Quantitative MRI versus perioperative arthroscopy to measure stage 1 ruptures of the supraspinatus tendon for surgical planning.

BACKGROUND: Accurate preoperative assessment of supraspinatus tendon tear (STT) size is important for surgical planning. Our aims were to evaluate the correlation between stage 1 STT size measured preoperatively by quantitative (q)MRI and size measured perioperatively by arthroscopy. The concordance between preoperative tear size and the surgical plan was also assessed. METHODS: This prospective, non-randomized, non-controlled, interventional study was carried out in patients with a stable stage 1 STT. Three months before surgery, STT size was measured in the sagittal and coronal planes by a radiologist by qMRI (1.5T). Three months later, the surgeon measured the size of the tear again on the same qMRI scans and decided on the most appropriate surgical plan. During arthroscopy, the surgeon measured the size of the tear again using a graduated sensor hook and carried out the repair. STT size measured preoperatively was compared to that measured by arthroscopy and the concordance between preoperative STT size and the surgical plan was determined. RESULTS: Sixty-seven patients were included (mean age: 59.5 ± 8.9 years; 58.2% female). These was good concordance between STT size measured by qMRI vs. arthroscopy in the coronal plane (concordance correlation coefficient (CCC) =0.36 [95%CI: 0.16‒0.53]; Pearson's correlation coefficient =0.42 [95%CI: 0.2‒0.6]; P=0.0004) and in the sagittal plane (CCC =0.51 [95%CI: 0.33‒0.65]; Pearson's correlation coefficient =0.57 [95%CI: 0.38‒0.71]; P<0.0001). Preoperative STT size concurred with the surgical plan in 85% of patients. CONCLUSION: There was good concordance between STT size measured by qMRI and that measured perioperatively by arthroscopy. However, preoperative STT size measured by qMRI did not concur with the surgical plan in 15% of patients and in these patients the surgical procedure had to be revised during surgery.

Acromioclavicular joint separation: Retrospective study of non-operative and surgical treatment in 38 patients with grade III or higher injuries and a minimum follow-up of 1 year.

INTRODUCTION: Acromioclavicular (AC) joint separation is a common shoulder injury. When the injury is graded as type III or higher in the Rockwood classification, surgical treatment can be proposed. However, an increasing number of practitioners are shifting back to conservative treatment as it is associated with fewer complications and seemingly close functional outcomes. The aim of our study was to evaluate the functional recovery of operated and non-operated patients with grade III or higher AC joint injuries. Secondarily, the reliability and relevance of the Rockwood classification was evaluated within and between raters. MATERIALS AND METHODS: We did a retrospective two-center study of 38 patients treated between 2014 and 2020. The clinical evaluation involved various functional outcome scores (Constant, QuickDASH, ASES, UCLA, SSV, STT) and a pain assessment (VAS). Return to sports and to work was also documented. The radiological evaluation consisted of Zanca AP and lateral axillary views immediately after the injury and at each radiographic follow-up visit until the final visit. An intra- and inter-rater analysis was also done for the Rockwood classification. RESULTS: There was no significant difference in the functional scores (Constant score surgery group=91, nonoperative group=83; p=0.09) or the pain on VAS at the final assessment. Return to work and to sports was significantly faster in patients treated non-operatively. No complication was found in the non-operated patients, while nine of the operated patients suffered a complication. The inter-rater reliability of the Rockwood classification was found to be poor (kappa=0.08) to fair (kappa=0.35), while the intra-rater reliability was moderate (kappa=0.6) to good (kappa=0.63). DISCUSSION/CONCLUSION: No matter which treatment is used, the functional outcomes and patient satisfaction level a minimum of 1 year after the injury appear to be identical. Thus, surgery should be only for patients whose AC joint is painful 7 days after the injury (VAS>7) and whose function has not improved. For young and athletic patients or for patients who simply want to regain nearly normal function, it is important to remember that the time to return to work and sports is longer with surgical management and to take into consideration the potential postoperative complications. While none of the patients who received the non-operative treatment required a secondary stabilizing surgery, this is a possible recourse. LEVEL OF EVIDENCE: III.

Reverse shoulder arthroplasty for recent proximal humerus fractures: Outcomes in 422 cases.

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

CT scan evaluation of glenoid bone and pectoralis major tendon: interest in shoulder prosthesis.

INTRODUCTION: The shoulder arthroplasty brings satisfaction to patients in terms of quality of life and indolence. However whether anatomic implant or reverse, it does not escape from the loosening of the glenoid component. Moreover, optimal implantation is required to ensure the functional outcome without shortening of the arm. The purpose of this study is obtain CT scan evaluation of the glenoid bone stock in order to optimize glenoid component implantation and obtain a reference to determine optimal humeral component placement in case of humeral proximal fracture. MATERIALS AND METHODS: Between 2010 and 2011 we have analyzed 200 intact shoulder's CT. We measured maximal and minimal width in the transverse plane of the glenoid, the distance from the pectoralis major (PM) tendon to the humeral head, the greater tubercle, change of curvature and the anatomical neck. RESULTS: Mean maximum width was 27.4 ± 3.4 mm and mean minimum width was 15.5 ± 2.8 mm. Distances between upper edge of PM tendon to: humeral head, greater tubercle, change of curvature and anatomical neck were respectively: 67.6 ± 9.98 mm, 57.8 ± 10.3 mm, 28.7 ± 9 mm, and 34.2 ± 9.7 mm. CONCLUSION: Our study has produced an assessment of glenoid bone stock for optimal positioning of the glenoid implant but also to obtain a reference to determine the ideal location of the humeral component in the case of proximal humerus fracture.