Postoperative rotator cuff integrity: can we consider type 3 Sugaya classification as retear?

BACKGROUND: Sugaya classification is a widely accepted classification system that is used to analyze postoperative rotator cuff tendon integrity. However, there are inconsistencies in the literature as to whether type 3 Sugaya should be considered as a retear or healed tendon. PURPOSE: We aimed to show that type 3 Sugaya is not a retear by comparing the long-term supraspinatus and infraspinatus muscle degeneration and the functional outcomes of type 3 with those of type 4 and 5 Sugaya. We hypothesized that the clinical course of type 3 Sugaya would be different from type 4 or 5 Sugaya. METHOD: The study was a retrospective multicenter review of all the rotator cuff repair done in 2003-2004. We included all the patients who had undergone supraspinatus repair with 10-year follow-up (magnetic resonance imaging done with full functional assessment). Data collection included pre- and postoperative supraspinatus and infraspinatus fatty infiltration, supraspinatus muscle atrophy, and Constant score with a separate analysis of its Strength subsection. Supraspinatus tendon integrity at 10-year follow-up was determined according to Sugaya classification. The patients were divided into 2 groups: type 3 Sugaya and type 4 and 5 Sugaya. Statistical comparison was done between the groups. RESULTS: There was no significant difference in the preoperative fatty infiltration of the supraspinatus and infraspinatus, supraspinatus muscle atrophy, and Constant score between the 2 groups. However, type 3 Sugaya patients had significantly better scores in the preoperative Strength subsection. Postoperatively, type 3 Sugaya patients showed significantly lesser fatty infiltration of the supraspinatus and infraspinatus, lesser supraspinatus muscle atrophy, and higher Constant score compared with type 4 and 5 Sugaya (P < .001). CONCLUSION: Patients with type 3 Sugaya supraspinatus tendon exhibited lesser muscle degeneration in the supraspinatus and infraspinatus and performed better in functional assessment compared with type 4 and 5 Sugaya patients. We inferred that type 3 Sugaya should not be considered as a retear.

Biomechanical model of distal articular humeral fractures-influence of bone density on the fracture threshold.

INTRODUCTION: Working hypothesis: The distal humeral bone density influences supracondylar fracture threshold. The aim of this study was first to develop a reproducible model of intra-articular distal humeral fractures and second to establish a relationship between bone mineral density (BMD) and the fracture threshold of the humerus. MATERIALS AND METHODS: An original model of the fracture was developed using ten sawbones. After obtaining a reproducible and clinically relevant fracture model, we tested 21 cadaveric distal humeri for which the BMD was known with a stainless-steel custom-made proximal ulna jig. Fractures were created using a servo hydraulic-testing machine in axial compression to simulate a fall onto an outstretched hand. Fracture lines, load to failure, and rigidity of the bone were recorded based on the stress-strain curves. RESULTS: The fracture generation was reliable, reproducible, and clinically relevant (type B2). A significant correlation between the BMD and the fracture threshold was found. Mean threshold was 901.86 N/m2. Mean distal humerus BMD was 0.9097 g/cm2 (r = 0.7321). CONCLUSIONS: We developed a reproducible articular fracture of the distal humerus model and found a correlation between the fracture threshold and bone mineral density.

Long-term outcomes of latissimus dorsi transfer for irreparable rotator cuff tears.

PURPOSE: The primary objective of this retrospective study was to validate electrophysiological results of latissimus dorsi tendon transfer (LDTT) to determine if this transfer is active for different daily living tasks, and the secondary objective was to correlate these clinical results. METHODS: With a mean follow-up of 4.7 years, 14 latissimus dorsi tendon transfers were retrospectively reviewed. Patients were clinically evaluated with the constant score and the SSV. Healing of the tendon on the greater tuberosity and atrophy of the LDTT muscle was determined by ultrasound and compared with the contralateral side. Electrical activity was analyzed by electromyography in active elevation, abduction, and external rotation. RESULTS: Twelve patients are satisfied (SSV). At the last follow-up, the EMG found a significant electrical activity in the abduction and external rotation and a lower activity in adduction and internal rotation. The mean constant score increased from 29 to 51, the mean forward elevation increased from 89° to 135°, the mean abduction from 92° to 105°, and the external rotation from 12° to 24°. The ultrasound found 12 healed tendons and two ruptures at the myotendinous junction. CONCLUSION: Electrical activity in abduction and external rotation testifies that the LDT transfer acts as an active muscle transfer and acts not only a muscle tenodesis that covers the humeral head.

Clinical and structural outcome twenty years after repair of isolated supraspinatus tendon tears.

BACKGROUND: This study evaluated the clinical and structural outcome 20 years after repair of isolated supraspinatus tendon tears. We hypothesized that the results would deteriorate over time. MATERIALS AND METHODS: For this retrospective multicenter study, 137 patients were recalled for a clinical and imaging assessment. Six patients (4.3%) had died from unrelated causes, 52 (38.0%) were lost to follow-up, and 13 (9.5%) had undergone reoperations. This left 66 patients for clinical evaluation. Radiographs and magnetic resonance imaging were additionally performed for 45 patients, allowing assessment of osteoarthritis, tendon healing, fatty infiltration (FI), and muscle atrophy. RESULTS: The Constant Score (CS) improved from 51.5 ± 14.1 points preoperatively to 71 points (P < .05) with a mean Subjective Shoulder Value (SSV) of 77.2% ± 22%. Tendon discontinuity (Sugaya IV-V) was present in 19 of 45 patients (42 %), and there was advanced FI (Goutallier III-IV) of the supraspinatus in 12 (27%) and of the infraspinatus muscle in 16 (35%). Supraspinatus atrophy was present in 12 patients (28%), advanced arthritis in 6, and cuff tear arthropathy in 12 (30%). The CS and SSV were significantly inferior for shoulders with FI of stages III to IV (P < .05). The CS was lower in cuff tear arthropathy and correlated with infraspinatus FI. CONCLUSIONS: At 20 years after surgical repair of isolated supraspinatus tears, the clinical outcome remains significantly above the preoperative state. FI of the infraspinatus is the most influential factor on long-term clinical outcome.

Does the cement mantle thickness influence the glenoid loosening in anatomic total shoulder arthroplasty? An experimental study.

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

Clinical and anatomic results of rotator cuff repair at 10 years depend on tear type.

PURPOSE: Although good short-term and mid-term outcomes are reported for rotator cuff repair, few studies have investigated long-term outcome with clinical and MRI evaluation. The hypothesis was that 10 years following repair of rotator cuff tear, the clinical and anatomic results depend on the extension of the tear. METHODS: The records of all 965 patients who underwent repair of rotator cuff tears in 2003 were retrieved. The patients were reviewed in 2014 for evaluation at a minimum follow-up of 10 years. A total of 511 patients were evaluated clinically, of whom 397 were also evaluated using MRI. There were 289 isolated supraspinatus tears (SS), 94 tears with posterior extension (P), 92 with anterior extension (A) and 36 with anteroposterior (AP) extension. RESULTS: The Constant score had significantly improved from 53.8 ± 14.7 preoperatively to 77.7 ± 12.1 (P < 0.0001) at 10 years, with no significant difference between the four groups. The rate of retear (Sugaya IV, V) was lower in the SS group (19%) and higher in the P (32%) and AP groups (31%). At review, infraspinatus fatty degeneration was significantly greater (Fuchs > 2) in the P (P < 0.001) and AP (P < 0.001) groups and subscapularis fatty degeneration was significantly greater (Fuchs > 2) in the A (P < 0.001) and AP (P < 0.001) groups. The rate of osteoarthritis (Samilson > 2) was significantly higher at 11% (P = 0.001) in the A group. The failure rate was significantly lower (P = 0.044) in the SS group (25%) than the massive rotator cuff tear groups (A, P and AP groups) (35%). Complications occurred in 51 shoulders (10%) and repeat surgery was required in 62 shoulders (12%), with no difference between the four groups. CONCLUSIONS: The long follow-up period of this study, large series of patients and MRI evaluation of tendon repair allowed us to demonstrate that 10 years following rotator cuff tear repair, between 68 and 81% of tendons had healed. These findings are of value in predicting response to surgical treatment. Tears with posterior extension had a higher risk of retear. However, surgical repair appeared to give a good functional outcome whatever the type of tear, despite the overall rate of complications and repeat surgery. LEVEL OF EVIDENCE: IV.

Tenodesis renders better results than tenotomy in repairs of isolated supraspinatus tears with pathologic biceps.

BACKGROUND: Many authors recommend systematic biceps tenotomy or tenodesis when repairing rotator cuff tears, regardless of whether the biceps is normal or pathologic. The purpose of this study was to determine whether 10-year outcomes of repairs of isolated supraspinatus tears are influenced by adjuvant biceps tenodesis or tenotomy. METHODS: Patients who underwent repair of isolated supraspinatus tears were recalled for evaluation at a minimum follow-up of 10 years. A total of 249 patients (51% men) aged 56.7 ± 6.3 years were evaluated clinically (Constant score), of whom 182 were also evaluated using magnetic resonance imaging (Sugaya classification). The biceps was intraoperatively found to be pathologic in 52% of shoulders, of which 39% had a tenotomy and 54% had a tenodesis; it was found to be normal in 48% of shoulders, of which 88% were left intact. RESULTS: There were no significant differences in Constant scores for patients who had normal biceps without adjuvant procedures (77.1 ± 11.7) compared with patients who had pathologic biceps with either tenodesis (79.8 ± 11.5, P = .104) or tenotomy (75.3 ± 10.7, P = .420). However, for patients who had pathologic biceps, Constant scores were significantly better for those with tenodesis compared with those with tenotomy (P = .025). Multivariable regression revealed Constant scores to be significantly lower for women, as well as patients with fatty infiltration of stages 1 and 2, but significantly higher for patients who underwent tenodesis. CONCLUSION: Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears, unless biceps pathology is observed intraoperatively, for which tenodesis grants better function and strength than tenotomy.

Ten-year clinical and anatomic follow-up after repair of anterosuperior rotator cuff tears: influence of the subscapularis.

BACKGROUND: Anterosuperior rotator cuff tears are more frequent than expected. We report the results of a 10-year follow-up study after repair. Our hypothesis was that the extent of the subscapularis tear influenced the prognosis. MATERIALS AND METHODS: The study population consisted of all 138 patients who underwent surgery in 14 participating centers in 2003 for full-thickness tears of the rotator cuff with lesions in the subscapularis and supraspinatus tendons. The patients were divided into 2 groups, depending on whether the subscapularis lesion affected only the superior half of the tendon (group A) or extended into the lower half (group B). Ninety-two patients (56 ± 7 years; 71 in group A and 21 in group B) were available for follow-up after 10 years (127 ± 16 months) with magnetic resonance imaging to evaluate tendon healing and muscle condition. RESULTS: The mean Constant scores were 59 ± 16 before surgery and 77 ± 14 at follow-up (P = 1.7 × 10-12). The retear rates were 25% for the supraspinatus and 13.5% for the subscapularis tendon. The clinical results for group A patients were better than those for group B. Severe fatty infiltration was observed more frequently in the subscapularis than in the supraspinatus muscle (27% vs. 12% of cases). Supraspinatus healing influenced subscapularis healing and fatty infiltration. CONCLUSIONS: Repair of anterosuperior rotator cuff tears is satisfactory at 10 years, particularly if the subscapularis tear is not extensive. An extensive subscapularis tear is a negative prognosis factor. Postoperatively, fatty infiltration of the subscapularis muscle was frequently observed despite tendon healing.

Fatty infiltration of stage 1 or higher significantly compromises long-term healing of supraspinatus repairs.

BACKGROUND: Fatty infiltration (FI) compromises outcomes of rotator cuff repairs. Most clinicians consider FI of the infraspinatus, whether it is torn or intact, because it is most rapidly affected. The purpose of this study was to report long-term outcomes of isolated supraspinatus repairs and to determine their associations with FI of the infraspinatus and supraspinatus. METHODS: The records of 182 patients who underwent repair of isolated supraspinatus tears and had preoperative magnetic resonance imaging were retrieved. Of these, 147 patients were evaluated at 10 years' follow-up using the Constant score and magnetic resonance imaging scans. RESULTS: Preoperative FI was greater in the supraspinatus (52% stage ≥1) than in the infraspinatus (29% stage ≥1). The 10-year Constant scores were influenced by FI of the supraspinatus (P = .006) but not of the infraspinatus (P = .422). Multivariable regression confirmed that Constant scores were significantly lower for female patients, repetitive work, and stage 1 and stage 2 FI of the supraspinatus in addition to open surgery. Retear rates (Sugaya types IV-V) were also influenced by FI of the supraspinatus (P = .001) but not of the infraspinatus (P = .979). Shoulders with supraspinatus FI at stages 0, 1, and 2 had retear rates of 10%, 22%, and 31%, respectively. Multivariable regression affirmed that the odds of retears are significantly increased by both stage 1 and stage 2 FI of the supraspinatus. CONCLUSIONS: The Constant scores and retear rates were significantly associated with FI of the torn supraspinatus (stage ≥1) but not of the intact infraspinatus. The authors recommend that rapid surgical intervention be considered, before accumulation of fat, especially for young, active patients.

Intratendinous rupture of the supraspinatus: anatomical and functional results of 24 operative cases.

INTRODUCTION: The aim was to describe the natural history of intratendinous partial rotator cuff tears as well as the anatomical and clinical results of surgical treatment of a cohort of 24 patients. PATIENTS AND METHODS: There were 14 men and 10 women with a mean age of 50 years. The right shoulder was involved in 17 cases. For 16 cases, a progressive history of shoulder pain was reported. Pre-operatively, a painful and positive Jobe's sign was observed in only 13 cases. Pre-operative mean absolute constant score was 63.52 points. Based on standard MRI, intratendinous lesions were diagnosed on the coronal view with hyper-signal within the tendon in the T2 FatSat sequence. No fatty infiltration was noted. Fourteen open and 10 arthroscopic repairs were performed. RESULTS: Patients were reviewed with clinical assessment and MRI. The final Constant score was 81.3 points with a mean gain of 18.5 points. Patients were back to work after a mean of 5.8 months and to sports after 6 months. The mean subjective result was of 8.9/10. Three cases of reflex sympathetic dystrophy were observed. DISCUSSION: Intratendinous tears of the supraspinatus tendon are rare and difficult to diagnose. Diagnosis relies on MRI (T2 FatSat). Trauma is not usually described. Chronic calcifying tendonitis may also contribute to the development of such tears. There is no associated fatty infiltration of the muscle. The Jobe's test is frequently painful or positive. Arthroscopic resection of the tendon insertion with reinsertion to the greater tuberosity seems to be the optimal treatment. LEVEL OF EVIDENCE: Retrospective study, IV.

The intra- and inter-observer reliability of the CT-scan based X index to quantify glenoid bone loss in chronic anterior shoulder instability and its impact on decision making.

PURPOSE: The X index is a measure of the antero-inferior glenoid bone loss on unilateral 2D CT-scans in the preoperative analysis of chronic anterior shoulder instability. Recurrence rate was shown to be higher after stabilization surgery if X index is superior or equal to 0.4. The objective of this study was to assess the intra- and inter-observer reliability of the X index. METHODS: Sixty patients with an X index ≥0.4 were included retrospectively. The X index was measured twice by two independent evaluators, 15 days apart. The measurement was performed on a unilateral 2D CT-scan by dividing the length of the antero-inferior glenoid defect over the maximal antero-posterior diameter of the glenoid. Reliability of X index was assessed with intra-class correlation coefficient (ICC, ρ). Two points were added to the ISIS calculation if its glenoid criterion was "zero" and we compared this modified score to the original one. RESULTS: The intra-observer reliability of the X index measurement was "excellent" (ρ = 0.95 ± 0.01, p < 0.0001) while the inter-observer reliability was "good" (ρ = 0.59 ± 0.08, p < 0.0001). In patients with a glenoid bone loss visualized by the X index, 48.3 % had a negative sclerotic glenoid line sign. This proportion significantly decreased with the augmentation of the X index, p = 0.02. The average original ISIS score was 3.4 ± 1.9 and became 4.3 ± 1.7 (p < 0.00001) when the X index was incorporated. CONCLUSIONS: The X index is a reliable and simple unilateral 2D CT-scan measurement. AP shoulder radiographs significantly underestimated glenoid bony lesions.

Routine one-stage exchange for chronic infection after total hip replacement.

PURPOSE: We hypothesized that a routine one-stage exchange for treatment of chronically infected total hip replacement (THR) will lead to (1) a higher rate of infection recurrence and (2) a poorer hip outcome than the published rates after two-stage exchange. METHODS: Sixty-five cases have been treated consecutively with one-stage exchange. All patients have been followed for a period of three to six years or until death or infection recurrence. RESULTS: The five-year rate for infection recurrence was 16%. The five-year survival rate for recurrence of the index infection was 8%. Forty-two percent of the hips had a good or excellent PMA score, and 46% a good or excellent OH score. CONCLUSIONS: Routine one-stage exchange was not associated with a higher recurrence rate and a poorer hip function than previously published series of two-stage exchange. Therefore, there is little support to choose two-stage exchange as the routine treatment for management of chronically infected THR.

Morphological analysis of the glenoid version in the axial plane according to age.

PURPOSE: Total shoulder arthroplasty planning requires a preoperative assessment of the glenoid version. This study aimed to determine the morphologic profile of the glenoid cavity and our null hypothesis was that age may affect the spiraling aspect. METHOD: 114 CT arthrographies of patients from 15 to 78 years old were included. Four groups were defined according to age: 15-29, 30-44, 45-59 years old, and over 60. The version of the glenoid was measured in the axial plane according to the most common method: a line is drawn between the osseous anterior and posterior margins of the glenoid and the version corresponds to the angle between this line and the transverse axis of the glenoid. The transverse axis of the scapula is determined by a line drawn from the center of the glenoid fossa to the medial border of the scapula. The axial plane (perpendicular to the supero-inferior axis of the glenoid cavity) was defined by multiplanar reconstruction. The measurements were performed at three regions of interest: the level of the coracoid process (region A), the level of the notch on the anterior border of the glenoid (region B), and the region of the greater antero-posterior diameter (region C). RESULTS: 96 % of the glenoid cavities included were retroverted. The mean version in region A was 11.9° (0-24.3, S-D 5.2), in region B 6.85° (-5.2 to 12.1, S-D 4.13) and in region C 4.04° (-7.7 to 11.1, S-D 4.04). The difference between the mean version of region A and region B was 5.02° and the difference between the mean version of the region B and the mean version of the region C was 2.81°. When considering the rate of change of the mean version between two adjacent regions, no difference was observed between the four groups of age. DISCUSSION: The analysis showed the importance of the axial reconstruction plan chosen to allow interpretable and reproducible measures. A decreasing version of the glenoid superior-to-inferior was observed, presenting a spiraling twist as described in previous studies. The profile of variation does not change in the four groups of patients included. The reconstruction of an articular surface as close to the anatomy as possible would also participate in establishing the muscular balance and the constraints on implants. Up to now, implants do not take into account this cranio-caudal twisting.

Anatomic attachment of the ACL. Comparison between radiological and CT analysis.

PURPOSE: The following hypothesis was tested: the location of the tibial and femoral anterior cruciate ligament (ACL) attachments will differ according to the measurement technique (plain radiographs or CT-scan) in relation to the anatomic frame of reference. METHODS: 10 gross specimens were studied. The location of metallic reference pins implanted around the tibial and femoral ACL attachments was recorded with reference to the bone contours with a caliper on the anatomic preparation, with standard plain AP and lateral radiographs and with a CT-scan. Results were compared with appropriate statistical tests at a 0.05 level of significance. RESULTS: The mean ratio between the antero-posterior tibia measurement and the center of the ACL tibial attachment varied from 50 to 52%. The mean ratio between the medio-lateral tibia measurement and the center of the ACL tibial attachment varied from 49 to 51%. The mean ratio between the antero-posterior femur measurement and the center of the ACL femoral attachment varied from 74 to 80%. The results were significantly different between the three techniques (respectively P = 0.003, P = 0.02 and P = 0.045). DISCUSSION: The paired differences were small (3% at the tibia, 6% at the femur). There was a strong correlation and a good agreement between the three techniques. It is likely that the small differences on the tibia have few, if any, clinical relevance. CONCLUSION: Both radiographic and CT-scan measurement techniques used during the present study have the potential to be used as quality control after ACL replacement. LEVEL OF EVIDENCE: Diagnostic study-investigating a diagnostic test. Development of diagnostic criteria in a consecutive series of patients and a universally applied "gold" standard, Level II.

Arthroscopic intramedullary nailing of humeral fractures through the rotator interval.

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

Post-traumatic elbow osteoarthritis after radial head arthroplasty: Prevalence and risk factors.

BACKGROUND: One of the treatment options for comminuted radial head fractures is radial head arthroplasty (RHA), especially when the elbow is also dislocated. While the clinical outcomes of RHA have been well documented, the incidence of post-traumatic osteoarthritis after RHA and its risk factors are not well known. OBJECTIVE: To determine the incidence of post-traumatic elbow osteoarthritis (humeroulnar and humeroradial joints) after RHA and identify its risk factors. METHODS: All patients who underwent RHA at our hospital between 2008 and 2016 were included retrospectively. The inclusion criteria were primary RHA, recent radial head fracture (isolated or associated with elbow dislocation), minimum 1 year of follow-up, clinical and radiographic examination at final assessment. The exclusion criteria were pre-existing elbow osteoarthritis, RHA revision, multiple fractures of the ipsilateral upper limb or polytrauma. The final assessment consisted of a clinical examination [joint range of motion (ROM) and Mayo Elbow Performance Score (MEPS)] and standard radiographs. The correlation between the incidence and severity of osteoarthritis and various risk factors was determined. RESULTS: Seventy-three patients were included in the analysis with a mean age of 56 years (21-85). The injuries consisted of 41 terrible triad, 15 isolated radial head fractures, 11 Monteggia fractures and 6 transolecranon fracture-dislocations. The mean follow-up was 3.4 years (1-10.9). At the final assessment, osteoarthritis was visible in the humeroulnar compartment in 56% of cases and in the humeroradial compartment in 72% of cases. There was a statistical correlation between the presence of humeroulnar osteoarthritis at the final assessment and ROM in flexion-extension (p=0.003), MEPS (p<0.001), duration of immobilization (p=0.03) and presence of posterior subluxation on immediate postoperative radiographs (p=0.012). The correlation between humeroradial osteoarthritis at the final assessment and ROM in flexion-extension (p=0.0054), RHA implant position (p<0.01), and unipolar configuration (p=0.027) was statistically significant. CONCLUSION: In our study, elbow osteoarthritis incidence after RHA was 56% in the humeroulnar joint and 72% in the humeroradial joint. RHA implant placement, posterior subluxation immediately postoperative and the duration of immobilization were significantly corelated with osteoarthritis. LEVEL OF EVIDENCE: IV; case series without control group.

Pitfalls and complications with locking plate for proximal humerus fracture.

PURPOSE: The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures. PATIENTS AND METHODS: Seventy-three adult patients with a displaced 3- (24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months. RESULTS: Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score (P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score (P = .029). Quality of the reduction of the greater tuberosity influenced final results (P = .037). Screw cutout rate was 13.7%, with an influence to the constant score (P = .001). A too high plate positioning influenced the constant score (P = .002). CONCLUSION: Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.

Comparison of bipolar and monopolar radial head prostheses in elbow fracture-dislocation.

INTRODUCTION: The role of bipolar radial head prostheses (RHP) in elbow fracture-dislocation is controversial, with some reports of poorer stabilization than with monopolar designs. The aim of the present study was to compare mono- versus bi-polar RHPs in elbow fracture-dislocation. The study hypothesis was that mono- and bi-polar RHPs do not differ in clinical and radiological results, complications or revision rates. MATERIAL AND METHODS: A single-center retrospective study included 58 patients, with a mean age of 55 years (range, 21-84 years). All received RHP for elbow dislocation with association: terrible triad, Monteggia fracture-dislocation, transolecranal dislocation or divergent dislocation. Two groups were compared: Mono-RHP, with monopolar prosthesis (n=40), and Bi-RHP, with bipolar prosthesis (n=18). All patients underwent clinical and radiological examination at last follow-up. RESULTS: Mean follow-up was 42.7 months (range, 12-131 months). There were no significant (p>0.05) inter-group differences in range of motion or Mayo Elbow Performance Score. Mono- versus bi-polar design did not correlate with onset of complications (p=0.89), surgical revision (p=0.71), persistent or recurrent instability (p=0.59), or ulnohumeral (p=0.62) or capitulum (p=0.159) osteoarthritis at last follow-up. DISCUSSION AND CONCLUSION: No differences were found between mono- and bi-polar RHPs in the treatment of elbow fracture-dislocation. Clinical and radiographic results were similar, as were complications and revision rates. The literature is inconclusive, reporting contradictory conclusions. We see no contraindications to bipolar RHPs in elbow dislocation with association, notably terrible triad injury. LEVEL OF EVIDENCE: III, Retrospective case-control study.

Biomechanics of open Bankart and coracoid abutment procedures in a human cadaveric shoulder model.

The specific aims of this experiment were (1) to develop a clinically relevant model of anteroinferior shoulder dislocation in the apprehension position to compare the biomechanics of the intact anterior capsuloligamentous structures, and (2) to evaluate the initial strength of an open Bankart and of a coracoid abutment procedure. Fifteen shoulders from deceased donors were used. For the intact shoulders, mean peak load was 486 N, and stiffness was 26,7 N/mm. For the Bankart repair, the mean peak load was 264 N, and mean stiffness was 14.1 N/mm. Transosseous repairs failed by suture pullout through soft tissues. For the coracoid abutment repair, the mean peak load was 607 N and stiffness was 25.57 N/mm. This study reveals that the biomechanical performance of the Bankart and coracoid abutment repairs fails to reproduce the properties of the natural intact state.

Anterior capsule re-attachment in terrible triad elbow injury with coronoid tip fracture.

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