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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.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.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%).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.

Despite curative hepatectomy, most colorectal liver metastasis (CRLM) patients relapse locally within 2 years. Genomic predictors for hepatic recurrence are poorly understood. This study was designed to identify genomic signatures for recurrence in resected CRLM patients treated with adjuvant hepatic artery infusion (HAI) and/or systemic (SYS) chemotherapy.Patients undergoing curative hepatectomy and adjuvant HAI+SYS or SYS between January 2000 and October 2017 with next-generation sequencing data were catalogued. Gene and signaling-level alterations were checked for association with time to any (AR), liver (LR), and extrahepatic recurrence (ER) by using Kaplan-Meier analysis.Of 172 receiving HAI+SYS, 100 patients recurred, with 69 LR and 83 ER. Five- and ten-year LR-free rates were 57% (95% confidence interval [CI] 48-65%) and 51% (95% CI 41-60%), respectively. Five- and 10-year ER-free, rates were 51% (95% CI 43-58%) and 45% (95% CI 36-54%), respectively. More ER was observed with tumors harboring altered KRAS (38% [95% CI 25-50%] vs. 63% [95% CI 53-71%], p-adj = 0.003) and RAS/RAF (36% [95% CI 25-48%] vs. 66% [95% CI 56-74%], p-adj 0.001) than wild-type. Co-altered RAS/RAF-TP53 was associated with worse AR (26% [95% CI 14-40%] vs. 48% [95% CI 39-57%], p-unadj 0.001), ER (30% [95% CI 17-45%] vs. 62% [95% CI 53-70%], p-unadj 0.001), and LR rate (40% [95% CI 24-57%] vs. 70% [95% CI 60-77%], p-unadj = 0.002). On multivariable analysis, controlling for clinical risk score, ablation, margin status, and primary T-stage, co-altered RAS/RAF-TP53 was associated with increased risk for AR (HR = 2.14, 95% CI 1.38-3.31, p-unadj 0.001), LR (HR = 1.79, 95% CI 1.06-3.02, p-unadj = 0.029), and ER (HR = 2.81, 95% CI 1.78-4.44, p-unadj 0.001).Altered KRAS, RAS/RAF, and RAS/RAF-TP53 associated with earlier local and distant recurrence in resected CRLM patients receiving adjuvant HAI+SYS. Co-altered RAS/RAF-TP53 was a novel predictor of LR warranting investigation of whether genomic cooperativity is associated with this relapsing phenotype. Systemic therapies tailored to high-risk tumor biology are needed to reduce distant relapse after hepatectomy.

To evaluate the efficacy of chemotherapy in patients with microsatellite instability-high (MSI-high) gastric cancer.Although MSI-high gastric cancer is associated with superior prognosis, recent studies question the benefit of perioperative chemotherapy in this population.Locally advanced gastric adenocarcinoma patients who either underwent surgery alone or also received neoadjuvant, perioperative, or adjuvant chemotherapy between 2000-2018 were eligible. MSI status, determined by next generation sequencing or mismatch repair protein immunohistochemistry, was determined in 535 patients. Associations among MSI status, chemotherapy administration, and overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were assessed.In 535 patients, 82 (15.3%) had an MSI-high tumor and approximately 20% better OS, DSS, and DFS. Grade 1 (90-100%) pathological response to neoadjuvant chemotherapy was found in 0 of 40 (0%) MSI-high tumors versus 43 of 274 (16%) MSS. In the MSI-high group, the 3-year OS rate was 79% with chemotherapy versus 88% with surgery alone (P=0.48). In the MSS group, this was 61% versus 59%, respectively (P=0.96). After multivariable interaction analyses, patients with MSI-high tumors had superior survival compared with patients with MSS tumors whether given chemotherapy (HR 0.53, 95% CI 0.28-0.99) or treated with surgery alone (HR 0.15 vs. MSS, 95% CI 0.02-1.17).MSI-high locally advanced gastric cancer was associated with superior survival compared to MSS overall, despite worse pathological chemotherapy response. In patients with MSI-high gastric cancer who received chemotherapy, the survival rate was approximately 9% worse compared with surgery alone, but chemotherapy was not significantly associated with survival.

Various implant designs have been proposed to increase active range of motion (ROM) and avoid notching in patients treated by reverse total shoulder arthroplasty (RSA). The purpose of this study was to investigate the efficacy and safety of an onlay prosthesis design combining a 135° humeral neck-shaft angle with the glenoid component lateralized and inferiorized.A retrospective descriptive study was conducted of the clinical and radiological outcomes at the final follow-up (≥24 months) of all RSAs performed by the same surgeon between September 2015 and December 2016 in the study center. At the last follow-up, patients were clinically assessed for ROM, Constant score, and subjective shoulder value and radiologically for scapular notching and glenoid radiolucent lines. Patients were followed up radiographically at 1 month and clinically at between 6 and 12 months (midterm) and again at between 24 and 48 months (final follow-up). Scapular notching was graded as per the Sirveaux classification at the last follow-up on anterior-posterior radiographs.Seventy-nine RSAs were included with a mean follow-up time of 31 months. The mean Constant score at the final follow-up was 42 points higher than before surgery (69 vs. 27,This study shows that an RSA design with a 135° humeral neck-shaft angle and an inferiorized and lateralized glenoid component is associated with significant improvements in active ROM, especially in rotation, and a low notching rate. However, rates of 3.8% for dislocation and 5% for glenoid loosening are certainly a concern at such a short follow-up of two years. Future studies with a larger population are needed to confirm these rates.

Radiographic stress shielding is a common finding in uncemented convertible short-stem shoulder arthroplasty (UCSSSA). The distal filling ratio (DFR) has been described as a predictor for the occurrence of stress shielding. A DFR 70% was mentioned as a risk factor for the occurrence of stress shielding for some UCSSSA. However, measurements were only performed on conventional radiographs and no validation exists for 3D automated planning tools.DFR was manually measured on postoperative true ap radiographs of 76 shoulder arthroplasties using a standardized protocol and were compared to preoperative CT scans with an automated calculation of the DFR after virtual implantation of the stem.The mean DFR measured on X-rays was 75.9% (SD = 8.7; 95% CI = 74-78) vs. 78.9% (SD = 9.1; 95% CI = 76.8-83) automatically measured on CT scans. This difference was significant (p 0.001). In 7 out of 76 cases (9%) the difference between manual measurement on radiographs and computerized measurement on CT scans was 10%.Manual measurement of the DFR is underestimated on conventional radiographs compared to automated calculation on CT scans be a mean of 3%. Therefore, automated measurement of the DFR on CT scans seems to be beneficial, especially in cases with osteopenic cortices. Manual measurement of the DFR on conventional ap radiographs in cases without CT scans, however, is still a viable alternative.Level IV, retrospective study.

INTRODUCTION It has been well established that the subscapularis is divided in two different parts with a tendinous insertion at its superior two-thirds and a muscular attachment on its inferior third. The objective of this cadaveric study was to follow the muscular insertion of the subscapularis medially in order to determine the origin of this inferior muscle insertion and whether a subscapularis minor can be individualized MATERIALS AND METHODS: Twenty-six shoulders from thirteen fresh-frozen cadaveric specimens (5 males and 8 females; mean age, 74.4 years) were dissected in our anatomy lab. The humeral insertion of the subscapularis was then analyzed, and the inferior muscular part of the insertion was identified. The muscle fibers were followed medially until their scapular origin which was recorded as line drawings and photographs. We measured the dimensions of both the humeral insertion and of the scapular origin of the fibers going to the muscular portion. RESULTS In all cases, the fibres going to the tendinous portion and those going to the muscular portion of the insertion had a different orientation. The fibres going to the muscular portion of the humeral insertion did not originate from the subscapularis fossa but on the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The mean length of the superior tendinous portion of the humeral insertion was 3.42 cm (± 0.43 cm); the mean length of the inferior muscular portion of the humeral insertion was 1.88 cm (± 0.80 cm). The mean length of the scapular origin in the depression at the infero-lateral part of the scapular pillar of the fibres going to the muscular portion of the humeral insertion was 3.7 cm (± 0.17 cm). CONCLUSION The fibres of the subscapularis do not all originate from the subscapularis fossa. An additional origin exists at the inferior part of the glenoid neck and in a depression at the infero-lateral part of the scapular pillar. The fibers which originate at this location all insert on the humerus at the muscular portion of the subscapularis humeral insertion. This portion however does not seem to correspond to the so-called subscapularis minor which has been previously described.

Background The coronoid process is an important stabilizer of the elbow, and its anatomy has been extensively studied. However, data documenting the relationship of the coronoid relative to the radial head (RH) are limited. The latter is a good landmark for the surgeon when debriding or reconstructing the coronoid. This imaging-based study quantified the anatomic relationship between the coronoid and the proximal radius and ulna. Methods We investigated 80 cadaveric upper extremities (18 paired elbows) by 3-dimensional digital analysis of computed tomography data. After construction of a standardized coordinate system, the relationships between the coronoid, the anterior-most point of the RH, the deepest point of the articular surface of the RH, the top of the lesser sigmoid notch, and the deepest point of the guiding ridge of the trochlear notch were analyzed. Results The mean height of the tip of the coronoid was 36 ± 4 mm (range, 26-43 mm). The mean height of the anterior-most point of the RH was 40 ± 4 mm (range, 28-47 mm). The mean distance between the tip of the coronoid and the anterior-most point of the RH was 4.5 ± 1 mm (range, 2-10 mm). For paired elbows, the heights of the tip of the coronoid and the anterior-most point of the RH were similar between sides. Conclusion This study described the relationship between the coronoid and RH. This information should prove useful when reconstructing a coronoid from a medial approach in the case of an intact RH. The difference in radiographic height between the tip of the coronoid and anterior RH in the normal elbow averages 5 mm. However, when we account for the normal cartilage thickness of the RH and coronoid, a 3- to 6-mm difference in height would be seen at surgery depending on whether the cartilage of the coronoid process is intact or removed. The distance between the tip of the coronoid and the anterior-most point of the RH is similar to the size of shavers used when debriding osteophytes during arthroscopy.

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.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.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 narrowing3 mm was a discriminatory metric for type A glenoids. Posterior humeral subluxation70% 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 retroversion16°.Pathoanatomic metrics with the identified threshold values can be used to discriminate glenoid types in shoulders with PGHOA.

Implant manufacturers typically offer several sizes of a humeral stem for shoulder arthroplasty so that time zero fixation can be achieved with the optimal size. Stem size can be templated preoperatively but is definitively determined intraoperatively. The purpose of this study was to determine if preoperatively acquired parameters, including patient demographics and imaging, could be used to reliably predict intraoperative humeral stem size.A cohort of 290 patients that underwent shoulder arthroplasty (116 anatomic and 174 reverse) was analyzed to create a regression formula to predict intraoperative stem size. The initial cohort was separated into train and test groups (randomly selected 80% and 20%, respectively). Patient demographics, anatomical measurements, and statistical shape model parameters determined from a preoperative shoulder arthroplasty planning software program were used for multilinear regression. The implant used for all cases was a short-stemmed metaphyseal-fit prosthesis.Metaphyseal bone density, humeral statistical shape model parameters, and humeral intramedullary canal diameter were identified as highly predictive of intraoperative final humeral prosthesis size. On the train group, a coefficient of determination RPreoperative criteria such as humeral geometry and proximal humeral bone density can be combined in a single multilinear equation to predict intraoperative humeral stem size within one size variation. Embedding the surgeon's decision-making process into an automated algorithm potentially allows this process to be applied across the surgical community. Predicting intraoperative decisions such as humeral stem size also has potential implications for the management of implant stocks for both manufacturers and health-care facilities.

In vitro data demonstrate the potential benefits of the pyrocarbon as a bearing material against cartilage or bone. And pyrocarbon-free interposition arthroplasty has been used with positive outcomes for over 10 years for hand and wrist joint replacements. This study reports the midterm results of a Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in primary and secondary glenohumeral osteoarthritis and in avascular osteonecrosis.This prospective noncontrolled, multicenter study included 67 consecutive patients who underwent PISA in France and Sweden.A cohort of 48 patients, aged 50 ± 12 years, was available for clinical assessment at a mean follow-up of 67.6 ± 9.3 months. A favorable change was reported with a mean absolute Constant score improvement of 32 ± 20 points. The highest Constant score improvement was observed in patients with avascular osteonecrosis (42 ± 18 points;The radiographic findings seem to confirm the interest of pyrocarbon in preserving bony surfaces. But the risk of tuberosity thinning suggests considering the use of PISA with caution in most degenerative glenohumeral joint pathologies, although the midterm outcomes highlight PISA as a suitable solution for patients presenting with posttraumatic osteonecrosis without malunion of the tuberosities and with an intact rotator cuff.

Background: At our craniofacial center patients are routinely admitted to a regular ward, or floor, rather an intensive care unit (ICU) after uncomplicated craniosynostosis surgery. In this study, we review the safety of our postoperative placement policy, examining the rate of transfer from floor to ICU. Methods: The charts of patients who underwent craniosynostosis surgery from 2009 through 2017 at a single children’s hospital were reviewed. Postoperative hospital courses were characterized as preoperatively-planned ICU admission, perioperatively-planned ICU admission, or primary floor admission. The primary outcome was transfer from floor to ICU. Secondary outcomes included duration of hospitalization. Results: Chart review yielded 420 patients. Three hundred sixty-eight (88%) were admitted directly to the floor and 52 (12.0%) directly to an ICU. Of patients admitted to the floor, 2 (0.5%) were transferred to an ICU. Twenty-four patients with syndromic and 20 patients with multisutural craniosynostosis were admitted to the floor. Only 1 patient from each group (the same patient; 4.2% and 5.0%, respectively), was transferred to an ICU. Thirty-two ICU admissions were preoperatively planned and 20 were perioperatively planned. Reasons for preoperatively planned ICU admission included significant comorbidities and type of surgery. Reasons for perioperatively planned ICU admissions included significant intraoperative adverse events, excessive blood loss, and failure of clearance from the post-anesthesia care unit (PACU). Patients admitted to the ICU had a statistically significant longer mean length of hospitalization (4.8 days vs 2.7 days) than did patients admitted to the floor. Conclusions: Most postoperative craniosynostosis surgery patients—including patients with syndromic and/or multisutural synostosis—are managed safely on the floor at our center. Some patients still need postoperative ICU admission, but are easily identified preoperatively, intraoperatively, or in the PACU. Our findings should be applicable to other large craniofacial centers.

Resume Introduction Les blessures de l’epaule des rugbymen professionnels sont frequentes, souvent liees a des traumatismes de haute intensite. Leur prevention par une evaluation isocinetique fait partie integrante de la preparation physique des joueurs. Cependant, les profils isocinetiques des muscles rotateurs internes (RI) et externes (RE) d’epaule des joueurs de rugby, precedemment definis, ne prennent pas en compte leur poste de jeu. Le but de cette etude etait de comparer le profil isocinetique des muscles RE et RI des joueurs de rugby en fonction de leur poste : avants et arrieres. Methodes Quarante-deux joueurs de rugby professionnels etaient evalues. Un dynamometre Con–Trex etait utilise pour tester les muscles RI et RE des deux epaules. Les donnees etaient obtenues successivement en mode concentrique a 60°/s et 240°/s puis en mode excentrique a 60°/s. Le pic de couple (PC), le pic de couple rapporte au poids des RI et RE et le ratio RE/RI etaient mesures a chaque vitesse angulaire. Resultats Le pic de couple des RI et RE etait plus eleve pour les avants par rapport aux arrieres pour le cote dominant pour tous les modes de contraction (p 0,05), sur le ratio RE/RI (p > 0,05) et sur le ratio mixte (p = 0,54). Conclusion Les avants avaient une plus grande force musculaire des epaules que les arrieres. En rapportant les resultats au poids, la force musculaire et le profil isocinetique etaient similaires.

Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures. After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement. Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems. The incidence of complications such as dislocation, notching and acromial fractures has also evolved. Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled. Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures. Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085

We report the long-term patient-reported outcomes and objective outcomes of a homodigital neurovascular island flap for distal phalangeal amputations in the fingers (with the thumb excluded) for 20 patients at a median follow-up of 4.4 years (IQR 2.2 to 12.3). We assessed the global subjective and aesthetic outcomes, range of motion, sensitivity and strength. The patient-reported median subjective global score was 7.5/10 points (IQR 7 to 9) and the aesthetic score was 8/10 points (IQR 8 to 9). Range of motion, sensitivity and strength were similar to the uninjured side. Stiffness was present in more than half of the cases; 14 patients had a hook nail deformity and seven patients reported symptomatic cold intolerance. At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap. Level of evidence: IV

Background Early glenohumeral impingement leads to poor range of motion and notching in reverse shoulder arthroplasty. The aim was to find from planning software which implant configuration provides the best motions in reverse shoulder arthroplasty. Patients and Methods Reverse shoulder arthroplasty planning (Glenosys) was made in 31 patients (12 men, 19 women, 76 ± 6 yo) and impingements were analyzed. Inlay (155°-inclined) and Onlay (145°-inclined) humeral designs were tested. Four configurations were tested for each shoulder: “INLAY”: non-lateralized glenoid-inlay humerus, “BIO-INLAY”: lateralized glenoid (BIO-RSA)-inlay humerus, “ONLAY”: non-lateralized glenoid-onlay humerus, and “BIO-ONLAY”: lateralized (BIO-RSA) glenoid-onlay humerus. Results BIO-ONLAY and BIO-INLAY groups presented a significantly better result in all tested motion ( p Conclusion Glenoid lateralization delays the glenohumeral impingement in reverse shoulder arthroplasty and gives the best rotations, adduction and extension when associated with neutral inclination and humeral 145° inclination. Greater tuberosity abutment has to be avoided in abduction and the Inlay design provides the best abduction.

Background: PITX2 DNA methylation has been shown to predict outcomes in high-risk breast cancer patients after anthracycline-based chemotherapy. To determine its prognostic versus predictive value, the impact of PITX2 DNA methylation on outcomes was studied in an untreated cohort vs. an anthracycline-treated triple-negative breast cancer (TNBC) cohort. Material and Methods: The percent DNA methylation ratio (PMR) of paired-like homeodomain transcription factor 2 (PITX2) was determined by a validated methylation-specific real-time PCR test. Patient samples of routinely collected archived formalin-fixed paraffin-embedded (FFPE) tissue and clinical data from 144 TNBC patients of 2 independent cohorts (i.e., 66 untreated patients and 78 patients treated with anthracycline-based chemotherapy) were analyzed. Results: The risk of 5- and 10-year overall survival (OS) increased continuously with rising PITX2 DNA methylation in the anthracycline-treated population, but it increased only slightly during 10-year follow-up time in the untreated patient population. PITX2 DNA methylation with a PMR cutoff of 2 did not show significance for poor vs. good outcomes (OS) in the untreated patient cohort (HR = 1.55; p = 0.259). In contrast, the PITX2 PMR cutoff of 2 identified patients with poor (PMR >2) vs. good (PMR ≤2) outcomes (OS) with statistical significance in the anthracycline-treated cohort (HR = 3.96; p = 0.011). The results in the subgroup of patients who did receive anthracyclines only (no taxanes) confirmed this finding (HR = 5.71; p = 0.014). Conclusion: In this hypothesis-generating study PITX2 DNA methylation demonstrated predominantly predictive value in anthracycline treatment in TNBC patients. The risk of poor outcome (OS) correlates with increasing PITX2 DNA methylation.

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 0–2.5 mm (Zone A), 2.5–5 mm (Zone B) and 5–7.5 mm (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.

© 2019 Journal of Shoulder and Elbow Surgery Board of Trustees Background: The purpose of this study was 2-fold: (1) to quantify type E2 bone loss orientation and its association with rotator cuff fatty infiltration and (2) to examine reverse baseplate designs used to manage type E2 glenoids. Methods: Computed tomography scans of 40 patients with type E2 glenoids were examined for pathoanatomic features and erosion orientation. The rotator cuff fatty infiltration grade was compared with the erosion orientation angle. To compare reconstructive options in light of the pathoanatomic findings, virtual implantation of 4 glenoid baseplate designs (standard, half wedge, full wedge, and patient-matched) was conducted to determine the volume of bone removal for seating and impingement-free range of motion. Results: The mean type E2 erosion orientation angle was 47° ± 17° from the 0° superoinferior glenoid axis, resulting in the average erosion being located in the posterosuperior quadrant directed toward the 10:30 clock-face position. The type E2 neoglenoid, on average, involved 67% of the total glenoid surface (total surface area, 946 ± 209 mm2; neoglenoid surface area, 636 ± 247 mm2). The patient-matched baseplate design resulted in significantly (P ≤.01) less bone removal (200 ± 297 mm3) for implantation, followed by the full-wedge design (1228 ± 753 mm3), half-wedge design (1763 ± 969 mm3), and standard (non-augmented) design (4009 ± 1210 mm3). We noted a marked difference in erosion orientation toward a more superior direction as the subscapularis fatty infiltration grade increased from grade 3 to grade 4 (P

Short- and mid-term outcomes after massive cuff tear repair are well reported, but there is no documentation of the clinical and structural outcomes at 20 years of follow-up. The hypothesis of the present study was that at 20 years, deterioration of the shoulder would have occurred and led to a substantial number of reoperations.The authors retrospectively recalled all 127 patients operated for massive rotator cuff tears in 1994 at 6 different centers. At the 20-year follow-up, 26 patients died and 35 were lost to follow-up. Thirteen (10.2%) had been reoperated. This left 53 patients for personal clinical assessment. Forty-nine consented to standardized radiographic evaluation for assessment of osteoarthritis, 36 patients underwent magnetic resonance imaging, allowing assessment of tendon healing, atrophy, and fatty infiltration (FI) of the cuff muscles.The final Constant-Murley score (CS) was 68 ± 17.7 (range, 8-91) vs. 44 ± 15.3 (range, 13-74) preoperatively (P.05). The final Subjective Shoulder Value (SSV) was 73% ± 23% (range, 0-100). Retears (Sugaya IV and V) were found in 17 cases (47%). Nine patients (17%) had cuff tear arthropathy (Hamada stage 4). The CS and SSV for the shoulders with FI stages III or IV were significantly inferior (53 ± 19 points and 65% ± 14% respectively) than for those with FI stages 0-II (respectively, 71.6 ± 6 points and 73% ± 4%) (P.05).Twenty years after surgical repair of massive rotator cuff tears, the functional scores remain satisfactory, and the rate of revision is low.

Aims Patient-specific instrumentation has been shown to increase a surgeon’s precision and accuracy in placing the glenoid component in shoulder arthroplasty. There is, however, little available information about the use of patient-specific planning (PSP) tools for this operation. It is not known how these tools alter the decision-making patterns of shoulder surgeons. The aim of this study was to investigate whether PSP, when compared with the use of plain radiographs or select static CT images, influences the understanding of glenoid pathology and surgical planning. Methods A case-based survey presented surgeons with a patient’s history, physical examination, and, sequentially, radiographs, select static CT images, and PSP with a 3D imaging program. For each imaging modality, the surgeons were asked to identify the Walch classification of the glenoid and to propose the surgical treatment. The participating surgeons were grouped according to the annual volume of shoulder arthroplasties that they undertook, and responses were compared with the recommendations of two experts. Results A total of 59 surgeons completed the survey. For all surgeons, the use of the PSP significantly increased agreement with the experts in glenoid classification (x2 = 8.54; p = 0.014) and surgical planning (x2 = 37.91; p < 0.001). The additional information provided by the PSP also showed a significantly higher impact on surgical decision-making for surgeons who undertake fewer than ten shoulder arthroplasties annually (p = 0.017). Conclusions The information provided by PSP has the greatest impact on the surgical decision-making of low volume surgeons (those who perform fewer than ten shoulder arthroplasties annually), and PSP brings all surgeons in to closer agreement with the recommendations of experts for glenoid classification and surgical planning. Cite this article: Bone Joint J 2020;102-B(3):365–370

© 2019 Journal of Shoulder and Elbow Surgery Board of Trustees Background: Little is known about the cortical-like and cancellous bone density variations in superiorly eroded glenoids due to cuff tear arthropathy. The purpose of this study was to analyze regional bone density in type E2 glenoids. Methods: Clinical shoulder computed tomography scans were obtained from 32 patients with a type E2 superior erosion (10 men and 22 women; mean age, 73 years). Measurement regions were organized into quadrants (superior, inferior, anterior, and posterior) and depth regions. The depth regions were incremented by 2 mm from 0 to 10 mm. A repeated-measures multiple analysis of variance was performed to assess differences and interactions between mean densities (cortical-like and cancellous bone) in each depth, in each quadrant, and between sexes. Results: The lowest cancellous bone density was found in the inferior glenoid quadrant compared with all other quadrants (307 ± 50 Hounsfield units [HU], P < .001). At the glenoid surface, the superior quadrant contained the highest mean density for cortical-like bone (895 ± 97 HU); this differed significantly from the posterior, anterior, and inferior quadrants (P ≤ .033). As for depth of measurement, cortical-like bone was most dense at the glenoid surface (0-2 mm, 892 ± 91 HU), and density decreased significantly at depths greater than 2 mm (P ≤ .019). Conclusion: In patients with type E2 glenoids due to cuff tear arthropathy, the densest bone was found in the superior quadrant in the area of erosion. The inferior quadrant, which tends to be unloaded as the humeral head migrates superiorly, had the lowest density bone. In addition, the best-quality bone was located at the glenoid surface as compared with deeper in the vault.

This study explores whether genomic profiles of colorectal liver metastasis (CRLM) patients with early onset (EO, 50 years old) and screening age (SA) primary diagnosis are associated with overall survival (OS).All patients undergoing hepatectomy between 2002 and 2017 were identified and tumor specimens with next-generation sequencing data were cataloged. Gene and signaling-level alterations were checked for association with OS from primary diagnosis accommodating for left-truncated survival.Of 1822 patients, 333 were sequenced-127 (38%) EO-CRLM and 206 (62%) SA-CRLM patients. More aggressive features presented in EO-CRLM patients-synchronous metastatic presentation (83% vs. 75%, p 0.001) and primary node-positive disease (71% vs. 61%, p 0.001). The median OS from primary diagnosis was 11.8 years (95% confidence interval = 7.94-NA). Five-year OS did not differ by age (p = 0.702). On multivariable analysis, altered APC (EO-CRLM: [hazard ratio [HR] = 0.37, p = 0.018] vs. SA-CRLM:[HR = 0.61, p = 0.260]), BRAF (EO-CRLM:[HR = 4.38, p = 0.007] vs. SA-CRLM:[HR = 4.78, p = 0.032]), and RAS-TP53 (EO-CRLM:[HR = 2.82, p = 0.011] vs. SA-CRLM:[HR = 2.35, p = 0.003]) associated with OS.Despite bearing more aggressive features, EO-CRLM patients had similar genomic profiles and survival as SA-CRLM patients. Better performance status in younger patients leading to increased treatment tolerance may partly explain this. As screening and treatment strategies from older patients are applied to younger patients, genomic predictors of biology identified historically in older cohorts could apply to EO patients.

Background: The purpose of this study was to develop novel three-dimensional (3D) measures of bone density from computed tomography (CT) scans and to compare them with validated two-dimensional (2D) radiographic assessments of bone density. Patient demographic data were also analyzed to see if there were any predictors of bone density (age, sex, etiology). Methods: The study group consisted of 290 consecutive patients undergoing primary shoulder arthroplasty surgery (total anatomic, reverse, and hemiarthroplasty). All underwent preoperative CT imaging. Three 3D CT measurements (metaphysis cancellous, metaphysis cortical, and proximal diaphysis) were developed and automated into software. The developed 3D measurements were compared with validated 2D measures (Tingart and Gianotti Index). Patient demographic data were correlated with these measurements. The difference between the size of the final sounder and of the final stem was calculated as Delta. Results: There was moderately strong correlation between Tingart and Gianotti measures (0.674, P

Glenoid bone loss in anatomic total shoulder arthroplasty (aTSA) remains a controversial and challenging clinical problem. Previous studies have shown high rates of glenoid loosening for aTSA in shoulders with retroversion, posterior bone loss, and posterior humeral head subluxation. This study is the first to present minimum 2-year follow-up data of an all-polyethylene, biconvex augmented anatomic glenoid component for correction of glenoid retroversion and posterior humeral head subluxation.This study is a multicenter, retrospective review of prospectively collected data on consecutive patients from 7 global clinical sites. All patients underwent aTSA using the biconvex posterior augmented glenoid (PAG). Inclusion criteria were preoperative computed tomographic (CT) scan, minimum 2 years since surgery, preoperative and minimum 2-year postoperative range of motion examination, and patient-reported outcome measures (PROMs). Glenoid classification, glenoid retroversion, and posterior humeral head subluxation were measured from preoperative CT and radiography and postoperative radiography. Statistical comparisons between pre- and postoperative values were performed with a paired t test.Eighty-six of 110 consecutive patients during the study period (78% follow-up) met the inclusion criteria and were included in our analysis. Mean follow-up was 35 ± 10 months, with a mean age of 68 ± 8 years (range 48-85). Range of motion statistically improved in all planes from pre- to postoperation. Mean visual analog scale score improved from 5.2 preoperation to 0.7 postoperation, Single Assessment Numeric Evaluation score from 43.2 to 89.5, Constant score from 41.8 to 76.9, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score from 49.8 to 86.7 (all P .0001). Mean glenoid retroversion improved from 19.3° to 7.4° (P .0001). Posterior subluxation improved from 69.1% to 53.5% and posterior decentering improved from 5.8% to -3.0% (P .0001). There was 1 patient with both a prosthetic joint infection and radiographic glenoid loosening that required revision. Seventy-nine of 86 patients had a Lazarus score of 0 (no radiolucency seen about peg or keel) at final follow-up.This study shows that at minimum 2-year follow-up, a posterior-augmented all-polyethylene glenoid can correct glenoid retroversion and posterior humeral head subluxation. Clinically, there was significant improvement in both range of motion and PROMs.

Background: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) have shown good clinical outcomes in primary avascular necrosis of the humeral head (PANHH) both in short and long terms. The purpose of this study was to assess the complications, the clinical and radiological outcomes of shoulder arthroplasty in young patients with PANHH. Methods: One hundred and twenty-seven patients aged under 60 years old and suffering from PANHH were operated with arthroplasty. Patients were assessed clinically and radiographically before surgery with a minimum of 2 years of follow up (FU). Results: HA was performed on 108 patients (85%). Two patients were revised for painful glenoid wear after 2 and 4 years. TSA was performed on 19 patients (15%). Five TSA had to be revised for glenoid loosening (n = 4) or instability (n = 1). Revision rate was 26% with TSA and 2% with HA. There were no significant differences between HA and TSA in terms of clinical outcomes. Conclusions: With a mean FU of 8 years, HA and TSA improved clinical outcomes of patients with PANHH. HA revisions for painful glenoid wear were rare (2%). The revision rate was excessively high with TSA (26%).

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.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.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).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.

Resume Introduction Les resultats des reparations a ciel ouvert ou arthroscopiques de la coiffe des rotateurs sont bien rapportes dans la litterature. Le but de l’etude etait d’evaluer la prevalence et le retentissement clinique de l’omarthrose 20 ans apres la reparation de la coiffe des rotateurs. Hypothese L’hypothese etait que, a long terme, la plupart des epaules presentaient une omarthrose glenohumerale. Materiels et Methodes Les auteurs ont revu retrospectivement 322 patients operes d’une rupture de la coiffe des rotateurs en 1994 dans 6 centres differents, avec une evaluation clinique et radiographique. Apres 20 ans de suivi, 24 patients ont ete reoperes (5 arthroplasties) et 53,4 % ont ete perdus de vue. Cent vingt-six patients ont ete evalues cliniquement. Ils ont beneficie d’une imagerie par resonance magnetique (IRM) afin d’evaluer la cicatrisation du tendon supra-epineux (Sugaya), l’infiltration graisseuse (Goutallier) des muscles de la coiffe des rotateurs et une radiographie afin d’analyser le stade d’omarthrose centree (Samilson) et excentree (Hamada et Fukuda). Seuls les patients avec des donnees completes ont ete selectionnes. Resultats L’âge moyen etait de 52,3 ans (25,3 a 68,6 ans) au moment de l’operation. Le score de Constant etait de 45,3 ± 19,6 en preoperatoire et de 67,4 ± 18,7 points a 20 ans. Le SSV moyen etait de 73,5 ± 21 au dernier recul. Le taux d’omarthrose etait de 29 %. Les patients omarthrosiques avaient un score de Constant significativement moins eleve par rapport aux patients sans omarthrose (61 contre 71 points, p = 0,02), principalement en raison d’une diminution significative de la force (5,4 contre 8,7, p = 0,007). Les ruptures massives de la coiffe des rotateurs etaient significativement associees a un taux plus eleve d’omarthrose. Seuls 4,8 % des patients operes d’une rupture de la coiffe ont beneficie d’une prothese d’epaule inversee. Il y avait significativement moins d’omarthrose en cas de cicatrisation tendineuse. Une rupture iterative du tendon supra-epineux etait significativement associee a une infiltration graisseuse importante du muscle infra-epineux et sur l’evolution vers une omarthrose. Conclusion Vingt ans apres une reparation de la coiffe des rotateurs a ciel ouvert, le taux d’omarthrose etait de 29 %. Les ruptures massives de la coiffe des rotateurs etaient significativement associees a un taux plus eleve d’omarthrose. La cicatrisation du tendon supra-epineux etait significativement associee a une absence d’arthrose. Niveau de preuve IV, etude observationnelle.

Purpose Outcomes of open or arthroscopic rotator cuff repairs are well reported in the literature. The purpose of the study was to evaluate the prevalence and clinical impact of osteoarthritis 20 years following rotator cuff repair. The hypothesis was that, at long follow-up, most shoulders would have developed gleno-humeral osteoarthritis. Methods The authors retrospectively recalled all 322 patients, operated for rotator cuff tears in 1994 at 6 different centres, for clinical and radiographic assessment. At 20 years of follow-up, 24 were re-operated (5 arthroplasty) and 53.4% were lost to follow-up. This left 126 patients, had been clinically assessed, had Magnetic Resonance Images (MRI) that allowed anatomic assessment of tendon healing (Sugaya), fatty infiltration (Goutallier), and X rays in order to analyse arthritis without head migration (Samilson) and with head migration (Hamada and Fukuda). Only patients with complete data were selected. Results Mean aged was 52.3 years (25.3–68.6) at index operation. The Constant score was 45.3 ± 19.6 preoperatively to 67.4 ± 18.7 points at 20 years. The SSV was 73.5 ± 21 postoperatively. The rate of osteoarthritis was 29%. Osteoarthritis was associated with a significant inferior Constant score compared to the non-arthritic group (61 versus 71 points, p = 0.02), mainly due to a significant lower strength (5.4 versus 8.7 points, p = 0.007). Massive rotator cuff tears were significantly associated with a higher rate of osteoarthritis. Only 4,8% patients after cuff repear needed a reverse shoulder arthroplasty. Significantly less osteoarthritis was observed when the rotator cuff repair remained intact. Suprasupinatus retear had a significant influence on fatty infiltration of the infrasupinatus muscle and on the progression towards osteoarthritis. Conclusion Twenty years after open rotator cuff repair, the rate of osteoarthritis was 29%. Massive rotator cuff tears were significantly associated with a higher rate of osteoarthritis. Less osteoarthritis was observed when suprasupinatus healed. Level of evidence IV.

Background Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy. Methods A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined. Results A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA. Conclusion In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.

Several risk factors leading to loosening of the glenoid have been described; however, there is no detailed information available on the exact numbers or percentages for each patient-related risk factor, implant-related risk factor, or risk factors related to surgical technique. Therefore, the aim of this multicenter study was to analyze these risk factors in a large cohort of patients treated with a 3rd-generation cemented total shoulder arthroplasty. Four-hundred seventy-one shoulder arthroplasties with a mean follow-up of 8.1 years were included. There were 318 women and 153 men. The mean age at the time of arthroplasty was 68 (range 35–90) years. The dominant shoulder was treated in 294 cases and the nondominant in 177. The following risk factors for loosening of the cemented keeled glenoid component were examined: gender, age, hand dominance, glenoid morphology, reaming on the glenoid side (reaming down the complete subchondral bone layer), glenohumeral mismatch, glenoid component design, and fatty degeneration of the rotator cuff. No influence on radiographic glenoid loosening was found for patient age at surgery, gender, hand dominance, preparation technique on the glenoid side, or fatty degeneration of the rotator cuff (p > 0.067). Excessive reaming on the native glenoid led to a 3.7-fold higher risk for glenoid component loosening (p

To analyze the learning curves of 5 experienced, fellowship-trained shoulder surgeons and their respective 25 first arthroscopic Latarjet cases in regard to surgical time, graft placement, complication rates, and recurrent instability.The first 25 arthroscopic Latarjet procedures of 5 surgeons were retrospectively analyzed in an international multicenter setting, and thus 125 patients were included in this study. The surgical time, intraoperative and postoperative events out of the ordinary, and graft positioning were examined.The 125 patients consisted of 16 women (12.8%) and 109 men (87.2%). In 81.6% (n = 102), surgery was undertaken as a first-line procedure, whereas 18.4% (n = 23) were revisions. Surgical time decreased significantly from an average of 123.8 minutes (range 70 to 210) to 92.6 minutes (range 50 to 160) from the first 5 cases to the last 5 cases of each surgeon within a period of2 years. Overall, 22 events in 21 patients requiring additional treatment were reported (17.6%). Five (4%) were unlikely to affect final outcome and did not require revision surgery. Twelve (9.6%) required revision surgery that was not trauma related yet was prone to affect outcomes. Five events were trauma-related (4%), 4 requiring revision surgery and 1 treated conservatively. Overall, 6 patients (4.8%) had recurrent shoulder instability, 3 as a result of a traumatic event. Conventional radiology showed the bone-block in ideal positioning in 93 cases (74.4%), flush with the glenoid in a true anteroposterior view. In 3 cases (2.4%), it was considered too high, 15 too low (12%), 5 too lateral (4%), and 15 too medial (12%). Some patients had combinations of the above.This analysis shows that surgical time in arthroscopic Latarjet can be significantly reduced after only 20 cases. However, complication rates did not decrease over this time. The authors believe that the arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting.Level IV, retrospective cohort study.

Background This study aims to identify risk factors related to postoperative instability after reverse shoulder arthroplasty and evaluate the modalities and results of treatments in a large series of patients, with medium to long-term follow-up. Methods Retrospective multicenter series of 1035 consecutive Grammont type reverse shoulder arthroplasties implanted between 1992 and 2010. 19.9% had a reverse shoulder arthroplasty with bony lateralization on the glenoid side. Patients were reviewed and radiographed with minimum five years’ follow-up. Results At a mean follow-up of eight years, the overall rate of postoperative instability was 3.0%. Instability was more frequent in case of reverse shoulder arthroplasty for revision surgery, in younger patients, in case of scapular notching, and tuberosity resorption. Lateralized reverse shoulder arthroplasties were associated with a lower instability rate. A reoperation to restore stability was needed in 70% of cases. The improvement in Constant Score was lower in patients with unstable reverse shoulder arthroplasties when compared to stable reverse shoulder arthroplasties. Conclusions Younger patients are at higher risk for instability after Grammont type reverse shoulder arthroplasty implantation. Conversely, lateralized reverse shoulder arthroplasties resulted protective. When conservative treatment had failed, shoulder stability can be obtained with reoperation or prosthetic revision (needed in 70% of the cases), but to the price of lower functional results.

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

In shoulder arthroplasty, there is a trend for shorter humeral implants to facilitate stem revision and preserve bone stock. This review evaluates the clinical and radiographic outcome of anatomical total shoulder replacement with uncemented humeral short stems. A systematic review was performed using PubMed and Cochrane databases. The search terms “short stem” (all) and “shoulder” (title/abstract) were used. The minimum follow-up was 20 months. The demographic data, clinical outcome (pain, range of motion, outcome scores), radiographic outcome (humeral bone adaptations, humeral loosening, glenoid loosening), risk for high radiographic bone adaptations, complications, and revision were determined. Ten studies comprising 653 shoulder arthroplasties were included in the analysis. At an average follow-up of 20–64 months, the clinical parameters of pain, range of motion, and outcome scores improved significantly in all studies. The most frequent radiographic finding was calcar resorption in 15–71% of patients. High filling ratio, lack of metaphyseal porous coating, and poor bone quality were associated with high bone adaptation. The radiographic changes did not influence the clinical outcome in any study. In 13 of 653 patients (2%), humeral stem loosening was observed leading to stem revision in nine patients, with one study reporting eight of 73 patients with humeral stem loosening. The average weighted complication rate was 6% and the average weighted revision rate was 4%. The short- to medium-term results of uncemented anatomical short-stem shoulder arthroplasty are encouraging and the clinical results are comparable to other 3rd- and 4th-generation shoulder arthroplasties. Further studies with longer follow-up are needed to evaluate and understand why the radiographic changes occur and to prove the theory of bone-sparing revision surgeries.

Background Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA. Methods There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio. Results At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014). Conclusions The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

The main complication of volar locking plates for distal radius fractures is flexor tendon rupture. The flexor pollicis longus (FPL) is the most commonly ruptured. Repair of the pronator quadratus (PQ) is one of the ways to prevent tendon rupture. The main purpose of this series was to evaluate the role of PQ repair after volar plating to prevent flexor tendon rupture using ultrasound (US). This work was a mono-operator prospective series of 20 consecutive patients with volar locking plates for distal radius fracture between September 2014 and May 2015. The PQ was repaired in all patients. A clinical, ultrasound, and perioperative evaluation of the flexor tendon was performed by this same surgeon. There was no flexor tendon rupture or tenosynovitis. There were no type A cases, which are characterized by contact between the plate and the FPL, and mostly type C cases, which are characterized by no contact between the plate and the FPL on US imaging. The suture of the PQ was sustainable over time when we removed the plate. Pronator quadratus repair is one of the ways to prevent flexor tendon rupture after volar plating. The outward-running suture is an effective technique for repairing the PQ. Ultrasound may be helpful during follow-up to detect asymptomatic flexor tendon irritation.

Background Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up. Materials and methods We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views. Results Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points). Conclusions Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture.

Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients.A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture.A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion.Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.

Background Rotator cuff fatty infiltration (FI) is one of the most important parameters to predict the outcome of certain shoulder conditions. The primary objective of this study was to define a new computed tomography (CT)–based quantitative 3-dimensional (3D) measure of muscle loss (3DML) based on the rationale of the 2-dimensional (2D) qualitative Goutallier score. The secondary objective of this study was to compare this new measurement method to traditional 2D qualitative assessment of FI according to Goutallier et al and to a 3D quantitative measurement of fatty infiltration (3DFI). Materials and methods 102 CT scans from healthy shoulders (46) and shoulders with cuff tear arthropathy (21), irreparable rotator cuff tears (18), and primary osteoarthritis (17) were analyzed by 3 experienced shoulder surgeons for subjective grading of fatty infiltration according to Goutallier, and their rotator cuff muscles were manually segmented. Quantitative 3D measurements of fatty infiltration (3DFI) were completed. The volume of muscle fibers without intramuscular fat was then calculated for each rotator cuff muscle and normalized to the patient’s scapular volume to account for the effect of body size (NVfibers). 3D muscle mass (3DMM) was calculated by dividing the NVfibers value of a given muscle by the mean expected volume in healthy shoulders. 3D muscle loss (3DML) was defined as 1 – (3DMM). The correlation between Goutallier grading, 3DFI, and 3DML was compared using a Spearman rank correlation. Results Interobserver reliability for the traditional 2D Goutallier grading was moderate for the infraspinatus (ISP, 0.42) and fair for the supraspinatus (SSP, 0.38), subscapularis (SSC, 0.27) and teres minor (TM, 0.27). 2D Goutallier grading was found to be significantly and highly correlated with 3DFI (SSP, 0.79; ISP, 0.83; SSC, 0.69; TM, 0.45) and 3DML (SSP, 0.87; ISP, 0.85; SSC, 0.69; TM, 0.46) for all 4 rotator cuff muscles (P Conclusion The Goutallier score has been helping surgeons by using 2D CT scan slices. However, this grading is associated with suboptimal interobserver agreement. The new measures we propose provide a more consistent assessment that correlates well with Goutallier’s principles. As 3DML measurements incorporate atrophy and fatty infiltration, they could become a very reliable index for assessing shoulder muscle function. Future algorithms capable of automatically calculating the 3DML of the cuff could help in the decision process for cuff repair and the choice of anatomic or reverse shoulder arthroplasty.

Background: The Walch type B pattern of glenohumeral osteoarthritis is characterized by posterior humeral head subluxation (PHHS). At present, it is unknown whether the percentage of subluxation measured on axillary radiographs is consistent with measurements on 2-dimensional (2D) axial or 3-dimensional (3D) volumetric computed tomography (CT). The purpose of this study was to evaluate PHHS across imaging modalities (radiographs, 2D CT, and 3D CT). Methods: A cohort of 30 patients with Walch type B shoulders underwent radiography and standardized CT scans. The cohort comprised 10 type B1, 10 type B2, and 10 type B3 glenoids. PHHS was measured using the scapulohumeral subluxation method on axillary radiographs and 2D CT. On 3D CT, PHHS was measured volumetrically. PHHS was statistically compared between imaging modalities, with P ≤ .05 considered significant. Results: The mean PHHS value for the entire group was 69% ± 24% on radiographs, 65% ± 23% with 2D CT, and 74% ± 24% with 3D volumetric CT. PHHS as measured on complete axillary radiographs was not significantly different than that measured on 2D CT (P = .941). Additionally, PHHS on 3D volumetric CT was 9.5% greater than that on 2D CT (P < .001). There were no significant differences in PHHS between the type B1, B2, and B3 groups with 2D or 3D CT measurement techniques (P > .102). Conclusion: Significant differences in PHHS were found between measurement techniques (P < .035). A 9.5% difference in PHHS between 2D and 3D CT can be mostly accounted for by the linear (2D) vs. volumetric (3D) measurement techniques (a linear 80% PHHS value is mathematically equivalent to a volumetric PHHS value of 89.6%). Surgeons should be aware that subluxation values and therefore thresholds vary across different imaging modalities and measurement techniques.

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.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).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).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.

Introduction: In the context of reverse shoulder arthroplasty, some parameters of glenoid baseplate placement follow established golden rules, while other parameters still have no consensus. The assessment of glenoid wear in the future location of the glenoid baseplate varies among surgeons. The objective of this study was to analyze the inter-observer reproducibility of glenoid baseplate 3D positioning during virtual pre-operative planning. Method: Four shoulder surgeons planned the glenoid baseplate position of a reverse arthroplasty in the CT scans of 30 degenerative shoulders. The position of the glenoid guide pin entry point and the glenoid baseplate center was compared between surgeons. The baseplate’s version and inclination were also analyzed. Results: The 3D positioning of the pin entry point was achieved within ± 4 mm for nearly 100% of the shoulders. The superoinferior, anteroposterior and mediolateral positions of the baseplate center were achieved within ± 2 mm for 77.2%, 67.8% and 39.4% of the plans, respectively. The 3D orientation of the glenoid baseplate within ± 10° was inconsistent between the four surgeons (weak agreement, K = 0.31, p = 0.17). Discussion: The placement of the glenoid guide pin was very consistent between surgeons. Conversely, there was little agreement on the lateralization, version and inclination criteria for positioning the glenoid baseplate between surgeons. These parameters need to be studied further in clinical practice to establish golden rules. Three-dimensional information from pre-operative planning is beneficial for assessing the glenoid deformity and for limiting its impact on the baseplate position achieved by different surgeons. Level of evidence: III.

The arm change position (ACP) is a new parameter for evaluating the humerus' 3D displacement following reverse shoulder arthroplasty (RSA) during 3D pre operative planning. The purpose of this study was to analyze the relationship between ACP variations after RSA and simulated passive joint mobility. The assumption is that the ACP will to help optimize the passive joint mobility of a RSA implant.In 30 degenerative shoulders, four shoulder surgeons planned a RSA with virtual motion analysis. After this analysis, each plan was revised to optimize the range of motion. Relationships between the differences in movement amplitude and the differences in ACP were evaluated.Arm lengthening and humerus lateralization were significantly associated with better joint mobility in all three planes (frontal, sagittal and axial). They were equally important for improving external rotation, extension, flexion and adduction. Anterior displacement of the humerus improved both internal and external rotation.The ACP is a useful preoperative planning parameter for RSA. It could help with selecting the best implant combination, as well as determining their position, in order to optimize the simulated passive mobility relative to humerus displacement after RSA. To validate the value of the ACP in clinical practice, a prospective study is needed in which the postoperative joint mobility is measured in vivo as a function of the ACP.III, case control study.