Three-dimensional evaluation of the transverse rotator cuff muscle's resultant force angle in relation to scapulohumeral subluxation and glenoid vault morphology in nonpathological shoulders.

BACKGROUND: Static posterior subluxation of the humeral head (SPSH) results in glenohumeral osteoarthritis. Treatment strategies for SPSH with or without resulting osteoarthritis remain challenging. There is growing interest in evaluating the rotator cuff muscle volume, fatty infiltration, or forces in osteoarthritic shoulders with SPSH, mainly due to a possible transverse force imbalance. In nonpathological shoulders, the transverse angle of the rotator cuff muscle's resultant force may be associated with scapulohumeral alignment and glenoid vault morphology, despite an assumed transverse force balance. The purpose of this study was to assess the transverse rotator cuff muscle's resultant force angle (TRFA) and its relationship with the scapulohumeral subluxation index (SHSI) and selected glenoid vault parameters using computer modeling. METHODS: Computed tomography scans of 55 trauma patients (age 31 ± 13 years, 36 males) with nonpathological shoulders were analyzed and all measurements performed in 3-dimension. We placed landmarks manually to determine the humeral head center and the rotator cuff tendon footprints. The contours of the rotator cuff muscle cross-sectional areas were automatically predicted in a plane perpendicular to the scapula. Each rotator cuff muscle was divided into virtual vector fibers with homogeneous density. The resultant force vector direction for each muscle, corresponding to the rotator cuff action line, was calculated by vectorially summing the normalized fiber vectors for each muscle, weighted by the muscle trophic ratio. The resultant force vector was projected on the axial plane, and its angle with the mediolateral scapular axis was used to determine TRFA. The SHSI according to Walch, glenoid version angle (GVA), glenoid anteroposterior offset angle (GOA), glenoid depth, glenoid width, and glenoid radius were also evaluated. RESULTS: The mean values for TRFA, SHSI, GVA, GOA, glenoid depth, glenoid width, and glenoid radius were 7.4 ± 4.5°, 54.3 ± 4.8%, -4.1 ± 4.4°, 5.1 ± 10.8°, 3.3 ± 0.6 mm, 20 ± 2 mm, and 33.6 ± 4.6 mm, respectively. The TRFA correlated strongly with SHSI (R = 0.731, P < .001) and GVA (R = 0.716, P < .001) and moderately with GOA (R = 0.663, P < .001). The SHSI was strongly negatively correlated with GVA (R = -0.813, P < .001) and moderately with GOA (R = -0.552, P < .001). The GVA correlated strongly with GOA (R = 0.768, P < .001). In contrast, TRFA, SHSI, GVA, and GOA did not correlate with glenoid depth, width, or radius. CONCLUSION: Despite an assumed balance in the transverse volume of the rotator cuff muscles in nonpathological shoulders, variations exist regarding the transverse resultant force depending on the SHSI, GVA, and GOA. In healthy/nonosteoarthritic shoulders, an increased glenoid retroversion is associated with a decreased anterior glenoid offset.

Surgical approaches to the capitellum: a comparative anatomic study.

BACKGROUND: Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach). METHODS: The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach. RESULTS: The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface. CONCLUSION: Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

Phone Administration of the Western Ontario Shoulder Instability Index Is More Reliable Than Administration via Email.

BACKGROUND: The Western Ontario Shoulder Instability (WOSI) questionnaire is a 21-item questionnaire to evaluate quality of life in patients with shoulder instability. Completing the questionnaire is time-consuming because each item is evaluated on a visual analog scale. Telephone or email versions of the score are appealing alternatives to administering it during the standard in-person patient visit; however, their validity and reliability remain unknown. QUESTIONS/PURPOSES: (1) Does the numerical scale (NS) version of the WOSI correlate with the original WOSI and Quick-DASH? (2) Do telephone and email administration of the NS-WOSI have good reliability and consistency? (3) Compared with the original WOSI form, does the NS form lead to faster completion for patients and quicker data extraction for researchers? METHODS: Between 2014 and 2019, 50 patients with a documented history of shoulder dislocation with persistent symptomatic shoulder instability, whether anterior, posterior, or multidirectional; patients scheduled for surgery; and patients with traumatic or nontraumatic injuries were prospectively recruited from the outpatient clinic of two university hospitals acting as Level 1 trauma centers and sports traumatology tertiary referral centers. The median (IQR) age was 28 years (24 to 36), and 80% (40 of 50) were men. Most (52% [26 of 50]) patients had two to five lifetime shoulder dislocations. Validity of the NS-WOSI was assessed using the Pearson correlation coefficient during an in-person visit; the original WOSI questionnaire (or its previously validated French-language version), NS-WOSI, and Quick-DASH questionnaires were administered in a random order. After a minimum 7-day interval, 78% (39 of 50) of patients completed the phone interview, and 74% (37 of 50) of patients completed the email version of the NS-WOSI score to evaluate NS-WOSI's reliability using the intraclass correlation coefficient (ICC), which was interpreted as poor (< 0.5), moderate (0.50-0.75), strong (0.75-0.90), and very strong (> 0.90). The standard error of measurement (SEM) was used to evaluate variability around the true score, with a low value indicating a high reliability. The 95% minimal detectable change (MDC 95% ) was calculated to evaluate the minimal change in score that was not related to measurement errors. Lastly, the Cronbach alpha was used to assess internal consistency (intercorrelation strength), where a value > 0.70 was considered good. The time needed for the patient to complete the various versions and for researchers to extract data was recorded. RESULTS: The NS-WOSI score was very strongly correlated with the original WOSI score (r = 0.96 [95% confidence interval (CI) 0.93 to 0.98]; p < 0.001). Although telephone-acquired and email-acquired data for the NS-WOSI questionnaires were correlated with the NS-WOSI (telephone r = 0.91 [95% CI 0.83 to 0.95]; p < 0.001; email r = 0.84 [95% CI 0.71 to 0.91]; p < 0.001), the ICC was higher for telephone interviews (0.92 [95% CI 0.86 to 0.96] versus email 0.80 [95% CI 0.64 to 0.89]), indicating that although both had good reliability, the phone interview was more suitable. The phone interview was also preferable to email regarding SEM (3% [52 of 2100 points] versus 6% [132 of 2100 points]) and the MDC 95% (7% [144 of 2100 points] versus 17% [366 of 2100 points]). The 95% CI of the MDC acquired by email was superior to the reported minimum clinically important difference for the original WOSI (7% [152 of 2100 points]), meaning that an error of measurement could wrongly be interpreted as a clinically significant change in score. Internal consistency was deemed good, with a Cronbach alpha of 0.96 (95% CI 0.92 to 98) and 0.89 (95% CI 0.79 to 0.94) for NS-WOSI telephone and email, respectively. The time to complete the NS-WOSI was reduced compared with the original WOSI (221 ± 153 seconds versus 266 ± 146 seconds, mean difference -45 seconds [95% CI -72 to -12]; p = 0.009). Lastly, data extraction was faster (62 ± 15 seconds versus 209 ± 52 seconds, mean difference -147 seconds [95% CI -164 to -130]; p < 0.001) with the NS-WOSI than with the original WOSI. CONCLUSION: The NS-WOSI in person, by telephone, or by email is a valid, reliable, and timesaving alternative to the original WOSI questionnaire. However, the reliability of data acquisition by telephone interviews was superior to that of email. CLINICAL RELEVANCE: Given that there were no important differences in performance for the NS-WOSI, regardless of whether it was administered in person or by phone, we suggest that physicians use both interchangeably based on patient convenience. However, we do not recommend using the email version, especially for research purposes, since it was not as reliable when compared with in-person administration. The responsiveness of the modified NS-WOSI, as well as factors influencing response rates to phone interview, are questions that remain to be explored.

The POSI study: gender differences in 94 cases of postoperative shoulder surgery infection: results of a 7-year retrospective multicenter study.

BACKGROUND: Contrary to lower limb infection, POstoperative Shoulder surgery Infection (POSI) often involves Cutibacterium acnes. Our aim was to describe patient characteristics and pathogens retrieved in POSI to guide initial empiric antibiotic selection with suspected infection during revision. We also compared microorganisms in infection following trauma, arthroplasty (AP), and arthroscopy (AS). METHODS: A multicenter retrospective study from 2010 to 2016 reviewed laboratory databases and medical records to identify patients with a previous shoulder surgery and a confirmed shoulder infection. The following procedures were included: AP, AS, fracture fixation (FF), and another open surgery (OS). A confirmed shoulder infection was defined as 2 positive cultures or more of the same microorganism, or clear clinical infection with 1 positive culture or more. RESULTS: Among the 5 hospitals and 28 surgeons involved, 94 POSI cases were identified. Mean age was 59 years at index surgery (range: 22-91) with a majority of men (n = 70, 74%). Among POSI cases, AP was the most common index surgery (n = 41), followed by FF (n = 27), AS (n = 16), and OS (n = 10). The median time between index surgery and the first positive sample was 5 months and the mean was 23 months (minimum 6 days to maximum 27 years), illustrating a positively skewed distribution. Cutibacterium spp were identified in 64 patients (68%), including 59 C acnes patients (63%), which was the most frequent germ in all 4 surgical groups. In 86% of cases, C acnes was identified at the first revision. The other 2 most common germs were Staphylococcus epidermidis and Staphylococcus aureus, with 29% and 17%, respectively. Polymicrobial infection was present in 30% of patients. Gender analysis revealed that C acnes was twice as frequent in men (male = 52 of 70, female = 7 of 24; P < .001). S epidermidis was more prevalent in women (n = 11; 46%) compared with men (n = 16; 21%) (P = .032). C acnes infection was most frequent in arthroscopic surgery (n = 14; 70%, P = .049). S epidermidis was 3 times more prevalent in chronic than in acute cases. CONCLUSION: Empiric antimicrobial therapy following POSI, while waiting for culture results, should cover C acnes, S epidermidis, and S aureus. There is a significant gender difference regarding POSI culture results. C acnes is more frequent in men, but should still be covered in women as it was found in 29% of cases.

Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review.

PURPOSE: Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS: The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS: One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION: TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE: Systematic Review, Therapeutic Level II.

[Support algorithm for lateral elbow pain syndrome in adults]. / Douleurs latérales du coude chez l'adulte : algorithme de prise en charge.

Lateral elbow pain syndrome in adults is a frequent complaint leading to consultation in primary care medicine. The lateral side of the elbow joint represents a complex anatomy with close proximity of bony structures (humerus, radius, and ulna), ligaments (lateral ligament complex), tendons (origin of the extensors of the wrist and fingers), and nerves (branches of the radial nerve) making diagnostic and therapeutic management demanding. This article aims to provide a basis for reflection to better define treatment options for pathologies frequently encountered in clinical practice.

Les douleurs de la face latérale du coude chez l'adulte sont un motif fréquent de consultation en médecine de premier recours. La face latérale de cette articulation représente une anatomie complexe avec une proximité des structures osseuses (humérus, radius et ulna), ligamentaires (complexe ligamentaire latéral), tendineuses (origine des extenseurs du poignet et des doigts) et nerveuses (branches du nerf radial) rendant l'orientation diagnostique et la prise en charge thérapeutique exigeantes. Cet article propose une base de réflexion pour mieux définir les options de prises en charge des pathologies fréquemment retrouvées en pratique clinique.

Image-guided percutaneous cryoablation of unresectable sacrococcygeal chordoma: Feasibility and outcome in a selected group of patients with long term follow-up.

BACKGROUND: Chordoma is a rare malignant tumor of the axial skeleton. Percutaneous cryoablation (PCA) is a minimally invasive technique that allows freezing of tumors under imaging control. The purpose of our retrospective study was to investigate the outcome of PCA in a selected cohort of patients with sacrococcygeal chordoma, with a minimum of 5 years follow-up. MATERIALS AND METHODS: Four patients were treated in 10 sessions. The mean follow-up was 57.3 months. We evaluated the feasibility, the procedure-related complications, the impact on pain control and oncological outcomes. RESULTS: Freezing of 100% of the tumor volume was possible in 60%. Pain control was not reliably evaluable. Local recurrence occurred in 90% of the treated lesions; the mean time to progression was 8.1 months (range 1.5-16). At last follow-up, one patient had died of the disease, one of another cause and one was receiving the best supportive care. The only patient alive without the disease had received additional carbon-ion radiotherapy. The 5-year survival rate after index PCA was 50%. CONCLUSION: Complete freezing of the tumor was technically challenging, mainly due to the complex local anatomy. Recurrence occurred in 90% of the lesions treated. PCA should be considered with caution in the curative management of sacrococcygeal chordoma.

[Management of rotator cuff disorders. How to choose the most appropriate treatment option for my patient ?] / Prise en charge des lésions de la coiffe des rotateurs : choisir la meilleure option pour le patient.

Shoulder pain in the context of rotator cuff disorders is a frequent source of medical consultation. A wide range of therapeutic options is reported in the literature. Non- or minimally invasive treatments include physiotherapy, anti-inflammatory medication, and infiltration of corticosteroids or platelet-rich plasma. Surgical treatments include subacromial debridement, long head of the biceps tenotomy/tenodesis, rotator cuff repair, superior capsular reconstruction, and tendon transfers. Reverse shoulder arthroplasty completes the therapeutic arsenal. Guiding and advising the patient in the face of all these options can therefore be challenging. This article aims to summarize the clinical, demographic, and imaging characteristics useful in guiding and choosing the most appropriate treatment option for each patient.

La pathologie de la coiffe des rotateurs est une source fréquente de consultation. Les options thérapeutiques proposées dans la littérature sont vastes. Les traitements conservateurs comprennent la physiothérapie, les anti-inflammatoires ainsi que l'infiltration de corticostéroïdes ou de plasma riche en plaquettes. Les traitements chirurgicaux incluent le débridement sous-acromial, les gestes sur le tendon du long chef du biceps, la réinsertion des tendons de la coiffe des rotateurs, la reconstruction capsulaire supérieure et les transferts tendineux. La prothèse d'épaule inversée vient compléter l'arsenal thérapeutique. Conseiller le patient face à toutes ces options peut donc s'avérer complexe. Cet article vise à résumer les caractéristiques cliniques, démographiques et radiologiques permettant d'orienter au mieux chaque patient.

Influence of coracoid anatomy on the location of glenoid rim defects in anterior shoulder instability: 3D CT-scan evaluation of 51 patients.

PURPOSE: Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior-inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation. METHODS: Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes. RESULTS: Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = -0.625; 95% CI 0.423-0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior-inferior lesions. A more laterally prominent coracoid was also correlated with anterior-inferior lesions (r = 0.433; 95% CI 0.179-0.633; p = 0.002). CONCLUSION: This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior-inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft. LEVEL OF EVIDENCE: Level 4 basic science.

Cementless short-stem total hip arthroplasty in the elderly patient - is it a safe option?: a prospective multicentre observational study.

BACKGROUND: Due to its bone preserving philosophy, short-stem total hip arthroplasty (THA) has primarily been recommended for young and active patients. However, there may be benefits for elderly patients given a less invasive operative technique due to the short curved implant design. The purpose of this study was to compare the clinical and radiological outcomes as well as perioperative complications of a calcar-guided short stem between a young (< 60 years) and a geriatric (> 75 years) population. METHODS: Data were collected in a total of 5 centers, and 400 short-stems were included as part of a prospective multicentre observational study between 2010 and 2014 with a mean follow-up of 49.2 months. Preoperative femur morphology was analysed using the Dorr classification. Clinical and radiological outcomes were assessed in both groups as well as perioperative complications, rates and reasons for stem revision. RESULTS: No differences were found for the mean visual analogue scale (VAS) values of rest pain, load pain, and satisfaction, whereas Harris Hip Score (HHS) was slightly better in the young group. Comparing both groups, none of the radiological parameters that were assessed (stress-shielding, cortical hypertrophy, radiolucency, osteolysis) reached differences of statistical significance. While in young patients aseptic loosening is the main cause of implant failure, in the elderly group particularly postoperative periprosthetic fractures due to accidental fall have to be considered to be of high risk. The incidence of periprosthetic fractures was found to be 0% in Dorr type A femurs, whereas in Dorr types B and C fractures occurred in 2.1 and 22.2% respectively. CONCLUSIONS: Advanced age alone is not necessarily to be considered as contra-indications for calcar-guided short-stem THA, although further follow-up is needed. However, markedly reduced bone quality with femur morphology of Dorr type C seems to be associated with increased risk for postoperative periprosthetic fractures, thus indication should be limited to Dorr types A and B. TRIAL REGISTRATION: German Clinical Trials Register; DRKS00012634 , 07.07.2017 (retrospectively registered).

Total clavicle reconstruction with free peroneal graft for the surgical management of chronic nonbacterial osteomyelitis of the clavicle: a case report.

BACKGROUND: Chronic nonbacterial osteomyelitis (CNO) is a rare chronic autoinflammatory syndrome affecting mainly children and young adults. The natural history of the disease is marked by recurrent pain as the mainstay of inflammatory outbreaks. Typical radiographic findings are osteosclerosis and hyperostosis of the medial clavicle, sternum and first rib. Compression of the brachial plexus is exceedingly rare and one of the few surgical indications. Literature on total clavicle reconstruction is scarce. While claviclectomy alone has been associated with fair functional and cosmetic outcomes, several reconstruction techniques with autograft, allograft or even cement ("Oklahoma prosthesis") have been reported with the aim of achieving better pain control, cosmetic outcome and protecting the brachial plexus and subclavian vessels. We herewith report a unique case of complicated CNO of the clavicle treated with total clavicle reconstruction using a free peroneal graft. CASE PRESENTATION: A 21-year-old female patient presented with CNO of her left clavicle, associated with recurrent, progressive and debilitating pain as well as limited range of motion. In recent years, she started complaining of paresthesia, weakness and pain radiating to her left arm during arm abduction. The clavicle diameter reached 6 cm on computed tomography, with direct compression of the brachial plexus and subclavian vessels. Following surgical biopsy for diagnosis confirmation, she further developed a chronic cutaneous fistula. Therefore, a two-stage total clavicle reconstruction using a vascularized peroneal graft stabilized by ligamentous reconstruction was performed. At two-year follow-up, complete pain relief and improvement of her left shoulder Constant-Murley score were observed, along with satisfactory cosmetic outcome. CONCLUSIONS: This case illustrates a rarely described complication of CNO with direct compression of the brachial plexus and subclavian vessels, and chronic cutaneous fistula. To our knowledge, there is no consensus regarding the optimal management of this rare condition in this context. Advantages and complications of clavicle reconstruction should be carefully discussed with patients due to limited evidence of superior clinical outcome and potential local and donor-site complications. While in our case the outcomes met the patient's satisfaction, it remains an isolated case and further reports are awaited to help surgeons and patients in their decision process.

[Three-dimensional surgical planning, patient-specific instrumentation and intraoperative navigation in shoulder arthroplasty]. / Planification 3D, instrumentation spécifique au patient et navigation peropératoire en arthroplastie d'épaule.

Total shoulder arthroplasty has become an effective treatment option, for both pain relief and restoration of shoulder range of motion. The key factor limiting long-term prosthetic survival remains glenoid implant loosening. Proper glenoid implant positioning and orientation during surgery was shown to significantly reduce complication rates. The emergence of new technologies now allows for three-dimensional (3D) surgical planning, patient-specific instrumentation and augmented-reality-based intraoperative navigation. Such novel tools have been developed to aid and improve the surgeon's performance. The future will tell whether the gains in term of surgical precision will also translate into better functional outcomes for patients and prolonged survival of glenoid implants.

La prothèse totale d'épaule permet de nos jours d'obtenir des résultats fiables tant sur le plan de l'antalgie que de la récupération des amplitudes articulaires. Le facteur clé limitant la survie de la prothèse reste le descellement de l'implant glénoïdien. Une orientation correcte de celui-ci permet une diminution du risque de complications. L'essor des nouvelles technologies permet la planification en trois dimensions (3D), la création d'instrumentation spécifique au patient ou encore la navigation peropératoire à l'aide de la réalité augmentée. Ces nouveaux outils ont été développés dans le but d'aider et d'améliorer la performance des chirurgiens. L'avenir devra déterminer si le gain en termes de précision chirurgicale pourra également se traduire par un bénéfice fonctionnel pour le patient et une survie augmentée des implants, notamment glénoïdiens.

[Olecranon fractures]. / Fractures de l'olécrâne.

Olecranon fractures represent 5 % of all adult fractures. Management is most often surgical. Conservative treatment is recommended for non-displaced fractures or patients who would be poor surgical candidates. Prolonged immobilization of the elbow may cause joint stiffness, whereas surgical treatment can be complicated by loss of reduction or wound issues with secondary infection of the material. In this article, we discuss the pathology and the principles of treatment based on the literature, to allow the general practitioner to guide the patient towards the most suitable treatment.

Les fractures de l'olécrâne représentent 5 % de l'ensemble des fractures. Leur prise en charge est le plus souvent chirurgicale et le traitement conservateur est réservé aux fractures non déplacées ou à des patients qui seraient de mauvais candidats à la chirurgie. L'immobilisation prolongée du coude peut être responsable d'une raideur articulaire, alors qu'un traitement chirurgical peut entraîner des complications comme le démontage de l'ostéosynthèse ou des problèmes de cicatrisation avec infection précoce du matériel. Dans cet article, nous voulons rappeler les connaissances anatomopathologiques ainsi que les principes du traitement, basés sur la littérature, afin de permettre au médecin d'orienter son patient vers le traitement le plus adapté.

The smartphone inclinometer: A new tool to determine elbow range of motion?

BACKGROUND: There are easily accessible tools on smartphones (APP) for measuring elbow range of motion (ROM). The purpose of this study is to evaluate the validity of a particular APP in determining elbow ROM in comparison with the commonly used goniometer (GON), surgeon estimation of range (EST) and measurement on X-ray (XR). METHODS: The study included 20 patients (40 elbows). Flexion, extension, pronation and supination were measured using three different methods: EST, GON and APP. Radiographic measurements were taken using the average humeral diaphysis axis and dorsal midthird of ulna in flexion and extension. RESULTS: The accuracy of the three different methods has been compared to GON using statistical analysis (ANOVA and paired samples test). There was no statistically significant difference for XR flexion measurement (mean of 2.8° ± 1.5°). The APP overestimated flexion (mean of 6.4° ± 1.0°), and EST underestimated it (mean of - 7.9° ± 1.1°). For extension, the mean difference was 2.8° ± 0.7° for EST and - 26.8° ± 3.1° for XR. The APP method did not significantly differ from GON. Supination accuracy was greater with EST (2.7° ± 1.7°) than with APP (5.9° ± 1.9°). There was no difference for pronation measurement with both EST and APP. CONCLUSIONS: This study is the first comparing four measurement techniques of elbow ROM. Our results showed that EST was only accurate for forearm rotation. The XR scored the best for flexion but is less reliable for extension. Surprisingly, compared to GON, APP did not correlate as we expected for flexion and supination, but the other methods were also inaccurate. We found APP to be very useful to measure complete arc of motion (difference between maximal flexion and maximal extension). LEVEL OF EVIDENCE: III, Retrospective review of a prospective cohort of elbow fracture patients: Diagnostic Study.

[Clavicle fracture : what's new in 2017?] / Fracture de clavicule : quoi de neuf en 2017 ?

Clavicle fracture is a common injury for the general practitioner, the accident and emergency department doctor and the orthopedic trauma surgeon. Historically, most clavicle fractures were treated conservatively. During the last two decades, clinical studies have shown higher rates of nonunion or symptomatic malunion than previously thought. These publications lead to an increase in surgical management of clavicle fractures. However, recent randomized controlled trials failed to confirm any strong clinical outcome improvement after surgical treatment. Based on recent literature, we present up-to-date recommendations and a treatment algorithm for clavicle fractures management.

Les fractures de clavicule représentent une lésion fréquemment rencontrée, aussi bien par le médecin généraliste, l'urgentiste que par le chirurgien orthopédiste. Leur prise en charge, historiquement principalement conservatrice, a connu un bouleversement majeur au cours des deux dernières décennies, suite à la publication d'études qui mettaient en avant des taux de pseudarthrose et de cal vicieux (raccourcissement cliniquement symptomatique) plus importants que ceux publiés par le passé. Ces travaux ont conduit à une augmentation des prises en charge chirurgicales initiales. Cependant, les récentes études contrôlées randomisées peinent à confirmer le bénéfice clinique de l'ostéosynthèse. En s'appuyant sur la littérature récente, nous présentons les recommandations actuelles, ainsi qu'un algorithme de prise en charge, pour les fractures de clavicule.

Knee arthrodesis with modular nail after failed TKA due to infection.

INTRODUCTION: Knee arthrodesis is an established procedure for limb salvage after failed total knee arthroplasty (TKA) in cases of recurrent infection, soft tissue damage, reduced bone stock or with a deficient extensor mechanism. Walking with an arthrodesis is more efficient and less costly in terms of energy expenditure than above-knee amputation. Surgical options include an arthrodesis nail, external fixator or compression plate. We present our results of knee arthrodesis using the modular Wichita Fusion Nail(®) in patients after infected TKA. METHODS: Fifteen patients with irretrievably failed TKA, due to infection, who underwent arthrodesis with the Wichita Fusion Nail(®) from 2004 to 2012 were retrospectively reviewed to assess fusion rate, time to fusion, complication rate, including new infections, and ambulatory status. RESULTS: Three patients were lost to follow-up. Mean follow-up was 33 months (6-132 months). At their most recent follow-up, all patients were walking with full weight bearing on a fused arthrodesis. Mean time to union was 9 months (3-29 months). Three patients necessitated a revision arthrodesis to achieve union after a mean of 5 months after the last procedure. CONCLUSION: Arthrodesis with the Wichita Fusion Nail(®) provides satisfactory results in patients with failure after infected TKA, with 75 % primary union rate and no new or persistent infection at last follow-up visit. Although burdened with a high complication rate, it represents an acceptable option for limb salvage in this particular pathology.

Glenohumeral joint force prediction with deep learning.

Deep learning models (DLM) are efficient replacements for computationally intensive optimization techniques. Musculoskeletal models (MSM) typically involve resource-intensive optimization processes for determining joint and muscle forces. Consequently, DLM could predict MSM results and reduce computational costs. Within the total shoulder arthroplasty (TSA) domain, the glenohumeral joint force represents a critical MSM outcome as it can influence joint function, joint stability, and implant durability. Here, we aimed to employ deep learning techniques to predict both the magnitude and direction of the glenohumeral joint force. To achieve this, 959 virtual subjects were generated using the Markov-Chain Monte-Carlo method, providing patient-specific parameters from an existing clinical registry. A DLM was constructed to predict the glenohumeral joint force components within the scapula coordinate system for the generated subjects with a coefficient of determination of 0.97, 0.98, and 0.98 for the three components of the glenohumeral joint force. The corresponding mean absolute errors were 11.1, 12.2, and 15.0 N, which were about 2% of the maximum glenohumeral joint force. In conclusion, DLM maintains a comparable level of reliability in glenohumeral joint force estimation with MSM, while drastically reducing the computational costs.

Corrective Open-wedge Valgus Proximal Humerus Lengthening Osteotomy. Technique and Case Series.

Symptomatic varus malunion after proximal humeral fractures is associated with weakness and painful limitation of shoulder range of motion. When there is conformity of the articular surface and no avascular necrosis, a head-preserving procedure is best indicated. Arthroscopic arthrolysis, subacromial decompression, and tuberoplasty have been described for the treatment of mild deformity. In cases with more severe deformity, corrective extracapsular lateral closing wedge valgus osteotomy has been reported as a reliable treatment option, in terms of both pain relief and improved function. While this procedure adequately restores rotator cuff tensioning, it is associated with a shortening of the lever arm to the deltoid muscle, secondary to a loss of humeral length. We describe our technique and results with a vascular-sparing, medial open-wedge osteotomy, using a structural allograft and lateral locking plate. In our opinion, this procedure is safe and effective, with the potential to improve functional outcomes in young and active patients.

Automatic quantification of scapular and glenoid morphology from CT scans using deep learning.

OBJECTIVES: To develop and validate an open-source deep learning model for automatically quantifying scapular and glenoid morphology using CT images of normal subjects and patients with glenohumeral osteoarthritis. MATERIALS AND METHODS: First, we used deep learning to segment the scapula from CT images and then to identify the location of 13 landmarks on the scapula, 9 of them to establish a coordinate system unaffected by osteoarthritis-related changes, and the remaining 4 landmarks on the glenoid cavity to determine the glenoid size and orientation in this scapular coordinate system. The glenoid version, glenoid inclination, critical shoulder angle, glenopolar angle, glenoid height, and glenoid width were subsequently measured in this coordinate system. A 5-fold cross-validation was performed to evaluate the performance of this approach on 60 normal/non-osteoarthritic and 56 pathological/osteoarthritic scapulae. RESULTS: The Dice similarity coefficient between manual and automatic scapular segmentations exceeded 0.97 in both normal and pathological cases. The average error in automatic scapular and glenoid landmark positioning ranged between 1 and 2.5 mm and was comparable between the automatic method and human raters. The automatic method provided acceptable estimates of glenoid version (R2 = 0.95), glenoid inclination (R2 = 0.93), critical shoulder angle (R2 = 0.95), glenopolar angle (R2 = 0.90), glenoid height (R2 = 0.88) and width (R2 = 0.94). However, a significant difference was found for glenoid inclination between manual and automatic measurements (p < 0.001). CONCLUSIONS: This open-source deep learning model enables the automatic quantification of scapular and glenoid morphology from CT scans of patients with glenohumeral osteoarthritis, with sufficient accuracy for clinical use.

Is sling immobilization necessary after open Latarjet surgery for anterior shoulder instability? A randomized control trial.

BACKGROUND: There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction. METHODS: This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate postoperative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 1.5-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score and visual analog pain scale (VAS). At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport during the first postoperative year, along with patient satisfaction at one postoperative year, will also be recorded. DISCUSSION: This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction. TRIAL REGISTRATION: The protocol was approved by the ethical committee board (CCER 2019-02,469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397 ) in July 2020.