Hallucination Rates and Reference Accuracy of ChatGPT and Bard for Systematic Reviews: Comparative Analysis.

BACKGROUND: Large language models (LLMs) have raised both interest and concern in the academic community. They offer the potential for automating literature search and synthesis for systematic reviews but raise concerns regarding their reliability, as the tendency to generate unsupported (hallucinated) content persist. OBJECTIVE: The aim of the study is to assess the performance of LLMs such as ChatGPT and Bard (subsequently rebranded Gemini) to produce references in the context of scientific writing. METHODS: The performance of ChatGPT and Bard in replicating the results of human-conducted systematic reviews was assessed. Using systematic reviews pertaining to shoulder rotator cuff pathology, these LLMs were tested by providing the same inclusion criteria and comparing the results with original systematic review references, serving as gold standards. The study used 3 key performance metrics: recall, precision, and F1-score, alongside the hallucination rate. Papers were considered "hallucinated" if any 2 of the following information were wrong: title, first author, or year of publication. RESULTS: In total, 11 systematic reviews across 4 fields yielded 33 prompts to LLMs (3 LLMs×11 reviews), with 471 references analyzed. Precision rates for GPT-3.5, GPT-4, and Bard were 9.4% (13/139), 13.4% (16/119), and 0% (0/104) respectively (P<.001). Recall rates were 11.9% (13/109) for GPT-3.5 and 13.7% (15/109) for GPT-4, with Bard failing to retrieve any relevant papers (P<.001). Hallucination rates stood at 39.6% (55/139) for GPT-3.5, 28.6% (34/119) for GPT-4, and 91.4% (95/104) for Bard (P<.001). Further analysis of nonhallucinated papers retrieved by GPT models revealed significant differences in identifying various criteria, such as randomized studies, participant criteria, and intervention criteria. The study also noted the geographical and open-access biases in the papers retrieved by the LLMs. CONCLUSIONS: Given their current performance, it is not recommended for LLMs to be deployed as the primary or exclusive tool for conducting systematic reviews. Any references generated by such models warrant thorough validation by researchers. The high occurrence of hallucinations in LLMs highlights the necessity for refining their training and functionality before confidently using them for rigorous academic purposes.

Subjective Shoulder Value for Sport Is a Simple, Reliable, and Valid Score to Assess Shoulder Function in Athletes.

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

Revision rotator cuff repair: can a Sugaya III tendon considered to be healed or not.

BACKGROUND: Sugaya et al described a classification system to assess postoperative rotator cuff tendon healing. Although Sugaya I and II tendons can be considered as healed and Sugaya type IV and V can be considered as retorn, the exact status of Sugaya III tendons remains unclear. The objective of this study was to evaluate the impact of Sugaya III tendons on postoperative functional scores in a population of patients undergoing revision rotator cuff repair. METHODS: We retrospectively studied the records of all patients who underwent revision rotator cuff repair in one of 12 different institutions between July 2001 and December 2020. A total of 203 shoulders were included (59% males, mean age: 51 ± 8 years old, mean follow-up 11.5 years [range: 2-28.8 yr]). Fifty-four patients (61% males, mean age 52 ± 6 years old, mean follow-up 14.1 years [range: 10.4-28.8 yr]) had a follow-up ≥10 years (mean 14.1 years [range: 10.4-28.8 yr]) and were included in a long-term follow-up subgroup analysis. Structural integrity of the repaired tendon was evaluated on magnetic resonance imaging at last follow-up. Functional scores, acromiohumeral index (AHI), and progression of fatty infiltration and of osteoarthritis were compared according to Sugaya type. RESULTS: Mean Constant score and mean strength were significantly higher in Sugaya I and II tendons than in Sugaya III (P = .021 and .003) and Sugaya IV and V tendons (P = .07 and .038), but did not differ between Sugaya III and Sugaya IV and V tendons. Mean Subjective Shoulder Value, pain, AHI were significantly higher and fatty infiltration and progression in the Hamada classification were significantly lower in Sugaya I and II tendons and in Sugaya III than in Sugaya IV and V tendons (P < .05), but did not differ between Sugaya I and II and Sugaya III tendons. Similar characteristics could also be observed in the long-term follow-up subgroup. CONCLUSION: Sugaya III tendons after revision rotator cuff repair do not allow restoration of strength thereby impacting the Constant score. However, there seems to be a protective effect of Sugaya III tendons with regard to pain, progression of proximal migration of the humeral head, osteoarthritis, and fatty infiltration, which seems to last at long-term follow-up.

Total shoulder arthroplasty for primary glenohumeral osteoarthritis: does posterior humeral subluxation persist after correction of the glenoid version at 5 years minimum?

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

Glenoid lateralization and subscapularis repair are independent predictive factors of improved internal rotation after reverse shoulder arthroplasty.

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

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND: 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. METHODS: 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 distance < 6 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). RESULTS: 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 index > 2 (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. CONCLUSION: 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 index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

Outcomes following revision of the revision total elbow arthroplasty.

BACKGROUND: There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure. METHODS: We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification. RESULTS: We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases. CONCLUSIONS: RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Reverse shoulder arthroplasty in rheumatoid arthritis: survival and outcomes.

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

Simulation in shoulder arthroplasty education using three-dimensional planning software: the role of guidelines and predicted range of motion.

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

Clinical and radiological outcomes of reverse shoulder arthroplasty for acute fracture in the elderly.

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

A Population Pharmacokinetic Analysis of Continuous Infusion of Cloxacillin during Staphylococcus aureus Bone and Joint Infections.

Intravenous administration of antibiotics is recommended during the early phase of methicillin-susceptible S. aureus (MSSA) bone and joint infection (BJI). We sought to compare the plasma concentrations of cloxacillin administered alternately by continuous and intermittent infusion (CI and ItI) in patients with MSSA BJI. In this prospective crossover trial, patients were randomly assigned to receive either 3 days of CI (two 75-mg/kg 12-h cloxacillin infusions per day) and then 3 days of ItI (four 37.5-mg/kg 1-h cloxacillin infusions per day) or vice versa. The drug concentration measurement was performed on day 3 of each type of administration at 1, 6, and 11 h and at 1, 2, 3, 4, and 6 h after the beginning of CI and ItI, respectively. We used the nonparametric algorithm NPAG to estimate population pharmacokinetic (PK) parameters. The final model was used to perform pharmacokinetic/pharmacodynamic (PK/PD) simulations and calculate the probabilities of target attainment (PTA) for several ItI and CI dosing regimens. We considered two PK/PD targets of time spent above the MIC for free cloxacillin concentrations (fT>MIC): 50 and 100%. Eighty-four concentrations from 11 patients were analyzed. A two-compartment model adequately described the data. ItI with q6h regimens and short 1-h infusions of 2,000 or 3,000 mg were associated with low PTA, even for the low target (50% fT>MIC) while 3-h infusions and continuous infusions (6 to 12 g/day) were associated with a PTA of >90% for an MIC up to 0.5 mg/liter. These results support the use of prolonged or continuous infusion of cloxacillin in patients with BJI.

Reverse shoulder-allograft prosthesis composite, with or without tendon transfer, for the treatment of severe proximal humeral bone loss.

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

SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae.

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

Bony increased-offset-reverse shoulder arthroplasty: 5 to 10 years' follow-up.

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

Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients.

INTRODUCTION: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure. METHODS: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. CONCLUSIONS: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.

Reverse shoulder arthroplasty for acute fractures in the elderly: is it worth reattaching the tuberosities?

HYPOTHESIS: Reverse Shoulder Arthroplasty (RSA) may be indicated in displaced proximal humerus fractures in elderly patients. We hypothesized that tuberosity fixation and healing around the prosthesis would result in better outcomes and patient satisfaction. METHODS: Thirty-eight acute displaced or dislocated 3- and 4-part fractures in elderly patients were treated with reattachment of the tuberosities around a RSA. The mean age at surgery was 80 ± 4 years (range, 70-88 years). A specific reverse fracture stem that incorporated a cancellous bone autograft (harvested from the fractured head) and a standardized suturing technique for tuberosity fixation were used in all operations. Patients were evaluated and radiographed with a minimum 2-year follow-up (mean 36 ± 8 months). RESULTS: The tuberosity union rate was 84% (32 of 38). There were 4 tuberosity resorptions and 2 tuberosity migrations with nonunion, which were associated with significantly lower subjective results (Subjective Shoulder Value of 65% vs. 83%, P = .029) and lower active mobility in forward elevation (115° ± 26° vs. 141° ± 25°, P = .023) and external rotation (11° ± 12° vs. 27° ± 12°, P = .010). Among the 5 disappointed patients, 3 presented with tuberosity resorption and 2 with tuberosity migration and nonunion. CONCLUSIONS: Despite the advanced age of the patients, tuberosity reattachment and use of bone graft results in a high rate of tuberosity healing. Tuberosity reconstruction and healing in reverse shoulder arthroplasty for fractures improves active forward elevation, external rotation, and patient satisfaction.

Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under.

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

The reverse shoulder arthroplasty angle: a new measurement of glenoid inclination for reverse shoulder arthroplasty.

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

Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing.

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.

Long-term humeral complications after Grammont-style reverse shoulder arthroplasty.

BACKGROUND: Recent experiences with Grammont reverse shoulder arthroplasty (RSA) have revealed some problems related to the biomechanical changes of the shoulder and humeral stem complications. We analyzed humeral complications in a long-term follow-up of a large series of RSAs, searching for correlations between these and the initial etiology, the follow-up duration, and the clinical outcomes. MATERIALS AND METHODS: Preoperative and postoperative clinical and radiologic assessments of 1035 RSAs with a minimum 5-year follow-up (implanted in 7 specialized shoulder centers between 1993 and 2010) were retrospectively collected. Postoperative humeral complications, managed conservatively or surgically, were radiographically documented. RESULTS: Overall, a 3.3% rate of postoperative humeral complications was found in our database. We identified 17 cases (1.6%) with postoperative humeral fractures, 15 cases (1.4%) with aseptic humeral loosening, and 3 cases (0.3%) with humeral stem disassembly. The humeral complications were more frequent in RSAs implanted for tumors, fracture sequelae, and revision for failed arthroplasty. DISCUSSION: Humeral complications after RSA are not rare, increase with longer follow-up, and have a negative impact on functional outcomes. Postoperative humeral fractures are more frequent in elderly patients, operated on through a superior approach, and after cemented stem implantation. In the absence of associated humeral loosening, conservative treatment should be preferred. Proximal humeral bone loss (due to revisions and tumors) is the most significant risk factor for humeral loosening. Implant unscrewing was initially related to a technological problem, which has been solved, and this complication has disappeared.