Glenoid loosening and migration in reverse shoulder arthroplasty.

AIMS: The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years. PATIENTS AND METHODS: We retrospectively studied the records of 79 patients (19 men, 60 women; 84 shoulders) aged 70.4 years (21 to 87) treated for aseptic loosening of the glenosphere following RSA. Clinical evaluation included pre- and post-treatment active anterior elevation (AAE), external rotation, and Constant score. RESULTS: From the original cohort, 29 shoulders (35%) were treated conservatively, 27 shoulders (32%) were revised by revision of the glenosphere, and 28 shoulders (33%) were converted to hemiarthroplasty. At last follow-up, conservative treatment and glenoid revision significantly improved AAE, total Constant score, and pain, while hemiarthroplasty did not improve range of movement or clinical scores. Multivariable analysis confirmed that conservative treatment and glenoid revision achieved similar improvements in pain (glenoid revision vs conservative, beta 0.44; p = 0.834) but that outcomes were significantly worse following hemiarthroplasty (beta -5.00; p = 0.029). CONCLUSION: When possible, glenoid loosening after RSA should first be treated conservatively, then by glenosphere revision if necessary, and last by salvage hemiarthroplasty Cite this article: Bone Joint J 2019;101-B:461-469.

Epidemiology of malpractice claims in the orthopedic and trauma surgery department of a French teaching hospital: A 10-year retrospective study.

INTRODUCTION: Orthopedic and trauma surgery is the specialty for which claims for compensation are most often filed. Little data exists on the subject in France, especially in a teaching hospital. We conducted a retrospective study aimed at (1) identifying the epidemiological characteristics of patients filing claims against the orthopedic surgery and traumatology department of a teaching hospital in France, (2) analyzing the surgical procedures involved, the type of legal proceedings, and the financial consequences. HYPOTHESIS: The epidemiological profile of proceedings seeking damages in France is consistent with the data from European and American studies. MATERIALS AND METHODS: An observational, retrospective, single-center study of all claims for damages between 2007 and 2016 involving the orthopedic and trauma surgery department of a teaching hospital was carried out. Patients' epidemiological data, the surgical procedure, type of legal proceeding, and financial consequences were analyzed. RESULTS: Of the 51,582 surgical procedures performed, 71 claims (0.0014%) were analyzed (i.e., 1/726 procedures). A significant increase in the number of cases (p=0.040) was found over a 10-year period. Of these, 36/71 (53.7%) were submitted to the French regional conciliation and compensation commission (CRCI), 23/71 (32.8%) were filed with the administrative court, and 12/71 (13.4%) were submitted for an amicable settlement. The most common reason for which patients filed claims was hospital-acquired infections, with 36/71 (50.7%) cases. Twenty-nine complaints (40.8%) resulted in monetary damages being awarded to the patient, with an average award of € 28,301 (€ 2,400-299,508). Damage awards were significantly higher (p<0.05) for cases involving surgery on a lower limb than those involving an upper limb. CONCLUSION: Claims against orthopedic surgeons have been increasing significantly over the last 10 years. Although rare, they represent a significant cost to society. Hospital-acquired infections are the main reason for disputes in our specialization. LEVEL OF EVIDENCE: IV, retrospective study.

Shoulder patient-specific guide: First experience in 10 patients indicates room for improvement.

BACKGROUND: Implantation of the glenoid component of a total shoulder prosthesis can be facilitated by using a patient-specific guide (PSG) designed to ensure replication of the preoperatively planned position. The objective of this study was to assess the reliability and accuracy of a PSG in replicating the planned glenoid component position during total shoulder arthroplasty (TSA). HYPOTHESIS: Additional criteria should be used for 3D preoperative planning and PSG design to further improve the accuracy of glenoid component positioning. MATERIAL AND METHODS: We studied 10 patients who underwent TSA with use of a PSG to position the glenoid component after preoperative 3D planning. Postoperative glenoid version and tilt were measured and compared to the planned values. We also used new criteria to assess implant rotation and global 3D position, as well as accuracy of the 3D pilot hole for the glenoid guide-pin. RESULTS: Mean errors in glenoid position were -1.7°±4.4° for version, -0.4°±4.9° for tilt, and 6.0°±13.5° for rotation. Mean difference in global orientation of the glenoid implant versus the planned value was 4.9°±2.5°. Mean 3D discrepancy in glenoid pilot hole position was 2.9±0.5mm; the discrepancy was greater in the mediolateral direction (1.9±0.9mm) than in the supero-inferior (1.1±1.2mm) and antero-posterior (0.8±1.2mm) directions. DISCUSSION: The poor performance of the PSG in controlling rotation and reaming may explain the difference in global glenoid position compared to the planned value. Improvements in PSG design to incorporate these two parameters deserve consideration. LEVEL OF EVIDENCE: II, prospective cohort study.

Superior glenoid inclination and glenoid bone loss : Definition, assessment, biomechanical consequences, and surgical options.

Correct anatomical alignment of the glenoid component is of central importance for wear and loosening in shoulder endoprostheses. The aim of this article is to review and clarify the biomechanical and clinical effects of incorrect glenoid inclination in reverse and anatomical joint replacements. Based on the literature and on our own work, statements are made about the following: (1) the glenoid inclination of a normal glenoid, a degenerative glenoid and a glenoid implant, and the consequences if superior inclination is too large, and (2) the surgical technique as well as tips and tricks for correct adjustment of the inclination. The inclination of the glenoid plane is a morphological parameter of the scapula with high individual variation and is best measured using reformatted computed tomography using three-dimensional software for reconstruction and evaluation. The standard value is between 0 and 10°. Excessive superior inclination promotes translation of the humeral head and the formation of rotator cuff tears-in a degenerative glenoid, to superior wear. The correct amount of superior inclination of the glenoid component is essential for the survival of the implant. Positioning without excessive superior inclination is therefore mandatory. Precise preoperative determination of glenoid inclination and wear is important in order to correctly plan the positioning of an implant. This serves as the basis for deciding whether a bone graft or patient-specific instrumentation is necessary. Thus, the surgeon also has prognostic parameters for the anticipation of possible complications as a result of the bone defect and abnormal orientation. However, the evaluation must always include the position of the scapula in these considerations.

Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases.

INTRODUCTION: No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other. MATERIAL AND METHODS: This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN). RESULTS: After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group. CONCLUSION: If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area. LEVEL OF EVIDENCE: IV, retrospective study.

Lateral elbow ligamentoplasty by autologous tendon graft in posterolateral rotatory instability: Results in 18 cases at a mean 5 years' follow-up.

INTRODUCTION: Posterolateral rotatory instability is the most frequent form of elbow instability. This clinical entity, described by O'Driscoll et al. in 1991, concerns young subjects following elbow trauma. Diagnosis is founded on symptomatology and positive posterolateral rotatory instability test. Treatment is based on reconstruction of the ulnar bundle of the lateral collateral ligament. The present study assessed medium-term clinical and radiological results in lateral ligamentoplasty for posterolateral elbow instability. MATERIALS AND METHODS: A retrospective continuous single-center series included 19 cases: 11 male, 8 female, operated on between 1995 and 2010; mean age was 37.8 years (range, 20-63 years). Surgery consisted in lateral ulnar collateral ligament reconstruction by autologous palmaris longus tendon graft following Nestor et al. (1992). RESULTS: Eighteen patients were assessed at a mean 61 months' follow-up. Mean time off work was 3.2 months (range, 2-7 months); all patients returned to work. No revision surgery was required. Mean range of motion in flexion, extension, pronation and supination was respectively 135°, 8°, 84° and 76°. Instability test was systematically negative at follow-up. Mean Mayo Clinic and Quick-DASH scores were respectively 90 (range, 60-100) and 21 (range, 0-63). All patients were satisfied or very satisfied with their result. CONCLUSION: Lateral ulnar collateral ligament reconstruction by autologous palmaris longus tendon graft provided reliable and lasting results. We consider it to be the reference treatment for chronic instability, and sometimes in acute post-traumatic instability. LEVEL OF EVIDENCE: IV.

Do subacromial ultrasonography findings predict efficacy of intra-bursal injection? Prospective study in 39 patients.

BACKGROUND: Ultrasonography has become an investigation of choice in the management of shoulder pain. The objective of this study was to determine whether the efficacy of subacromial-subdeltoid bursa injection correlated with the ultrasound findings. MATERIAL AND METHODS: We prospectively recruited patients who were seen between November 2012 and November 2013 for subacromial pain and whose rotator cuff was either intact or showed a full-thickness tear less than 1cm in length. A standardised physical examination of the shoulder was followed immediately by static and dynamic ultrasonography, intra-bursal injection of lidocaine, and a repetition of the same physical examination. Recorded ultrasonography features were the appearance of the bursa, shape of the coraco-acromial ligament, and bursal deformation induced by passage under the coraco-acromial ligament during dynamic imaging. A response to the injection was defined as greater than 75% improvements in at least three of the physical examination parameters. RESULTS: We included 39 patients with a mean age of 56.7 years. Ultrasonography showed abnormalities of the bursa in 30 patients, including 1 with an intra-bursal effusion, 10 with thickening, and 19 with both. Deformation of the bursa under the coraco-acromial ligament was noted in 26 patients. The proportions of patients with bursal effusion and with bursal thickening were similar in the 20 responders and 19 non-responders. Neither were any significant differences found for coraco-acromial ligament shape or bursal deformation under the ligament. CONCLUSIONS: No correlation was found between ultrasonography findings and the efficacy of a local anaesthetic injection into the subacromial bursa. These findings suggest that ultrasound abnormalities may constitute mere physiological changes, in keeping with earlier studies in asymptomatic individuals. Thus, subacromial impingement may be currently overdiagnosed.

Failed subacromial decompression. Risk factors.

BACKGROUND: Arthroscopic subacromial decompression (acromioplasty) is widely held to be effective, although pain may persist after the procedure. The objective of this study was to evaluate the proportion of patients with residual pain (i.e., the failure rate) after isolated subacromial decompression and to look for predictors of failure. MATERIAL AND METHOD: We conducted a retrospective multicentre study of 108 patients managed with isolated arthroscopic subacromial decompression between 2007 and 2011, for any reason. We excluded patients in whom surgical procedures on the rotator cuff tendons were performed concomitantly. Data were collected from the medical records, a telephone questionnaire, and radiographs obtained before surgery and at last follow-up. Failure was defined as persistent pain (visual analogue scale score>3) more than 6 months after surgery and at last follow-up. RESULTS: The failure rate was 29% (31/108). Two factors significantly predicted failure, namely, receiving workers' compensation benefits for the shoulder condition and co-planing. Heterogeneous calcific tendinopathy and deep partial-thickness rotator cuff tears were also associated with poorer outcomes, but the effect was not statistically significant. DISCUSSION: Co-planing may predict failure of subacromial decompression, although whether this effect is due to an insufficient degree of co-planing or to the technique itself is unclear. Nevertheless, in patients with symptoms from the acromio-clavicular joint, acromio-clavicular resection is probably the best option. Receiving workers' compensation benefits was also associated with treatment failure, as a result of well-known parameters related to the social welfare system. CONCLUSION: Isolated arthroscopic subacromial decompression is effective in 70% of cases. We recommend the utmost caution if co-planing is considered and/or the patient receives workers' compensation benefits for the shoulder condition, as these two factors are associated with a significant increase in the failure rate. LEVEL OF EVIDENCE: IV (retrospective study).

Effect of scapular pillar anatomy on scapular impingement in adduction and rotation after reverse shoulder arthroplasty.

BACKGROUND: Notching of the scapular pillar is the main radiographic complication seen during follow-up of reverse shoulder arthroplasties. Several recommendations pertaining to the implantation technique and glenoid component design have been suggested. No studies have investigated potential anatomic risk factors for inferior scapular impingement. HYPOTHESIS: A specific anatomic shape of the scapular pillar promotes the development of notching. MATERIALS AND METHODS: The Aequalis Reversed(®) (Tornier Inc., Edina, MN, USA) prosthesis was implanted into 40 cadaver scapulae. We measured maximal range-of-motion (ROM) in internal rotation, external rotation, and adduction. The anatomic specimens were then imaged using two-dimensional computed tomography (CT) and the scapular neck angle, surface area under the scapular pillar, and distance from the central glenosphere peg to the inferior glenoid rim were measured. Associations between these CT parameters and ROM values were assessed using statistical independence tests. RESULTS: ROM values were greatest when the surface area under the scapular pillar was above 0.8 cm(2) (P<0.5). This feature combined with a scapular neck angle less than 105° produced the largest ROM values (P<0.5). DISCUSSION: The scapular neck angle alone is not sufficient to identify a scapular morphology that increases the risk of notching. The surface area under the scapular pillar, in contrast, discriminates between scapulae with and without a high risk of notching. The surface area under the scapular pillar is influenced by the inferior glenoid offset. CONCLUSION: We were unable to define a specific scapular shape at high risk for notching. The prevention of notching should rely chiefly on a rigorous glenoid component implantation technique, with particular attention to the inferior offset. LEVEL OF EVIDENCE: III, experimental study.

Isolated paralysis of the serratus anterior muscle: surgical release of the distal segment of the long thoracic nerve in 52 patients.

INTRODUCTION: Isolated serratus anterior (SA) paralysis is a rare condition that is secondary to direct trauma or overuse. Patients complain of neuropathic pain and/or muscle pain secondary to overexertion of the other shoulder stabilizing muscles. As the long thoracic nerve (LTN) passes along the thorax, it can be compressed by blood vessels and/or fibrotic tissue. The goal of the current study was to evaluate the outcomes of surgical release of the distal segment of the LTN in cases of isolated SA paralysis. PATIENTS AND METHODS: This was a retrospective study of 52 consecutive cases operated on between 1997 and 2012. The average patient age was 32 years (range 13-70). Patients had been suffering from paralysis for an average of 2 years (range 4-259 months); the paralysis was complete in 52% of cases. Every patient underwent a preoperative electroneuromyography (ENMG) assessment to confirm that only the SA was affected and there were no signs of re-innervation. RESULTS: Every patient had abnormal intraoperative findings. There were no complications. All patients showed at least partial improvement following the procedure. The improvement was excellent or good in 45 cases (86.7%), moderate in 4 cases (7.7%) and slight in 3 cases (5.6%). In 32 cases (61.5%), the winged scapula was completely corrected; it was less prominent in 19 cases and was unchanged in one case. The best outcomes following surgical release occurred in patients who presented without preoperative or neuropathic pain and were treated within 18 months of paralysis. DISCUSSION: Isolated SA paralysis due to mechanical injury resembles entrapment neuropathy. We discovered signs of LTN compression or restriction during surgery. Surgical release of the distal segment of the LTN is a simple, effective treatment for pain that provides complete motor recovery when performed within the first 12 months of the paralysis. LEVEL OF EVIDENCE: IV.

Shoulder stabilization by modified Latarjet-Patte procedure: results at a minimum 10 years' follow-up, and role in the prevention of osteoarthritis.

INTRODUCTION: In 1995, our team modified the Latarjet-Patte procedure by associating "south-north" capsule retention with reinsertion to the edge of the glenoid cavity to the coracoid bone-block. HYPOTHESIS: The present minimum 10-year follow-up study tested the hypothesis that the rate of osteoarthritis could be reduced by the strictly extra-articular position of the bone-block and stability be enhanced by the associated Bankart effect. MATERIAL AND METHOD: Between January 1995 and December 2001, 78 shoulders were stabilized using the modified Latarjet-Patte procedure in 76 patients with a mean age at surgery of 26.7 years; 89.7% could be followed up, 82.8% of whom also had radiographic follow-up. Fifty-nine were sports players, including 25 at competition level. Stability was assessed on a questionnaire, any dislocation or subluxation being counted as recurrence. RESULTS: At a mean 13 years' follow-up (range, 10-15 years), there had been no revision surgery. Mean Duplay score was 82.6, mean Subjective Shoulder Value 91.9% and the satisfaction rate 98.5%. The recurrence rate was 1.4% and 10 patients reported residual apprehension. The osteoarthritis rate was 8.5%. Seven bone-blocks projected, but only one was associated with osteoarthritis (stage 1) (non-significant). There were 4 non-unions and 9 lyses, without instability or pain. DISCUSSION: The modified procedure provided a low rate of recurrence and an incidence of osteoarthritis (8.5%) much lower than in any other published series with a minimum 10 years' follow-up. The strictly extra-capsular situation of the bone-block appeared as an important factor in limiting long-term osteoarthritis. Capsule reinsertion also seemed to alleviate the radiologic complications. LEVEL OF EVIDENCE: IV, retrospective study.

Influence of glenoid component design and humeral component retroversion on internal and external rotation in reverse shoulder arthroplasty: a cadaver study.

BACKGROUND: A common disadvantage of reverse shoulder arthroplasty is limitation of the range of arm rotation. Several changes to the prosthesis design and implantation technique have been suggested to improve rotation range of motion (ROM). HYPOTHESIS: Glenoid component design and degree of humeral component retroversion influence rotation ROM after reverse shoulder arthroplasty. MATERIAL AND METHODS: The Aequalis Reversed™ shoulder prosthesis (Tornier Inc., Edina, MN, USA) was implanted into 40 cadaver shoulders. Eight glenoid component combinations were tested, five with the 36-mm sphere (centred seating, eccentric seating, inferior tilt, centred with a 5-mm thick lateralised spacer, and centred with a 7-mm thick lateralised spacer) and three with the 42-mm sphere (centred with no spacer or with a 7-mm or 10-mm spacer). Humeral component position was evaluated with 0°, 10°, 20°, 30°, and 40° of retroversion. External and internal rotation ROMs to posterior and anterior impingement on the scapular neck were measured with the arm in 20° of abduction. RESULTS: The large glenosphere (42 mm) was associated with significantly (P<0.05) greater rotation ROMs, particularly when combined with a lateralised spacer (46° internal and 66° external rotation). Rotation ROMs were smallest with the 36-mm sphere. Greater humeral component retroversion was associated with a decrease in internal rotation and a significant increase (P<0.05) in external rotation. The best balance between rotation ROMs was obtained with the native retroversion, which was estimated at 17.5° on average in this study. DISCUSSION: Our anatomic study in a large number of cadavers involved a detailed and reproducible experimental protocol. However, we did not evaluate the variability in scapular anatomy. Earlier studies of the influence of technical parameters did not take humeral component retroversion into account. In addition, no previous studies assessed rotation ROMs. CONCLUSION: Rotation ROM should be improved by the use of a large-diameter glenosphere with a spacer to lateralise the centre of rotation of the gleno-humeral joint, as well as by positioning the humeral component at the patient's native retroversion value.

Tranexamic acid decreases risk of haematomas but not pain after hip arthroplasty.

BACKGROUND: Tranexamic acid decreases total blood loss after total hip arthroplasty (THA). Total blood loss is the sum of external bleeding and bleeding into tissues, i.e., haematomas. Haematomas may cause acute or even chronic postoperative pain. HYPOTHESIS: Tranexamic acid decreases haematomas, thereby diminishing postoperative pain after THA. METHODS: In a retrospective matched case-control study, patients receiving tranexamic acid (15 mg/kg, before the incision and again at skin closure) were compared to controls not given tranexamic acid. Matching was on sex, surgeon, and peri-operative analgesics (ketamine, ketoprofen, pregabalin, and nefopam). Standardised protocols were used for anaesthesia, analgesia, and blood sparing. Haematoma volume was computed as the difference between total blood loss (estimated from the erythrocyte counts on days -1 and +5) and measured external blood loss. Patients were monitored from D0 to D7 then interviewed by telephone on D30, D90, and D180. To detect a 30%-decrease in the morphine dose at H24 (criterion 1) and D7 (criterion 2) and a 20% decrease in haematoma volume on D5 (criterion 3), the required numbers of patients were 90, 90, and 77, respectively; therefore, 95 patients were included. RESULTS: Tranexamic acid decreased haematoma volume by 30% (351±254 mL versus 247±189 mL erythrocytes, P=0.002), had no effect on morphine consumption at H24 (12±11 mg versus 14±12 mg, P=0.346), increased morphine consumption on D7 (26±24 mg versus 35±36 mg, P=0.029), and had no effect on long-term pain. DISCUSSION: After THA, tranexamic acid decreases haematoma volume without improving analgesia. LEVEL OF EVIDENCE: 3 (case-control study).

Meniscus matching: evaluation of direct anatomical, indirect radiographic, and photographic methods in 10 cadaver knees.

INTRODUCTION: When performing meniscus transplantation, allograft size must be carefully matched to the host knee anatomy. The radiographic method devised by Pollard et al. is the current reference standard for meniscus size matching. The primary objective of this study was to compare the accuracy of radiographic measurement according to Pollard, direct anatomic measurement, and photographic measurement. HYPOTHESIS: Anatomic and photographic allograft size measurement is as reliable as radiographic host-knee sizing according to Pollard et al. MATERIALS AND METHODS: Three methods for measuring meniscal width and length based on reliable landmarks were assessed in 10 cadaver knees: direct measurement of anatomic specimens, measurement of photographs, and the radiographic method described by Pollard et al. RESULTS: No significant differences were found between the anatomic and radiographic methods, whereas the anatomic and photographic methods produced significantly different results. Compared to the anatomic method, mean overall measurement error was 7.9% for the radiographic method and 24.1% for the photographic method. DISCUSSION: The photographic method used in everyday practice during allograft harvesting is not reliable. Correcting for magnification bias might improve the performance of the photographic method. The radiographic method described by Pollard et al. is acceptable, with a margin of error of about 10%, which is considered tolerable. In practice, however, the radiographic method is burdensome to use. CONCLUSION: The best measurement method is direct measurement of the specimen during allograft harvesting. LEVEL OF EVIDENCE: Level IV.

Surgical management of rotator cuff tears in adults: Prospective study of 50 consecutive patients and professional practice self-assessment.

INTRODUCTION: As part of quality-improvement efforts, we self-assessed our professional practices regarding the surgical management of rotator cuff tears comparatively to recommendations issued by the French National Authority for Health (HAS). MATERIAL AND METHODS: An independent observer prospectively evaluated 50 consecutive patients with rotator cuff tears treated surgically over a 1-year period. For each patient, we identified divergences with the 20 relevant HAS recommendations. RESULTS: Initially, 54% of practices were found to diverge from HAS recommendations, 10% regarding the preoperative work-up, 14% the duration of initial medical treatment, and 30% the nature of the surgical procedure. DISCUSSION: A review of the data showed that 26% of practices diverged from recommendations, 10% regarding the preoperative work-up, 2% the duration of initial medical treatment, and 14% the nature of the surgical procedure. Overall, for the 26% of divergent practices, 10% were related to judgement or evaluation errors and 16% to a deliberate and substantiated decision made by the surgeons. CONCLUSION: The clinical practice guidelines issued by the HAS, although useful and necessary, were shown by our study to exhibit a number of limitations. Thus, our data illustrate the complexity of surgical management decisions. LEVEL OF EVIDENCE: Level IV (cases series).

Revision of total shoulder arthroplasty.

In France, the number of revisions for total shoulder arthroplasty (TSA) has increased by 29% between 2006 and 2010. Published studies have reported a revision rate of approximately 11% for hemi-arthroplasty and total anatomical implants, and 10% for reversed implants. The decision to revise or not revise a TSA requires that a rigorous, clinical, laboratory and imaging initial assessment be done in order to answer five questions. Is it infected? Is it unstable? Is it worn? Is it loosened? How is the rotator cuff? This assessment and an evaluation of the bone stock are required to decide whether or not to revise. If the problem is infection, the best solution is not always complete removal of the implant, which results in very poor shoulder function. In such a situation, a multidisciplinary consultation is essential in the decision-making. If the problem is instability, the cause must be identified and rectified. Instability is often caused by insufficient restoration of the humerus length. If the problem is loosening, the type of revision must take into account the patient's age, the rotator cuff status and the available bone stock. The possibilities to reimplant an anatomical glenoid are scarce, and only for cases with minor bone loss and an intact cuff. If a bone graft without reimplantation of a glenoid component is preferred, it should be a tricortical graft to resist wear and medialisation. In the other cases, a reversed shoulder implant with an autograft is preferable. Whether or not the humeral stem is loose, it must often be removed. However, its removal is very difficult, risky and it often causes complications, with humerus fracture being the most common. The possibility of reconstruction depends on the quality of the remaining bone stock. In all these risky situations, the patient should be duly informed and should take part in the decision-making process.

Nefopam after total hip arthroplasty: role in multimodal analgesia.

BACKGROUND: Multimodal analgesia combining several non-opioid analgesics is recommended for pain control after surgery. In one study of total hip arthroplasty (THA), pain relief achieved by adding ketamine to the paracetamol-ketoprofen combination was statistically significant but remained inadequate in most patients. In two other studies, the analgesic effect of nefopam was synergistic with that of ketoprofen and additive with that of paracetamol. Adding nefopam to the paracetamol-ketoprofen-ketamine combination has not been evaluated. HYPOTHESIS: Adding nefopam to the paracetamol-ketoprofen-ketamine combination significantly improves analgesia after THA. MATERIAL AND METHODS: A prospective single-centre comparative non-randomised study (control group then nefopam group) was conducted in patients undergoing THA under general anaesthesia. All patients received paracetamol-ketoprofen-ketamine and morphine/droperidol patient-controlled analgesia. The nefopam group also received a continuous infusion of nefopam (120 mg/d for 48 h). Pain was evaluated daily for 7 days. The main evaluation criteria were morphine consumption, and pain intensity evaluated using a numerical rating scale and a validated questionnaire. To detect a 40% morphine-sparing effect by H24 (α=0.05 and ß=0.2), 85 patients were needed in each group. RESULTS: The two groups (90 patients/group) had no significant differences for perioperative characteristics, pain scores, morphine consumption at H24 (nefopam, 13 ± 12 mg and control, 14 ± 13 mg, P=0.39), or functional recovery. Compared to the control group, the nefopam group had lower rates of nausea/vomiting (P<0.0001), pruritus (P=0.002), and visual disturbances (P=0.02). DISCUSSION: Nefopam failed to improve pain relief when added to a multimodal analgesia regimen but alleviated several morphine-induced side effects. Redundancy between nefopam and ketamine may explain the absence of greater pain relief. This study emphasises the need for clinical evaluations of every analgesic regimen, as the available data were not sufficient to predict these results. LEVEL OF EVIDENCE: Level III, case-control study.

Shoulder hemiarthroplasty: outcomes and long-term survival analysis according to etiology.

BACKGROUND: The indications for hemiarthroplasty in glenohumeral joint diseases remain controversial and depend mainly on the original underlying diagnosis. Our objective was to investigate the influence of the primitive aetiology on long-term prosthesis survival and on the Constant-Murley score. MATERIALS AND METHODS: We studied 272 shoulders with the following diagnoses: fracture sequelae (n=73), primary osteoarthritis (n=67), cuff tear arthropathy (n=43), avascular necrosis (n=40), rheumatoid arthritis (n=31), and other (n=18). Of the 272 shoulders, 139 were evaluated after at least 8 years (mean follow-up, 134 months). In all, 30 prostheses required removal. Functional status was evaluated using the Constant-Murley score and survival rate using the Kaplan-Meier method with prosthesis removal or conversion to total arthroplasty as the endpoint. RESULTS: Ten-year prosthesis survival was 88.13% overall, 100% in the rheumatoid arthritis group, 94.9% in the avascular necrosis group, 94.2% in the primary osteoarthritis group, 81.5% in the cuff tear arthropathy group, and 76.8% in the fracture sequelae (P=0.05). The mean Constant-Murley score after 8 years or more was 70.1 in avascular necrosis, 60.7 in primary osteoarthritis, 57.7 in fracture sequelae, 55.3 in rheumatoid arthritis, and 46.2 in cuff tear arthropathy (P=0.0006). The complication rate with the initial population as the denominator was 24.7% in fracture sequelae, 18.6% in cuff tear arthropathy, 15% in avascular necrosis, 8.9% in primary osteoarthritis, and 3.2% in rheumatoid arthritis. CONCLUSIONS: The best indication for shoulder hemiarthroplasty is avascular necrosis and the worst indications are cuff tear and post-traumatic fracture sequellae. Rheumatoid arthritis and primary glenohumeral osteoarthritis are good indications in patients younger than 50 years of age. LEVEL OF EVIDENCE: Level IV, retrospective study.

Total shoulder arthroplasty - arthroplasty for glenohumeral arthropathies: results and complications after a minimum follow-up of 8 years according to the type of arthroplasty and etiology.

INTRODUCTION: Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology. The aim of our study was to evaluate the rate of complications and the functional improvement with different types of shoulder arthroplasties after a minimum follow-up of 8 years. MATERIALS AND METHODS: This was a multicenter retrospective study of 198 shoulders including 85 primary osteoarthritis of the shoulder, 76 cuff tear arthropathies, 19 avascular necrosis and 18 rheumatoid arthritis. Arthroplasties included 104 anatomic total shoulder arthroplasties (TSA), 77 reverse arthroplasties and 17 hemiarthroplasties. Ten patients had their arthroplasty revised, and 134 patients with TSA were able to be present at the final follow-up or provide information on their case. Function was evaluated by the Constant-Murley score and loosening by standard radiographs. RESULTS: In the group with primary osteoarthritis of the shoulder, there were eight complications (11%) including six (8.3%) requiring implant revision. In the group of rotator cuff arthropathies, there were nine (14.7%) complications including four (6.5%) requiring implant revision. In the group with rheumatoid arthritis, there was one complication, and no surgical revision was necessary. There were no complications in the group with avascular necrosis. Glenoid migration occurred in 28.5% of anatomic TSA, and 3.4% of reverse arthroplasties. This difference was significant (P<0.001). The Constant-Murley score was significantly improved in all etiologies. CONCLUSIONS: Glenohumeral arthropathies can be successfully treated by arthroplasty. Anatomic TSA was shown to be associated with a high risk of glenoid loosening at radiographic follow-up, which makes us hesitate to use the cemented polyethylene implant, especially in young patients. LEVEL OF EVIDENCE: IV - Retrospective study.

[Tolerance and efficacy of peripheral nerve blocks for carpal tunnel release]. / Tolérance et efficacité des blocs nerveux périphériques pour la chirurgie du canal carpien.

INTRODUCTION: Several peripheral nerve block techniques (PNB) are performed for hand surgery. Their tolerance by patients or their efficacy are poorly described. We evaluated them for blocks at the wrist and at the brachial canal. PATIENTS AND METHODS: Cohort of outpatients undergoing open carpal tunnel release under PNB with arm tourniquet. Various anaesthetic protocols existed in our staff. The primary end points were a moderate to severe pain (greater than 3/10 on a numerical rating scale) felt during needle puncture, nerve stimulation, mepivacaine injection, at the surgical site (intraoperatively) or at the arm tourniquet, an intraoperative lidocaine supplementation, the occurrence of vasovagal events. For each primary end point, a logistic regression analyzed: the effects of gender, age, operated side, Emla(®)application, sedation before PNB (midazolam-sufentanil), wrist or brachial canal approach, musculocutaneous or radial block were using. RESULTS: Between January 2007 and June 2010, 551 consecutive patients were analyzed. Puncture pain, mepivacaine injection pain, pain tourniquet and vasovagal events were associated with wrist block (P=0.003, relative risk=1.86; P<0.001, RR=4.22; P<0.001, RR=4.52; P=0.035, RR=6.40). An intraoperative pain greater than 3/10 at the surgical site, or a supplementation by the surgeon were associated with the absence of musculocutaneous block (P=0.013, RR=2.44; P=0.013, RR=2.51). DISCUSSION: Wrist blocks are less tolerated than brachial canal blocks. The musculocutaneous nerve might often participate in the palm sensitive innervation. For open carpal tunnel release, median, ulnar and musculocutaneous nerves blocks at the brachial canal should be preferred.