Is preoperative 3D planning reliable for predicting postoperative clinical differences in range of motion between two stem designs in reverse shoulder arthroplasty.

BACKGROUND: We aim to predict a clinical difference in the postoperative range of motion (RoM) between 2 reverse shoulder arthroplasty (RSA) stem designs (Inlay-155° and Onlay-145°) using preoperative planning software. We hypothesized that preoperative 3D planning could anticipate the differences in postoperative clinical RoM between 2 humeral stem designs and by keeping the same glenoid implant. METHODS: Thirty-seven patients (14 men and 23 women, 76 ± 7 years) underwent a BIO-RSA (bony increased offset-RSA) with the use of preoperative planning and an intraoperative 3-dimensional-printed patient-specific guide for glenoid component implantation between January 2014 and September 2019 with a minimum follow-up of 2 years. Two types of humeral implants were used: Inlay with a 155° inclination (Inlay-155°) and Onlay with a 145°inclination (Onlay-145°). Glenoid implants remained unchanged. The postoperative RSA angle (inclination of the area in which the glenoid component of the RSA is implanted) and the lateralization shoulder angle were measured to confirm the good positioning of the glenoid implant and the global lateralization on postoperative X-rays. A correlation between simulated and clinical RoM was studied. Simulated and last follow-up active forward flexion (AFE), abduction, and external rotation (ER) were compared between the 2 types of implants. RESULTS: No significant difference in RSA and lateralization shoulder angle was found between planned and postoperative radiological implants' position. Clinical RoM at the last follow-up was always significantly different from simulated preoperative RoM. A low-to-moderate but significant correlation existed for AFE, abduction, and ER (r = 0.45, r = 0.47, and r = 0.57, respectively; P < .01). AFE and abduction were systematically underestimated (126° ± 16° and 95° ± 13° simulated vs. 150° ± 24° and 114° ± 13° postoperatively; P < .001), whereas ER was systematically overestimated (50° ± 19° simulated vs. 36° ± 19° postoperatively; P < .001). Simulated abduction and ER highlighted a significant difference between Inlay-155° and Onlay-145° (12° ± 2°, P = .01, and 23° ± 3°, P < .001), and this was also retrieved clinically at the last follow-up (23° ± 2°, P = .02, and 22° ± 2°, P < .001). CONCLUSIONS: This study is the first to evaluate the clinical relevance of predicted RoM for RSA preoperative planning. Motion that involves the scapulothoracic joint (AFE and abduction) is underestimated, while ER is overestimated. However, preoperative planning provides clinically relevant RoM prediction with a significant correlation between both and brings reliable data when comparing 2 different types of humeral implants (Inlay-155° and Onlay-145°) for abduction and ER. Thus, RoM simulation is a valuable tool to optimize implant selection and choose RSA implants to reach the optimal RoM.

Early morbidity and mortality after one-stage bilateral shoulder arthroplasty.

PURPOSE: One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. METHODS: A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. RESULTS: There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. CONCLUSIONS: One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.

Tutors' perspective on the impact of their anatomy tutoring experience and ethics of body donation.

PURPOSE: To explore the future of former anatomy tutors, their perception of the impact that the anatomy near-peer teaching (NPT) program have had on them, in terms of academic performance, professional development, personal growth, long-term anatomical knowledge, and views on body donor ethics. Additionally, we compared their academic performance with non-tutor peers in terms of ranking at the National Qualifying Examination (NQE). METHODS: A voluntary survey was emailed to all anatomy tutors from 2005 to 2024, using an online Google Forms questionnaire including closed and open-ended questions across four themes. Quantitative data were analyzed descriptively, while qualitative responses underwent thematic analysis. A Wilcoxon signed-rank test was performed to compare former tutors' NQE rankings to their peers. RESULTS: Forty-seven out of 48 tutors responded. Tutors reported a positive program impact, including improvements in technical skills (100%), teamwork (97.9%), communication (89.4%), and organizational skills (76.6%), and good long-term anatomical knowledge retention (85.7%). Dissection on body donors was deemed essential for anatomy learning while shaping professional and ethical values. Of the 36 residents/specialists, 38.9% ranked in the top 10% at the NQE, with a statistically significant higher rank than their peers (p = 0.0011), and 100% obtained their desired specialty. CONCLUSION: This results suggest that the anatomy NPT program significantly enhanced tutors' academic performance, technical skills, personal and professional development, and was useful to foster a positive perception of dissection on body donors and reinforced the importance of anatomical knowledge in clinical practice.

Normo-or slightly overcorrection show better results after medial closing wedge high tibial osteotomy.

PURPOSE: The objectives of this study were to evaluate functional results, revision-free survival, and the influence of postoperative alignment on outcomes after MCWHTO. METHODS: This retrospective study included 27 MCWHTO operated on from 2009 to 2021. Radiographic measurements were performed pre- and postoperatively. The HKA (Hip-Knee-Ankle angle), MPTA (Medial Proximal Tibial angle), LDFA (Lateral Distal Femoral Angle), JLO (Joint Line Obliquity), and JLCA (Joint Line Convergence Angle) were evaluated. The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee Score, and the Subjective Knee Value (SKV) as well as revision-free survival were evaluated. Postoperative alignment and its influence on clinical outcomes were also analysed. RESULTS: The mean follow-up was 61.9 months ± 31.4 (13-124). The HKA, MPTA, and JLCA angles were decreased post-operatively (respectively, Δ = 5.9° ± 2.6, p < 0.001; Δ = 6.1° ± 3.2, p < 0.001 and Δ = 2.5° ± 1.9, p < 0.001). LDFA and JLO were unchanged, post-operatively (respectively, Δ = 0.1° ± 2.2, p = 0.93 and Δ = 1.2° ± 3.3, p = 0.23). Postoperative HKA correlated with knee IKS (R = - 0.15, p = 0.04) and function IKS (R = - 0.44, p = 0.03). Postoperative LDFA correlated with knee IKS(R = 0.8, p < 0.01). Patients with postoperative HKA ≤ 180° had better KOOS (Δ = 12.3, p = 0.04) and IKS function (Δ = 28.1, p < 0.01) than those with HKA > 180°. CONCLUSION: Functional results and revision-free survival after MCWHTO are satisfactory when the deformity is located in the proximal tibia. The joint line obliquity is not significantly altered with small tibial correction and, obtaining an overall neutral or slightly varus alignment under the conditions of this study allowed an improvement in the postoperative clinical scores. The literature is still inconclusive on the ideal alignment for valgus deformities and larger series are needed to draw definitive conclusions. LEVEL OF EVIDENCE: IV, case series.

Restoration of preoperative tibial alignment improves functional results after medial unicompartmental knee arthroplasty.

PURPOSE: The alignment obtained after unicompartmental knee arthroplasty (UKA) influences the risk of failure. Kinematic alignment after UKA based on Cartier angle restauration is likely to improve clinical outcomes compared with mechanical alignment. The purpose of this study is to analyze the influence of implant alignment and native knee restoration after UKA using the conventional techniques on clinical outcomes. METHODS: This retrospective study included 144 medial UKA patients from 2015 to 2020. Radiographic measurements were performed pre- and postoperatively. Outliers were defined as follows: Δ Cartier > 3° (difference between the preoperative and postoperative Cartier angle); Δ MPTA (Medial Proximal Tibial angle) and postoperative TCA (Tibial Coronal component Angle) > 3° (difference between the positioning of the tibial implant and the preoperative proximal tibial deformity). The Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Society (IKS) Function and Knee score, the Forgotten Joint Score (FJS), and the Subjective Knee Value (SKV) were evaluated. A Student t test or a non-parametric Wilcoxon test was used for non-normal data to compare pre- and postoperative values for functional scores and angular measurements. The correlation of postoperative angles with functional outcomes was assessed by the Spearman's rank correlation coefficient. RESULTS: During the inclusion period, 214 patients underwent medial UKA, 71 patients were excluded, and 19 were lost to follow-up leaving 124 patients with 144 knees (20 bilateral UKA) included for analysis with a mean follow-up of 54.7 months ± 22.1 (24-95). The Δ Cartier was significantly correlated with IKS function (R2 = 0.06, p < 0.001) and FJS (R2 = 0.05, p < 0.01) scores. The Δ preoperative MPTA-TCA was significantly correlated (p < 0.001) with KOOS (R2 = 0.38), IKS Knee (R2 = 0.17), IKS function (R2 = 0.34), SKV (R2 = 0.08), and FJS (R2 = 0.37) scores. In subgroup analysis, non-outliers (< 3°) for Δ preoperative MPTA-TCA had better KOOS score (Δ = 23.5, p < 0.001) and IKS Function (Δ = 17.7, p < 0.001) compared to outliers (> 3°) patients. CONCLUSION: Functional results after medial UKA can be influenced by implant alignment in the coronal plane with slight clinical improvement when positioning the tibial implant close to the preoperative tibial deformity, rather than by restoring the Cartier angle. This series suggests the interest of a more personalized alignment strategy, but these results will have to be confirmed by other controlled studies. LEVEL OF EVIDENCE: IV, retrospective case series.

Validation of the shoulder range of motion software for measurement of shoulder ranges of motion in consultation: coupling a red/green/blue-depth video camera to artificial intelligence.

PURPOSE: Clinical evaluation of the shoulder range of motion (RoM) may vary significantly depending on the surgeon. We aim to validate an automatic shoulder RoM measurement system associating image acquisition by an RGB-D (red/green/blue-depth) video camera to an artificial intelligence (AI) algorithm. METHODS: Thirty healthy volunteers were included. A 3D RGB-D sensor that simultaneously generated a colour image and a depth map was used. Then, an open-access convolutional neural network algorithm that was programmed for shoulder recognition provided a 3D motion measure. Each volunteer adopted a randomized position successively. For each position, two observers made a visual (EyeREF) and goniometric measurement (GonioREF), blind to the automated software which was implemented by an orthopaedic surgeon. We evaluated the inter-tester intra-class correlation (ICC) between observers and the concordance correlation coefficient (CCC) between the three methods. RESULTS: For manual evaluations EyeREF and GonioREF, ICC remained constantly excellent for the widest motions in the vertical plane (i.e., abduction and flexion). It was very good for ER1 and IR2 and fairly good for adduction, extension, and ER2. Differences between the measurements' means of EyeREF and shoulder RoM was significant for all motions. Compared to GonioREF, shoulder RoM provided similar results for abduction, adduction, and flexion and EyeREF provided similar results for adduction, ER1, and ER2. The three methods showed an overall good to excellent CCC. The mean bias between the three methods remained under 10° and clinically acceptable. CONCLUSION: RGB-D/AI combination is reliable in measuring shoulder RoM in consultation, compared to classic goniometry and visual observation.

Modern and synchronized clinical anatomy teaching based on the BDIE method (board-digital dissection-imaging-evaluation).

PURPOSE: Anatomy has historically been taught via traditional medical school lectures and dissection. In many countries, practical or legal issues limit access to cadaveric dissection. New technologies are favored by students and could improve learning, complementing traditional teaching. METHODS: All students in second-year medicine at a single medical school were submitted to a novel anatomical course with digital tool exposure. We explored a new combined teaching method: a physical blackboard lesson synchronized with digital dissection, imaging and direct evaluation (BDIE). Synchronized dissection is broadcast live in the classroom and in partner medical schools. Following the course, students completed a short survey about their perception of this new anatomic clinical course. RESULTS: The survey included 183 students whom 178 completed the questionnaire, i.e., a 97% response rate. Ninety-nine percent of students thought this synchronized method useful to improve their understanding of anatomy and 90% stated it helped them retain this learning. CONCLUSION: This BDIE method, in conjunction with teaching guidelines and dissection, is highly appreciated by students who consider it helps them to acquire lasting knowledge.

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

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

Spino-femoral muscles affect sagittal alignment and compensatory recruitment: a new look into soft tissues in adult spinal deformity.

OBJECTIVE: To quantify muscle characteristics (volumes and fat infiltration) and identify their relationship to sagittal malalignment and compensatory mechanism recruitment. METHODS: Female adult spinal deformity patients underwent T1-weighted MRI with a 2-point Dixon protocol from the proximal tibia up to the T12 vertebra. 3D reconstructions of 17 muscles, including extensors and flexors of spine, hip and knee, were obtained. Muscle volume standardized by bone volume and percentage of fat infiltration (Pfat) were calculated. Correlations and regressions were performed. RESULTS: A total of 22 patients were included. Significant correlations were observed between sagittal alignment and muscle parameters. Fat infiltration of the hip and knee flexors and extensors correlated with larger C7-S1 SVA. Smaller spinal flexor/extensor volumes correlated with greater PI-LL mismatch (r = - 0.45 and - 0.51). Linear regression identified volume of biceps femoris as only predictor for PT (R2 = 0.34, p = 0.005) and Pfat of gluteus minimus as only predictor for SVA (R2 = 0.45, p = 0.001). Sagittally malaligned patients with larger PT (26.8° vs. 17.2°) had significantly smaller volume and larger Pfat of gluteus medius, gluteus minimus and biceps femoris, but similar values for gluteus maximus, the hip extensor. CONCLUSION: This study is the first to quantify the relationship between degeneration of spino-femoral muscles and sagittal malalignment. This pathoanatomical study identifies the close relationship between gluteal, hamstring muscles and PT, SVA, which deepens our understanding of the underlying etiology that contributes to adult spinal deformity.

All-Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations.

PURPOSE: To report the outcomes of all-arthroscopic coracoclavicular (CC) ligament reconstruction and simultaneous diagnosis and treatment of glenohumeral pathologies in patients with symptomatic, chronic (>6 weeks), complete (Rockwood type III-V) acromioclavicular joint (ACJ) separations. METHODS: We prospectively followed up 57 consecutive patients treated arthroscopically for chronic Rockwood type III (n = 11), type IV (n = 19), and type V (n = 27) ACJ dislocations. Previous ACJ surgery failed in 11 (19%). The mean delay between injury and surgery was 39 months (range, 6 months to 17 years). The mean age at surgery was 42 years (range, 19-71 years). After glenohumeral exploration, an arthroscopic modified Weaver-Dunn procedure with CC suture button fixation (Twinbridge) was performed. The CC reduction and tunnel position were analyzed with radiographs and computed tomography. The mean follow-up period was 36 months (range, 12-72 months). RESULTS: Intra-articular pathology was treated arthroscopically in 27 patients (48%): 17 labral tears, 8 rotator cuff tears (3 partial and 5 complete), and 15 biceps lesions (4 SLAP lesions and 11 subluxations). At last follow-up, 7 patients (12%) experienced recurrent ACJ instability: 2 frank dislocations (1 trauma and 1 infection) and 5 ACJ subluxations. There was no significant correlation between subluxation and clinical outcome. The rate of recurrent ACJ instability was significantly higher in patients with higher-grade ACJ dislocations (P < .01) and/or previous failed surgery (P < .001). Recurrent subluxation was observed in 3 cases of lateral migration of the coracoid button with lateral tunnel placement, as well as 2 cases of anterior migration of the clavicular button with anterior tunnel placement. The Constant score increased from 67 (range, 28-89) to 85.5 (range, 66-100), and the mean Subjective Shoulder Value increased from 54% to 85% (P < .001). At last follow-up, 95% of patients (54 of 57) were satisfied. CONCLUSIONS: All-arthroscopic treatment allows successful CC ligament reconstruction and simultaneous diagnosis and treatment of frequently associated (48%) glenohumeral lesions. Higher-grade ACJ dislocations, previous ACJ surgery, and misplacement of bone tunnels are risk factors for recurrent instability. LEVEL OF EVIDENCE: Level IV, case series.

Arthroscopic Latarjet: Suture-Button Fixation Is a Safe and Reliable Alternative to Screw Fixation.

PURPOSE: To evaluate mid-term clinical outcomes, complications, bone-block healing, and positioning using suture-button fixation for an arthroscopic Latarjet procedure. METHODS: Patients with traumatic recurrent anterior instability and glenoid bone loss underwent guided arthroscopic Latarjet with suture-button fixation. We included patients with anterior shoulder instability, glenoid bone loss >20%, and radiographic and clinical follow-up minimum of 24 months. Patients with glenoid bone loss <20% or those that refused computed tomography imaging were excluded. Bone-block fixation was accomplished with 2 cortical buttons connected with a looped suture (4 strands). The looped suture was tied posteriorly with a sliding-locking knot. After transfer of the bone block on the anterior neck of the scapula, compression (100 N) was obtained with the help of a tensioning device. Clinical assessment was performed at 2 weeks, 3 months, 6 months, and then yearly with computed tomography completed at 2 weeks and 6 months to confirm bony union. RESULTS: A consecutive series of 136 patients underwent arthroscopic Latarjet with 121 patients (89%; mean age 27 years) available at final follow-up (mean follow-up, 26 months; range, 24-47 months). No neurologic complications or hardware failures were observed; no patients had secondary surgery for implant removal. The transferred coracoid process healed to the scapular neck in 95% of the cases (115/121). The bone block did not heal in 4 patients; it was fractured in 1 and lysed in another. Smoking was a risk factor associated with nonunion (P < .001). The coracoid graft was positioned flush to the glenoid face in 95% (115/121) and below the equator in 92.5% (112/121). At final follow-up, 93% had returned to sports, whereas 4 patients (3%) had a recurrence of shoulder instability. The subjective shoulder value for sports was 94 ± 3.7%. Mean Rowe and Walch-Duplay scores were 90 (range, 40-100) and 91 (range, 55-100), respectively. CONCLUSIONS: Suture-button fixation is an alternative to screw fixation for the Latarjet procedure, obtaining predictable healing with excellent graft positioning, and avoiding hardware-related complications. There was no need for hardware removal after suture-button fixation. The systematic identification of the axillary and musculocutaneous nerves reduced risk of neurologic injury. A low instability recurrence rate and excellent return to pre-injury activity level was found. Suture-button fixation is simple, safe, and may be used for both open and arthroscopic Latarjet procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Mortality, complication, and fusion rates of patients with odontoid fracture: the impact of age and comorbidities in 204 cases.

PURPOSE: The French Society of Spine Surgery (SFCR) conducted a prospective epidemiologic multicenter study. The purpose was to investigate mortality, complication, and fusion rates in patients with odontoid fracture, depending on age, comorbidities, fracture type, and treatment. METHODS: Out of 204 patients, 60 were ≤ 70 years and 144 were > 70 years. Demographic data, comorbidities, treatment types and complications (general medical, infectious, neurologic, and mechanical), and death were registered within the first year. Fractures were classified according to Anderson-D'Alonzo and Roy-Camille on the initial CT. A 1-year follow-up CT was available in 144 patients to evaluate fracture consolidation. RESULTS: Type II and oblique-posterior fractures were the most frequent patterns. The treatment was conservative in 52.5% and surgical in 47.5%. The mortality rate in patients ≤ 70 was 3.3% and 16.7% in patients > 70 years (p = 0.0002). Fracture pattern and treatment type did not influence mortality. General medical complications were significantly more frequent > 70 years (p = 0.021) and after surgical treatment (p = 0.028). Neurologic complications occurred in 0.5%, postoperative infections in 2.0%, and implant-related mechanical complications in 10.3% (associated with pseudarthrosis). Fracture fusion was observed in 93.5% of patients ≤ 70 years and in 62.5% >70 years (p < 0.0001). Pseudarthrosis was present in 31.5% of oblique-posterior fractures and in 24.3% after conservative treatment. CONCLUSIONS: Age and comorbidities influenced mortality and medical complication rates most regardless of fracture type and treatment choice. Pseudarthrosis represented the main complication, which increased with age. Pseudarthrosis was most frequent in type II and oblique-posterior fractures after conservative treatment.

Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer.

BACKGROUND: The purpose of this study was to characterize a subgroup of cuff-deficient patients with isolated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L'Episcopo procedure to restore horizontal muscle balance. METHODS: During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L'Episcopo tendon transfer was performed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months). RESULTS: Preoperatively, despite maintained active elevation (average of 161°), ILER patients complained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L'Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear arthropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery. CONCLUSIONS: ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In properly selected cases (Hamada stage 1 or 2), the modified L'Episcopo transfer is effective at restoring anterior-posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohumeral joint.

Is it possible to give a single definition of the rectosigmoid junction?

AIM: The rectosigmoid junction is the limit separating the sigmoid colon and rectum. This transition zone has different definitions. We want to highlight different landmarks of the rectosigmoid junction (RSJ), to help the clinicians to adopt a consensual definition. METHOD: We reviewed anatomical, endoscopic, physiological and surgical points of view concerning the rectosigmoid junction (RSJ). RESULTS: The rectosigmoid junction has a different definition depending on who is studying it. Nevertheless, it is a high pressure location, a place connecting different muscles organizations, neurological systems or vascular anastomosis. The clear pathophysiology of the RSJ is not yet determined with certainty, but its resection is essential for the therapeutic care of patients and also for the improvement of surgical skills. From a surgical point of view, anatomical landmarks has to be chosen: easily reproducible and identifiable. The disappearance of taenia coli (belonging to the colon) and the peritoneal reflection (recto-genital pouch), located below the upper rectum, seem the most reliable. The level of rectal section must, in any case, be below the promontory. CONCLUSION: There is not a single definition, but rather several definitions of the RSJ. Each one of them reflects one appearance of this region: embryological and anatomical evolution or clinical entity. From a surgical point of view, the criterion which seems to be the most reliable is the disappearance of taenia coli and the peritoneal reflection (recto-genital pouch).

Cervical sagittal deformity develops after PJK in adult thoracolumbar deformity correction: radiographic analysis utilizing a novel global sagittal angular parameter, the CTPA.

PURPOSE: To describe reciprocal changes in cervical alignment after adult spinal deformity (ASD) correction and subsequent development of proximal junctional kyphosis (PJK). This study also investigated these changes using two novel global sagittal angular parameters, cervical-thoracic pelvic angle (CTPA) and the T1 pelvic angle (TPA). METHODS: Multicenter, retrospective consecutive case series of ASD patients undergoing thoracolumbar three-column osteotomy (3CO) with fusion to the pelvis. Radiographs were analyzed at baseline and 1 year post-operatively. Patients were substratified into upper thoracic (UT; UIV T6 and above) and lower thoracic (LT; UIV below T6). PJK was defined by >10° angle between UIV and UIV + 2 and >10° change in the angle from baseline to post-op. RESULTS: PJK developed in 29 % (78 of 267) of patients. CTPA was linearly correlated with cervical plumbline (CPL) as a measure of cervical sagittal alignment (R = 0.826, p < 0.001). PJK patients had significantly greater post-operative CTPA and SVA than patients without PJK (NPJK) (p = 0.042; p = 0.021). For UT (n = 141) but not LT (n = 136), PJK patients at 1 year had larger CTPA (4.9° vs. 3.7°, p = 0.015) and CPL (5.1 vs. 3.8 cm, p = 0.022) than NPJK patients, despite similar corrections in PT and PI-LL. CONCLUSIONS: The prevalence of PJK was 29 % at 1 year follow-up. CTPA, which correlates with CPL as a global analog of cervical sagittal balance, and TPA describe relative proportions of cervical and thoracolumbar deformities. Patients who develop PJK in the upper thoracic spine after thoracolumbar 3CO also develop concomitant cervical sagittal deformity, with increases in CPL and CTPA.

Estimation of spinopelvic muscles' volumes in young asymptomatic subjects: a quantitative analysis.

PURPOSE: Muscles have been proved to be a major component in postural regulation during pathological evolution or aging. Particularly, spinopelvic muscles are recruited for compensatory mechanisms such as pelvic retroversion, or knee flexion. Change in muscles' volume could, therefore, be a marker of greater postural degradation. Yet, it is difficult to interpret spinopelvic muscular degradation as there are few reported values for young asymptomatic adults to compare to. The objective was to provide such reference values on spinopelvic muscles. A model predicting the muscular volume from reduced set of MRI segmented images was investigated. METHODS: A total of 23 asymptomatic subjects younger than 24 years old underwent an MRI acquisition from T12 to the knee. Spinopelvic muscles were segmented to obtain an accurate 3D reconstruction, allowing precise computation of muscle's volume. A model computing the volume of muscular groups from less than six MRI segmented slices was investigated. RESULTS: Baseline values have been reported in tables. For all muscles, invariance was found for the shape factor [ratio of volume over (area times length): SD < 0.04] and volume ratio over total volume (SD < 1.2 %). A model computing the muscular volume from a combination of two to five slices has been evaluated. The five-slices model prediction error (in  % of the real volume from 3D reconstruction) ranged from 6 % (knee flexors and extensors and spine flexors) to 11 % (spine extensors). CONCLUSION: Spinopelvic muscles' values for a reference population have been reported. A new model predicting the muscles' volumes from a reduced set of MRI slices is proposed. While this model still needs to be validated on other populations, the current study appears promising for clinical use to determine, quantitatively, the muscular degradation.

Clinical and radiologic outcomes of pyrocarbon radial head prosthesis: midterm results.

BACKGROUND: The modular pyrocarbon (MoPyC) radial head prosthesis (Tornier, Saint-Ismier, France) is a monoblock modular radial head prosthesis. This study assessed midterm outcomes after implantation of the prosthesis. MATERIALS: A retrospective study was conducted of a consecutive cohort of 65 patients who underwent radial head replacement with the MoPyC prosthesis from January 2006 to April 2013. Indications were fractures, early or late failures from orthopedic or fixation treatments, and revisions after another implant. Patients were observed for >2 years for range of motion, pain, and stability; function by the Mayo Elbow Performance Score (total score, 100) and grip strength were assessed. Quality of stem implantation, bone resorption around the neck, and periprosthetic lucency were noted and quantified on radiographs. Capitellum shape and density as well as humeroulnar aspect (river delta sign) were evaluated. Complications and revision procedures were noted. RESULTS: We evaluated 52 of 65 patients (mean follow-up, 46 ± 20 months; range, 24-108). The Mayo Elbow Performance Score was 96 ± 7; pain score, 42 ± 7/45; and motion score, 18 ± 2/20. Function and stability were excellent. Radiology revealed 92% of patients with cortical resorption around the neck without mechanical failure. Bone resorption was mostly anterior and lateral; it resolved within the first year and thereafter was stable. Eight patients underwent revision surgery for stiffness. No implant failures were noted. CONCLUSION: Results of the MoPyC radial head prosthesis appear to be satisfactory. Bone resorption around the neck (stress shielding) is frequent and stable after 1 year and does not impair stem fixation. The MoPyC prosthesis appears to be a reliable solution for replacing the radial head.

Stabilisation of a loosened femoral gamma nail by percutaneous cement injection (cementoplasty): a new technique.

Surgical repair of pertrochanteric and subtrochanteric fractures in the elderly is usually achieved using an endomedullary nail. Unfortunately, even today, some of the patients who undergo this intervention develop periprosthetic bone absorption over time that can lead to loosening of the prosthesis, resulting in pain, joint instability and the need for revision surgery. Surgical revision is hindered by potential complications related to patients' existing underlying medical conditions. It is often the case that these patients are weak and present comorbidities, which can lead to an absolute contraindication to surgery. An interesting alternative could be the stabilisation by percutaneous injection of cement (cementoplasty) in the periprosthetic space under CT and fluoroscopic guidance. In patients with absolute contraindication we performed percutaneous cementoplasty as treatment for femoral prosthesis loosening. Our procedure was technically a success following the end of the intervention period (follow-up: 6 months). The patient no longer experienced significant pain and showed stability of the prosthesis, as demonstrated by CT.

Acute compartment syndrome of the lower limbs: Fasciotomy or dermofasciotomy? A cadaver study of compartment pressures.

BACKGROUND: Acute compartment syndrome (ACS) of the lower limbs is a function-threatening event usually managed by extended dermofasciotomy. Closure of the skin may be delayed, creating a risk of complications when there is an underlying fracture. Early treatment at the pre-ACS stage might allow isolated fasciotomy with no skin incision. The primary objective of this study was to compare intracompartmental pressure (ICP) changes after fasciotomy and after dermofasciotomy. The secondary objectives were to evaluate potential associations linking the starting ICP to achievement of an ICP below the physiological cut-off of 10mm Hg and to determine whether the ICP changes after fasciotomy and dermofasciotomy varied across muscle compartments. HYPOTHESIS: Fasciotomy with no skin incision may not provide a sufficient ICP decrease, depending on the initial ICP value. MATERIAL AND METHODS: A previously validated model of cadaver ACS of the lower limbs was used. Saline was injected gradually to raise the ICP to>15mmHg (ICP15), >30mmHg (ICP30), and >50mmHg (ICP50). We studied 70 leg compartments (anterior, lateral, and superficial posterior) in 13 cadavers (mean age, 89.1±4.6years). ICP was monitored continuously. Percutaneous, minimally invasive fasciotomy consisting in one to three 1-cm incisions was performed in each compartment. ICP was measured before and after fasciotomy then after subsequent skin incision. The objective was to decrease the ICP below 10mmHg after fasciotomy or dermofasciotomy. RESULTS: Overall, mean ICP was 37.8±19.1mmHg after the injection of 184.0±133.01mL of saline. In the ICP15 group, the mean ICP of 16.1mmHg fell to 1.4mmHg after fasciotomy (ΔF=14.7) and 0.3mmHg after dermofasciotomy (ΔDF=1.1). Corresponding values in the ICP30 group were 33.9mmHg, 4.7mmHg (ΔF=29.2), and 1.2mmHg (ΔDF=3.5); and in the ICP50 group, 63.7mmHg, 17.0mmHg (ΔF=46.7), and 1.2mmHg (ΔDF=15.8). Thus, in the group with initial pressures >50mmHg, the ICP decrease was greater after both procedures, but fasciotomy alone nonetheless failed to achieve physiological values (<10mmHg). The pressure changes were not significantly associated with the compartment involved (anterior, lateral, or superficial posterior) (p<0.05). CONCLUSION: Under the conditions of this study, higher baseline ICPs were associated with larger ICP drops after fasciotomy and dermofasciotomy. Nevertheless, when the baseline ICP exceeded 50mmHg, fasciotomy alone failed to decrease the ICP below 10mmHg. Adding a skin incision achieved this goal. LEVEL OF EVIDENCE: IV, experimental study.

An Evaluation of the Reliability of Manual Landmark Identification on 3D Segmented Wrists.

BACKGROUND: Three-dimensional (3D) preoperative planning is increasingly used in orthopaedic surgery. Two-dimensional (2D) characterization of distal radial deformities remains inaccurate, and 3D planning requires a reliable reference frame at the wrist. We aim to evaluate the reliability of the determination of anatomical points placed manually on 3D models of the radius to determine which of those points allow reliable morphometric measurements. METHODS: Twenty-three radial scans were reconstructed in 3D. Five operators specialized in the upper limb manually positioned 8 anatomical points on each model. One of the operators repeated the operation 6 times. The anatomical points were based on previously published 3D models used for radial inclination and dorsopalmar tilt measurements. The repeatability and reproducibility of the measurements derived using this manual landmarking were calculated using different measurement methods based on the identified points. An error of ≤2° was considered clinically acceptable. RESULTS: This study of intraobserver and interobserver variability of the anatomic points allowed us to determine the least variable and most accurately defined points. The middle of the ulnar border of the radius, the radial styloid, and the midpoint of the ulnar incisura of the radius were the least variable. The palmar and dorsal ends of the ridge delineating the scaphoid and lunate facets were the most variable. Only 1 of the radial inclination measurement methods was clinically acceptable; the others had a repeatability and reproducibility limit of >2°, making those measurements clinically unacceptable. CONCLUSIONS: The use of isolated points seems insufficient for the development of a wrist reference frame, especially for the purpose of measuring dorsopalmar tilt. If one concurs that an error of 2° is unacceptable for all distal radial measurements, then clinicians should avoid using 3D landmarked points, due to their unreliability, except for radial inclination measured using the radial styloid and the midpoint of the ulnar edge of the radius. A characterization of the wrist using 3D shapes that fit the articular surface of the radius should be considered. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.