Intramedullary nailing of humeral shaft fractures: percutaneous nailing in the lateral position through the Neviaser approach is a reliable technique.

BACKGROUND: Displaced humeral shaft fractures are frequently treated by osteosynthesis in the active patient. We aimed to evaluate the results of intramedullary nailing (IMN) in the lateral position with the Neviaser approach and to compare them with those from IMN nailing in the standard position and conventional approach. METHODS: In the retrospectively evaluated, single-center study, we compared 20 cases of long IMN for fractures of the proximal or middle third of the humerus shaft (Multilock; Synthes Laboratory) in the lateral position with the percutaneous Neviaser approach with 52 cases of IMN in the standard position. The mean age of patients was 62 ± 21 years. Clinical outcomes were analyzed: Constant score, subjective shoulder evaluation score and range of motion. Radiographically, entry point at the proximal part of the humerus, the healing rate and the possible association between the critical shoulder angle (CSA) and the correct positioning of the nail were assessed. RESULTS: With a mean follow-up of 26 ± 2 months, the healing rate was 89% (64/72) in the overall series, (eight patients in non-union), with no difference between the two groups. The overall mean active anterior elevation (AAE) was 125 ± 22°, mean external rotation (ER1) was 35 ± 17°, and mean internal rotation (IR) was at L3. The mean Constant score was 58 ± 23 and subjective shoulder evaluation score 73 ± 12%. ranges of motion were better in the lateral than standard position group (AAE 133 ± 17 vs. 122 ± 23, P = .03; ER1 47 ± 13 vs. 30 ± 16, P < .001; IR T12 vs. L5, P = .02). The nail was less often protruding in the lateral than standard position group (1/20 [5%] vs. 20/52 [38.5%], P = .002). The nail was better positioned from the anteroposterior view (nail centered: 16/20 [75%] vs. 26/52 [50%], P = .047) and lateral view (nail centered: 18/20 [90%] vs. 34/52 [65.4%], P = .02) in the lateral than standard position group. We found no association between nail position, type of approach and CSA. CONCLUSIONS: In the short-term follow-up, osteosynthesis of humeral shaft fractures by using long IMN in the lateral position with the Neviaser approach is a reliable technique. The positioning of the nail, in particular its entry point, and the clinical results were better with the lateral position and Neviaser approach than with the standard position and conventional approach. Further studies with a larger number of patients, assessment of the learning curve, and analysis of the impact of this technique on comorbidities (unchanged cerebral perfusion) are needed to fully validate this technique.

Isolated volar dislocation of the distal radioulnar joint: Current concepts review and case report.

Isolated volar distal radioulnar joint (DRUJ) dislocation is a rare condition with only a few cases reported in the literature. Its diagnosis is often overlooked in the acute phase, and there is no consensus in its management. We present the case of a 20-year-old male patient with an isolated volar radioulnar dislocation, together with a review of the literature. The aim is to present and summarize the acute management of this condition and propose a therapeutic algorithm.

Latarjet in women for anterior shoulder instability: a case series analysis.

PURPOSE: The Latarjet procedure is traditionally used to treat chronic anterior shoulder instability associated with glenoid bone loss. However, few series have analyzed outcomes in a female-only population. The objective of this study was to evaluate the clinical and radiological outcomes of a Latarjet bone block in this specific population. METHODS: This single-center retrospective study included 15 women (mean age 35 ± 11.3; 19-60) reviewed with a minimum follow-up of 2 years. The procedure was performed using the open bone block screw technique (n = 7) or by arthroscopy with cortical button (n = 8). Clinical evaluation was based on active range of motion measurements, Rowe and Walch-Duplay scores, and subjective shoulder value (SSV). Radiographic analysis explored bone block healing at the last follow-up. RESULTS: At a mean follow-up of 48 months (32-86), no recurrence was reported. The mean Rowe score was 91 points (70-100), Walch-Duplay 90 points (60-100), and SSV 87% (70-100). The active mobilities reached 169° (± 9°) in elevation, 57° (± 15°) in external rotation at side, and 89° (± 6°) in abduction. The return-to-sport rate was 91%. Five patients experienced persistent anterior pain, with screws requiring hardware removal in 2 (p = 0.02). Radiological assessment detected one case of nonunion (7%). CONCLUSION: Women treated with the Latarjet procedure experienced satisfactory midterm clinical outcomes. The arthroscopic technique using cortical button fixation seems to avoid residual anterior pain requiring hardware removal.

Incongruity of the scapulohumeral arch: an indirect sign of posterior subluxation of the humeral head in primary glenohumeral osteoarthritis.

BACKGROUND: In symptomatic glenohumeral osteoarthritis, arthroplasty is the gold standard to restore a mobile and painless shoulder. The kind of arthroplasty chosen is mainly based on the evaluation of the rotator cuff and the type of glenoid. The aim of this study was to analyze the scapulohumeral arch in primary glenohumeral osteoarthritis (PGHOA) with an uninjured cuff and to determine whether posterior humeral subluxation influences the Moloney line, which corresponds to an intact scapulohumeral arch. MATERIALS AND METHODS: Between 2017 and 2020, 58 anatomic total shoulder arthroplasties were implanted in the same center. We included all patients with complete preoperative imaging (radiographs and magnetic resonance imaging or arthro-computed tomography scans) assessing an intact rotator cuff. A total of 55 shoulders that had undergone surgery with a total anatomic shoulder prosthesis were analyzed after determination of the type of glenoid in the frontal plane according to the Favard classification on an anteroposterior radiograph and in the axial plane according to the Walch classification on computed tomography scans. The grade of osteoarthritis was evaluated according to the Samilson classification. We analyzed whether there was a rupture of the Moloney line on the frontal radiograph and assessed the acromiohumeral distance. RESULTS: After preoperative analysis of 55 shoulders, 24 shoulders had type A glenoids and 31 had type B glenoids. Scapulohumeral arch rupture was observed in 22 shoulders, and posterior subluxation of the humeral head was found in 31 shoulders, of which 25 had type B1 glenoids and 6 had type B2 glenoids according to the Walch classification. Most glenoids were type E0 (n = 47.85%). Incongruity of the Moloney line was more frequent in shoulders with type B glenoids (20 of 31 [65%]) than those with type A glenoids (2 of 24 [8%], P < .001). No patient with a type A1 glenoid (0 of 15) had a rupture of the Moloney line, and only 2 patients with a type A2 glenoid (2 of 9) had incongruity of the scapulohumeral arch. CONCLUSION: In PGHOA, rupture of the scapulohumeral arch seen on anteroposterior radiographs, also known as the Moloney line, may be an indirect sign of posterior humeral subluxation, corresponding to a type B glenoid per the Walch classification. Incongruity of the Moloney line may indicate a rotator cuff injury or posterior glenohumeral subluxation with an intact cuff in PGHOA.

Surgical treatment in child's congenital toe syndactyly: Risk factor of recurrence, complication and poor clinical outcomes.

INTRODUCTION: Surgical treatment of toe syndactyly remains controversial. The strong demand from parents for a cosmetic release is increasing in our societies. But is it worth it? The objective was to assess medium-long term outcomes and to identify the risk factors of recurrence, complication and poor clinical outcomes. METHODS: Sixty-eight toe syndactylies (38 patients) undergoing surgery between 2008 and 2017 with a follow-up higher than two years were included consecutively and retrospectively. Four children (four syndactylies) were lost to follow-up and excluded. The mean age of the first surgery was 3.9 years old (0.8-16.7) and cohort mean follow-up was 6.9 years (2.8-11.2). In all patients, web release with a commissural dorsal flap was performed and associated a cutaneous resurfacing (spontaneous epithelialization, full-thickness skin graft taken from the popliteal crease, or a hyaluronic acid ester matrix). RESULTS: Eighteen syndactylies (28.1%) in 14 patients recurred and one syndactyly required revision surgery. An age of surgery above two years was the only risk factor for recurrence found in univariate (OD = 0.27[0.08;0.85];p = 0.02) and multivariate studies (IC 95% = 0.05-0.68;p = 0.02). Seven complications (11.7%) in seven syndactylies (6 patients) were reported with six keloids (9.4%) and one scar retraction (1.6%). Each complication underwent an additional procedure. African ethnicity (N = 15) represents a risk factor (N = 4/15; OD = 0.12[0.009;0.97];p = 0.02) for keloids formation. Withey's average score is 4.9 (1-11), mean OxAFQ-C score was 52/60 (30-60), 67% would repeat the surgery and 69% felt satisfied at last follow-up. The simple syndactyly would appear less satisfied than complex or complicated (p = 0.02). CONCLUSIONS: Surgical treatment of child's congenital syndactyly involves a risk of recurrence (28%) and potential complications (11,7%). Performed surgical procedure over two years old increase the risk of recurrence. African ethnicity is a risk factor in scarring complication. Only half of simple syndactylies are satisfied and prone to repeat the surgery.

Pyrocarbon unipolar radial head prosthesis: clinical and radiologic outcomes at long-term follow-up.

BACKGROUND: Several studies have already reported good short-term results with a pyrocarbon unipolar radial head prosthesis (Pyc-uRHP). The aim was to evaluate the evolution from mid- to long-term clinical and radiographic outcomes of a Pyc-uRHP. METHODS: This was a retrospective, single-center study. We followed up all the patients who underwent Pyc-uRHP surgery in our original study at 2 years of follow-up (52 patients), reaching a minimum of 7 years of clinical and radiologic follow-up. This study included 26 patients who underwent a clinical examination assessing mobility, the Mayo Elbow Performance Score, and the visual analog scale score and radiologic evaluation with anteroposterior and profile radiographs at a mean follow-up of 110 months (range, 78-162 months). The radiologic study analyzed signs of proximal osteolysis, stem loosening, capitellar wear, and humeroulnar osteoarthritis. RESULTS: No patients required revision. Eight patients required reoperation: coronoid screw removal in 1 and arthrolysis for stiffness in 7. The mean time to reoperation was 11 months. The mean Mayo Elbow Performance Score at last follow-up was 96 ± 9 (of 100), with a pain score of 42 ± 7 (of 45), mobility score of 19 ± 2 (of 20), stability score of 10 (of 10), and function score of 25 (of 25). Comparison with clinical data from the mid-term delay did not reveal any significant difference. All patients presented with proximal osteolysis around the neck but without progression. No stem loosening was noted. The rates of humeroulnar osteoarthritis (12% at mid-term vs. 80% at last follow-up, P < .0001) and capitellar lesions (34% at mid-term vs. 80% at last follow-up, P = .001) increased significantly. CONCLUSION: We have shown that a Pyc-uRHP at 9 years' follow-up provided stable and satisfactory clinical results. Osteolysis of the radial neck was always present but it did not evolve, and no stem loosening was noted. Finally, we have shown a clear worsening of radiologic humeroulnar osteoarthritis and capitellar lesions that remained asymptomatic.

Results of radial head prostheses implanted during Essex-Lopresti syndrome in multicentric study.

AIMS: The aim was to evaluate the results of radial head prostheses (RHP) in Essex-Lopresti injury (ELI) and to compare results after RHP between acute and chronic ELI. PATIENTS AND METHODS: Thirty-one patients treated with RHP for ELI were selected from a multicenter retrospective series of 310 RHP, with follow-up greater than two years. Two groups were acute ELI group (n=19, average diagnosis = 5+/-9 days) and chronic ELI group (n=12, average diagnosis 8.4+/-7.1 months). RHP was associated in some cases with K-wires: during acute ELI to stabilize the distal radio-ulnar joint (n=4) or during chronic ELI with ulnar osteotomy or palliative surgery (n=4). Clinical and radiologic evaluation was performed including analysis of the complications and revisions rates, pain level, range of motion, and MEPS (Mayo Elbow Performance Score) and DASH score (Disabilities of the Arm, Shoulder and Hand). RESULTS: At last follow-up (71+/-38 months), survival of RHP in the acute ELI group was 84% (16/19) and 92% (11/12) in the chronic ELI group without statistically significant difference. Flexion (acute=131degrees+/-13.4 vs chronic=22+/-12.8, p=0.041) and supination (ELI=71+/-16.8 vs chronic=58+/-17.4; p=0.045) were better in acute ELI group. The DASH score was also better in the acute group (15+/-9.1 versus 24+/-15.2, p=0.048). There was more advanced stage of humero-radial osteoarthritis in the chronic ELI group (0.7+/-0.5 versus 1.4+/-0.6, p=0.041). CONCLUSION: RHP in acute ELIs provide better clinical results, although RHPs are part of the therapeutic arsenal to treat chronic ELI.

Pyrocarbon interposition shoulder arthroplasty in young arthritic patients: a prospective observational study.

BACKGROUND: We evaluated survival and midterm results of pyrocarbon interposition shoulder arthroplasty (PISA) in arthritic patients younger than 65 years. METHODS: Fifty-eight PISAs (InSpyre; Tornier-Wright, Bloomington, MN, USA), implanted in 56 patients between 2010 and 2015, were prospectively observed. The mean age at surgery was 52 ± 13 years. The cause was primary osteoarthritis (18), fracture sequelae (16), post-instability arthritis (15), aseptic necrosis (3), inflammatory disease (2), and failed hemiarthroplasty (4); 34 shoulders (61%) had previously undergone surgery. Glenoid erosion was assessed in 4 grades according to the Sperling classification. Humeral erosion was also assessed in 4 grades. Multivariate analysis was used to determine predisposing risk factors for both humeral and glenoid erosion. RESULTS: At a mean follow-up of 47 ± 15 months, survival rate was 90%. Six patients (10%) required conversion to reverse total shoulder prosthesis for painful glenoid erosion (n = 2) and humeral erosion with greater tuberosity stress fractures (n = 4). The mean Constant score and subjective shoulder value significantly increased from 36 ± 14 points to 70 ± 15 points and 32% ± 14% to 75% ± 19%, respectively (P < .001). Humeral medialization was observed in 78% of the cases with increased pain score. Uncorrected anteroposterior implant subluxation (12 cases) was associated with lower Constant score (50 points vs. 72 points; P = .02) and lower subjective shoulder value (53% vs. 78%; P = .002). On multivariate analysis, no risk factors for glenoid or humeral erosion were found. CONCLUSION: At midterm follow-up, PISA does not protect from progressive glenoid erosion and can lead to greater tuberosity erosion and stress fractures. Longer follow-up is required to see whether PISA survival will be superior to that of hemiarthroplasty.

Can Pyrocarbon be used as a functional spacer for the treatment of recalcitrant shoulder infections?

Background: The most common treatment approach in periprosthetic joint infection (PJI) and chronic shoulder joint infection (SJI) is a two-stage revision involving interval placement of an antibiotic cement spacer or a resection arthroplasty. Knowing that Pyrocarbon has a smooth surface that prevents pathogen adhesion, the question arises whether it could be used as a temporary or permanent functional spacer? Purpose: The primary objective of the present study was to assess the rate of infection eradication after temporary or definitive implantation of Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in patients with recalcitrant PJI or SJI. Our secondary objective was to assess mid-term clinical and radiographic outcomes. Methods: Fifteen patients (mean age: 52 ± 19 years) with chronic shoulder infection underwent, after joint débridement, implantation of PISA (InSpyre; Tornier-Stryker, Kalamazoo, MI, USA) with tailored perioperative antibiotics. In 7 cases, PJI occurred after hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 2), hemireverse (n = 2), and resurfacing arthroplasty (n = 1). In 8 cases, SJI occurred in the context of failed surgery after fracture sequelae (n = 4), instability (n = 2), and cuff arthropathy (n = 2). Preoperatively, patients had a mean of 3 previous failed surgeries before PISA implantation. Patients were evaluated with clinical, laboratory, and radiographic assessment at a minimum of 2 years after surgery. Results: At a mean follow-up of 55 ± 18 months, no patient experienced reinfection after temporary (3 cases) or definitive (12 cases) PISA implantation. The adjusted Constant score increased from 33% ± 20 preoperatively to 65% ± 28 at last follow-up and SSV from 22% ± 19 to 63% ± 23 (P < .001). Active forward elevation increased from 27° ± 19 to 113° ± 30, external rotation from 7° ± 21 to 25° ± 25, and internal rotation level 3 ± 2 to level 5 ± 2 points (P < . 001). On final radiographs of definitive PISA, complete humeral densification, or a neocortex, formed around the implant in 64% (7/11). Conclusion: Our data suggest that, after washout, débridement and tailored antibiotics, PISA can be used as a temporary or definitive functional spacer for the treatment of recalcitrant shoulder infections and presents the following advantages: (1) PISA does not seem to be a risk for recurrent infection thanks to the antibacterial property of Pyrocarbon; (2) PISA can be used as a temporary or a definitive spacer without causing bone erosion, thanks to the low modulus of elasticity of Pyrocarbon; (3) PISA can be used as a salvage procedure in case of complete glenoid or humeral destruction, thanks to the sphericity of the implant needing no implant anchorage.

Comparison of Return to Sports and Competition After the Arthroscopic Bristow-Latarjet Procedure Versus Arthroscopic Bankart Repair in Adolescents With Recurrent Anterior Shoulder Instability.

BACKGROUND: The use of isolated soft tissue repair versus bone block stabilization for the treatment of recurrent anterior shoulder instability in adolescents has no scientific evidence. PURPOSE: To compare the clinical outcomes of adolescent patients who underwent isolated arthroscopic Bankart (iB) repair with those who underwent the arthroscopic Bristow-Latarjet procedure in addition to Bankart (BLB) repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 60 shoulders in adolescents (aged 13-18 years) were reviewed with a minimum 2 years' follow-up: iB repair (n = 36) and arthroscopic Bankart repair with an additional Bristow-Latarjet procedure (BLB; n = 24). The characteristics of the patients in each group in terms of age at the first instability episode, age at surgery, hyperlaxity, participation in at-risk sports, and Instability Severity Index Score were comparable. The mean follow-up was longer in the iB group (7.7 vs 4.1 years, respectively), whereas the rates of patients engaged in competition and those with glenoid lesions were higher in the BLB group. The primary outcome measures were failure, defined as the recurrence of instability (clinical dislocation or subluxation), and return to sports. The mean follow-up was 6.2 years (range, 2-16 years). RESULTS: At the last follow-up, the rate of recurrence was significantly higher in the iB group, with 22% (8/36) failures, than in the BLB group, with 8% (2/24) instability recurrences (P < .05). The rate of return to sports at the same level was significantly higher after the BLB repair than after iB repair (79% vs 47%, respectively; P < .001). No statistical difference was found in patient-reported outcome scores between treatment groups (P > .05). Although failures occurred early after the BLB repair, 88% of failures after iB repair occurred after 2 years. On multivariate analysis, adolescents in the iB group with >3 episodes of preoperative dislocation and shoulder hyperlaxity (external rotation >90°) had a 60% recurrence rate (P < .005). CONCLUSION: Adolescent patients undergoing the BLB repair had a lower rate of recurrent instability and higher rates of return to sports and competition than those undergoing iB repair. Patients with shoulder hyperlaxity (external rotation >90°) and >3 dislocations had an unacceptable failure rate of 60% after iB repair.

Arthroscopic Distal Clavicle Bone Bock Combined With Hill-Sachs Remplissage for Primary Anterior Shoulder Instability Treatment.

Arthroscopic distal clavicle transfer is an effective option to treat anterior shoulder instability with glenoid bone loss. The use of this free bone graft in an all-inside procedure, with a cortical button fixation makes the construct simpler to perform and allows to be combined with a Hill-Sachs Remplissage to address humeral bone defect. The morbidity of the donor site is low and provide the biologic capacity of an autograft. We report a step-by-step procedure, and the rationale are discussed.

Dynamic pediatric shoulder instability: Etiology, pathogenesis and treatment.

Dynamic shoulder instability in children or adolescents, whose glenohumeral growth plates are still open, is a rare condition with an etiology that is hard to decipher. Atraumatic and recurrent forms are most common, contrary to adults. Disruptions to capsule and ligament maturation, muscle balance or bone growth can lead to glenohumeral instability. The etiology assessment, which needs to be multidisciplinary in atraumatic forms, aims to collect the medical history, analyze the direction of the instability, determine whether it is voluntary or involuntary, and look for a history of trauma, connective tissue abnormality, psychological disorder, neuromuscular pathology or congenital malformation. The initial treatment is conservative. It requires a multidisciplinary team when the shoulder instability is voluntary. Surgical treatment is reserved for symptomatic forms that do not respond to conservative treatment and have an impact on daily life and/or sports participation after a minimum of 6 months of well-conducted rehabilitation. The results of surgical stabilization mainly depend on the features of the instability, the anatomical structures damaged and the etiology. Episodes of recurrent instability in children/adolescents with open glenohumeral growth plates can fade in adulthood or can get worse with the development of structural damage. Early detection of poor outcomes and suitable treatment will help to limit the occurrence of osteoarthritis in the medium and long term. LEVEL OF EVIDENCE: Expert opinion.

Outcomes at Long-term Follow-up After Open Latarjet Versus Open Bankart Repair in Rugby Players.

Background: Because rugby is a collision sport, it exposes players to a high risk of recurrence after anterior shoulder stabilization. Therefore, the choice of surgical procedure warrants close attention in order to optimize the time to return to sport and the stability of the shoulder throughout the player's career. Hypothesis: The open Latarjet procedure would allow for a faster return to play and provide a lower rate of recurrence than the open Bankart repair at long-term follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: The study retrospectively enrolled 62 competitive rugby players who had undergone an anterior shoulder instability procedure and had at least 5 years of follow-up data. A total of 32 players treated with an open Bankart repair (BK group) were compared with 30 players (31 shoulders) treated with an open Latarjet procedure (LT group). Outcomes between groups were compared with the Rowe score, Walch-Duplay score, recurrence rate, and osteoarthritis evaluation on plain radiograph (Samilson classification). Results: The recurrence rate was significantly higher at 18.8% for the BK group (mean follow-up, 6.9 ± 1.7 years) compared with 3.3% for the LT group (mean follow-up, 6.2 ± 1.4 years) (P = .04). No postoperative complications occurred in the BK group, whereas 1 infection and 1 hematoma required a second surgery in the LT group (P = .14). In the BK and LT groups, 97% and 90% of players, respectively, were able to return to rugby at the same level or higher (P = .27), at a mean time of 8 and 6.3 months, respectively (P = .03). The mean Rowe and Walch-Duplay scores were not significantly different between the groups; however, the osteoarthritis rate was significantly higher in the BK versus the LT group (68% vs 38%, respectively; P = .03); 23% of patients, all in the BK group, had Samilson grade 2 osteoarthritis. Conclusion: The open Latarjet procedure outperformed the open Bankart procedure in terms of stability, time to return to play, and radiological outcomes at long-term follow-up in competitive rugby players.

Which preoperative factors influence the patient's short-term subjective assessment after rotator cuff repair?

INTRODUCTION: To highlight the preoperative risk factors that influence postoperative patient satisfaction following Rotator Cuff Repair (RCR) and to determine whether this satisfaction was correlated with tendon healing. HYPOTHESIS: Preoperative factors influence patient satisfaction, assessed by SSV (Subjective Shoulder Value) postoperatively, with a correlation with tendon healing. METHODS: With a mean age of 60.6 years (40-72), 102 patients with arthroscopic RCR were included retrospectively. The preoperative SSV score was less than or equal to 50%. There was clinical and radiological follow-up with an ultrasound evaluation of tendon healing 6 months postoperatively. We divided the patients into 2 groups using a postoperative SSV of 85% as the cut-off; 55 patients in the first group (SSV>85%); and 47 patients in the second group (SSV<85%). RESULTS: In multivariate analysis, Preoperative risk factors for poor postoperative SSV after RCR were: tobacco use [-8.41 (-13.64; -3.17) p=0.002], fatty infiltration [-3.65 (-6.24 -1.06) p=0.006] and workers compensation [-19.15 (-24.04; -14.27) p<0.001]. When patients were not in workers compensation, the lower their SSV score before surgery, the higher their postoperative SSV score. For patients in workers compensation, the higher the SSV preoperatively, the less elevated was SSV postoperatively. The Sugaya ultrasound classification did not influence the SSV score (p=0.15) CONCLUSIONS: Smoking, fatty infiltration and patients in workers compensation are factors of poorer subjective results evaluated by the SSV score. Tendon healing did not influence the SSV score and patient satisfaction. LEVEL OF EVIDENCE: IV, cohort study.

After failed radial head arthroplasty, what are the options? Risk factors and results of revisions in a multicenter study.

Introduction: Few multicenter studies have analyzed the outcome of revision surgery of radial head arthroplasties (RHA) in the medium term follow up. The objective is twofold: to determine the factors associated with revision of RHAs and to analyze the results of revision with 2 surgical techniques: isolated removal of the RHA or revision with a new RHA (R-RHA). Hypothesis: There are associated factors of RHA revision and RHA revision results in satisfactory clinical and functional outcomes. Methods: Twenty-eight patients were included in this multicenter retrospective study, with all surgical indications for initial RHA being traumatic/post-traumatic. The mean age was 47 ± 13 years with a mean follow-up of 70 ± 48 months. This series included two groups: the isolated RHA removal group (n = 17) and the revision RHA with new radial head prosthesis (R-RHA) group (n = 11). Evaluation was clinical and radiological with univariate and multivariate analysis. Results: Two factors associated with RHA revision were identified: a pre-existing capitellar lesion (p = 0.047) and a RHA placed for a secondary indication (<0.001). Revision for all 28 patients resulted in improved pain (pre-op Visual Analog Scale 4.7 ± 3 vs. post-op 1.57 ± 2.2, p < 0.001), mobilities (pre-op flexion 118 ± 20 vs. post-op 130 ± 13, p = 0.03; pre-op extension -30 ± 21 vs post-op -20 ± 15, p = 0.025; pre-op pronation 59 ± 12 vs post-op 72 ± 17, p = 0.04; pre-op supination 48 ± 2 vs post-op 65 ± 22, p = 0.027) and functional scores. Mobility and pain control were, for stable elbows, satisfactory in the isolated removal group. When the initial or revision indication was instability, the DASH (Disabilities of the Arm, Shoulder and Hand = 10 ± 5) and MEPS (Mayo Elbow Performance score = 85 ± 16) scores were satisfactory in the R-RHA group. Discussion: In the case of a radial head fracture, RHA is a satisfactory first-line solution without pre-existing capitellar injury, its results being much weaker in the case of ORIF failure and fracture sequelae. In case of RHA revision, isolated removal or R-RHA adapted according to the pre-operative radio-clinical exam. Level of evidence: IV.

Comparative study of a Y- anatomical and innovative locking plate versus double plate for supracondylar humeral fracture.

INTRODUCTION: There is no "gold standard" for the type of plate to be used for distal extra-articular humeral fractures; the most used is plating of each column. The objective was to evaluate the short-term clinical and radiological results of a Y- anatomical and innovative locking plate (YALP). HYPOTHESIS: The hypothesis is: this anatomical and innovative locking plate will produce satisfactory and reliable results on extra-articular distal humerus fracture superior to double plate fixation. MATERIALS AND METHODS: In a retrospective observational multicenter study, all patients with a distal humerus fracture type 13 A2.2 according to AO classification fixed with a new Y-plate (YALP) were compared to the results of double plate fixation for the same type of fracture. With a follow-up of more than 12 months, the objective and subjective clinical elbow criteria as well as the overall function of the upper limb and radiological assessment were collected. RESULTS: With an average follow up of 24±11 months, 26 patients met the inclusion criteria and received a YALP and 24 patients received double plate. All patients whose fracture had healed except one were pain-free (mean VAS 0.3±0.6). All patients had good subjective results (mean SEV 96%±4). Elbow function was excellent (mean total MEPS 96±4) with normal triceps strength (23/24 patients had a triceps strength graded 5/5 and one patient 4/5) and range of motion (flexion 139±8, extension -7±8 and pronosupination greater than 155 degrees). The operating time was shorter in the YALP group (84 ± 23minutes versus 97 ± 28minutes, p=0.03). The double plate group had more complications; the overall complication rate was significantly higher (p=0.02) in the double 90-degree plate group (12/24, 50%) with four nonunions, four symptomatic ulnar nerves, three hardware removals for pain and one radial nerve injury versus 5/26 complications (19%, p=0.02) in the Y-plate group: one iliac graft for nonunion, 1 plate removal due to functional discomfort, 1 twisted YALP, 1 broke interfragmentary screw and one symptomatic ulnar nerve. DASH, SEV, MEPS scores and flexion-extension range were better in the YALP group. DISCUSSION: YALP produces satisfactory results in supracondylar fractures of the distal humerus. The results of YALP appear to be better than the results with two 90° plates for the same fracture type with a shorter operative time and easier management of fractures with proximal diaphyseal extension. LEVEL OF EVIDENCE: III; case control study.

"Champagne Fracture": A Superior Fracture-Dislocation of the Proximal Humerus: A Case Report.

A 79-year-old right-handed woman presented with an indirect trauma to her left shoulder after a fall down the stairs. X-rays and computed tomography showed a four-part glenohumeral fracture-dislocation with a subcutaneous ectopic location of the humeral head in the retroclavicular space. A reverse total shoulder arthroplasty was performed using a deltopectoral approach with direct superior extraction of the humeral head. The result at 2 years was a subjective shoulder value of 80%, an absolute Constant score of 59, and a relative Constant score of 92/100. To the best of our knowledge, this is the first description in the literature of such a lesion of superior glenohumeral fracture-dislocation and its treatment.

What is the patient acceptance when only scapulectomy is possible in case of malignant tumor? A case series.

Background: Scapulectomy is one of the surgical options in the case of malignant lesions in the scapula with an indication of surgical removal. Very few series in the literature have looked at postoperative quality of life and emotional acceptance, particularly in the case of scapulectomy without reconstruction. The objective is to assess the midterm results of scapulectomies in terms of function, quality of life, and acceptance for the patient. Methods: With a mean follow-up of 85 months (range 42 months-180 months), 11 scapulectomies for malignant tumors were performed with a mean age of 50 years: 5 partial scapulectomies, 4 total scapulectomies, and 2 subtotal scapulectomies. There were 6 chondrosarcomas, 2 high-grade osteosarcomas, 1 malignant peripheral nerve sheath tumor, and 1 low-grade atypical epithelioid sarcoma. The radio-clinical analysis was focused on functional results and mental health evaluation. Results: The mean Musculoskeletal Tumor Society score of 11 scapulectomies was 20 ± 5 at 66% of normal, with the Disabilities of the Arm, Shoulder and Hand (DASH) score of 35 ± 26, and the Toronto Extremity Salvage Score of 76%. Patients had controlled pain (mean visual analog scale 1/10). Mobilities of the 11 scapulectomies were correct: average active anterior elevation of 89.5 ± 43 degrees, average abduction of 81 ± 42 degrees, average external rotation of 30 ± 25 degrees, and average internal rotation was at L5. Scapulectomy results in impaired physical and mental health compared with the general population (PCS-12 = -9; MCS-12 = -7). Partial scapulectomy, compared to total scapulectomy, gave better results: Musculoskeletal Tumor Society score (14 ± 1 vs. 24 ± 1 P = .0175), acceptance (45 ± 9 vs. 92 ± 16, P = .0184), mental health (MCS-12: 29 ± 1 vs. 55 ± 4, P = .0175), and Toronto Extremity Salvage Score (84 ± 5 vs. 68 ± 7, P = .0195). Partial and subtotal scapulectomies were better accepted (45 ± 9 vs. 86 ± 23, P = .0323) and tolerated (MCS-12: 29 ± 1 vs. 52 ± 6, P = .0099) by the patient compared to total scapulectomy. Conclusion: Total or partial scapulectomies without scapula reconstruction remain a disabling procedure performed with consequences on the physical and mental health of the patients. Partial or subtotal scapulectomy should be performed whenever possible because it seems to be associated with a better functional prognosis as well as less poor mental health and emotional acceptance of the patients, even though total scapulectomy may be necessary to obtain a complete curative tumor resection, which is the main goal.

Reconstruction by allograft-prosthetic composite reverse shoulder arthroplasty after proximal humerus tumor resection: Clinical and radiographic assessment at a minimum 2years' follow-up.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) is an option to conserve limb function after resection of proximal humerus malignancy. An allograft-composite RSA is an alternative to a tumor prosthesis, and can restore proximal humeral bone stock. The aim of the present study was to assess medium-term radiographic and clinical results for such composite implants. METHODS: Patients with malignant proximal humerus tumor treated by resection and reconstruction by composite RSA were retrospectively analyzed at a minimum 24months' follow-up. Clinical assessment used Constant score, Subjective Shoulder Value (SSV) and ADLER score. Standard radiographic work-up assessed allograft absorption and screened for implant loosening. RESULTS: Eleven patients were included, with a mean age of 51years (range: 19-87years) and mean 30months' follow-up (range: 24-84months). Mean tumor resection was 10cm (range: 6-17cm). Etiologies comprised chondrosarcoma (n=6), osteosarcoma (n=2), B-cell lymphoma (n=1) and single metastasis (n=2). Bony increased-offset allograft was associated to humerus reconstruction in 8 cases, and latissimus dorsi tendon transfer in 5 cases. Mean Constant score was 49 points, SSV 52%, and ADLER score 20 points. Increased glenoid implant offset associated to tendon transfer significantly improved anterior elevation and external rotation. Radiographic allograft consolidation to the native humerus was acquired in 73% of cases, while osteolysis in the epiphyseal-metaphyseal zone was found in 64%. There were no cases of humeral implant loosening. Glenoid allograft absorption was systematic (8/8 cases), without inducing loosening of the implant baseplate. CONCLUSION: Composite reverse shoulder arthroplasty is functionally effective after massive resection. However, allograft absorption is a drawback, casting doubt on continued use on the glenoid side. LEVEL OF EVIDENCE: IV.

Arthroscopic Latarjet: 2 or 4 Cortical Buttons for Coracoid Fixation? A Case-Control Comparative Study.

BACKGROUND: While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons. PURPOSE: To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months). RESULTS: The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B (P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B (P≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B (P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009). CONCLUSION: A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).