounced in anterior quadrants of A2, B1, B2 and B3 glenoids., Conclusion: This study demonstrates that osteoarthritic glenoids have greater bone density than non-arthritic glenoids, independent of depth of interest. It also confirms that N glenoids have uniform erosion wear patterns and that B1 and B2 glenoids have irregular wear patterns. It is the first study to reveal that A1, A2 and B3 glenoids, though geometrically symmetrical, have irregular bony densities similar to B2 glenoids. These findings have clinical implications for reaming the glenoid and implant fixation., Level of Evidence: Basic Science, Anatomy, Imaging., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Our aim was to analyze the epidemiology, etiologies, and revision options for failed shoulder arthroplasty from 2 tertiary centers., Methods: From 1993 to 2013, 542 failed arthroplasties were revised in 540 patients (65% women): 224 hemiarthroplasties (HAs, 41%), 237 anatomic total shoulder arthroplasties (TSAs, 44%) and 81 reverse total arthroplasties (RSAs, 15%). Data about patients, pathology, and reintervention procedures, as well as intraoperative data, were analyzed from our 2 local registries that prospectively captured all the revision procedures. Patients had an average follow-up period of 8.7 years., Results: The revision rate was 12.7% for HAs, 6.7% for TSAs, and 3.9% for RSAs. HAs were revised earlier (33 ± 40 months) than RSAs (47 ± 150 months) and TSAs (69 ± 61 months). Glenoid failure was a major cause of reintervention: erosion in HAs (29%) or loosening in TSAs (37%) and RSAs (24%). Instability was another major cause of reintervention: 32% in RSAs, 20% in TSAs, and 13% in HAs. Humeral implant loosening led to revision in 10% of RSAs, 6% of HAs, and 6% of TSAs. Multiple reinterventions were required in 21% of patients, mainly for instability (26%) and/or infection (25%). The final implant was an RSA in 48%, especially when associated with cuff insufficiency, instability, and/or bone loss. Final reimplantation was possible in 90% of cases, with the remaining 10% treated with a resection or spacer., Conclusion: Glenoid failure and instability are the most common causes of revision. Soft-tissue insufficiency and/or infection results in multiple revisions. Surgeons must recognize all complications so that they can be addressed at the first revision operation and avoid further reinterventions. RSA was the most common final revision implant., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: To determine how different combinations of humeral stem and glenosphere designs for reverse shoulder arthroplasty (RSA) influence range of motion (ROM) and muscle elongation., Methods: A computed tomography scan of a non-pathologic shoulder was used to simulate all shoulder motions, and thereby compare the ROM and rotator cuff muscle lengths of the native shoulder versus 30 combinations of humeral components (1 inlay straight stem with 155° inclination and five onlay curved stems with 135°, 145° or 155° inclinations, using concentric, medialized or lateralized trays) and glenospheres (standard, large, lateralized, inferior eccentric and bony increased-offset (BIO-RSA))., Results: Only five of the 30 combinations restored ≥ 50% of the native ROM in all directions: the 145° onlay stem (concentric tray) combined with lateralized or inferior eccentric glenospheres and the 145° stem (lateralized tray) combined with either a large, lateralized or inferior eccentric glenosphere. Lengthening of the supraspinatus and infraspinatus, observed for all configurations, was greatest using onlay stems (7-30%) and BIO-RSA glenospheres (13-31%). Subscapularis lengthening was observed for onlay stems combined with BIO-RSA glenospheres (5-9%), while excessive subscapularis shortening was observed for the inlay stem combined with all glenospheres except the BIO-RSA design (> 15%)., Conclusions: The authors suggest implanting 145° onlay stems, with concentric or lateralized trays, together with lateralized or inferior eccentric glenospheres.

Background: We evaluated survival and midterm results of pyrocarbon interposition shoulder arthroplasty (PISA) in arthritic patients younger than 65 years., Methods: Fifty-eight PISAs (InSpyre; Tornier-Wright, Bloomington, MN, USA), implanted in 56 patients between 2010 and 2015, were prospectively observed. The mean age at surgery was 52 ± 13 years. The cause was primary osteoarthritis (18), fracture sequelae (16), post-instability arthritis (15), aseptic necrosis (3), inflammatory disease (2), and failed hemiarthroplasty (4); 34 shoulders (61%) had previously undergone surgery. Glenoid erosion was assessed in 4 grades according to the Sperling classification. Humeral erosion was also assessed in 4 grades. Multivariate analysis was used to determine predisposing risk factors for both humeral and glenoid erosion., Results: At a mean follow-up of 47 ± 15 months, survival rate was 90%. Six patients (10%) required conversion to reverse total shoulder prosthesis for painful glenoid erosion (n = 2) and humeral erosion with greater tuberosity stress fractures (n = 4). The mean Constant score and subjective shoulder value significantly increased from 36 ± 14 points to 70 ± 15 points and 32% ± 14% to 75% ± 19%, respectively (P < .001). Humeral medialization was observed in 78% of the cases with increased pain score. Uncorrected anteroposterior implant subluxation (12 cases) was associated with lower Constant score (50 points vs. 72 points; P = .02) and lower subjective shoulder value (53% vs. 78%; P = .002). On multivariate analysis, no risk factors for glenoid or humeral erosion were found., Conclusion: At midterm follow-up, PISA does not protect from progressive glenoid erosion and can lead to greater tuberosity erosion and stress fractures. Longer follow-up is required to see whether PISA survival will be superior to that of hemiarthroplasty., (Copyright © 2019. Published by Elsevier Inc.)

Background: Results of anatomic shoulder arthroplasty for glenohumeral osteoarthritis with severe glenoid retroversion are unpredictable with a high rate of glenoid loosening. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative, with good early results. We sought to confirm this at longer follow-up (minimum 5 years). The study hypothesis was that early results would endure over time., Methods: We retrospectively reviewed all RSAs performed in 7 centers from 1998 to 2010. The inclusion criteria were primary glenohumeral osteoarthritis with B1, B2, B3, or C glenoid. Forty-nine shoulders in 45 patients fulfilled the criteria. Bone grafting was performed in 16 cases. Clinical outcomes were evaluated with the Constant score (CS) and shoulder range of motion., Results: The mean total CS increased from 30 preoperatively to 68 points (P < .001) with significant improvements in all the subsections of the CS and range of motion. Scapular notching was observed in 20 shoulders (43%), grade 1 in 5 (11%), grade 2 in 7 (15%), grade 3 in 5 (11%), and grade 4 in 3 (6%). The glenoid bone graft healed in all the shoulders. Partial inferior lysis of the bone graft was present in 8 cases (50%). Scapular notching and glenoid bone graft resorption had no influence on the CS (P = .147 and P = .798)., Conclusion: RSA for the treatment of primary glenohumeral osteoarthritis in patients with posterior glenoid deficiency and humeral subluxation without rotator cuff insufficiency resulted in excellent clinical outcomes at a minimum of 5 years of follow-up., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze the functional results after unipolar or bipolar arthroscopic soft tissue stabilization in the treatment of recurrent anterior instability after a coracoid bone block procedure., Methods: We studied a retrospective series of 41 patients (33 male, 8 female) with recurrent anterior shoulder instability after Bristow (n = 7) or Latarjet (n = 34) coracoid bone block treated with unipolar (isolated Bankart, n = 22) or bipolar (Bankart + Hill-Sachs remplissage, n = 19) arthroscopic stabilization., Results: The mean follow-up was 72 (25-208) months. Severe glenoid erosion (>25%) was found in 17 patients, and a medium or deep Hill-Sachs lesion (Calandra 2 and 3) was found in 24 patients. A radiographic control was available in 28 patients at final follow-up. Five patients (12%) presented a recurrence of instability (4 subluxations, 1 dislocation). Two patients required revision surgery, 1 in each group. At final follow-up, persistent anterior apprehension was more frequent in patients presenting with severe glenoid bone loss (P = .04) and in patients with medium or deep Hill-Sachs lesions who were treated with unipolar stabilization (P = .04). Return to sports was achieved in 81% of cases. Visual analog scale was 1.3 ± 2, subjective shoulder value was 83% ± 18%, Rowe score was 78 ± 24, and Walch-Duplay score was 76 ± 28. No patients developed severe glenohumeral arthritis (Samilson 4)., Conclusions: Arthroscopic soft tissue stabilization provides good functional results after failed coracoid bone block with an acceptable rate of recurrence and a return to sports in most cases. Patients with significant Hill-Sachs lesions showed better results when treated with combined Bankart repair and Hill-Sachs remplissage. Severe glenoid bone loss was associated with poorer functional results., Level of Evidence: Level IV, case series., (Copyright © 2019. Published by Elsevier Inc.)

Background: The ageing of the population is steadily increasing the frequency of displaced proximal humerus fractures (PHFs) in elderly patients. The last decade has seen a shift from hemi-arthroplasty (HA) to reverse shoulder arthroplasty (RSA) in these patients. The primary objective of this study was to assess short- and long-term outcomes of RSA in a large cohort of elderly patients with recent PHFs. The secondary objectives were to evaluate radiological outcomes and short- and long-term morbidity and mortality rates., Hypothesis: Outcomes of RSA to treat PHFs in older patients are satisfactory, reliable, and sustained over time., Material and Methods: This retrospective multi-centre study included 898 patients with a mean age of 79 years, among whom 422 underwent a standardised clinical and radiological evaluation at least 1 year after RSA. Some patients were re-evaluated twice. An evaluation within the first 5 years was available for 420 patients (≤5-Y group), whereas 119 patients were re-evaluated more than 5 years after RSA (>5-Y group). Some patients had one re-evaluation either within or after 5 years and others had both an early and a late re-evaluation; thus the total number of re-evaluation was greater than the number of patients., Results: Mean active forward elevation was 115°±29°, mean external rotation with the elbow by the side was 17°±19°, mean internal rotation (hand-to-back) was 4.3±2.5 points, mean absolute Constant score was 57±15, and mean Subjective Shoulder Value was 70%±18%. Re-implantation of the tuberosities followed by healing in the anatomical position was associated with significantly better outcomes, notably regarding rotations. Even in the absence of healing in the anatomical position, tuberosity repair was associated with better clinical outcomes compared to tuberosity excision. Humeral loosening occurred in 3.5% of patients and was associated with tuberosity excision. Glenoid loosening was seen in 3.5% of patients and was associated with superior tilt of the glenoid component. The main complication was prosthesis instability, which occurred in 2.5% of patients, a proportion similar to that seen in the general population. Post-operative patient survival was not significantly different from that in the general population of the same age. Prosthesis survival was 91% after 20 years., Conclusion: Clinical outcomes of RSA for PHF in elderly patients were not only satisfactory but also reproducible and sustained over time. Tuberosity re-implantation around the prosthesis is the key step for optimising the functional outcomes, notably by restoring rotations and decreasing the risk of complications (prosthesis instability and humeral loosening)., Level of Evidence: IV, retrospective observational study., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Purpose: Osteoarthritis may be observed after surgery for instability and in the natural history of pathology. The primary objective was to analyze the late clinical and radiographic results of reverse shoulder arthroplasties (RSA) for patients who had instability arthropathy., Methods: This is a retrospective cohort of 25 patients with a mean follow-up of 6.6 years. Patients had a history of instability surgery (80%) or multiple closed reductions. All were clinically evaluated with the constant score (CS), and radiologically (true AP view and Y view)., Results: No significant differences in pre- and post-operative function, radiologic status, and complication rate between the patients treated with a prior bone block procedure for the anterior instability and those treated by a capsular plication or non-operatively. A 36-mm sphere was implanted in 67%. Bone grafting of the glenoid was needed in 71%. No intra-operative complication has been reported. Clinically, the active anterior elevation increased from 70° to 140° (p < 0.01) and external rotation from 9° to 21° (p = 0.02). The adjusted CS increased from 38 to 98 (p < 0.01). Two early post-operative complications were collected: one spine fracture and one superficial infection. No early or late dislocation or neurologic complication was observed. At the latest follow-up, there were 38.10% of glenoid spurs, and 55% of scapular notch., Conclusions: The overall complication rate in this specific group is relatively low. Patients' satisfaction rate is high and clearly higher than those reported with anatomic TSA for this indication. Clinical results are comparable to other studies describing results of RSA.

Background: Avoiding superior inclination of the glenoid component in reverse shoulder arthroplasty (RSA) is crucial. We hypothesized that superior inclination was underestimated in RSA. Our purpose was to describe and assess a new measurement of inclination for the inferior portion of the glenoid (where the baseplate rests)., Methods: The study included 47 shoulders with rotator cuff tear arthropathy (mean age, 76 years). The reverse shoulder arthroplasty angle (RSA angle), defined as the angle between the inferior part of the glenoid fossa and the perpendicular to the floor of the supraspinatus, was compared with the global glenoid inclination (β angle or total shoulder arthroplasty [TSA] angle). Measurements were made on plain anteroposterior radiographs and reformatted 2-dimensional (2D) computed tomography (CT) scans by 3 independent observers and compared with 3-dimensional (3D) software (Glenosys) measurements., Results: The mean RSA angle was 25° ± 8° on plain radiographs, 20° ± 6° on reformatted 2D CT scans, and 21° ± 5° via 3D reconstruction software. The mean TSA angle was on average 10° ± 5° lower than the mean RSA angle (P < .001); this difference was observed regardless of the method of measurement (radiographs, 2D CT, or 3D CT) and type of glenoid erosion according to Favard. In Favard type E1 glenoids with central concentric erosion, the difference between the 2 angles was 12° ± 4° (P < .001)., Conclusion: The same angle cannot be used to measure glenoid inclination in anatomic and reverse prostheses. The TSA (or β) angle underestimates the superior orientation of the reverse baseplate in RSA. The RSA angle (20° ± 5°) needs to be corrected to achieve neutral inclination of the baseplate (RSA angle = 0°). Surgeons should be aware that E1 glenoids (with central erosion) are at risk for baseplate superior tilt if the RSA angle is not corrected., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

As shoulder arthroplasty becomes increasingly common, the burden of revision shoulder arthroplasty is also increasing. Revision reverse shoulder arthroplasty requires an understanding of the causes of failure and the evaluation of these causes and their sequelae, including infection, instability, component loosening, humeral bone loss, and glenoid bone loss. Revision reverse shoulder arthroplasty is technically complex. On the humeral side, corticotomy may be required for component removal, and bone grafting may be necessary to achieve rotational stability and to restore humeral length and avoid undertensioning and instability. On the glenoid side, bone loss is common, structural bone grafting is not infrequently required, and proper component positioning is required to avoid impingement and component loosening. Although the outcomes are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function.

Purpose: To evaluate mid-term clinical outcomes, complications, bone-block healing, and positioning using suture-button fixation for an arthroscopic Latarjet procedure., Methods: Patients with traumatic recurrent anterior instability and glenoid bone loss underwent guided arthroscopic Latarjet with suture-button fixation. We included patients with anterior shoulder instability, glenoid bone loss >20%, and radiographic and clinical follow-up minimum of 24 months. Patients with glenoid bone loss <20% or those that refused computed tomography imaging were excluded. Bone-block fixation was accomplished with 2 cortical buttons connected with a looped suture (4 strands). The looped suture was tied posteriorly with a sliding-locking knot. After transfer of the bone block on the anterior neck of the scapula, compression (100 N) was obtained with the help of a tensioning device. Clinical assessment was performed at 2 weeks, 3 months, 6 months, and then yearly with computed tomography completed at 2 weeks and 6 months to confirm bony union., Results: A consecutive series of 136 patients underwent arthroscopic Latarjet with 121 patients (89%; mean age 27 years) available at final follow-up (mean follow-up, 26 months; range, 24-47 months). No neurologic complications or hardware failures were observed; no patients had secondary surgery for implant removal. The transferred coracoid process healed to the scapular neck in 95% of the cases (115/121). The bone block did not heal in 4 patients; it was fractured in 1 and lysed in another. Smoking was a risk factor associated with nonunion (P < .001). The coracoid graft was positioned flush to the glenoid face in 95% (115/121) and below the equator in 92.5% (112/121). At final follow-up, 93% had returned to sports, whereas 4 patients (3%) had a recurrence of shoulder instability. The subjective shoulder value for sports was 94 ± 3.7%. Mean Rowe and Walch-Duplay scores were 90 (range, 40-100) and 91 (range, 55-100), respectively., Conclusions: Suture-button fixation is an alternative to screw fixation for the Latarjet procedure, obtaining predictable healing with excellent graft positioning, and avoiding hardware-related complications. There was no need for hardware removal after suture-button fixation. The systematic identification of the axillary and musculocutaneous nerves reduced risk of neurologic injury. A low instability recurrence rate and excellent return to pre-injury activity level was found. Suture-button fixation is simple, safe, and may be used for both open and arthroscopic Latarjet procedure., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: The Constant score, allows an objective and subjective assessment of the shoulder function. It has been proven to have a poor interobserver reliability for some of its aspects and is not usable as a remote assessment tool., Hypothesis: The Constant-Murley functional shoulder score can be assessed with a self-administered questionnaire., Methods: We conducted a prospective continuous study in a shoulder-specialized service. For each patient seen in consultation or hospitalized for a shoulder pathology, a self-administered questionnaire was delivered, and a clinical examination was performed by a surgeon. The questionnaire, in French language, was composed of checkboxes only, with pictures preferred over text for most items. Correlations with surgeon examination were assessed with the intraclass correlation coefficients, differences with the paired t-test., Results: One hundred consecutive patients were analyzed. Correlation between the two scores was excellent (0.87), as were the range of motion and the pain subscores (0.85 and 0.78), good for the activity (0.69) and fair for the strength (0.57). The mean total score was 3 points lower for the self-administered questionnaire (CI95 [-5; -1]; p<0.01). Activity and pain were not significantly different (-0.4/20 and -0.3/40; p>0.05) but pain and force were slightly different (+0.8/15; -3.0/25; p<0.01)., Conclusion: The Auto-Constant questionnaire in French is an excellent estimator of the Constant score, and of its pain and mobility sub-scores. It is less accurate for the evaluation of the strength, but differences between sub-scores compensate and allow its use in daily practice., Level of Proof: II, Prospective continuous clinical series., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Humeral bone loss is commonly encountered during revision shoulder arthroplasty and anticipating humeral bone defects can help the revision surgeon make appropriate plans to achieve adequate fixation and stability. No validated classification system exists to characterize humeral bone loss in the setting of revision shoulder arthroplasty., Questions/purposes: The purposes of this study were (1) to create a classification system for humeral bone loss in revision shoulder arthroplasty; (2) to determine the classification system's reliability; and (3) to determine whether humeral bone loss type is associated with intraoperative humeral-related reconstruction characteristics., Methods: This was a comparative retrospective radiographic study. First, six surgeons from five centers collaborated to create a classification by consensus. Second, two surgeons from two other centers who had fellowship training in shoulder and elbow surgery, who were blinded to each other's grades and all patient details other than plain radiographs, and who were not involved in creation of the system, classified true AP, AP, and lateral (axillary and/or scapular-Y) radiographs from 108 revision (413 radiographs) from one center that were performed between November 15, 2006, and January 4, 2018. Interobserver reliability was calculated by comparing those two reviews and determining Cohen's κ. In addition, one reviewer repeated his assessments twice, 4 months apart, to determine intraobserver reliability using Cohen's κ. Third, we performed a retrospective chart study of these same revisions to determine intraoperative humeral-related reconstruction characteristics such as the use of greater tuberosity fixation, stem length, humeral bone grafting, and the use of proximal humeral replacement or total humeral replacement; at the center where these revisions were performed during that timespan, no attempt to classify bone loss was made. During that period, the general indications for greater tuberosity fixation included the absence of a stable osseous connection between the greater tuberosity and the shaft of the humerus with a tuberosity amendable to repair; the general indications for use of longer stems were inability to obtain a minimum of two cortical widths of overlap between the implant and the humeral diaphysis and/or loss of the greater tuberosity; and the general indications for proximal and total humeral replacement were bone loss that was felt to be too severe to allow reconstruction with allograft., Results: The classification system consists of three types of humeral bone loss: Type 1 is loss of the epiphysis with subtypes for loss of the calcar and loss of the greater tuberosity; Type 2 is loss of the metadiaphysis above the deltoid attachment with a subtype for cortical thinning; and Type 3 is bone loss extending below the deltoid attachment with a subtype for cortical thinning. We studied 108 revisions: 38 (35%) without bone loss, 34 (31%) Type 1, 27 (25%) Type 2, and nine (8%) Type 3. For reliability, interrater κ was 0.545 and in 71% (77 of 108) of revisions, the two raters agreed on a numeric type. Intrarater κ was 0.615 and in 77% (83 of 108) of revisions, the rater agreed with himself as to the numeric type. Stem length increased with class type (Type 1 median [range] 130 [70-210], Type 2 150 [70-210], Type 3 190 [70-240], p = 0.005). Most greater tuberosity fixation for intraoperative fracture was in Types 1 and 2 (13 of 18 compared with the five of 18 of greater tuberosity fixation that was within Types 0 and 3, p = 0.043). Most bone grafting was in Types 2 and 3 (eight of 13 compared with five of 13 of bone grafting was in Types 0 and 1, p = 0.044). Most proximal humeral and total humeral replacements were in Type 3 (three of four compared with one of four, p < 0.001)., Conclusions: We developed the Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) system, which has adequate, if imperfect, reliability to classify humeral bone loss in the setting of revision shoulder arthroplasty. This classification system may be useful to anticipate the complexity of humeral reconstruction. Further validation incorporating advanced imaging and further evaluators will be necessary., Level of Evidence: Level III, diagnostic study.

Purpose: Glenoid loosening after total shoulder arthroplasty (TSA) is influenced by the position of the glenoid component. 3D planning software and patient-specific guides seem to improve positioning accuracy, but their respective individual application and role are yet to be defined. The aim of this study was to evaluate the accuracy of freehand implantation after 3D pre-operative planning and to compare its accuracy to that of a targeting guide., Method: Seventeen patients scheduled for TSA for primary glenohumeral arthritis were enrolled in this prospective study. Every patient had pre-operative planning, based on a CT scan. Glenoid component implantation was performed freehand, guided by 3D views displayed in the operating room. The position of the glenoid component was determined by manual segmentation of post-operative CT scans and compared to the planned position. The results were compared to those obtained in a previous work with the use of a patient-specific guide., Results: The mean error for the central point was 2.89 mm (SD ± 1.36) with the freehand method versus 2.1 mm (SD ± 0.86) with use of a targeting guide (p = 0.05). The observed difference was more significant (p = 0.03) for more severely retroverted glenoids (> 10°). The mean errors for version and inclination were respectively 4.82° (SD ± 3.12) and 4.2° (SD ± 2.14) with freehand method, compared to 4.87° (SD ± 3.61) and 4.39° (SD ± 3.36) with a targeting guide (p = 0.97 and 0.85, respectively)., Conclusion: 3D pre-operative planning allowed accurate glenoid component positioning with a freehand method. Compared to the freehand method, patient-specific guides slightly improved the position of the central point, especially for severely retroverted glenoids, but not the orientation of the component.

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 < .001) and C (56%, P < .001). Overall, the mean adjusted Constant-Murley score was significantly higher in group A (93% ± 22%) than in group B (82% ± 22%) and group C (80% ± 24%) (P < .001), but there was no difference between groups B and C (P = .88). Anterior active elevation and external rotation were significantly better in group A than in groups B and C (P < .001). The instability rate was significantly higher in group C (n = 15 [12.5%], P < .001) than in group A (n = 2) or group B (n = 3)., Conclusion: In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. GT excision is associated with the worst functional results and increases the risk of postoperative shoulder instability., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)