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Background During the surgical treatment of terrible triad elbow injury (TTEI), the usefulness of re-attaching the anterior joint capsule when the coronoid tip is fractured remains unclear. The primary objective of this study was to assess potential benefits during surgery for TTEI of re-attaching the joint capsule when the coronoid tip is fractured. Hypothesis Re-attaching the anterior joint capsule in TTEI with a fractured coronoid tip improves clinical and radiological outcomes and decreases the complication and revision rates. Materials and methods This single-centre retrospective study included patients who underwent surgery at the acute phase of TTEI with a fractured coronoid tip. In all patients, a physical examination and elbow radiographs were performed at least 1 year after surgery. A statistical analysis was done to compare the groups with vs. without re-attachment of the anterior capsule and coronoid tip. Results The study included 30 patients, 16 females and 14 males, with a mean age of 51 years (range: 21–84 years). Among them, 11 did and 19 did not undergo re-attachment. The two groups were comparable regarding demographic features and follow-up duration. No significant differences were found at last follow-up for flexion-extension motion arc (p = 0.75), pronation-supination motion arc (p = 0.3051), or the Mayo Elbow Performance Score (p = 0.19). Radiographic evidence of humero-radial osteoarthritis was significantly more common in the absence of re-attachment (p = 0.04), whereas no differences were evidenced regarding humero-ulnar osteoarthritis (p = 0.73), the occurrence of subluxation or dislocation (p = 0.43), or loosening of the radial head implant (p = 0.47). The complication and revision rates were similar in the two groups. Conclusion In our experience, re-attaching the anterior capsule during the surgical treatment of TTEI with a coronoid tip fracture did not improve the clinical or radiographic outcomes after a mean follow-up of 54 months. Level of evidence IV, retrospective study.

Resume L’objectif de ce travail etait de preciser l’etat actuel des connaissances concernant l’apport de l’arthroscopie de poignet dans la prise en charge des fractures articulaires du radius distal (FARD). Une revue de la litterature des 10 dernieres annees a ete realisee. Avec l’utilisation des mots cles « distal radius fracture », « articular », « wrist arthroscopy » l’analyse des bases de donnees a permis de colliger 21 articles permettant de repondre aux questions suivantes : (1) L’arthroscopie permet-elle une amelioration de la reduction des FARD ? (2) Quel est l’apport diagnostique et therapeutique de l’arthroscopie dans la prise en charge des lesions ligamentaires associees ? (3) L’arthroscopie contribue-t-elle a l’amelioration des scores fonctionnels ? Concernant la reduction des FARD, l’apport de l’arthroscopie reste controverse : avec un recul limite (moyenne 15 mois) et plusieurs etudes de type IV, il n’est pas mis en evidence de maniere univoque une amelioration de la reduction articulaire avec l’assistance arthroscopique. L’interet de l’arthroscopie dans la gestion en un temps des lesions ligamentaires intracarpiennes est souligne. Sur 12 etudes, il est retrouve un taux de 41 % de lesions du ligament scapholunaire : un quart d’entre elles sont completes et reparables sous arthroscopie. Il est retrouve un taux de 48 % de lesions du TFCC : 30 % d’entre elles sont des desinsertions peripheriques ulnaires reparables sous arthroscopie. Toutes les lesions diagnostiquees ne sont pas reparees actuellement. Des etudes comparatives a plus long recul permettraient de clarifier l’apport positif de l’arthroscopie dans l’amelioration des scores fonctionnels. Niveau de preuve IV.

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

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%).

Introduction The superior part of the glenohumeral joint capsule has an intimate relationship with the tendons of the rotator cuff and the tendon of the long head of the biceps. One of the strategies currently proposed in the event of a massive cuff rupture is to reconstruct this superior capsule. The main objective of this anatomical study was to describe the superior joint capsule of the embryonic glenohumeral joint and its relationship to the tendons of the rotator cuff. Hypothesis The hypothesis was that this structure was an anatomical entity, morphologically identifiable from the embryogenesis of the joint (more pronounced tissue boundaries in the fetus). Material and methods In total, 101 continuous fetal anatomical sections (4 fetuses of 336 mm), in the frontal plane, made it possible to identify and measure: diameters of the humeral head and glenoid, dimensions of the joint capsule insertion zone at the level of the greater tubercle, as well as the different thicknesses of this insertion zone. The ratios above the head of the biceps and against the superior labrum were also measured. Results At the level of its distal insertion on the greater tuberosity, the thickness of the superior joint capsule varies on average between 0.8 mm laterally and 1.2 mm next to the tendons of the supraspinatus and infraspinatus; the thickness is 0.9 mm next to the middle part of the supraspinatus tendon (the “rotator cable” zone). For its insertion at the level of the glenoid labrum, the superior capsule measures 0.6 mm thick on average. The capsule around the tendon of the long head of the biceps is 1.5 mm thick on average. Discussion Here, we confirm the existence of this superior joint capsule, which can potentially be reconstructed. It is inserted on the greater tubercle covering 30 to 60% of its surface with variations in thickness. The joint capsule is fused to the supraspinatus tendon at the rotator cuff insertion area, preventing independent reinsertion of the tendon. Level of evidence IV; anatomical study.

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

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.

Background: The aim of the study was to describe the innervation of flexor hallucis longus (FHL) and obtain its surgical coordinates to facilitate selective neurotomy. Materials and methods: Fifteen embalmed lower limbs of adults were studied. Anatomical dissections to isolate the innervating branches of FHL were performed. Distance between the supplying nerve of FHL, including both its origin and termination, and the medial malleolus were obtained, providing anatomical coordinates beneficial for surgery. Results: In all cases, FHL was innervated by only one branch, which originated from the tibial nerve. Mean distance between the medial malleolus and the nervous branch origin was 21.39 ± 3.05 cm. Mean distance between the medial malleolus and the nervous branch termination was 12.7 ± 1.59 cm. Length of the nervous branch innervating FHL was proportional to the length of the leg, measuring 8.69 ± 2.45 cm. All nerves were located 15–17.4 cm above the medial malleolus. Conclusions: This anatomical study traced valuable surgical coordinates useful for performing selective peripheral neurotomy on the nerve branch innervating the FHL.

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.

Resume Introduction Le moyen de fixation d’un transplant de reconstruction du ligament croise anterieur (LCA) est debattu. La fixation tibiale des greffes tendineuses constitue la faiblesse principale pour des raisons mecaniques et anatomiques. La ligamentoplastie aux ischio-jambiers (STG) pedicules pourrait avoir un interet mecanique. L’objectif du travail etait de comparer la resistance maximale de la fixation tibiale d’une plastie STG pediculee non fixee par vis, a celle d’une plastie pediculee fixee par vis d’interference et a celle d’une plastie non pediculee. L’hypothese etait que le caractere pedicule de la greffe augmentait la resistance maximale de la fixation tibiale par rapport au transplant libre. Materiel et methodes Cinq paires de genoux apparies (10 genoux) de cadavres humains congeles etaient etudies. Les tendons du semi-tendineux et du gracile etaient prepares en une greffe a 4 brins pediculee au tibia. Le transplant etait passe au travers du tunnel tibial en utilisant l’ancillaire et les reperes habituels. 3 groupes etaient crees. Groupe 1 : transplant pedicule non fixe par vis d’interference. Groupe 2 : transplant pedicule, fixe par une vis d’interference. Groupe 3 : constitue des genoux du groupe 1 dont le greffon etait detache (transplant libre) apres le premier test et fixe par une vis d’interference dans le tunnel. Le diametre de la vis etait calibre au transplant. Le test de traction etait realise sur machine hydraulique (Instrom 8500), dans l’axe du tunnel. Le critere de jugement principal etait la charge maximale a la rupture. Le critere secondaire etait la mesure de la rigidite. La comparaison des groupes etait realisee par un test de Friedman et par la methode de Nemenyi au seuil de 5 %. Resultats La charge a la rupture du groupe 1 etait augmentee de 33 % par rapport a celle du groupe 3 (89,2 N vs 67,2 N p > 0,05) Celle du groupe 2 etait augmentee de 25 % par rapport a celle du groupe 1 (111,2 N vs 89,2 N, p > 0,05) et de 65 % par rapport a celle du groupe 3 (111,2 N vs 67,2 N p = 0,005). Il n’apparaissait pas de difference de rigidite entre le groupe 1 et 2 (p = 1). Discussion L’hypothese etait confirmee : la conservation de l’insertion anatomique tibiale des tendons ischio-jambiers augmente la charge maximale a la rupture du transplant. Dans les conditions d’experimentation il semble que l’adjonction d’une vis augmente la tenue mecanique de la plastie pediculee (+25 % en valeur absolue), mais la difference n’est pas significative. Niveau de preuve III, etude de laboratoire controlee.

Background The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures. Methods We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression (“back-slap” hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months). Results Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively. Conclusions Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.

Background Glenoid component loosening is the most frequent failure mode. Few data are available on the effect of thickness of cement on glenoid loosening. The purpose of this study is to determine if the cement mantle thickness influences the mode and localization of loosening. Our hypotheses are: 1) failure is caused by traction stresses generated within the cement mantle and 2) a thicker cement mantle amplifies the rocking horse effect. Methods Using bone substitute, an experimental protocol was designed to compare loosening of a keeled glenoid prosthesis in axial traction and off-centered-load, to recreate the rocking-horse effect (1.000.000 cycles). Different standardized mantle of cement between the back of the glenoid and the foam were tested (0–1 – 2–3 mm). The displacement of the polyethylene was assessed with an LVDT (Linear Variable Differential Transformer) gauge when the prosthetic humeral head loaded the opposite part of the implant. Results The loosening took place within the keel of the implant, and at the polyethylene–cement interface in traction if there was cement at the back of the polyethylene. For cycling loading, we observed a loosening at this interface, with associated fracture of the cement, only for cement 2 and 3 mm thick. Conclusion This experimental study suggests that the cement mantle should be as thin as possible between the back of the implant and the sub-chondral bone but should be optimized around the keel of the implant. Level of evidence Basic Science Study.

Resume L’ultrasonographie (US) est un outil facile a utiliser et peu couteux qui facilite le diagnostic et la gestion de l’epaule douloureuse. Elle est surtout utilisee par les radiologues et les rhumatologues, malgre l’efficience diagnostique constatee par divers medecins specialistes dans le cadre de leur consultation en cabinet. L’US presente des avantages supplementaires par rapport aux autres modalites d’imagerie dans l’evaluation de l’epaule en phase postoperatoire, pour s’assurer de l’integrite de la coiffe des rotateurs et du positionnement correct des ancres et sutures, et pour effectuer l’analyse de la coiffe des rotateurs apres arthroplastie. Une comprehension elementaire des principes de l’US, accompagnee d’un manuel expliquant les techniques de base de l’evaluation de l’epaule saine, pathologique et postoperatoire, ainsi que les possibilites de traitement sous guidage US, faciliteraient l’inclusion de l’US dans l’arsenal diagnostique des chirurgiens orthopedistes.

One of the treatment options for comminuted radial head fractures is radial head arthroplasty (RHA), especially when the elbow is also dislocated. While the clinical outcomes of RHA have been well documented, the incidence of post-traumatic osteoarthritis after RHA and its risk factors are not well known.To determine the incidence of post-traumatic elbow osteoarthritis (humeroulnar and humeroradial joints) after RHA and identify its risk factors.All patients who underwent RHA at our hospital between 2008 and 2016 were included retrospectively. The inclusion criteria were primary RHA, recent radial head fracture (isolated or associated with elbow dislocation), minimum 1 year of follow-up, clinical and radiographic examination at final assessment. The exclusion criteria were pre-existing elbow osteoarthritis, RHA revision, multiple fractures of the ipsilateral upper limb or polytrauma. The final assessment consisted of a clinical examination [joint range of motion (ROM) and Mayo Elbow Performance Score (MEPS)] and standard radiographs. The correlation between the incidence and severity of osteoarthritis and various risk factors was determined.Seventy-three patients were included in the analysis with a mean age of 56 years (21-85). The injuries consisted of 41 terrible triad, 15 isolated radial head fractures, 11 Monteggia fractures and 6 transolecranon fracture-dislocations. The mean follow-up was 3.4 years (1-10.9). At the final assessment, osteoarthritis was visible in the humeroulnar compartment in 56% of cases and in the humeroradial compartment in 72% of cases. There was a statistical correlation between the presence of humeroulnar osteoarthritis at the final assessment and ROM in flexion-extension (p=0.003), MEPS (p0.001), duration of immobilization (p=0.03) and presence of posterior subluxation on immediate postoperative radiographs (p=0.012). The correlation between humeroradial osteoarthritis at the final assessment and ROM in flexion-extension (p=0.0054), RHA implant position (p0.01), and unipolar configuration (p=0.027) was statistically significant.In our study, elbow osteoarthritis incidence after RHA was 56% in the humeroulnar joint and 72% in the humeroradial joint. RHA implant placement, posterior subluxation immediately postoperative and the duration of immobilization were significantly corelated with osteoarthritis.IV; case series without control group.

Objective: This study aims to provide morphometric analysis of endoscopic endonasal approach (EEA) to ventral-medial portion of posterior paramedian skull base (VMPPSB). Furthermore, it aims to investigate the surgical exposure obtained through EEA with and without Eustachian tube (ET) removal, emphasizing the role of contralateral nostril (CN) access. Methods: Five fresh adult head specimens were prepared for dissection. A pre-dissection and a post-dissection CT study was performed. A surgically oriented classification into 4 regions was used: 1) tubercular region; 2) occipital condyle region; 3) parapharyngeal space (PPhS) region; 4) jugular foramen (JF) region. Student's t-test was used to compare angulations and measures of EEA with access from the ipsilateral and CN, respectively with and without ET removal. Results: EEA to VMPPSB encompasses two medial trajectories (transtubercular and transcondylar) and two lateral pathways to PPhS and JF. The CN access, without removal of ET, allows a complete exposure of petrous and intrajugular portion of JF and superior PPhS without exposition of parapharyngeal segment of internal carotid artery. The ipsilateral nostril approach with ET removal allows to obtain a wider exposure, reaching medial sigmoid part of JF. No significant differences exist in regards to transtubercular and transcondylar approaches. Conclusions: This study suggests that EEA to PPSB allow the realization of a corridor directed to jugular tubercle, occipital condyle, medial parapharyngeal space and ventral-medial JF. The CN approach with ET preservation can expose petrous and intrajugular parts of JF and PPhS. Case series are needed to demonstrate benefits and drawbacks of these approaches.

Hypothesis/background Arthroscopic rotator cuff repair most commonly results in good clinical outcomes, however understanding of predictive factors influencing the final clinical outcome is limited. Aim The purpose of our study was to evaluate clinical outcomes of patients with healed supraspinatus tendon after arthroscopic rotator cuff repair and to identify its pre- and peri-operative predictive factors of good clinical results. Methods A multi-center prospective study followed up 188 patients, who had a healed tendon after an arthroscopic repair of isolated supraspinatus tear. Inclusion criteria were: age under 70 years old, isolated supraspinatus tear, stage 0 or I of fatty infiltration, healed supraspinatus tendon at one year postoperatively and the same arthroscopic double row rotator cuff repair used in all patients. Clinical assessment used Constant Murley Score (CMS) and Subjective Shoulder Value (SSV) preoperatively and at one year postoperatively. Ultrasound (US) control checked tendon repair quality based on Sugaya classification. Types I-II-III were considered as healed. Results The average age of our cohort was 57.57 (range; 41 to 70) years and the female to male ratio was 1.14 (range; 100 to 87). The average preoperative CMS was 53.75 ± 13.50 (mean ± SD; range; 16 to 83). At final follow up, the average postoperative CMS was 79.95 ± 12.05 (mean ± SD; range; 28 to 100). 12.22% (23/188) of patients, who had a CMS score below 70, had a clinically significant difference compared to the average CMS, due to the fact that the minimal clinically significant difference (MCID) in CMS is 10. A statistical analysis has shown that in patients with lower scores there was only a significant dominance of females (p-value = 0.001). No difference was found in regards to age, preoperative CMS, fatty degeneration and other factors. Conclusion Our study showed that despite all patients had a healed repair of supraspinatus, not all of them experienced a good final clinical outcome. The only factor negatively influencing the final clinical outcome was a female gender. No other structural factors seemed to influence the final clinical results. Futures studies should focus more on analyzing which personality traits and other psychosocial factors play an important role in determining the final outcome after arthroscopic rotator cuff repair. Level of evidence III; retrospective cohort study.

Introduction Antegrade nailing of humeral fractures is a proven technique with well-documented results. The standard surgical approach requires incision of the supraspinatus tendon to insert a nail, which comes with the risk of damaging the rotator cuff. The aims of this study were to describe a new surgical technique for arthroscopic humeral nailing that does not require opening the rotator cuff and to report the clinical and radiological outcomes of this technique. Materials and methods This was a single center, retrospective study of patients who had a humeral shaft or surgical neck fracture at our hospital in 2017 and underwent antegrade intramedullary nailing by arthroscopy. The nail was introduced through the rotator interval without opening the rotator cuff. All were reviewed at 1-year postoperative: clinical examination (joint range of motion and Constant score) plus AP and lateral radiographs of the shoulder. Results Eighteen patients (12 women, 6 men) with a mean age of 65.4 years (37–84) were included retrospectively. One patient died during the follow-up period thus 17 patients were available for analysis. At the 1-year follow-up, the mean forward flexion was 152.1° (90–180), the mean external rotation was 56.1° (30-80), the mean absolute Constant score was 73.9 (54–88) points and the mean adjusted Constant score was 93.5 (67–100) points. Bone union was achieved in 16/17 patients (94%) with 1 patient experiencing a nonunion. There were no complications. Conclusion Arthroscopic antegrade nailing of humeral shaft and surgical neck fractures through the rotator interval yields good clinical and radiological results in our hands. This new, rotator cuff-sparing technique is a viable option for treating humeral fractures by arthroscopy. Level of evidence IV; retrospective study without control group.

Resume Introduction La radiographie standard de face de l’articulation acromio-claviculaire (AC), reste la reference pour evaluer la degenerescence arthrosique. Objectif A l’aide d’une etude radiographique standardisee de face d’une articulation AC, l’objectif de ce travail etait de determiner si cette incidence radiographique est fiable et reproductible pour l’evaluation de l’interligne articulaire AC. Methode Une scapula et la clavicule, sans arthrose AC, ont ete utilisees pour l’etude. La scapula a ete positionnee dans un support, puis sous controle scopique, radiographie de face stricte de l’AC a ete realisee. A partir de cette position 0, une radiographie a ete realisee en variant l’angle de 5°–10°–15° dans tous les plans de l’espace. Les cliches ont ete realises lors de la meme seance pour ne pas modifier la distance tube-scapula puis ont ete exportes vers Osirx pour l’analyse. Nous avons mesure : les distances superieure et inferieure de l’AC, et la surface de l’interligne articulaire. Resultats Nous n’avons retrouve aucune reproductibilite des mesures de l’interligne articulaire AC en fonction de l’inclinaison du rayon par rapport a la radiographie de face stricte. Conclusion La radiographie standard de face de l’interligne AC ne permet pas une analyse fine de la degradation arthrosique de cette articulation. Probablement que seuls le scanner ou l’IRM permettent d’analyser la degenerescence de cette articulation. Niveau de preuve IV, etude fondamentale.

Introduction Conventional radiography using an anteroposterior view of the acromioclavicular (AC) joint is the gold standard for evaluating arthritic degeneration. Objective Based on a standardised AP view of the AC joint, the objective of this study was to determine whether this radiographic view is reliable and reproducible for evaluating the AC joint space. Methods A cadaver scapula–clavicle unit, free of osteoarthritis, was used for this study. The scapula was positioned in a stand; and then with fluoroscopy guidance, a strict AP view of the AC joint was taken. Starting from this “0” position, a radiograph was taken by varying the angle by 5°, 10°, and 15° in every plane in space. All radiographs were taken during a single session to ensure the distance between the X-ray tube and scapula did not change. The images were then exported to OsiriX for processing; the superior and inferior AC distance and the joint area were measured. Results There was no reproducibility in the AC joint measurements as a function of the incidence angle relative to a strict AP view. Conclusion Conventional radiography using an AP view of the AC joint cannot be used to do a fine analysis of arthritic degeneration of this joint. It is likely that only CT scan or MRI is sufficient to analyse osteoarthritis in this joint. Level of evidence IV, basic science study.

Objective: This study aims to provide morphometric analysis of endoscopic endonasal approach (EEA) to the ventral-medial portion of posterior paramedian skull base. Furthermore, it aims to investigate the surgical exposure obtained through EEA with and without eustachian tube (ET) removal, emphasizing the role of contralateral nostril (CN) access. Methods: Five fresh adult head specimens were prepared for dissection. A predissection and a postdissection computed tomography study was performed. A surgically oriented classification into 4 regions was used: 1) tubercular region; 2) occipital condyle region; 3) parapharyngeal space (PPhS) region; and 4) jugular foramen (JF) region. The Student t-test was used to compare angulations and measures of EEA with access from the ipsilateral and CN, respectively, with and without ET removal. Results: EEA to the ventral-medial portion of posterior paramedian skull base encompasses 2 medial trajectories (transtubercular and transcondylar) and 2 lateral pathways to the PPhS and JF. The CN access, without removal of the ET, allows a complete exposure of the petrous and intrajugular portion of the JF and superior PPhS without exposition of the parapharyngeal segment of internal carotid artery. The ipsilateral nostril approach with ET removal allows to obtain a wider exposure, reaching the medial sigmoid part of the JF. No significant differences exist in regard to transtubercular and transcondylar approaches. Conclusions: This study suggests that EEA to posterior paramedian skull base allows the realization of a corridor directed to the jugular tubercle, occipital condyle, medial PPhS, and ventral-medial JF. The CN approach with ET preservation can expose the petrous and intrajugular parts of the JF and PPhS. Case series are needed to demonstrate benefits and drawbacks of these approaches. Keywords: Anatomy; Endoscopic endonasal approach; Eustachian tube; Internal carotid artery; Posterior paramedian skull base.

Background. The indications for reverse shoulder arthroplasty (RSA) have been widely expanded, but only a few studies report the long-term survival of these implants. Our objective was to report the long-term survivorship of a large series of RSAs implanted for different etiologies. Methods. A retrospective multicenter study including all the RSAs was performed in six shoulder-specialized centers with at least 2 years of follow up. We reviewed 1611 RSAs, operated between 1993 and 2010, including 497 cuff-tear arthropathies (CTA), 239 revision RSAs, 188 massive cuff tears (MCT), 185 fracture sequelae (FS), 183 failed previous cuff repairs (FCR), and 142 primary osteoarthritis (POA). The mean follow-up was 5.6 ± 3.9 years (range 2–20). Results. Overall, 266 RSAs (16.5%) had at least one complication leading to 64 reoperations (4.0%) and 110 revision surgeries (6.8%). The most frequent complications were infection (3.8%), instability (2.8%), and humerus-related complications (2.8%). At 10 years, the survival without revision surgery was 91.0% in primary RSAs and 80.9% in revision RSAs for failed arthroplasty (p < 0.001). In the primary RSA group, MCT and FCR led to 10-year survivals for over 95% but fracture sequelae and tumors had the lowest 10-year survivals (83.9% and 53.1%). Younger patients had a lower 10-year survival. In revision RSAs, male patients had a significantly lower survival than females (72.3% vs. 84.5% at 10 years, p = 0.020). Discussion. Primary RSA for cuff-deficient shoulders or POA leads to a high 10-year survival, but revision RSA or primary RSA for FS and tumors are at high-risk for revision. Surgeons should be aware of high rates of complications and lower survival rates of RSA in younger patients, in males, and in RSAs for revision surgery.

Onset of radial neck osteolysis (RNO) has been reported after radial head replacement (RHR), but data are sparse regarding impact and risk factors. We therefore conducted a retrospective study, 1) to quantify RNO after RHR, 2) to assess clinical and radiological impact, and 3) to identify risk factors.RNO prevalence is high, but functional impact is limited.A single-center retrospective study included all patients undergoing RHR for acute radial head fracture between 2008 and 2017: 53 patients, with a mean age of 53.8±15.7 years [range, 21-85 years]. At a minimum 2 years' follow-up, patients were assessed clinically on joint range of motion and Mayo Elbow Performance Score (MEPS) and radiologically on standard radiographs. Associations between RNO and various parameters were assessed.At a mean 46.7±19.8 months' follow-up [range, 24-84 months], RNO was found in 54.7% of cases (29/53), with mean 4.0 ±2.8mm distal extension [range, 1.2-13.4mm], corresponding to 13.4±7.3% of stem height [range, 2.7-27.7%]. RNO at last follow-up was not significantly associated with reduced flexion-extension (121.9° versus 114.0°; p=0.11), pronation-supination (152.6° versus 138.3°; p=0.25) or MEPS (84.7 versus 84.8; p=0.97), or with higher rates of postoperative complications (11/29 (37.9%) versus 7/24 (29.2%); p=0.782) or surgical revision (11/29 (37.9%) versus 10/24 (41.7%); p=0.503). RNO was significantly associated with cementless fixation (19/29 (65.5%) versus 7/24 (29.2%); p=0.01), unipolar prosthesis (21/29 (72.4%) versus 7/24 (29.2%); p=0.002), high filling-ratio, whether proximal (88% versus 77%; p=0.002), middle (84% versus 75%; p=0.007) or distal (69% versus 59%; p=0.032), and shorter radial stem (33.2mm versus 46.3mm; p=0.011). No demographic parameters showed significant association with RNO at last follow-up.RNO was frequent after RHR, but without clinical or radiological impact in the present series. The risk factors identified here argue for involvement of stress shielding.IV, cohort study.

The two-dimensional fluoroscopic method of percutaneous pedicle screw instrumentation has been clinically described as reliable method in the caudal thoracic and lumbosacral spine. Its accuracy has not been clearly reported in the cranial thoracic spine. The aim of this in vitro study was to investigate percutaneous pedicle screw placement accuracy according to pedicle dimensions and vertebral levels. Six fresh-frozen human specimens were instrumented with 216 screws from T1 to S1. Pedicle isthmus widths, heights, transversal pedicles and screws were measured on computed tomography. Pedicle cortex violation ≥ 2 mm was defined as screw malposition. The narrowest pedicles were at T3–T5. A large variability between transversal pedicle axes and percutaneous pedicle screw was present, depending on the spinal level. Screw malposition rates were 36.1% in the cranial thoracic spine (T1–T6), 16.7% in the caudal thoracic spine (T7–T12), and 6.9% in the lumbosacral spine (L1–S1). The risk for screw malposition was significantly higher at cranial thoracic levels compared to caudal thoracic (p = 0.006) and lumbosacral (p

Introduction Simulation workshops for surgical training of residents are becoming popular. The gold standard for teaching thoracolumbar pedicle screw placement are cadaver labs; however, the availability of human bodies is limited. The primary objective of this study was to determine if training on a synthetic bone model improves the apprenticeship of accurate pedicle screw placement. The secondary objective was to check the influence of residents’ previous experience in spine surgery. Hypothesis The main hypothesis was that theoretical learning with practical application on synthetic bone was superior to theoretical learning alone. Methods Twenty-three orthopedic residents were taught about free-hand pedicle screw placement using a theoretical presentation. Six residents had previous experience with screwing techniques. After randomization in two groups, 11 residents (group 1) participated in a workshop on synthetic bone, whereas 12 residents received only theoretical instruction (group 2). Each resident was asked to place two thoracic screws (T7-T11) and two lumbar screws (L1-L5) on a cadaver. Screw placement accuracy was analyzed using the Gertzbein classification on computed tomography (grades 0 and 1 = accurate positioning; grades 2 and 3 = malposition > 2 mm). Results Rates of accurate screw positioning were 64.0% and 62.5% for thoracic levels, and 72.7% and 66.6% for lumbar levels in group 1 and 2, respectively. There was no significant difference in malposition rates on cadavers between the groups (p = 0.1809). A resident who was first trained by simulation had a chance of decreasing the Gertzbein score with an odds-ratio of 1.7714 [0.7710–4.1515]. The odds ratio was 4.5188 [0.0456–0.8451] when comparing residents with previous experience in spinal surgery to novice residents. Discussion Theoretical teaching associated with a simulation model is relevant for learning a surgical technique. A single simulation workshop on synthetic bone seems insufficient to improve pedicle screw placement accuracy compared to theoretical teaching alone. Progressive experience and the repetition of technical gestures during hands-on supervised learning in spine surgery with a senior surgeon had an influence on the accuracy of pedicle screw placement. Level of evidence II.

Introduction Rotator cuff tears often occur in combination with acromioclavicular (AC) arthropathy. But it can be difficult to separate pain caused by the rotator cuff tear from pain caused by the AC joint, despite clinical and other examinations. Distal clavicle resection (DCR) is increasingly being done at the same time as arthroscopic rotator cuff repair. The aim of this study was to compare the functional outcomes 1 year after arthroscopic rotator cuff repair between patients who simultaneously undergo DCR and patients who do not. The primary hypothesis was that DCR improves the clinical outcomes. Material and methods This was a prospective, multicenter, randomized, single-blind study of 200 patients who underwent isolated supraspinatus repair using the same technique. The patients were randomized into two groups: 97 patients who also underwent DCR and 103 patients who did not. The patients were followed until 1 year postoperative according to a standardized radiological and clinical review protocol. Results At 1 year postoperative, all the clinical outcomes were worse in the DCR group, although only external rotation with elbow at side (53° vs. 59°, p = 0.04) and the SSV (86.5 vs. 90.1, p = 0.04) were statistically different. Overall shoulder pain was higher in the DCR group during the first 3 months postoperative (p = 0.04). At 1 year, the DCR group had more residual pain; this pain was mainly located on the superior side of the shoulder (p = 0.03), especially when more than 11 mm was resected (p = 0.01). More of the shoulders in the DCR group had failures in rotator cuff healing based on ultrasonography (p = 0.5). Conclusion Our hypothesis was not confirmed. We do not recommend doing routine DCR with arthroscopic rotator cuff repair. Level of evidence I, prospective randomized simple blind study.

Introduction Physicians, whether in the public or private sector, are increasingly bound to “publish or perish”. Although researchers have become aware of certain ethical concerns relating to the concept of authorship, clinicians still tend to neglect issues of copyright. The present study aims: 1) to explain to orthopedic surgeons what exactly is protected by copyright in a scientific article; 2) to assess the legal implications of publishing contracts; and 3) to specify the means of publication that best boost the author's h-index. Material and methods The study was based on intellectual property legislation and jurisprudence and the underlying principles. The European and American medical and legal literature was analyzed. Results It is vital to understand the basic principles of copyright and the legal implications of publishing contracts. A scientific article is protected by copyright as soon as it has been written. This confers both moral and property rights. “Moral” rights protect the person of the author and are inalienable; unlike property rights, they cannot be transferred. Publishing contracts can only concern property and other derivative rights. Most scientific articles are published in open access via Creative Commons (CC) licenses. The greater the freedom of use provided for in the CC license, the more easily other authors can use the article, adding to it or altering it. As all CC licenses include an attribution clause, authors publishing under a relatively unrestrictive CC license increase the chances of boosting their h-index. Conclusion Forewarned is forearmed. Mastering the means of publication enables authors to make the most of their publications in boosting their h-index, and also to contribute to the new Open Science paradigm: abandoning some intellectual property in favor of innovation and knowledge sharing rather than clinging to data protection. Level of evidence IV.

Osteoarthritis may be observed after surgery for instability and in the natural history of pathology. The primary objective was to analyze the late clinical and radiographic results of reverse shoulder arthroplasties (RSA) for patients who had instability arthropathy. This is a retrospective cohort of 25 patients with a mean follow-up of 6.6 years. Patients had a history of instability surgery (80%) or multiple closed reductions. All were clinically evaluated with the constant score (CS), and radiologically (true AP view and Y view). No significant differences in pre- and post-operative function, radiologic status, and complication rate between the patients treated with a prior bone block procedure for the anterior instability and those treated by a capsular plication or non-operatively. A 36-mm sphere was implanted in 67%. Bone grafting of the glenoid was needed in 71%. No intra-operative complication has been reported. Clinically, the active anterior elevation increased from 70° to 140° (p

Resume Introduction La prothese totale d’epaule inversee (PTEI) est en train de devenir le traitement de choix des fractures deplacees de l’humerus proximal du sujet âge. Peu d’etudes ont analyse la population concernee et les consequences en termes de survie, alors que l’impact socioeconomique de ce type de chirurgie est important. Patients et methodes Etude epidemiologique, retrospective incluant tous les patients presentant une fracture deplacee de l’humerus proximal traites par PTEI dans 14 hopitaux francais publics et prives, entre 1995 et 2016. L’analyse des bases de donnees (PMSI) durant cette periode a permis d’isoler une cohorte de 898 patients operes d’une PTEI durant les 6 semaines suivant le traumatisme. Il s’agissait de fractures a 3 ou 4 fragments dans 87 % des cas. Nous avons analyse les caracteristiques epidemiologiques des patients lors du traumatisme, leur survie (selon Kaplan-Meier) et les eventuels facteurs influencant celle-ci. Resultats L’âge moyen au moment de la fracture et de la chirurgie etait de 79 ans (46–98 ans) ; il y avait 80 % de femmes (sexe ratio : 0,18 [p = 0,0042], dont 21 % d’obeses [IMC > 30]) ; 60 % des patients etaient ASA 1–2. Les comorbidites les plus frequentes etaient cardiovasculaires et neurologiques. Le taux de survie des patients apres chirurgie prothetique inversee de l’epaule etait de 94 % a 1 an, et de 73 % a 5 ans ; au recul de 19 ans, 42 % des patients etaient encore en vie. Dans 18 % des cas, les patients sont decedes dans les 15 premiers jours. La presence de comorbidites (score ASA > 3–4) (p Conclusion Malgre un âge eleve (79 ans) lors la fracture de l’humerus proximal, les patients traites par PTEI ont un taux de survie important (94 % a 1 an, 73 % a 5 ans), meilleur que celui observe pour les fractures du col du femur operes (81–87 % a 1 an, 38,3 % a 5 ans). La presence de comorbidites (score ASA > 3–4) et/ou de troubles cognitifs sont des facteurs de risque de mortalite precoce a prendre en compte pour eviter des deces precoces. Niveau de preuve IV, etude retrospective.

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

The objective of this study was to review current data on the contribution of wrist arthroscopy to the management of intra-articular distal radius fractures (IADRFs). The literature published over the last 10 years was reviewed by searching databases with the key indexing terms 'distal radius fracture', 'articular', and 'wrist arthroscopy'. The information in the 21 articles thus retrieved was used to answer the following questions: (i) Can arthroscopy improve the reduction of IADRFs? (ii) How does arthroscopy contribute to the diagnosis and treatment of concomitant ligament injuries? and (iii) Does arthroscopy help to improve the functional scores? The contribution of arthroscopy to IADRF reduction remains controversial. Follow-ups were limited (15 months on average) and some of the studies provided only level IV evidence. The data do not consistently suggest that arthroscopically assisted surgery may improve the quality of reduction. In contrast, they highlight the usefulness of arthroscopy in allowing the same-stage management of carpal ligament injuries. In the 12 studies providing data on this point, scapholunate inter-osseous ligament injuries were present in 41% of cases; one-fourth of these injuries were full-thickness tears that were successfully repaired by arthroscopy. The triangular fibrocartilage complex was injured in 48% of cases, and 30% of these injuries were peripheral ulnar detachments that were successfully repaired by arthroscopy. At present, arthroscopy does not allow the repair of all diagnosed ligament injuries. Comparative studies with longer follow-ups will shed light on the ability of arthroscopy to improve functional scores. LEVEL OF EVIDENCE: IV.

Resume Introduction Le traitement des lesions de la longue portion du biceps demeure un sujet de controverse. Une nouvelle technique de tenotomie en « T » de la longue portion du biceps de type autobloquante a ete developpee dans notre service depuis 2013. Hypothese L’objectif principal de cette etude etait d’evaluer l’apparition du signe de Popeye apres un geste de tenotomie en « T » et de le comparer a la technique de tenodese de la longue portion du biceps. Materiel et methodes Il s’agissait d’une etude retrospective, continue sur 180 patients presentant une lesion de la longue portion du biceps isolee ou associee a une rupture de la coiffe des rotateurs. Resultats Cent trente patients ont beneficie d’une tenotomie en « T » (groupe A), et 50 d’une tenodese (groupe B). L’âge moyen etait de 57,9 ans [23–88 ans] dans le groupe A et de 50,8 ans [20-66 ans] dans le groupe B. Au dernier suivi, 27,7 % des patients du groupe A et 24 % des patients du groupe B avaient un signe de Popeye (p = 0,616) apres test d’equivalence et ajustement sur les variables âge et activites professionnelles. De meme pour le score de Constant, les scores subjectifs postoperatoires, les crampes, le delai de reprise du travail et des activites professionnelles, il n’existait pas de difference statistiquement significative entre les deux groupes. Les douleurs dans la gouttiere etaient plus frequentes dans le groupe tenodese (44 % contre 25,4 %) (p = 0,025). Discussion La tenotomie en « T » de type autobloquante montre un taux non statistiquement significatif d’apparition du signe de Popeye avec des resultats cliniques equivalent a la tenodese et des suites operatoires plus simples. Niveau de preuve IV, etude retrospective.

Introduction Treatment of long head of the biceps lesions is controversial. A new technique of self-locking “T” tenotomy was developed in our department in 2013. Hypothesis The main objective of the present study was to assess onset of Popeye sign after “T” tenotomy, with comparison to long head of the biceps tenodesis. Material and methods A continuous retrospective study included 180 patients with long head of the biceps lesion, either isolated or associated with rotator cuff tear. Results 130 underwent “T” tenotomy (group A), and 50 tenodesis (group B). Mean age was 57.9 years (range, 23–88 years) in group A and 50.8 years (range, 20–66 years) in group B. At last follow-up, 27.7% of patients in group A and 24% in group B showed Popeye sign (P = 0.616), after equivalence test and adjustment on age and occupational activity. Bicipital groove pain was more frequent in the tenodesis group (44% versus 25.4%; P = 0.025). Discussion Self-locking “T” tenotomy did not significantly differ from tenodesis in onset of Popeye sign or clinical results, and showed better postoperative course. Level of evidence IV, retrospective study.

Resume Introduction Le kyste mucoide dorsal du poignet est une pathologie frequente et benigne. Le but de cette etude est d’objectiver les eventuelles lesions ligamentaires realisees par la capsulectomie arthroscopique puis de redefinir la place et les modalites des differents traitements medicaux et chirurgicaux. Materiel et methode Une capsulectomie progressive arthroscopique a ete pratiquee sur 13 poignets frais, par voie mediocarpienne (MC) et/ou radiocarpienne (RC) de maniere plus ou moins extensive. A ete realisee dans un second temps, une dissection et une evaluation des types et des eventuelles lesions ligamentaires concernant le Dorsal Radio-Carpal Ligament (DRCL), le Dorsal Inter-Carpal Ligament (DICL) et le Dorsal Capsulo Scapholunate Septum (DCSS). Resultats Une lesion etait retrouvee au niveau des DICL de type C (selon Viegas) lors des capsulectomies MC. Le DRCL et le DCSS (en absence de lesion du ligament scapholunaire preoperatoire) etaient toujours intacts sauf lors des capsulectomies RC et MC « elargies ». Discussion Le traitement medical a proposer en premiere intention, en cas de gene esthetique ou de douleur, est l’aspiration-infiltration. Les resultats sont variables avec 40 a 60 % de recidive, mais avec des taux de complications inferieurs au traitement chirurgical. Le traitement chirurgical arthroscopique se realisera volontiers par voie MC, le kyste etant le plus souvent situe distalement par rapport au DICL. Des mesures adjuvantes pourront etre realisees en cas de lesions associees retrouvees : le shrinkage du faisceau dorsal du SLIOL en cas d’instabilite scapholunaire ou une capsulodese arthroscopique en cas de lesion du DCSS. Le geste de capsulectomie doit etre controle, une lesion d’un DICL de type C pouvant se realiser par voie MC, le DCSS pouvant etre lese par une capsulectomie RC extensive.

Resume Introduction La prise en charge chirurgicale de l’instabilite posterieure isolee de l’epaule reste controversee du fait de resultats insatisfaisants pour cette pathologie rare, dont le diagnostic est parfois meconnu. L’echec de la prise en charge reeducative, chez un patient jeune et sportif, conduit a proposer un geste chirurgical capsulolabrale ou une butee osseuse. L’objectif de notre etude etait de rapporter les resultats des patients operes uniquement par geste capsulolabrale et de rechercher des facteurs de risques d’echec. Materiel et methodes Nous avons analyse les resultats de 101 patients operes par gestes capsulolabrales, dont 83 inclus retrospectivement et 18 de maniere prospective. Les gestes etaient realises de facon isolee ou en association parmi retente capsulaire, reinsertion labrale, fermeture de l’intervalle et comblement de l’encoche. Le critere principal etait la survenue d’un echec defini par une recidive d’instabilite et/ou de douleurs. Nous avons egalement analyse les resultats des scores specifiques (Walch–Duplay, Rowe modifie) et non specifiques (score de Constant, reprise d’activites) de l’instabilite d’epaule. Resultats Les resultats etaient satisfaisants avec un taux d’echec eleve (35 % en retrospectif au recul de 4,8 ± 2,6 ans et 22 % en prospectif au recul de 1,1 ± 0,3 ans) avec un critere d’echec severe. Nous avons retrouve une amelioration significative des differents scores. La reprise du travail a ete possible dans 92 % des cas et du sport, au niveau competition, dans 80 % des cas. Quatre-vingt pour cent des patients etaient satisfait et tres satisfait en postoperatoire. Aucun facteur de risque n’a pu etre mis en evidence de facon significative, mais un âge eleve, la realisation d’un geste isole et les formes cliniques mal definies etaient plus representees dans le groupe des patients en echecs. Conclusion La chirurgie capsulolabrale pour le traitement de l’instabilite posterieure de l’epaule a permis d’obtenir de bons resultats cliniques avec un taux d’echec important. Niveau de preuve 4. Etude retrospective.