The open Latarjet-Patte procedure for the treatment of anterior shoulder instability in professional handball players at a mean follow-up of 6.6 years.

BACKGROUND: The popularity of team handball is increasing, with >10 million children playing this overhead throwing and collision sport with highest demands on the shoulder joint. Because of the risk of recurrent instability, the Latarjet-Patte (LP) procedure has been recommended to treat young competitive players. This is the first LP outcome study in professional handball players. METHODS: We retrospectively included 20 shoulders (18 players [17 male patients]; mean age, 22.9 years [range, 17-35 years]; minimum follow-up period, 2 years; mean follow-up period, 6.6 years) operated on by 3 expert surgeons (2011-2020) with the Walch LP technique. We documented preoperative hyperlaxity (25%, n = 5), affected throwing arm (55%, n = 11), position (backcourt, winger, and goalkeeper, 22% each; full back and pivot, 17% each), >2 dislocations prior (20%, n = 4), >10 dislocations prior (5%, n = 1), previous failed Bankart or humeral avulsion of glenohumeral ligament (HAGL) repair (10%, n = 2), and large Hill-Sachs lesions (HSLs) (20%, n = 4). Clinical and radiographic outcomes, visual analog scale score, Subjective Shoulder Value, Walch-Duplay score, Rowe score, and return-to-sport (RTS) rate were recorded. RESULTS: The RTS rate was 85% (17 of 20 shoulders); rate of RTS at the same level, 80% (16 of 20); and rate of RTS with no throwing pain, 73% (8 of 11). The time to training with a ball was 3.2 months, and the time to competition was 4.9 months. The mean Rowe score, Walch-Duplay score, and Subjective Shoulder Value were 90 points, 88 points, and 89%, respectively. Shoulder symptoms led players to give up handball in 2 cases (10%), whereas 1 player (5%) stopped playing handball for other reasons. We recorded 1 recurrent dislocation (5%) (non-throwing arm, winger, no recurrence after rehabilitation). Persistent apprehension occurred in 1 goalkeeper (5%). Residual pain was seen in 4 shoulders (20%); this was relieved by screw removal in 1. Resistant pain (throwing shoulder) was seen in 2 backcourt players (10%, 1 of whom had a large HSL) and 1 goalkeeper (5%; large HSL with >10 dislocations prior), all 3 of whom were aged > 30 years. Bone block positioning was correct (no lateral overhang) in all shoulders. At final follow-up, 1 shoulder (5%) showed mild arthritic changes (>10 dislocations, large HSL). CONCLUSION: The open LP procedure is consistent in providing shoulder stability combined with return-to-throwing performance in professional handball players with a short time to RTS and high same-level RTS rate without increasing the risk of arthritic changes. Throwing shoulders of backcourt players, large HSLs, or age > 30 years may have an increased risk of persistent symptoms.

Effects of the open Latarjet procedure on shoulder kinematics and periscapular muscle activity three months postoperatively.

BACKGROUND: The debate surrounding the influence of the open Latarjet procedure on postoperative scapular motions persists, and there is no evidence regarding its effects on periscapular muscle activation. This study aimed to assess the short-term influence of open Latarjet procedure on scapular kinematics and periscapular muscle activity during arm raising and lowering based on comparisons between patient and healthy athletes. METHODS: 22 healthy male athletes and 22 male athletes scheduled for glenohumeral stabilization surgery by open Latarjet procedure were included. Scapular kinematics, periscapular muscle activities and shoulder-related quality of life were recorded prior to surgery and 3 months postoperatively for the Latarjet group. For the healthy group, same assessments were performed 3 months apart. Bilateral differences in both scapular kinematics and periscapular muscle activation ratios, and Western Ontario Shoulder Instability (WOSI) index were defined as dependent variables. RESULTS: Scapular kinematics of the operated shoulder, namely scapular upward/downward rotation, internal/external rotation and anterior/posterior tilt recorded between 20° and 120° of humerothoracic elevation, showed no alterations 3 months post-surgery (p>0.05), and did not differ from those observed in healthy athletes (p>0.05). Similarly, all periscapular muscle activations were not different within time and between groups (p>0.05). WOSI index of the operated shoulder was significantly improved postoperatively (871.9 ± 443.7 vs. 1346.3 ± 552.3) but remained higher than the WOSI indices of the non-operated shoulder or those of the healthy group (52.7±75.6). CONCLUSION: This study emphasizes the short-term effects of the open Latarjet procedure, demonstrating an improvement in the shoulder-related quality of life 3 months after surgery. Notably, during this period, both kinematics and periscapular muscle activity remained consistent, and similar to the patterns observed for healthy athletes.

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.

Neck shaft angle in reverse shoulder arthroplasty: 135 vs. 145 degrees at minimum 2-year follow-up.

BACKGROUND: The most common complication with reverse shoulder arthroplasty Grammont based design with a 155° neck shaft angle (NSA) is scapular notching. Scapular notching has been associated with reduced clinical outcomes. Reducing the humeral NSA from 155° has been shown to reduce the incidence of scapular notching however it is unknown whether there is a difference in scapular notching between a 145° and 135° NSA. The purpose of this study was to evaluate the effect of decreasing the NSA on scapular notching rate and postoperative range of motion comparing 145° and 135° NSA stems at minimum 2 yr of follow-up. METHODS: Consecutive patients undergoing primary reverse shoulder arthroplasty with a NSA of either 145° or 135° between January 2014 and February 2019 were retrospectively reviewed. Patients were included if they were over the age of 18, had minimum clinical follow-up of 24 mo with true postoperative anteroposterior radiographic view. RESULTS: One hundred and three patients were included for the final analysis: 73 with a 145° NSA and 30 with a 135° NSA stem. The mean age and mean follow-up were respectively 70.9 yr (range, 52.0-89.0) and 32.1 mo. The overall incidence of scapular notching was 46.6 %. There was a statistically significant difference in scapular notching between the 145° (53.4%) and 135° (30%) NSA groups (P = .028). There was no difference in terms of postoperative Constant-Murley Score (mean, 66.1 vs. 68.2; P = .395), Subjective Shoulder Value (mean, 76.5 vs. 83.1%, P = .167), forward flexion (mean, 140° vs. 142°, P = .704), abduction (mean, 123.2° vs. 121.5°, P = .771), external rotation with the arm at the side (mean, 34.1° vs. 37.3°, P = .341) and internal rotation (mean, 5.3 vs. 5.4 pts P = .336) between the 2 groups. CONCLUSION: This is the first study to compare the effect of a 145° vs. 135° NSA on scapular notching rates. The key finding of this study is that scapular notching rate was significantly reduced from 53% to 30% in 135° NSA compared to 145° NSA, after at least 24 mo of follow-up. Our data also show that glenoid lateralization and inferiorization has an influence on scapular notching. We are unable to state that the reduced scapular notching rate was due to a reduction in NSA alone. Despite a lower rate of scapular notching, the 135° NSA group has not shown any significant better clinical and functional outcomes.

Anterior Shoulder Instability Part III-Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. METHODS: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. CONCLUSION: Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. METHODS: A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. CONCLUSION: Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. LEVEL OF EVIDENCE: Level V, expert opinion.

Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement.

PURPOSE: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability. METHODS: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. RESULTS: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors. CONCLUSION: Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization. LEVEL OF EVIDENCE: Level V, expert opinion.

Early clinical and radiographic outcomes of anatomic total shoulder arthroplasty with a biconvex posterior augmented glenoid for patients with posterior glenoid erosion: minimum 2-year follow-up.

BACKGROUND: Glenoid bone loss in anatomic total shoulder arthroplasty (aTSA) remains a controversial and challenging clinical problem. Previous studies have shown high rates of glenoid loosening for aTSA in shoulders with retroversion, posterior bone loss, and posterior humeral head subluxation. This study is the first to present minimum 2-year follow-up data of an all-polyethylene, biconvex augmented anatomic glenoid component for correction of glenoid retroversion and posterior humeral head subluxation. METHODS: This study is a multicenter, retrospective review of prospectively collected data on consecutive patients from 7 global clinical sites. All patients underwent aTSA using the biconvex posterior augmented glenoid (PAG). Inclusion criteria were preoperative computed tomographic (CT) scan, minimum 2 years since surgery, preoperative and minimum 2-year postoperative range of motion examination, and patient-reported outcome measures (PROMs). Glenoid classification, glenoid retroversion, and posterior humeral head subluxation were measured from preoperative CT and radiography and postoperative radiography. Statistical comparisons between pre- and postoperative values were performed with a paired t test. RESULTS: Eighty-six of 110 consecutive patients during the study period (78% follow-up) met the inclusion criteria and were included in our analysis. Mean follow-up was 35 ± 10 months, with a mean age of 68 ± 8 years (range 48-85). Range of motion statistically improved in all planes from pre- to postoperation. Mean visual analog scale score improved from 5.2 preoperation to 0.7 postoperation, Single Assessment Numeric Evaluation score from 43.2 to 89.5, Constant score from 41.8 to 76.9, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score from 49.8 to 86.7 (all P < .0001). Mean glenoid retroversion improved from 19.3° to 7.4° (P < .0001). Posterior subluxation improved from 69.1% to 53.5% and posterior decentering improved from 5.8% to -3.0% (P < .0001). There was 1 patient with both a prosthetic joint infection and radiographic glenoid loosening that required revision. Seventy-nine of 86 patients had a Lazarus score of 0 (no radiolucency seen about peg or keel) at final follow-up. CONCLUSIONS: This study shows that at minimum 2-year follow-up, a posterior-augmented all-polyethylene glenoid can correct glenoid retroversion and posterior humeral head subluxation. Clinically, there was significant improvement in both range of motion and PROMs.

Adjusting Implant Size and Position Can Improve Internal Rotation After Reverse Total Shoulder Arthroplasty in a Three-dimensional Computational Model.

BACKGROUND: Efforts during reverse total shoulder arthroplasty (RSA) have typically focused on maximizing ROM in elevation and external rotation and avoiding scapular notching. Improving internal rotation (IR) is often overlooked, despite its importance for functional outcomes in terms of patient self-care and hygiene. Although determinants of IR are multifactorial, it is unable to surpass limits of bony impingement of the implant. Identifying implant configurations that can reduce bony impingement in a computer model will help surgeons during preoperative planning and also direct implant design and clinical research going forward. QUESTIONS/PURPOSES: In a CT-modeling study, we asked: What reverse total shoulder arthroplasty implant position improves the range of impingement free internal rotation without compromising other motions (external rotation and extension)? METHODS: CT images stored in a deidentified teaching database from 25 consecutive patients with Walch A1 glenoids underwent three-dimensional templating for RSA. Each template used the same implant and configuration, which consisted of an onlay humeral design and a 36-mm standard glenosphere. The resulting constructs were virtually taken through ROM until bony impingement was found. Variations were made in the RSA parameters of baseplate lateralization, glenosphere size, glenosphere overhang, humeral version, and humeral neck-shaft angle. Simulated ROM was repeated after each parameter was changed individually and then again after combining multiple changes into a single configuration. The impingement-free IR was calculated and compared between groups. We also evaluated the effect on other ROM including external rotation and extension to ensure that configurations with improvements in IR were not associated with losses in other areas. RESULTS: Combining lateralization, inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion resulted in a greater improvement in internal rotation than any single parameter change did (median baseline IR: 85° [interquartile range 73° to 90°]; combined changes: 119° [IQR 113° to 121°], median difference: 37° [IQR 32° to 43°]; p < 0.001). CONCLUSION: Increased glenosphere overhang, varus neck-shaft angle, and humeral anteversion improved internal rotation in a computational model, while glenoid lateralization alone did not. Combining these techniques led to the greatest improvement in IR. CLINICAL RELEVANCE: This computer model study showed that various implant changes including inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion can be combined to increase impingement-free IR. Surgeons can employ these currently available implant configurations to improve IR when planning and performing RSA. These findings support the need for further clinical studies validating the effect of implant configuration on resultant IR.

Modified L'Episcopo tendon transfer for isolated loss of active external rotation.

BACKGROUND: Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation. METHODS: A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up. RESULTS: Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%). CONCLUSION: In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.

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.

Grammont Award 2018: Scapular fractures in reverse shoulder arthroplasty (Grammont style): prevalence, functional, and radiographic results with minimum 5-year follow-up.

BACKGROUND: Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up. MATERIALS AND METHODS: We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views. RESULTS: Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points). CONCLUSIONS: Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture.

Three-dimensional characterization of the anteverted glenoid (type D) in primary glenohumeral osteoarthritis.

BACKGROUND: The Walch classification describes glenoid morphology in primary arthritis. As knowledge grows, several modifications to the classification have been proposed. The type D, a recent modification, was defined as an anteverted glenoid with or without anterior subluxation. Literature on the anteverted glenoid in primary osteoarthritis is limited. The purpose of this study, therefore, was to analyze the anatomic characteristics of the type D glenoid on radiographs and computed tomography (CT). METHODS: The shoulder arthroplasty databases from 3 institutions were examined to identify patients with primary glenohumeral osteoarthritis and glenoid anteversion (≥5°), with or without anterior subluxation. The type D study cohort consisted of 18 patients (3% of the osteoarthritis cohort) and was a mean of 70 years old, with 11 women and 7 men. All radiographs were reviewed, and computed tomography Digital Imaging and Communications in Medicine (National Electrical Manufacturers Association, Rosslyn, VA, USA) data were analyzed on validated 3-dimensional imaging software. Rotator cuff fatty infiltration, glenoid measurements (anteversion and inclination), and humeral head subluxation according to the scapular plane were determined. RESULTS: In the study cohort, the mean glenoid anteversion was 12° (range, 5°-24°), the mean inclination was 0°, and the mean anterior subluxation was 38% (range, 6%-56%). Eight patients (44%) had a biconcave glenoid with a posterosuperiorly positioned paleoglenoid and an anteroinferiorly positioned neoglenoid, and 10 patients had a monoconcave glenoid. Fatty infiltration of the rotator cuff muscles never exceeded Goutallier stage 2. CONCLUSION: The type D glenoid is an addition to the original Walch classification and is characterized by glenoid anteversion (≥5°), anteroinferior humeral head subluxation, and absence of severe subscapularis fatty infiltration.

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.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older.

BACKGROUND: The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization. METHODS: A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations. RESULTS: Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients. CONCLUSIONS: The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Postoperative radiographic findings of an uncemented convertible short stem for anatomic and reverse shoulder arthroplasty.

BACKGROUND: Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA. METHODS: There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio. RESULTS: At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014). CONCLUSIONS: The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

Arthroscopic Latarjet Techniques: Graft and Fixation Positioning Assessed With 2-Dimensional Computed Tomography Is Not Equivalent With Standard Open Technique.

PURPOSE: To analyze graft and fixation (screw and EndoButton) positioning after the arthroscopic Latarjet technique with 2-dimensional computed tomography (CT) and to compare it with the open technique. METHODS: We performed a retrospective multicenter study (March 2013 to June 2014). The inclusion criteria included patients with recurrent anterior instability treated with the Latarjet procedure. The exclusion criterion was the absence of a postoperative CT scan. The positions of the hardware, the positions of the grafts in the axial and sagittal planes, and the dispersion of values (variability) were compared. RESULTS: The study included 208 patients (79 treated with open technique, 87 treated with arthroscopic Latarjet technique with screw fixation [arthro-screw], and 42 treated with arthroscopic Latarjet technique with EndoButton fixation [arthro-EndoButton]). The angulation of the screws was different in the open group versus the arthro-screw group (superior, 10.3° ± 0.7° vs 16.9° ± 1.0° [P < .001]; inferior, 10.3° ± 0.8° vs 15.7° ± 0.9° [P < .0001]). The angulation of the EndoButtons was 5.7° ± 0.5°; this was different from that of open inferior screws (P = .003). In the axial plane (level of equator), the arthroscopic techniques resulted in lateral positions (arthro-screw, 1.5 ± 0.3 mm lateral [P < .001]; arthro-EndoButton, 0 ± 0.3 mm lateral [P < .0001]) versus the open technique (0.9 ± 0.2 mm medial). At the level of 25% of the glenoid height, the arthroscopic techniques resulted in lateral positions (arthro-screw, 0.3 ± 0.3 mm lateral [P < .001]); (arthro-EndoButton, 0.7 ± 0.3 mm lateral [P < .0001]) versus the open technique (1.0 ± 0.2 mm medial). Higher variability was observed in the arthro-screw group. In the sagittal plane, the arthro-screw technique resulted in higher positions (55% ± 3% of graft below equator) and the arthro-EndoButton technique resulted in lower positions (82% ± 3%, P < .0001) versus the open technique (71% ± 2%). Variability was not different. CONCLUSIONS: This study shows that the position of the fixation devices and position of the bone graft with the arthroscopic techniques are statistically significantly different from those with the open technique with 2-dimensional CT assessment. In the sagittal plane, the arthro-screw technique provides the highest positions, and the arthro-EndoButton technique, the lowest. Overall, the mean position of the bone block with the open Latarjet technique in the axial plane is slightly medial to the joint line, as recommended. Conversely, with the arthroscopic techniques, the bone grafts are more lateral with a slight overhang. The main differences are observed in the dispersion of the values (more extreme positions) with the arthro-screw technique, given the acknowledged limitations. Despite the statistical significance, the clinical significance of these differences is yet unknown. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Short-term radiographic results of a cemented polyethylene keeled glenoid component with varying backside radiuses of curvature.

BACKGROUND: This study analyzed the radiographic results of a cemented all-polyethylene keeled glenoid component available in different sizes and multiple backside radiuses of curvature. METHODS: The study group consisted of 118 cases (114 patients). There were 63 women and 51 men. Mean age at the time of arthroplasty was 68 years (range, 51-85 years). True anterior-posterior radiographs obtained postoperatively and at the final follow-up were analyzed for implant seating and the occurrence of radiolucent lines. Glenoid morphology and fatty infiltration of the rotator cuff muscles were examined using computed tomography scans. Mean follow-up was 38 months (range, 24-70 months). RESULTS: The mean radiolucent line score after surgery was 0.54 points (range, 0-3 points), and 90% had no or only 1 radiolucent line. At the final follow-up, the mean score was 1.06 points (range, 0-3 points), and 74% had no or only 1 radiolucent line. The score increased significantly over time (P < .001). No component was at risk for loosening. No correlation was found between patient age, sex, hand dominance, glenoid morphology, or fatty infiltration of the rotator cuff muscles and the occurrence of radiolucent lines. CONCLUSION: In the short-term, the glenoid component analyzed in this study showed promising radiographic results, with a low number of radiolucent lines without failure. However, the mean radiolucent line score increased significantly over time, and long-term observations are necessary to confirm a possible advantage compared with older component designs.

Increased scapular spine fractures after reverse shoulder arthroplasty with a humeral onlay short stem: an analysis of 485 consecutive cases.

BACKGROUND: Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients. METHODS: A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture. RESULTS: A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P < .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion. CONCLUSION: Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.

Is the two-dimensional computed tomography scan analysis reliable for coracoid graft positioning in Latarjet procedures?

BACKGROUND: The aim of the study was to develop a computed tomography (CT)-based measurement protocol for coracoid graft (CG) placement in both axial and sagittal planes after a Latarjet procedure and to test its intraobserver and interobserver reliability. METHODS: Fifteen postoperative CT scans were included to assess the intraobserver and interobserver reproducibility of a standardized protocol among 3 senior and 3 junior shoulder surgeons. The evaluation sequence included CG positioning, its contact area with the glenoid, and the angle of its screws in the axial plane. The percentage of CG positioned under the glenoid equator was also analyzed in the sagittal plane. The intraobserver and interobserver agreement was measured by the intraclass correlation coefficient (ICC), and the values were interpreted according to the Landis and Koch classification. RESULTS: The ICC was substantial to almost perfect for intraobserver agreement and fair to almost perfect for interobserver agreement in measuring the angle of screws in the axial plane. The intraobserver agreement was slight to almost perfect and the interobserver agreement slight to substantial regarding CG positioning in the same plane. The intraobserver agreement and interobserver agreement were both fair to almost perfect concerning the contact area. The ICC was moderate to almost perfect for intraobserver agreement and slight to almost perfect for interobserver agreement in analyzing the percentage of CG under the glenoid equator. CONCLUSION: The variability of ICC values observed implies that caution should be taken in interpreting results regarding the CG position on 2-dimensional CT scans. This discrepancy is mainly explained by the difficulty in orienting the glenoid in the sagittal plane before any other parameter is measured.