How to salvage the fractured coracoid during the Latarjet Procedure? An empirical approach.

The Latarjet procedure is a frequently used stabilization procedure in case of anterior shoulder instability with critical glenoid bone loss and/or off-track Hill Sachs lesions. Although uncommon, intra-operative graft fractures do occur. When confronted with this potentially challenging intra-operative complication, having a secondary solution is paramount to achieve a successful outcome. This technical note provides a treatment algorithm that may function as a useful guideline to assist surgeons that experience this potentially complex unintended event during a Latarjet procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

High Vertical and Horizontal Stability at Short-Term Follow-Up After an All-Endoscopic Double Cerclage Endobutton Technique for Acute Acromioclavicular Joint Separations.

PURPOSE: To evaluate the clinical and radiological outcomes in the treatment of acute acromioclavicular (AC) joint separations using an all-endoscopic double cerclage endobutton technique compared with an arthroscopic-assisted single-bundle endobutton technique and to analyze the complication, failure, and revision rates of both procedures. METHODS: All patients with acute Rockwood type IIIB and V AC joint separations who were operated on using an all-endoscopic double cerclage technique (2019-2022) or an arthroscopic-assisted single-bundle technique (2017-2019) were included. The follow-up period was at least 12 months. Clinical and radiographic assessment was performed at follow-up. Complications, failures, and revisions were also investigated. RESULTS: Twenty-eight patients (14 double cerclage group, 14 single-bundle group, all male) with an average age of 37 years (interquartile range [IQR], 15) were available for follow-up after 45 months (IQR, 38). The median time between trauma and surgery was 7 days (IQR, 8). Very good clinical results without significant differences were observed in both groups (Constant score, 94 [IQR, 12] vs 95 [IQR, 15], P = .427, AC joint instability score, 95 [IQR, 11] vs 87 [IQR, 22], P = .210). All patients returned to sport, with an average sports level of 95% compared with preoperative status. The single-bundle group showed significantly increased anteroposterior instability (6 vs 0, P = .006). A total of 5 complications occurred (2 vs 3), leading to 1 revision surgery in each group. CONCLUSIONS: Excellent clinical results and high vertical and horizontal stability can be achieved with the all-endoscopic double cerclage technique. Horizontal instability occurred significantly more frequently with the single-bundle technique. The prolonged operation time in the double cerclage group had no negative impact on postoperative outcomes, including complication and failure rates, and a learning curve to reduce this prolonged operative time should be considered. LEVEL OF EVIDENCE: Level III, retrospective comparative clinical series.

Reverse shoulder arthroplasty with a 155° neck-shaft angle inlay implant design without reattachment of the subscapularis tendon results in satisfactory functional internal rotation and no instability: a cohort study.

BACKGROUND: The aim of this study was to use the Activities of Daily Living which require Internal Rotation (ADLIR) questionnaire to assess the functional internal rotation in patients who had undergone reverse shoulder arthroplasty (RSA) without reattachment of the subscapularis (SSc) tendon at a minimum follow-up of 2 years. The secondary aim was to report the objective range of motion (ROM) and the rate of postoperative instability. MATERIALS AND METHODS: All consecutive primary RSA procedures without reattachment of the SSc tendon that were performed using a Delta Xtend prosthesis (an inlay system with a 155° neck-shaft angle) between January 2015 and December 2020 were identified to ensure a minimum follow-up of 2 years. Patients were contacted and requested to fill in several questionnaires, including the ADLIR and Auto-Constant scores. RESULTS: In total, 210 patients met the inclusion criteria; among those patients, 187 could be contacted and 151 completed questionnaires (response rate: 81%). The SSc tendon was fully detached without repair in all cases, and a superolateral approach was used in 130 (86%) cases. The median follow-up was 4.5 years (range: 2.0-7.6). At final follow-up, the mean ADLIR score was 88/100 (interquartile range (IQR): 81-96). The median level reached in internal rotation was the 3rd lumbar vertebra (IQR: lumbosacral region-12th thoracic vertebra). Of the 210 eligible patients, one required a revision for a dislocation within the first month after primary surgery. With regards to regression analysis with ADLIR score as the outcome, none of the factors were associated with the ADLIR score, although age and smoking approached significance (0.0677 and 0.0594, respectively). None of the explanatory variables were associated with ROM in internal rotation (p > 0.05). CONCLUSIONS: This study demonstrates that satisfactory ADLIR scores and internal rotation ROM were obtained at mid-term follow-up after RSA leaving the SSc detached. Leaving the SSc detached also did not lead to high instability rates; only one out of 210 prostheses was revised for dislocation within the first month after primary surgery.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study.

PURPOSE: To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up. METHODS: We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed. RESULTS: In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105). CONCLUSIONS: In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical and radiological outcome after arthroscopic rotator cuff repair using PEEK-CF anchors.

PURPOSE: The goal of this study was to evaluate the clinical and radiological outcome after arthroscopic rotator cuff repair using new carbonfiber reinforced polyetheretherketone (CF-PEEK) suture anchors. METHODS: One hundred (n=100) patients with rotator cuff tears were enrolled at seven French hospitals between July 2019 and June 2020. Pain levels, Constant score and Subjective Shoulder Value (SSV) were taken preoperatively and 6months postoperatively. Ultrasonography (US) was performed at 6months postoperatively to evaluate tendon healing using the Sugaya classification. Statistical analysis was done with the Student t-test with 95% confidence intervals. RESULTS: One hundred patients of the 100 patients were followed at 6months. The mean SSV and Constant score improved from 40.1% preoperatively to 78% at 6months (p<0.0001) and from 43 points preoperatively to 65 points at 6months (p<0.0001), respectively. The mean level of pain, as measured with the visual analogue scale, decreased from 5.9 to 1.6 (p<0.001). There were no postoperative complications that resulted in revision surgery. CONCLUSION: The study showed good results at 6months follow-up using carbonfiber reinforced PEEK anchors with improved Constant and SSV scores as well as a high ultrasonographic tendon healing rate, making PEEK-CF anchors safe to use, comparable to commonly used anchors. LEVEL OF EVIDENCE: IV.

Functional and radiographic outcomes of reverse shoulder arthroplasty with a minimum follow-up of 10 years.

BACKGROUND: The use of reverse shoulder arthroplasty (RSA) is becoming increasingly prevalent. However, few studies have been published reporting the long-term outcomes of RSA. This study aims to report the clinical, radiographic, and patient-reported outcomes of the Delta Xtend reverse shoulder prosthesis, performed by a single surgeon and with a minimum follow-up of 10 years. METHODS: All RSA procedures performed between 2005 and 2012 were identified. Patients were contacted and invited for a follow-up visit including clinical assessment, radiographs, and patient-reported outcome measures. Patients with a follow-up of less than 10 years were excluded. The revision-free implant survival was calculated at 10 years. Between 2005 and 2012, 119 procedures in 116 patients meeting inclusion criteria were identified. Of these patients, 35 were deceased before reaching the 10-year follow-up and 23 could not be reached. In total, 63 RSAs could be included in 61 patients (response rate: 75%). The median follow-up was 11.7 years (interquartile range [IQR]: 10.5-13.2). RESULTS: Of the 61 patients, 7 patients underwent a revision after a median of 3 years (IQR: 0.2-9.8) during the total follow-up period. The 10-year implant survival was 94% (95% confidence interval: 84-98). At final follow-up, the median anterior elevation was 135° (IQR: 130°-160°), the median abduction was 120° (IQR: 100°-135°), and the median level reached with internal rotation was L5 (IQR: sacrum-L5). The median Auto-Constant score was 68 (IQR: 53-78), the median Subjective Shoulder Value was 80 (IQR: 70-93), and the median pain score was 0.2/10 (IQR: 0-2). In total, radiographs could be obtained in 25 patients (40%). Scapular notching occurred in 10 patients (40%), which was classified as Sirveaux-Nerot grade IV in 3 patients (12%). Ossification occurred in 10 patients (40%), and stress shielding in 2 patients (8%). Radiolucencies were observed around the humeral component in 24 patients (96%) and around the glenoid component in 13 patients (52%). CONCLUSION: The long-term results of RSA with a Delta Xtend prosthesis are favorable, with long-term improvement in range of motion and patient-reported outcome measures, and a satisfactory implant survival rate. Interestingly, the radiographical analysis showed high prevalence of signs associated with loosening, which did not seem to translate to high complication rates or inferior results.

Developing a machine learning algorithm to predict the probability of aseptic loosening of the glenoid component after anatomical total shoulder arthroplasty: protocol for a retrospective, multicentre study.

INTRODUCTION: Despite technological advancements in recent years, glenoid component loosening remains a common complication after anatomical total shoulder arthroplasty (ATSA) and is one of the main causes of revision surgery. Increasing emphasis is placed on the prevention of glenoid component failure. Previous studies have successfully predicted range of motion, patient-reported outcomes and short-term complications after ATSA using machine learning methods, but an accurate predictive model for (glenoid component) revision is currently lacking. This study aims to use a large international database to accurately predict aseptic loosening of the glenoid component after ATSA using machine learning algorithms. METHODS AND ANALYSIS: For this multicentre, retrospective study, individual patient data will be compiled from previously published studies reporting revision of ATSA. A systematic literature search will be performed in Medline (PubMed) identifying all studies reporting outcomes of ATSA. Authors will be contacted and invited to participate in the Machine Learning Consortium by sharing their anonymised databases. All databases reporting revisions after ATSA will be included, and individual patients with a follow-up less than 2 years or a fracture as the indication for ATSA will be excluded. First, features (predictive variables) will be identified using a random forest feature selection. The resulting features from the compiled database will be used to train various machine learning algorithms (stochastic gradient boosting, random forest, support vector machine, neural network and elastic-net penalised logistic regression). The developed and validated algorithms will be evaluated across discrimination (c-statistic), calibration, the Brier score and the decision curve analysis. The best-performing algorithm will be used to create an open-access online prediction tool. ETHICS AND DISSEMINATION: Data will be collected adhering to the WHO regulation on data sharing. An Institutional Review Board review is not applicable. The study results will be published in a peer-reviewed journal.

Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK).

PURPOSE/INTRODUCTION: Over the last decades, there has been increasing interest in biological stimulation or bioaugmentation after rotator cuff repair. So far, there is no consensus on the appropriate composition of biologicals or which patients would benefit most, and moreover, these biologicals are often expensive. However, there are other, non-pharmacological strategies that are also believed to achieve biological stimulation. This randomised controlled trial evaluates the possible cumulative effect of pragmatic application of cryobiomodulation, photobiomodulation and electrobiomodulation-collectively called biomodulation-on the bone-to-tendon healing process after rotator cuff repair. METHODS: In this randomised, controlled proof of concept study, 146 patients undergoing arthroscopic repair of a full thickness posterosuperior or anterosuperior rotator cuff tear will be 1:1 randomly assigned to either a control group or to the additional biomodulation protocol group. The adjuvant biomodulation protocol consists of seven self-applicable therapies and will be administered during the first 6 weeks after surgery. Primary outcome will be healing of the rotator cuff as evaluated by the Sugaya classification on MRI at 1-year postoperatively. ETHICS AND DISSEMINATION: This study has been accepted by the National Ethical Review Board CPP Sud-Est IV in France and has been registered at Clinicaltrials.gov. The results of this study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04618484.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique.

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Developing a machine learning algorithm to predict probability of retear and functional outcomes in patients undergoing rotator cuff repair surgery: protocol for a retrospective, multicentre study.

INTRODUCTION: The effectiveness of rotator cuff tear repair surgery is influenced by multiple patient-related, pathology-centred and technical factors, which is thought to contribute to the reported retear rates between 17% and 94%. Adequate patient selection is thought to be essential in reaching satisfactory results. However, no clear consensus has been reached on which factors are most predictive of successful surgery. A clinical decision tool that encompassed all aspects is still to be made. Artificial intelligence (AI) and machine learning algorithms use complex self-learning models that can be used to make patient-specific decision-making tools. The aim of this study is to develop and train an algorithm that can be used as an online available clinical prediction tool, to predict the risk of retear in patients undergoing rotator cuff repair. METHODS AND ANALYSIS: This is a retrospective, multicentre, cohort study using pooled individual patient data from multiple studies of patients who have undergone rotator cuff repair and were evaluated by advanced imaging for healing at a minimum of 6 months after surgery. This study consists of two parts. Part one: collecting all potential factors that might influence retear risks from retrospective multicentre data, aiming to include more than 1000 patients worldwide. Part two: combining all influencing factors into a model that can clinically be used as a prediction tool using machine learning. ETHICS AND DISSEMINATION: For safe multicentre data exchange and analysis, our Machine Learning Consortium adheres to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. Institutional Review Board approval does not apply to the current study protocol.

The O'Brien test demonstrates a higher diagnostic value in identifying posteroinferior labral tears than superior labral anterior to posterior (SLAP) tears.

Background: The primary aim was to determine the diagnostic value of the O'Brien test in localizing labral tears of the shoulder. Methods: A consecutive series of patients electing for labral repair between January 2005 and March 2021 were included in this retrospective study. Inclusion criteria were as follows: (1) any patient with a labral tear who was elected for arthroscopic labral repair and (2) had documentation of the O'Brien test in the preoperative evaluation. Exclusion criteria were patients that had a negative arthrographically enhanced computed tomography or magnetic resonance imaging scan. During arthroscopy, the localization and extension of the labral tear was documented in a standardized 12-o'clock configuration. Anteroinferior, posteroinferior, superior labrum anterior to posterior (SLAP), and combined labral tears were documented. The sensitivity, specificity, positive and negative predictive values, accuracy, positive and negative likelihood ratios, receiver operating characteristic curve, and area under the curve were calculated to determine the diagnostic value. Results: The cohort consisted of 271 patients (77% male) and included 105 anteroinferior, 86 posteroinferior, 46 SLAP, and 32 combined parts of the labrum. The mean age at time of surgery was 30 (±10.2) years. The O'Brien test was positive in 142 (52%) patients and showed the highest sensitivity and specificity for the posteroinferior tears (83% and 62%) compared to the anteroinferior (16% and 25%), combined labral parts (69% and 50%), and SLAP (65% and 50%) tears. In addition, receiver operating characteristic-analysis demonstrated a significantly higher area under the curve for posteroinferior tears compared to the other tears (P < .001). Conclusion: The O'Brien test demonstrates more diagnostic value for posteroinferior tears than other labral tears. This includes the SLAP tear, for which the O'Brien test was originally designed. Clinical Relevance: These findings are helpful towards reinterpreting the O'Brien test as well as diagnosing, and more specifically localizing labral tears in clinics.

Correlation between preoperative clinical examination and intraoperatively found subscapularis tendon tear.

PURPOSE: Analyze the diagnostic value for subscapularis (SSC) tendon tears, their correlation between pain and strength on clinical tests, and compare them with intraoperative arthroscopic findings to prove their diagnostic value. METHODS: 110 consecutive patients undergoing arthroscopic rotator cuff repair were reviewed and allocated to isolated SSC (n = 39) and combined anterosuperior tendon tear (n = 71) groups and analyzed. Preoperative clinical testing included belly press (BPT), bear hug (BHT), lift-off (LOT), palm-up (PUT), and Jobe test (JT). All tests were performed in two categories: pain (in 4 categories: 0, 5, 10, and 15) and strength (from 0 to 5). The tendon tears were intraoperatively reviewed and classified. RESULTS: Mean age was 59 years (SD 10). The sensitivity of the BHT was 88.2% and 74.5% for BPT, while specificity was only 41.9% for BHT and 45% for BPT. Sensitivity of JT was 90.5% and 87.5% for PUT, while specificity was only 41% for JT and 28.2% for PUT. A low positive correlation for an intraoperative SSC lesion and the strength of BPT (Spearman rank correlation - 0.425; p value < 0.0001) and the strength of BHT ( - 0.362; p value = 0.001) could be found. With linear regression analysis estimated by ordinary least squares, a correlation between BPT strength and surgical grade of SSC lesion (- 0.528; 95% CI, - 0.923 to - 0.133; pvalue < 0.01) was found. CONCLUSION: The BHT showed a higher sensitivity for a SSC lesion, while the BPT had a higher correlation between preoperative testing, most notably internal rotation strength, and intraoperative surgical grade of the SSC tendon lesion. LEVEL OF EVIDENCE: Level II, Prospective cohort study for Diagnostic tests.

Predictive value of Gagey's hyperabduction test in identifying inferior glenohumeral ligament lesions.

INTRODUCTION: Clinical tests that can identify inferior glenohumeral ligament (IGHL) complex injuries are indispensable for the diagnosis of shoulder instability. Gagey's hyperabduction test had been developed to diagnose IGHL hyperlaxity, however, it is unclear whether the test is able to accurately diagnose an IGHL lesion. The aim of this study was to (1) determine the diagnostic performance of the Gagey test in identifying an IGHL lesion and (2) determine if a positive Gagey test is more predictive for an anterior or posterior IGHL lesion thanks to the heatmapping of the lesions. It was hypothesized that a Gagey test can accurately predict IGHL lesions, but would not be able to distinguish between anterior and inferior IGHL lesions. METHODS: A retrospective diagnostic accuracy study was conducted including all consecutive patients who underwent glenoid labral repair between January 2005 and September 2021 with a documented Gagey test prior to surgery. Using arthroscopic findings as a reference standard, the diagnostic performance characteristics of the Gagey test for each type of IGHL lesion (anterior, posterior and combined) were calculated and labral heatmapping was used to depict its localisation. RESULTS: A total of 167 patients were included, with a mean age of 29±10 years. The sensitivity, specificity and accuracy of the Gagey test on determining an IGHL lesion were 46%, 38% and 46%, respectively. The positive and negative predictive values were 88% and 7%, respectively. Heatmapping of the labral lesions demonstrated that a positive Gagey test was most predictive of anterior IGHL and axillary pouch tears and non-predictive of posterior IGHL lesions. DISCUSSION: The Gagey test demonstrated a low sensitivity and specificity to identify an IGHL lesion and therefore the hypothesis could not be confirmed. However, the Gagey test has a high positive predictive value to diagnose anterior IGHL lesions. Further prospective research with a more evenly distribution of lesions is needed to investigate the clinical value of the Gagey test to identify these lesions. Based on this data, the Gagey test seems especially important to support the results of other clinical tests such as the apprehension, relocation and surprise tests. LEVEL OF EVIDENCE: III, Retrospective Case-Control study.

Development and training of a machine learning algorithm to identify patients at risk for recurrence following an arthroscopic Bankart repair (CLEARER): protocol for a retrospective, multicentre, cohort study.

INTRODUCTION: Shoulder instability is a common injury, with a reported incidence of 23.9 per 100 000 person-years. There is still an ongoing debate on the most effective treatment strategy. Non-operative treatment has recurrence rates of up to 60%, whereas operative treatments such as the Bankart repair and bone block procedures show lower recurrence rates (16% and 2%, respectively) but higher complication rates (<2% and up to 30%, respectively). Methods to determine risk of recurrence have been developed; however, patient-specific decision-making tools are still lacking. Artificial intelligence and machine learning algorithms use self-learning complex models that can be used to make patient-specific decision-making tools. The aim of the current study is to develop and train a machine learning algorithm to create a prediction model to be used in clinical practice-as an online prediction tool-to estimate recurrence rates following a Bankart repair. METHODS AND ANALYSIS: This is a multicentre retrospective cohort study. Patients with traumatic anterior shoulder dislocations that were treated with an arthroscopic Bankart repair without remplissage will be included. This study includes two parts. Part 1, collecting all potential factors influencing the recurrence rate following an arthroscopic Bankart repair in patients using multicentre data, aiming to include data from >1000 patients worldwide. Part 2, the multicentre data will be re-evaluated (and where applicable complemented) using machine learning algorithms to predict outcomes. Recurrence will be the primary outcome measure. ETHICS AND DISSEMINATION: For safe multicentre data exchange and analysis, our Machine Learning Consortium adhered to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. No Institutional Review Board is required for this study.

Live Surgery: A retrospective study on the outcomes and complications of 7 orthopedic live surgery events.

INTRODUCTION: Live surgery has always been an invaluable part of medical education. Live Surgery Events (LSE) have recently been criticized in France, arguing that unnecessary risks have been placed on the patients. HYPOTHESIS: We want to report our experience in organizing the last 7 shoulder LSE over the past 12 years focusing on the results and complications during and after the surgeries performed during these courses. MATERIAL AND METHODS: 190 patients benefited from live shoulder surgery between 2005 and 2017. 11 of them were lost to follow up, thus 179 patients were included. The mean follow-up was 7,5 years for the instability group, 6,7 years for the rotator cuff group, 7,5 years for the arthroplasty group and 6,8 years for the nerve group. This study is a retrospective analysis of prospectively collected data. We report the epidemiology of the surgeries perfomed and analyzed the patient outcomes: peri and postoperative complications. We evaluated the educational benefit for the attendees of this shoulder LSE through a questionnaire. RESULTS: There were 6 (3.1%) peri or immediate postoperative complications. There were 33 (18%) long term complications needing 26 (14%) revisions. 90% of the surgeons audience attending the events evaluated the educational benefit from good to very good. DISCUSSION: Over the years, we have standardized the organization of the meeting to ensure maximum safety, while still respecting patient integrity and anonymity. Our complications rates seem within the ranges found in the current literature for each procedure. Our LSE has been an instrument for education, but also for matching patients with complex problems with experienced surgeons, to the benefit of the patient. Our experience has shown that LSE may induce potential dangers and complications can arise. However, these events should follow rigorous rules and not just recommendations. LEVEL OF EVIDENCE: IV; retrospective analysis of prospectively collected data.

Epidemiology of hand traumas during the COVID-19 confinement period.

INTRODUCTION: hand injuries are a common emergency mainly caused by domestic accidents or sport injuries. During the COVID-19 pandemic confinement period, with a cut off in transportation as well as in occupational and physical activities, we observed a decrease in medical and elective surgical activities but emergency cases of upper limb and hand surgery increased. MATERIALS AND METHODS: we conducted a retrospective epidemiological study to analyze two periods between the same dates in 2019 and 2020, for all the duration of the confinement period. We compared the numbers of consultations in the emergency department, elective surgeries, hand and upper limb emergency cases in our center and urgent limb surgeries in the nearby hospital. Then we compared the mechanisms and severity of injuries and the type of surgery. RESULTS: between 2019 and 2020 there was a decrease of consultations in the emergency department in our institution of 52%, a decrease of total elective surgeries of 75%, a decrease in surgeries for urgent peripheral limb injuries of 50%, whereas the hand and upper limb emergency remained stable or even increased by 4% regard to occupational and domestic accidents. There was a significant difference in the mechanism of injury with an increase of domestic accident and a decrease of occupational, road traffic and sport accidents. Severity of the injuries increased, with augmentation of the number of tissues involved and longer expected time of recovery. CONCLUSION: during the confinement period of the COVID-19 pandemic, despite an important reduction of medical activities, the amount and severity of hand emergency cases increased. A specific plan regarding duty shift organization for hand trauma should be maintained regardless of the sanitary situation.

All-Endoscopic Treatment of Acromioclavicular Joint Dislocation: Coracoclavicular Ligament Suture and Acromioclavicular Ligament Desincarceration.

Acute acromioclavicular (AC) joint dislocations are common and difficult to manage. The physiopathologic pattern begins with the rupture of the AC ligaments, then the coracoclavicular (CC) ligaments, and with an invasion of the clavicle through the deltotrapezial fascia. Therefore, we tend to perform a true suture of the CC ligaments, along with a release of the AC ligaments from the joint. We thus propose an all-endoscopic CC ligament suture and AC joint release. It starts with glenohumeral exploration enabling a repair of concomitant lesions when necessary. Dissection of the coracoid process is made, along with the lateral border of the conjoint tendon, medially the pectoralis minor tenotomy, and plexus brachial exposition and protection. Superiorly the CC ligaments are tagged and exposed. A major difference with others procedure then arises. We dissect the inferior and superior surfaces of the clavicle and the AC joint, although we maintain the continuity between the deltotrapezoid fascia and the AC ligaments. The AC dislocation is reduced under endoscopic control performing a true suture of the CC ligaments by the mean of 2 suture tapes and dog bones. After surgery, a shoulder brace is used for 6 weeks. Physiotherapy then begins.

Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation.

INTRODUCTION: Infraclavicular brachial plexus (BP) injury secondary to glenohumeral joint (GHJ) dislocation is a rather common complication, which may be accountable for long-lasting deficits. The purpose of this study was to assess the potential benefits of BP neurolysis in such presentation, using an endoscopic approach. MATERIALS AND METHODS: All patients who underwent endoscopic BP neurolysis in the setting of infraclavicular BP palsy due to GHJ dislocation were included. Preoperative physical examination was conducted to classify the observed motor and sensitive deficits into nerves and/or cord lesions. Six weeks after the trauma, examination was repeated and endoscopic BP neurolysis was elected if no significant improvements were observed. If nerve ruptures and/or severe damages were identified during surgery, nerve reconstructions were conducted within a month; in other cases, follow-up examinations were conducted at 6 weeks, 3 and 6 months to assess the course of postoperative recovery. RESULTS: Eleven patients were included, including 6 men and 5 women, with a mean age of 43 ± 23 years (16;73). Six patients had at least one cord involved, four patients had isolated axillary nerve palsy, and one patient had a complete BP palsy. In 7 patients with cord lesions and/or isolated axillary nerve palsy, at least grade-3 strength, according to the British Medical Research Council grading system, was noted in all affected muscles within 6 weeks following the neurolysis; after 3 months of follow-up, grade-4 strength was observed in all muscles, and all but patients but one had fully recovered within 6 months. In 3 patients with isolated axillary nerve palsy, complete nerve ruptures (n=2) and severe damages (n=1) were identified under scopic magnification; secondary nerve transfers were conducted to reanimate the axillary nerve, and all patients fully recovered within a year. In one patient with complete BP palsy, improvements started after 6 months of follow-up, and full recovery was yielded after 2 years. No intra- and/or postoperative complications were noted. CONCLUSIONS: At the cost of minimal additional morbidity, endoscopic BP neurolysis appears to be a safe and reliable procedure to shorten recovery delays in most patients presenting with BP palsy due to GHJ dislocation.

Direct transfer of C7 pectoral fascicles to the suprascapular nerve in C5/C6 brachial plexus palsies: an anatomical study.

We investigated a technique to reconstruct the suprascapular nerve in patients with C5/C6 brachial plexus palsies, using pectoral fascicles from the ipsilateral C7 root. Using a supraclavicular approach in eight cadavers, the suprascapular nerve was placed side by side with an anterior quadrant fascicle from the C7 root. Several criteria were assessed, including the fascicle length, the overlap between the two nerves and their respective diameters. The mean length of the C7 fascicles was 19.3 mm, with a mean overlap of 4.7 mm. The suprascapular nerve and the C7 fascicles had mean diameters of 2.2 mm and 2.1 mm, respectively. Pectoral fascicles from C7 seem to be an option for reconstruction of the suprascapular nerve in C5/C6 palsies. Clinical studies will be required to establish the potential limitations of this transfer, especially in cases with complex lesions of the suprascapular nerve.

Tissue on the Transferred Coracoid Graft After Latarjet Procedure: Histological and Morphological Findings.

BACKGROUND: Anterior shoulder instability is a debilitating condition that can require stabilization via a Latarjet procedure. PURPOSE: The aim of this study was to characterize the histological composition of the articular-sided surface of the coracoid bone graft after Latarjet procedure. Specific features of cells isolated from the coracoid and graft tissues were assessed. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Tissue samples were harvested from 9 consecutive patients undergoing arthroscopic debridement and screw removal after arthroscopic or open Latarjet procedure. Tissues were processed histologically. In 2 patients, the samples were analyzed to assess specific cellular properties. RESULTS: Safranin O staining indicated that glenoid tissues contained variable amounts of glycosaminoglycan (GAG) and round chondrocytic cells mainly organized in clusters. Graft tissues contained less GAG and were more cellular but were not organized in clusters and had variable morphological features. An association appeared to exist between the cartilage quality of glenoid tissues and that of the graft tissues. Cells isolated from glenoid and graft tissues exhibited similar proliferation capacity. CONCLUSION: The results of our analysis show that cells located at the articular-sided surface of transferred coracoid grafts demonstrate fibrocartilaginous properties and may have the capacity for chondral proliferation. Further studies are needed to confirm this observation and future application.