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Resume Introduction La chirurgie ambulatoire en France est definie par l’HAS comme une chirurgie programmee permettant la sortie du patient le jour-meme de son intervention, sans risque majore. Avec l’avenement de la readaptation acceleree apres chirurgie, l’ambulatoire est devenue courante en arthroplastie du membre inferieur. En France, seulement 1,1 % des protheses de genou, ont ete realisees en ambulatoire en 2017. Objectifs (1) Evaluer la morbi-mortalite precoce apres prothese d’epaule en ambulatoire pour valider les criteres d’eligibilite et de securite, et (2) evaluer l’acceptation de l’ambulatoire par les patients. Methodes Etude monocentrique avec criteres d’inclusion suivants : arthroplastie d’epaule primaire, score ASA 9/10 et le score EVA Resultats Entre fevrier 2016 et fevrier 2018, 36 patients se sont vu proposer une arthroplastie d’epaule en ambulatoire : 12 (33 %) ont refuse l’ambulatoire sans raison et 24 patients l’ont acceptee (7 HA, 9 TSA, 8 RSA). L’âge moyen des patients a la chirurgie etait de 70 ans (55–82) ; l’IMC moyen de 26 (21–32) et 14 patients etaient ASA 2 (66 %). En postoperatoire, malgre un score PADSS > 9/10 et un controle de la douleur, 3 patients (12 %) ont refuse de sortir. Deux patients (8 %) ne sont pas rentres a domicile le jour meme pour des raisons medicales (1 douleur et 1 HTA). Sur les 19 arthroplasties realisees en ambulatoire, aucune readmission ou complication n’ont ete notees. Aucun patient ambulatoire n’a utilise d’opiaces. Tous les patients etaient satisfaits du resultat fonctionnel ; 84 % satisfaits de l’ambulatoire ; 17 % regrettaient l’hospitalisation conventionnelle, se sentant pas assez encadres. Conclusions (1) L’arthroplasties d’epaule en ambulatoire peut etre proposee en toute securite, chez des patients selectionnes avec de faibles comorbidites, quel que soient l’âge et le type d’implant choisi. (2) Chez nos patients, le taux d’acceptation de l’ambulatoire pour une prothese d’epaule reste faible. Ces resultats doivent nous inciter a mieux eduquer les patients a l’ambulatoire. Niveau de preuves IV ; etude retrospective.

Isolated pathology of the long head of the biceps is an indication for biceps tenotomy. To date, needle arthroscopy allows a direct diagnosis of shoulder lesion. We aimed to evaluate the technical feasibility of an in-office biceps isolated tenotomy by needle arthroscopy. Advantages were found in the fast-track process and the high rate of satisfaction in our selected patients. It was also a way to correct the diagnosis of torn biceps missed by the imaging. However, performing this procedure requires previous experience in conventional arthroscopy and should not be performed on anxious patients. Further studies will be necessary to confirm the reproducibility of this promising method, which could be a valuable alternative to heavy in-operating room process., Technique Video Video 1 This video summarizes our technique for in-office biceps tenotomy (IOBT) with needle arthroscopy. Patient matches the indications for biceps tenotomy. He is positioned in a comfortable beach chair position. A posterior approach allows to introduce the scope into the joint and to visualize the intra-articular pathologic biceps. No other lesions are observed. Conventional scissors are introduced through the rotator cuff interval and are used to cut the biceps at its insertion. At the end of the procedure, the biceps is visualized in its groove. The IOBT is carried-out under local anesthesia on a compliant and well-informed patient. Simple bandages finally cover the approaches.

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

Aims The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR). Methods This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport. Results At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level. Conclusion Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718–724.

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.

International audience; Background: The pathogenesis of late-onset sepsis (LOS) in preterm infants is poorly understood and knowledge about risk factors, especially prenatal risk factors, is limited. This study aimed to assess the association between the cause of preterm birth and LOS in very preterm infants.Methods: 2052 very preterm singletons from a national population-based cohort study alive at 72 h of life were included. Survival without LOS was compared by cause of preterm birth using survival analysis and Cox regression models.Results: 437 (20.1%) had at least one episode of LOS. The frequency of LOS varied by cause of preterm birth: 17.1% for infants born after preterm labor, 17.9% after preterm premature rupture of membranes, 20.3% after a placental abruption, 20.3% after isolated hypertensive disorders, 27.5% after hypertensive disorders with fetal growth restriction (FGR), and 29.4% after isolated FGR. In multivariate analysis, when compared to infants born after preterm labor, the risk remained higher for infants born after hypertensive disorders (hazard ratio HR = 1.7, 95% CI = 1.2-2.5), hypertensive disorders with FGR (HR = 2.6, 95% CI = 1.9-3.6) and isolated FGR (HR = 2.9, 95% CI = 1.9-4.4).Conclusion: Very preterm infants born after hypertensive disorders or born after FGR had an increased risk of LOS compared to those born after preterm labor.Impact: Late-onset sepsis risk differs according to the cause of preterm birth. Compared with those born after preterm labor, infants born very preterm because of hypertensive disorders of pregnancy and/or fetal growth restriction display an increased risk for late-onset sepsis. Antenatal factors, in particular the full spectrum of causes leading to preterm birth, should be taken into consideration to better prevent and manage neonatal infectious morbidity and inform the parents.

AimsWe 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.MethodsConsecutive 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.ResultsIn 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.ConclusionAlthough 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.

To evaluate feasibility and validate both safety and efficiency of radiological percutaneous periprosthetic bone cementoplasty (RPPBC) performed under local anesthesia as an alternative minimally invasive treatment of aseptic implant loosening. In this case series, seven patients (mean age 81 years, range 73 to 89 years, 2 men and 5 women) were enrolled between February 2011 and January 2020 with confirmed aseptic loosening of orthopedic implants. One patient presented with tibial component loosening of an unicompartmental knee arthroplasty, one with glenoid component loosening from a reverse shoulder arthroplasty, one femoral gamma nail, and four presented with pedicle screw loosening after staged posterior lumbar interbody fusion. All patients underwent clinical, biochemical, and imaging assessments to confirm the diagnosis of aseptic loosening. All benefited from RPPBC under dual CT and fluoroscopic guidance. All procedures were performed under local anesthesia by an experienced radiologist. Preprocedural, immediate and 6-month post-cementoplasty pain levels on a visual analogue scale (VAS), and functional outcomes were evaluated. Immediate and 6-month postprocedural CTs were performed to evaluate the treated region. All RPPBC were well tolerated by patients throughout the procedure. None of the patients suffered from local or systemic infection post-RPPBC, or periprosthetic fractures. No recurrent implant loosening was observed. Six patients were pain free at 6 months. All patients expressed functional improvements during validated outcome score evaluations. RPPBC appears to be an efficient and reliable treatment strategy for aseptic loosening of orthopedic implants in elderly patients deemed unfit for revision surgery. • Radiological percutaneous periprosthetic bone cementoplasty offers immediate and long-lasting pain relief in elderly frail patients, or those deemed unfit for revision surgery despite presenting with symptomatic aseptic loosening of orthopedic implants. • Radiological percutaneous periprosthetic bone cementoplasty brings quick and long-lasting improvements in clinical functional outcomes and offer effective pain reduction, thereby improving the overall quality of life. • Radiological percutaneous periprosthetic bone cementoplasty is a safe, quick, reliable, and well-tolerated minimally invasive procedure which can be easily performed under simple locoregional anesthesia and requires short-term hospital stay.

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 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.

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.

Resume Introduction La morbi-mortalite precoce du remplacement prothetique bilateral de genou (PTG Bi) en une session operatoire est un sujet d’interet dans la litterature medicale. L’evolution clinique a long terme de cette strategie est quant a elle bien moins etudiee. L’objectif de cette etude etait de rapporter les complications tardives (> 90 jours), les resultats cliniques, KOOS et new IKS, ainsi que la survie prothetique des PTG Bi en une session operatoire. L’hypothese etait qu’une strategie de PTG Bi en une session operatoire entrainait peu de complications tardives et une survie prothetique compatible avec les criteres du National Institute of health and Clinical Excellence (NICE). Methode Cette etude retrospective monocentrique a analyse sur une periode de 8 ans, entre 2009 et 2016, une cohorte de patients ASA 1 et 2 operes par PTG bilaterales en une session operatoire. La population se composait de 116 patients, en majorite des femmes (65,5 % femmes vs 34,5 % d’hommes) avec un âge moyen a l’inclusion de 69 ans (32–85 ans) ; 22,4 % des patients etaient ASA 1 et 77,6 % ASA 2. Les complications tardives prothetiques, mecaniques ou infectieuses survenues apres les 90 premiers jours postoperatoires, les resultats cliniques (scores KOOS, new IKS) et radiographiques, ainsi que la courbe de survie, ont ete enregistres lors des consultations de controle systematiques a 3 mois, 6 mois et 1 an postoperatoire et lors du suivi a long terme ou lors d’un evenement intercurrent. Resultats Aucun patient n’etait perdu de vue. Quinze complications etaient recensees (6,5 %) : 4 infections, 4 problemes rotuliens (3 « clunck syndrome » et un syndrome douloureux rotulien), 4 raideurs, 2 douleurs inexpliquees et une fracture periprothetique femorale. Huit patients ont ete readmis (6,9 %) ; il y a eu 7 re-operations (3 %) et 2 revisions prothetiques (0,9 %). Les scores fonctionnels (KOOS et new IKS) etaient ameliores de maniere significative et 87 % des patients se disaient satisfaits ou tres satisfaits par cette intervention. A 5 ans de recul moyen, l’estimation de la survie prothetique par la methode de Kaplan-Meier etait de 98,4 % (IC 95 % = 0,933–0,996) Conclusion La realisation de PTG Bi en une session operatoire est une strategie fiable car elle engendre un faible taux de complications tardives, d’excellents resultats a moyen terme ainsi qu’une courbe de survie compatible avec les criteres du NICE, permettant ainsi de verifier l’hypothese de cette etude. Niveau de preuve IV, etude retrospective.

We report a case of a pyrocarbon humeral head resurfacing implant fracture, occurring 6 years after its implantation, without any obvious trauma or dislocation. Initial radiographs showed a proud and oversized pyrocarbon resurfacing implant. On clinical examination, the patient had a painful and pseudoparalyzed shoulder with subscapularis insufficiency. Imaging studies confirmed implant fracture and severe fatty infiltration (Goutallier, grade 4) of the subscapularis muscle. Intraoperatively, the implant was found to be fractured with multiple pyrocarbon debris in the glenohumeral joint. The implant was loose, and gross inspection showed no visible bony adhesion or ongrowth. Histologic analysis showed multiple seats of metallosis in the synovial tissue and cancellous bone of the humeral head. Successful management of this complication was managed with a thorough debridement and irrigation and revision to reverse shoulder arthroplasty. Our observation put into question the use of pyrocarbon as a humeral head resurfacing implant. The material seems to be too fragile to be used as a resurfacing implant and cannot achieve fixation of the implant to bone.

Resume Introduction Le remplacement prothetique bilateral de hanche offre l’avantage d’une seule anesthesie, d’un sejour hospitalier unique et d’une seule reeducation. L’ecueil theorique de cette strategie est une majoration du risque operatoire. Il existe peu de series francaises et aucune n’est comparative avec des arthroplasties unilaterales. Aussi, nous avons mene une etude comparative cas temoin de protheses bilaterales une seule seance (PTH Bi) versus unilaterales (PTH Uni) avec pour objectifs de : 1) comparer la morbi-mortalite, 2) la survie, 3) les scores fonctionnels et le taux de hanche oubliee. Hypothese Sur une population selectionnee ASA 1 ou 2 les PTH Bi ne modifiaient ni le le taux de complications ni la survie par rapport aux PTH unilaterales. Materiel et methode Entre 2004 et 2018, 327 patients ont ete inclus comportant 109 operes par PTH Bi et 218 operes par PTH Uni. Un patient opere par PTH bilaterale etait apparie a deux patients operes par PTH unilaterale selon l’âge, le sexe, le diagnostic, le score ASA 1 ou 2 et la voie d’abord anterieure ou posterieure. Le recul minimum etait de 12 mois et le recueil des complications dans les deux groupes a ete realise pour tous les patients. La morbi-mortalite precoce (≤ 90 jours) ou tardive (> 90 jours) etait renseignee ainsi que la survie prothetique des deux groupes. Les criteres secondaires concernaient la strategie d’epargne et les pertes sanguines, les scores fonctionnels et de satisfaction des patients. Resultats La mortalite etait nulle dans les deux groupes. Aucune difference significative concernant le taux de complications globales n’etait observee entre les groupes PTH Bi (38,5 %) versus PTH Uni (40,8 %) (p = 0,69) que les complications soient precoces (PTH Bi = 8,3 % [9/109] ; PTH Uni = 7,8 % [17/218] [p = 0,89]) ou tardives (PTH Bi = 30,3 % [33/109] ; PTH Uni = 33,0 % [72/218] [p = 0,61]). Le taux d’inegalite de longueur des membres inferieurs etait significativement inferieur dans le groupe PTH Bi (PTH Uni = (29/218) 13,3 % ; PTH Bi = [6/109] 5,5 % [p = 0,03]). Le taux de hanche oubliee etait significativement plus important dans le groupe PTH Bi (94/109 [86 %]) que dans le groupe PTH Uni (152/218 70 %) (p = 0,01). La survie de l’implant a 5 ans selon l’analyse de Kaplan-Meier etait de 97,2 % (IC 95 % = [91,9–99,1]) dans le groupe PTH Bi et de 96,6 % (IC 95 % = [93,0–98,4]) dans le groupe PTH Uni (p = 0,08). Discussion Cette etude montre que le remplacement prothetique bilateral en une session operatoire est une strategie recevable et non prejudiciable pour les patients presentant une coxarthrose bilaterale invalidante a faible risque operatoire (ASA 1 et 2). En effet sans modifier la mortalite, les complications ou la survie, la procedure bilaterale en une seance permet un meilleur controle des longueurs de membre et un taux de hanche oubliee plus important. Niveau de preuve III, etude cas temoin appariee.

Background One-stage bilateral hip replacement has the advantage of involving a single anesthesia, single hospital admission and single rehabilitation program. The theoretic drawback is increased surgical risk. Few French series have been reported, and none with comparison versus unilateral arthroplasty. We therefore conducted a comparative case-control study between 1-stage bilateral (1B-THA) and unilateral total hip arthroplasty (U-THA), assessing (1) morbidity/mortality, (2) survival, and (3) functional scores and forgotten hip rates. Hypothesis In a selected ASA 1 or 2 population, 1B-THA shows complications rates and implant survival comparable to U-THA. Material and method Between 2004 and 2018, 327 patients were included: 109 with 1B-THA, 218 with U-THA. One 1B-THA patient was matched to 2 U-THA patients on age, gender, diagnosis, ASA score 1 or 2, and anterior or posterior approach. Minimum follow-up was 12 months. Complications were collected for all patients in both groups. Early (≤ 90 days) or late (> 90 days) morbidity/mortality and implant survival were recorded for both groups. Secondary endpoints concerned blood-sparing strategy and blood loss, functional scores, and patient satisfaction. Results Mortality was zero in both groups. There was no significant difference in complications rates (1B-THA 38.5%, U-THA 40.8%) (p = 0.69), whether early (8.3% [9/109] and 7.8% [17/218] respectively [p = 0.89]) or late (30.3% [33/109] and 33.0% [72/218] respectively [p = 0.61]). Limb-length discrepancy was significantly less frequent in 1B-THA (5.5% [6/109] versus 13.3% [29/218] [p = 0.03]). Forgotten hip rate was significantly more frequent in 1B-THA (86% [94/109] versus 70% [152/218] [p = 0.01]). Five-year Kaplan-Meier implant survival was 97.2% (95% CI [91.9–99.1]) in 1B-THA and 96.6% (95% CI [93.0–98.4]) in U-THA (p = 0.08). Discussion One-stage bilateral total hip arthroplasty gave acceptable results in disabling bilateral osteoarthritis of the hip with low surgical risk in selected patients (ASA 1 or 2). Mortality, complications and implant survival were unaffected, but the 1-stage bilateral procedure allowed better control of limb-length and provided a higher rate of forgotten hip. Level of evidence III, matched case-control study.

Introduction Antegrade percutaneous intra-medullary nailing (IMN) has a poor reputation in the treatment of humerus fractures. The aim of the present study was to assess rotator cuff integrity and shoulder function after IMN in humerus fracture. Hypothesis Third-generation humeral nails (straight, small diameter, with locked screws) conserve rotator cuff tendon integrity and avoid the shoulder stiffness and pain incurred by 1st generation (large diameter, without self-blocking screw) and 2nd generation nails (curved, penetrating the supraspinatus insertion on the greater tuberosity). Methods Forty patients (26 female, 14 male; mean age, 60 years (range, 20-89 years)) with displaced humeral fracture (23 proximal humerus, 17 humeral shaft) underwent IMN using a 3rd generation nail (34 Aequalis™ (Tornier–Wright), 6 MultiLoc™ (Depuy-Synthes)). Mean clinical, radiologic and ultrasound follow-up was 8 months (range, 6-18 months); 22 patients agreed to postoperative CT scan. Results There were no revision surgeries for rotator cuff repair or secondary bone displacement. Mean Adjusted Constant Score (ACS) was 93 ± 22% and the Subjective Shoulder Value (SSV) 77 ± 18%. Elevation was 140 ± 36°, external rotation 48 ± 22° and internal rotation was to L3. Ultrasound found: 5 supraspinatus tendon lesions (12.5%) (2 full and 3 deep partial tears) without functional impact (ACS) 91% without vs. 107% with tear; (p = 0.12); 2 of the deep partial tears involved excessively lateral and high nail positioning. Eight patients (20%) had painful tendinopathy of the long head of the biceps (LHB) tendon associated with significantly impaired functional scores (ACS 65% vs. 100%; p Conclusion Supraspinatus tendon lesions following IMN with a 3rd-generation humeral nail were rare (12.5%) and asymptomatic; prevalence was not higher than in the general population in the literature (16%). LHB tendinopathy was frequent (20%) and symptomatic, and due to technical error in half of the cases. Level of evidence IV, retrospective study.

Clindamycin is an antibiotic with high bioavailability and appropriate bone diffusion, often proposed as an alternative in guidelines forA retrospective analysis was conducted at the University Hospital of Nice (France) between 2010 and 2019. We included patients with one shoulder implant surgical procedure and at least oneForty-eight SIJI were identified and 33 were treated with clindamycin, among which 25 were treated with monotherapy. The median duration of clindamycin antibiotherapy was 6 weeks. The average follow-up was 45 months; one patient was lost to follow-up. Twenty-seven patients out of 33 (82%) were cured with clindamycin, compared to 9/12 (75%) with other antibiotics. The rate of favorable outcomes increased to 27/31 (87%) with clindamycin and to 9/10 (90%) for other antibiotics when no septic revision strategies were excluded (The therapeutic strategy based on one- or two-stage revision associated with 6 weeks of clindamycin seems to be effective.

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.

International audience

International audience; Objective: To assess the association between early empirical antibiotics and neonatal adverse outcomes in very preterm infants without risk factors of early-onset sepsis.Study design: This is a secondary analysis of the EPIPAGE-2 study, a prospective national population-based cohort that included all liveborn infants at 22-31 completed weeks of gestation in France in 2011. Infants at high risk of early-onset sepsis (born after preterm labor or preterm premature rupture of membranes, or from mother who had clinical chorioamnionitis or received antibiotics during the last 72 hours) were excluded. Early antibiotic exposure was defined as antibiotics started at Day 0 or Day 1 of life, regardless of the duration and type of antibiotics. We compared treated and untreated patients by using inverse probability of treatment weighting based on estimated propensity score. Results: Among 648 very preterm infants at low risk of early-onset sepsis, 173 (26.2%) had early antibiotics treatment. Early antibiotic exposure was not associated with death or late-onset sepsis or necrotizing enterocolitis (OR=1.04 [95%CI=0.72-1.50]). However, it was associated with higher odds of severe cerebral lesions (OR=2.71 [95%CI=1.25-5.86]) and moderate-to-severe bronchopulmonary dysplasia (OR=2.30 [95%CI=1.21-4.38]). Conclusion: Early empirical antibiotics administrated in very preterm infants at low risk of early-onset sepsis were associated with a higher risk of severe cerebral lesions and moderate-to-severe bronchopulmonary dysplasia.

On the 16th of March 2020, in the face of a health emergency declared in France, the government imposed containment measures whose impact on orthopaedic and trauma surgery remains to be demonstrated. The hypothesis of this study was that confinement reduced orthopaedic and trauma surgical activity. The main objective was to assess orthopaedic and trauma surgical activity during confinement and to compare it to the activity outside confinement.This was a retrospective, monocentric, observational and comparative study of a continuous cohort of patients included during the confinement period of March 16th to May 11th, 2020. This cohort was retrospectively compared to a group of patients over the same non-confinement period in the previous year, from March 16th to May 11th, 2019. The primary outcome measured was the incidence rate of surgical activity in 2020 versus 2019 over an identical period. The secondary outcome was the analysis of the trauma identified.The number of patients operated on was significantly reduced during confinement: 194 patients were included in 2020, i.e. an incidence of 57 per 100,000 inhabitants against 772 patients included in 2019, i.e. an incidence of 227 per 100,000 inhabitants; p0.001. Planned orthopaedic surgery decreased from an incidence rate of 147 in 2019 to 5 in 2020 per 100,000 inhabitants (p0.001). Trauma surgery decreased from an incidence rate of 80 in 2019 to 50 in 2020 per 100,000 inhabitants (p: NS). We found a significant increase in patients over 65years of age during confinement, 70% compared to 61% in 2019; p=0.04. The rate of femoral neck fractures was significantly increased during confinement, 48.5% compared to 39.3% in 2019; p=0.03. Degenerative surgery was significantly reduced during confinement (p0.001).This study shows that the surgical activity of orthopaedics and trauma was significantly reduced by confinement, with a difference in incidence of 170 per 100,000 inhabitants, thus confirming the hypothesis of the authors. This decrease is due to both the cessation of planned orthopaedics and the 40% decrease in the number of trauma patients. During confinement, the percentage of patients over the age of 65 with a fracture increased significantly.Confinement had a significant impact on orthopaedic and trauma surgical activity.III; comparative and retrospective.

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear.Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months).The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index2 (OR, 10.2; P .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3.Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

The all-arthroscopic Latarjet is gaining popularity among shoulder surgeons, although the procedure is technically demanding and potentially dangerous, placing the brachial plexus and axillary vessels at risk when using screws for fixation of the bone block from the front. Matsen once wrote that "lateral to the coracoid is the safe side, while medial to the coracoid is the suicide." However, creation of a portal medial to the coracoid during arthroscopic reconstruction of the glenoid is needed to permit accurate positioning of the screws (parallel to the glenoid surface) and coracoid bone block (flush to the glenoid surface). Our own clinical experience with the arthroscopic Latarjet over the last decade has shown us that the safety of the arthroscopic medial transpectoralis portal depends on 3 technical considerations: (1) the portal should always be established in an outside-in fashion from anterior to posterior; (2) passing through the pectoralis major muscle with a relatively superficial trajectory, using a switching stick oriented with a 45° orientation toward the tip of the coracoid; and (3) under visual control of the anterior extra-articular subdeltoid space to end up lateral to the coracoid process. If these conditions are respected, surgeons should not worry: medial to the coracoid can also be a safe side! An inside-out technique (introducing a switching stick from posterior to anterior) is forbidden, as this would end up piercing the neurovascular structures. Once the coracoid has been osteotomized and the conjoint tendon retracted distally, all instruments passing though the transpectoral portal are directly in contact with the neurovascular structures. This is why working through the medial transpectoralis portal should be done only with the help of a cannula or half-pipe. Ideally, the transpectoral portal should not be used as a "working portal" but as a "protecting portal" instead, placing a stick or spreader to protect the neurovascular structures. To avoid working through the anterior medial portal, we have proposed a much safer alternative that consists of drilling the glenoid from posterior to anterior (using a guide and remaining inside the glenohumeral joint) and using cortical-buttons (instead of screws) for coracoid fixation. In this modern technique, the transpectoral portal makes the arthroscopic safe as it allows the introduction of a spreader to retract the subscapularis muscle and protect the neurovascular structures during transfer and fixation of the coracoid bone block.

Background Traditional initial management of proximal humerus fractures (PHF) involves arm immobilisation in a simple sling (SS) in an internally rotated position. We believe this risks fracture displacement and imbalance of soft tissues, encouraging malunion and stiffness. A neutral-rotation brace (NRB) maintains an arm position which may prevent this, leading to quicker and superior recovery. Methods We randomised patients with two- to four-part PHF into 4 weeks of immobilisation with either a SS or NRB, independent of surgery. Range of motion (ROM), subjective shoulder value (SSV), DASH, Constant–Murley (CMS) and Oxford Shoulder (OSS) scores were assessed at 6-weeks, 3-months and 1-year post-injury. Results The SS group included 11 patients vs 9 in the NRB group. At final follow-up, the SS and NRB groups had mean DASH scores of 42 vs 35, OSS 42 vs 46, CMS 71 vs 86, SSV 84% vs 92%, respectively. ROM was superior with the NRB (elevation 159°, ER 47° and IR score 8 vs 140°, 37° and 7 with SS). Conclusions Despite being a small series, our results demonstrate a trend towards NRB providing better outcomes. This feasibility study supports the need for a larger multi-centre randomised controlled trial comparing these immobilisation methods for PHF.

Bilateral total hip arthroplasty (Bi THA) for disabling bilateral hip osteoarthritis can be performed in one or two operative sessions. The objective of this study was to compare the complication rates of a group of patients who had bilateral THA in one operating session (Bi-1S THA) to a matched group of patients who had bilateral THA in two separate operating sessions (Bi-2S THA).This retrospective case-control study compared 84 Bi-1S THA matched to 84 Bi-2S THA by age, gender, diagnosis, ASA score (1-2) and surgical approach. The minimum follow-up was 12 months. Complication rates, total blood loss, number of blood transfusion units, and functional outcomes were assessed.Twelve patients (14.3%) in the Bi-1S THA group had minor or major complications, compared to twenty-one (25%) in the Bi-2S THA group (p=0.08): there were fewer minor complications in the Bi-1S THA group and a similar rate of major complications amongst the two groups. Total blood loss estimated using the OSTHEO formula was significantly lower in patients operated on by Bi-1S THA (1853±753mL versus 2804±1012mL, p0.0001). The number of blood transfusion units was similar between the groups (0.5±0.8 versus 0.3±1.4 respectively, p=0.55). No significant difference was found regarding the functional results.Under the conditions of this study, bilateral total hip arthroplasty in one operative session leads to fewer minor complications, and a similar rate of major complications, when compared to bilateral total hip arthroplasty in two separate sessions. This strategy can therefore be recommended for ASA 1 and 2 patients, under the age of 80 with disabling bilateral osteoarthritis.III, retrospective comparative study.

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.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.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% or20%), 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.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).

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%).

Reverse shoulder arthroplasty (RSA) is rapidly becoming the preferred treatment for displaced proximal humerus fractures in older patients. However, few studies have analyzed the target population and the effect of RSA on survival, although the socioeconomic impact of this type of surgery is considerable.This was a retrospective epidemiological study of all patients with a displaced proximal humeral fracture treated by RSA in 14 public and private hospitals throughout France between 1995 and 2016. The French hospital discharge database (PMSI) was analyzed to isolate an 898-patient cohort who underwent RSA within 6 weeks of the fracture event. In 87% of cases, this was a 3- or 4-fragment fracture. We analyzed the epidemiological characteristics of the patients at the time of fracture, their survival (Kaplan-Meier estimate) and factors that may impact survival.The mean age at the time of fracture and surgery was 79 years (46-98 years). Eighty percent of the cohort was female (sex ratio: 0.18 [p=0.0042], with 21% obesity rate [BMI30]) and 60% of patients were ASA 1-2. The most common comorbidities were cardiovascular and neurological. The survival rate after RSA was 94% at 1 year and 73% at 5years. At the latest follow-up of 19 years, 42% of patients were still alive. In 18% of cases, the patient died within the first 15 days. The presence of comorbidities (ASA score3-4) (p0.004) and/or cognitive disorders (p0.0001) were risk factors for early mortality. The time to surgery, type of fracture, associated fractures and discharge destination (return home, transfer to nursing home) had no effect on postoperative mortality in our cohort.Despite being older (79 years) at the time of proximal humerus fracture, patients who underwent RSA treatment had a high survival rate (94% at 1 year, 73% at 5years), which is better than the survivorship reported after surgical treatment of femoral neck fractures (81-87% at 1 year, 38% at 5years). The presence of comorbidities (ASA3-4) and/or cognitive disorders are risk factors for early mortality and should be taken into account to prevent early death.IV, Retrospective study.

Advantages of performing bilateral total hip arthroplasty (THA) in one stage include a single hospital stay, a single exposure to anaesthesia risks, and expedited rehabilitation. Controversy persists however, regarding safety, notably morbidity and mortality rates. Importantly, few studies have compared the anterior to the posterior approach for single-stage bilateral THA (1B-THA). The objective of this retrospective study in a uniform patient population was to compare the anterior and posterior approaches for 1B-THA in terms of: 1) early mortality rates, 2) early complications, 3) and 90-day re-admission rates, hospital stay lengths, and blood loss.1B-THA in patients younger than 80 years who have an ASA score of 1 or 2 is associated with no early mortality and with low early morbidity rates regardless of whether the anterior or posterior approach is used.A single-centre retrospective comparative design was used to assess 90-day mortality and morbidity rates in consecutive patients who underwent 1B-THA between 2004 and 2018. The groups managed with the anterior approach (AA) without traction table and posterior approach (PA) were compared. The ASA score was ≤2 and age ≤80 years in all patients. The groups were comparable for age, sex distribution, ASA score, pre-operative haemoglobin level, and reason for THA.We included 55 patients managed via the AA and 82 managed via the PA. No patients died in either group. Early complications occurred in 3 patients in the AA group and 6 in the AP group (p=0.74). No differences were noted between the two groups for each type of complication. In the AA group, 3 patients experienced major complications (p=0.06) (2 cerebrovascular events and 1 peri-prosthetic fracture). In the PA group, 6 patients experienced minor complications (1 case each of dislocation, piriformis syndrome, sacral pressure sore, and deep vein thrombosis and 2 cases of ilio-psoas irritation; p=0.08). Operative time was 144minutes (range, 110-195minutes) in the AA group and 171minutes (range, 108-255minutes) in the PA group (p0.001). Mean hospital stay length was 7.6 days (range, 3-13 days) overall, 6.7 days (range, 5-11 days) in the AA group, and 8.2 days (range, 3-13 days) in the PA group (p0.001). The early re-admission rate was 2.9% overall, with no difference between the AA group (3.6% [2/55]) and the PA group (2.4% [2/82]) A post-operative blood transfusion was required by 34/137 (24.8%) patients overall, 15/55(27.3%) patients in the AA group and 19/82 (23.2%) patients in the PA group (p=0.58).In selected patients (ASA score 1 or 2 and age ≤80 years), 1B-THA was not followed by any early deaths in the patients managed using the anterior or posterior approach. Total early morbidity rates were low. Neither the types of complications nor the early re-admission rates differed between the AA and PA groups. The shorter operative time in the AA group is ascribable to change in patient installation between the two arthroplasties when the PA is used.III, comparative study of consecutive patients.

Resume Introduction Le remplacement prothetique de hanche bilateral en une session operatoire offre les avantages d’un seul sejour hospitalier, d’une seule anesthesie et d’une reeducation raccourcie. Des controverses existent concernant les risques perioperatoires, et en particulier la morbi-mortalite. Surtout, peu d’etudes comparent les voies d’abord anterieure directe (VA) et posterieure (VP) dans cette indication. Aussi, nous avons realise une etude retrospective comparative afin de comparer entre VA et VP : 1) la mortalite, 2) les complications precoces et le taux de readmission jusqu’a 90 jours, 3) la duree d’hospitalisation. Hypothese La mortalite precoce apres PTH bilaterale en une session operatoire est nulle et la morbidite precoce faible quelle que soit la voie d’abord realisee. Methode Cette etude retrospective monocentrique comparait la morbi-mortalite precoce dans les 90 premiers jours postoperatoires apres PTH bilaterale en une session operatoire entre deux groupes : VA (n = 55 patients) et VP (n = 82 patients). Tous les patients avaient un score ASA ≤ 2 et un âge ≤ 80 ans, ont ete operes de maniere continue entre 2004 et 2018. Les deux groupes etaient comparables concernant le sexe, l’âge, le score ASA, l’hemoglobine preoperatoire et l’indication de la prothese. Resultats Le taux de deces precoce etait nul dans les deux groupes. Trois complications precoces sont survenues dans le groupes VA et six dans le groupe VP (p = 0,74). Aucune difference n’etait observee pour chaque type de complications, trois complications majeures ont ete observees apres VA (p = 0,06) (deux accidents vasculaires cerebraux et une fracture peri-prothetique) et six complications mineures apres VP (une luxation, une irritation de l’ilio-psoas, un syndrome du piriforme, une escarre sacree et une thrombose veineuse profonde) (p = 0,08). La duree operatoire pour l’intervention bilaterale par VA etait de 144 minutes [110–195 min] contre 171 minutes [108–255] pour la VP (p Discussion La mortalite perioperatoire, apres PTH bilaterale en une session etait nulle dans cette population selectionnee de patients (ASA 1 et 2 Niveau de preuve III, etude comparative en serie continue.

In the case of reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHFs) with tuberosity reconstruction, it is unclear whether the supraspinatus tendon continues to play a role. The aim of this study was to evaluate the clinical and radiological outcomes of RSA for PHFs in a large cohort of elderly patients and compare the results in the case of supraspinatus excision or preservation. In this retrospective multicentre study, 150 patients (mean age 77 years, 93% female) were reviewed and radiographed with a minimum follow-up of 24 months. The same Grammont prosthetic design was used in all cases (inclination angle 155°, non-lateralised glenosphere). Patients were divided into two groups: Group A (n = 117) underwent supraspinatus excision and Group B supraspinatus preservation (n = 33). Complications were recorded, and shoulder function, active mobility and subjective results were assessed. At a mean follow-up of 59 months, there was no statistical difference in the complication rate (6% vs. 6.8%, p = 1), mean Constant score (61 points vs. 59 points, p = 0.52), simple shoulder value (74% vs. 73.9%, p = 0.9), active anterior elevation (125° vs. 128°, p = 0.45) and internal rotation (4.9 points vs. 4.1 points, p = 0.2). However, mean active external rotation was better in Group A (22° vs. 13°, p = 0.01). The greater tuberosity healing rate in satisfactory position did not differ statistically between the groups (68% vs. 55%, p = 0.14). In the case of RSA with tuberosity reconstruction for acute PHFs, there is no clear evidence that supraspinatus preservation is advantageous.

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.

Background Reverse shoulder arthroplasty (RSA) is offered to young patients with a failed previous arthroplasty or a cuff-deficient shoulder, but the overall results are still uncertain. We conducted a systematic review of the literature to report the midterm outcomes and complications of RSA in patients younger than 65 years. Methods A search of the MEDLINE and Cochrane electronic databases identified clinical studies reporting the results, at a minimum 2-year follow-up, of patients younger than 65 years treated with an RSA. The methodologic quality was assessed with the Methodological Index for Non-Randomized Studies score by 2 independent reviewers. Complications, reoperations, range of motion, functional scores, and radiologic outcomes were analyzed. Results Eight articles were included, with a total of 417 patients. The mean age at surgery was 56 years (range, 21-65 years). RSA was used as a primary arthroplasty in 79% of cases and revision of a failed arthroplasty in 21%. In primary cases, the indications were cuff tear arthropathy and/or massive irreparable cuff tear in 72% of cases. The overall complication rate was 17% (range, 7%-38%), with the most common complications being instability (5%) and infection (4%). The reintervention rate was 10% at 4 years, with implant revision in 7% of cases. The mean weighted American Shoulder and Elbow Surgeons score, active forward elevation, and external rotation were 64 points, 121°, and 29°, respectively. Conclusions RSA provides reliable clinical improvements in patients younger than 65 years with a cuff-deficient shoulder or failed arthroplasty. The complication and revision rates are comparable to those in older patients.

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

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

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.

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.

Resume Introduction Le 14 juillet 2016 un terroriste utilisant un camion a percute la foule sur la Promenade des Anglais a Nice. Le bilan final sera de 87 morts et de 458 blesses. L’objectif de cette etude etait d’evaluer la strategie de prise en charge des blesses osteo-articulaires lors de cet attentat. L’hypothese etait que cette strategie avait permis de respecter un delai de prise en charge inferieur a 6 heures pour les fractures ouvertes. Materiel et methode Il s’agit d’une etude retrospective monocentrique du 14 au 31 juillet 2016, incluant tous les patients victimes de l’attentat presentant une lesion osteo-articulaire et hospitalises a l’hopital Pasteur 2. Les criteres d’evaluation pour chaque patient etaient : l’âge, le sexe, le type de lesion, l’Injury Severity Score (ISS), le traitement par « Damage Controle Orthopedique » (DCO) ou par « Tout En Un Temps » (TEUT), son delai, la duree operatoire, les reprises. Le critere de jugement principal etait le delai de prise en charge des differentes lesions. Resultats Parmi les 182 patients admis aux urgences, 32 presentant des lesions osteo-articulaires ont necessite une hospitalisation. Dix-huit etaient traumatises severes (ISS > 15) et 11 polyfractures. Ils presentaient des lesions de traumatologie routiere avec 45 % de fractures des membres inferieurs dont 25 % etaient ouvertes. Quatorze patients ont ete operes la premiere nuit et 19 au total. Un DCO a ete utilise 12 fois et une strategie TEUT 7 fois. Tous les patients ont ete pris en charge dans des delais recommandes, en particulier les 21 fractures ouvertes et les 2 fractures fermees de diaphyse femorale. Discussion Tous les patients presentant des lesions osteo-articulaires ont ete pris en charge dans des delais recommandes. Pour 25 % d’entre eux, une chirurgie en un temps aurait ete possible dans ce contexte d’afflux massif non saturant. Type d’etude IV, etude retrospective.

PURPOSE To report the outcomes of all-arthroscopic coracoclavicular (CC) ligament reconstruction and simultaneous diagnosis and treatment of glenohumeral pathologies in patients with symptomatic, chronic (>6 weeks), complete (Rockwood type III-V) acromioclavicular joint (ACJ) separations. METHODS We prospectively followed up 57 consecutive patients treated arthroscopically for chronic Rockwood type III (n = 11), type IV (n = 19), and type V (n = 27) ACJ dislocations. Previous ACJ surgery failed in 11 (19%). The mean delay between injury and surgery was 39 months (range, 6 months to 17 years). The mean age at surgery was 42 years (range, 19-71 years). After glenohumeral exploration, an arthroscopic modified Weaver-Dunn procedure with CC suture button fixation (Twinbridge) was performed. The CC reduction and tunnel position were analyzed with radiographs and computed tomography. The mean follow-up period was 36 months (range, 12-72 months). RESULTS Intra-articular pathology was treated arthroscopically in 27 patients (48%): 17 labral tears, 8 rotator cuff tears (3 partial and 5 complete), and 15 biceps lesions (4 SLAP lesions and 11 subluxations). At last follow-up, 7 patients (12%) experienced recurrent ACJ instability: 2 frank dislocations (1 trauma and 1 infection) and 5 ACJ subluxations. There was no significant correlation between subluxation and clinical outcome. The rate of recurrent ACJ instability was significantly higher in patients with higher-grade ACJ dislocations (P < .01) and/or previous failed surgery (P < .001). Recurrent subluxation was observed in 3 cases of lateral migration of the coracoid button with lateral tunnel placement, as well as 2 cases of anterior migration of the clavicular button with anterior tunnel placement. The Constant score increased from 67 (range, 28-89) to 85.5 (range, 66-100), and the mean Subjective Shoulder Value increased from 54% to 85% (P < .001). At last follow-up, 95% of patients (54 of 57) were satisfied. CONCLUSIONS All-arthroscopic treatment allows successful CC ligament reconstruction and simultaneous diagnosis and treatment of frequently associated (48%) glenohumeral lesions. Higher-grade ACJ dislocations, previous ACJ surgery, and misplacement of bone tunnels are risk factors for recurrent instability. LEVEL OF EVIDENCE Level IV, case series.

Resume Introduction Le score de Constant permet une evaluation objective et subjective de la fonction de l’epaule. Il a ete montre que sa fiabilite inter-observateur etait mediocre pour certains de ses sous-items et qu’il n’est pas utilisable a distance. Hypothese Le score fonctionnel de Constant-Murley peut etre estime par un auto-questionnaire. Methodes Nous avons realise une etude prospective continue dans un service universitaire specialise en chirurgie de l’epaule. Chaque patient vu en consultation ou hospitalise pour une pathologie de l’epaule a recu un auto-questionnaire et a ete examine par un chirurgien. Le questionnaire en version francaise etait compose seulement de cases a cocher sans texte manuscrit. La correlation avec l’examen du chirurgien etait evaluee a l’aide des coefficients de correlation intra-classe et les ecarts de points a l’aide du test de Student pour echantillons apparies. Resultats Cent patients ont ete examines. La correlation entre les deux scores totaux etait excellente (r = 0,87), de meme que pour les sous-items mobilite (r = 0,85) et douleur (r = 0,78). Elle etait bonne pour le sous-item activite (r = 0,69) et passable pour la force (r = 0,57). Le score total etait en moyenne significativement sous-estime de −3 points par les patients remplissant un auto-questionnaire (CI 95 (−5 ; −1) ; p Conclusion L’auto-Constant en version francaise est un excellent estimateur global du score de Constant-Murley total, et de ses sous-items douleur et mobilite. Il est moins precis pour l’evaluation de la force mais les differences entre les sous-items se compensent et permet son utilisation en pratique courante. Type d’etude Etude prospective continue. Niveau d’etude Niveau II.

Background: While patient age, tear size, and muscle fatty infiltration are factors known to affect the rate of tendon healing after rotator cuff repair, the effect of tendon delamination is less known. Purpose: To assess the effect of tendon delamination on rotator cuff healing after arthroscopic single-row (SR) repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients (N = 117) with chronic full-thickness rotator cuff tears underwent arthroscopic SR repair with the tension-band cuff repair. The mean ± SD age at the time of surgery was 60 ± 8 years. There were 25 small, 63 medium, and 29 large tears. Tendon delamination was assessed intraoperatively under arthroscopy with the arthroscope placed in the lateral portal. Patients were divided into 2 groups: those with nondelaminated (n = 80) and delaminated (n = 37) cuff tears. The 2 groups were comparable for age, sex, body mass index, preoperative pain, strength, and a Constant-Murley score. Repair integrity was evaluated with sonography (mean, 24 months after surgery; range, 6-62 months) and classified into 3 categories: type A, indicating complete, homogeneous, and thick coverage of the footprint; type B, partial coverage with a thin tendon; and type C, no coverage of the footprint. Results: The prevalence of tendon delamination observed under arthroscopy was 32% (37 of 117), which increased with tear size and retraction: from 15% in small tears to 32% in medium tears and 45% in large tears ( P = .028). Postoperatively, 83 patients had complete coverage of footprint (type A = 71%) and the cuff was considered healed, whereas 26 had partial coverage or a thin tendon (type B = 22%) and 8 had no coverage (type C = 7%). Overall, the rate of complete healing was 78% in nondelaminated cuff tears and 57% in the case of tendon delamination ( P = .029). In large retracted tears, the healing rate dropped from 81% in the absence of delamination to 39% when the tendons were delaminated ( P = .027). Conclusion: Tendon delamination increases with tear size and retraction. Patients with chronic delaminated and retracted rotator cuff tears (stage 2 or 3) are at risk of failure after SR cuff repair, whereas patients with small delaminated rotator cuff tears (stage 1) involving only the supraspinatus can be treated with an SR cuff repair with a high chance of tendon healing. These results suggest that SR cuff repair may be insufficient to treat delaminated chronic cuff tears. To improve the anatomic outcomes of rotator cuff repairs, surgeons should consider treating delaminated tears with a double-row or double-layer repair.

To evaluate mid-term clinical outcomes, complications, bone-block healing, and positioning using suture-button fixation for an arthroscopic Latarjet procedure.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 loss20%, and radiographic and clinical follow-up minimum of 24 months. Patients with glenoid bone loss20% 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.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.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 IV, therapeutic case series.