Validation of mixed-reality surgical navigation for glenoid axis pin placement in shoulder arthroplasty using a cadaveric model.

BACKGROUND: Mixed reality may offer an alternative for computer-assisted navigation in shoulder arthroplasty. The purpose of this study was to determine the accuracy and precision of mixed-reality guidance for the placement of the glenoid axis pin in cadaver specimens. This step is essential for accurate glenoid placement in total shoulder arthroplasty. METHODS: Fourteen cadaveric shoulders underwent simulated shoulder replacement surgery by 7 experienced shoulder surgeons. The surgeons exposed the cadavers through a deltopectoral approach and then used mixed-reality surgical navigation to insert a guide pin in a preplanned position and trajectory in the glenoid. The mixed-reality system used the Microsoft Hololens 2 headset, navigation software, dedicated instruments with fiducial marker cubes, and a securing pin. Computed tomography scans obtained before and after the procedure were used to plan the surgeries and determine the difference between the planned and executed values for the entry point, version, and inclination. One specimen had to be discarded from the analysis because the guide pin was removed accidentally before obtaining the postprocedure computed tomography scan. RESULTS: Regarding the navigated entry point on the glenoid, the mean difference between planned and executed values was 1.7 ± 0.8 mm; this difference was 1.2 ± 0.6 mm in the superior-inferior direction and 0.9 ± 0.8 mm in the anterior-posterior direction. The maximum deviation from the entry point for all 13 specimens analyzed was 3.1 mm. Regarding version, the mean difference between planned and executed version values was 1.6° ± 1.2°, with a maximum deviation in version for all 13 specimens of 4.1°. Regarding inclination, the mean angular difference was 1.7° ± 1.5°, with a maximum deviation in inclination of 5°. CONCLUSIONS: The mixed-reality navigation system used in this study allowed surgeons to insert the glenoid guide pin on average within 2 mm from the planned entry point and within 2° of version and inclination. The navigated values did not exceed 3 mm or 5°, respectively, for any of the specimens analyzed. This approach may help surgeons more accurately place the definitive glenoid component.

The Gritti-Stokes Amputation: Is It Still a Reliable Technique in the 21st Century? A Narrative Review.

Lower limb amputation is a common surgical procedure performed worldwide. Many individuals require amputation due to various circumstances, with amputations occurring above or below the knee. Surgeons rely on published research to determine the most appropriate technique based on intraoperative and postoperative outcomes. The Gritti-Stokes amputation (GSA) procedure, introduced in 1857, has shown positive results in terms of primary wound healing, reduced mortality rates during and after surgery, and accelerated healing and mobility. However, due to the need for highly trained surgeons and limitations in functional and cosmetic prosthesis fitting, concerns have been raised regarding its utility. Additionally, the procedure is underutilized in cases where it could potentially yield better results. This article provides a comprehensive review of the documented benefits of GSA, suitable candidate selection, limitations, various modifications, and a comparison with traditional approaches to lower limb amputation. The review is focused on evidence published in the last 100 years.

Latarjet procedure enables 73% to return to play within 8 months depending on preoperative SIRSI and Rowe scores.

PURPOSE: Systematic reviews report return to play (RTP) within 5.8 months (range, 3-8) following the Latarjet procedure, but the factors that influence RTP remain unknown. The present study aimed to report the rate and time of return to play (RTP) during the first 8 months following the Latarjet procedure, and to determine the influence of sport type or patient characteristics. METHODS: The authors retrospectively collected the records of patients that underwent Latarjet procedures for anterior shoulder instability between 2015 and 2017. Patients were excluded if they had any concomitant rotator cuff tendon lesions, or previous ipsilateral shoulder surgery. The authors retrieved patient demographics, time from injury to surgery, type of sport practiced (overhead/non-overhead, contact/non-contact), as well as pre- and postoperative Western Ontario Shoulder Instability index (WOSI), Shoulder Instability-Return to Sport After Injury index (SIRSI), and Rowe score. RESULTS: A total of 217 patients (217 shoulders) were eligible for inclusion, comprising 184 males and 33 females, aged 26.8 ± 7.3 years at index surgery. The main sport practiced prior to surgery involved overhead (n = 173, 80%) and/or contact (n = 152, 70%) activities. By 8 month follow-up, 158 patients (73%) resumed their main sport, at a mean of 5.1 ± 1.5 months. Multivariable analysis revealed that RTP was more likely in patients with higher preoperative Rowe score (OR, 1.02; p = 0.024) and SIRSI score (OR, 1.02; p = 0.008). CONCLUSIONS: By 8 months following the Latarjet procedure, 73% of patients had resumed their main sport. The likelihood of RTP was significantly associated with preoperative Rowe and SIRSI scores, but not with sport type. LEVEL OF EVIDENCE: IV.

Press-fit vs. cemented humeral stem fixation for reverse shoulder arthroplasty: functional outcomes at a mean follow-up of 9.5 years.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a reliable, long-term treatment option for degenerative shoulder pathology. However, the functional outcomes degrade around the fifth year postoperation, particularly for internal and external rotation. Long-term radiographic changes have been reported around the humeral stem, depending on the fixation method. OBJECTIVES: The primary objective was to compare the clinical outcomes of RSAs by fixation method-cemented vs. press-fit-after a minimum follow-up of 5 years. We hypothesized that proximal humeral osteolysis impacts the functional outcomes. DESIGN AND METHODS: Our study compared 2 matched cohorts: 56 RSAs with cemented stems and 56 RSAs with press-fit stems. We evaluated all the patients using the Constant-Murley score (CMS) and range of motion (ROM), which we measured preoperatively and at the final follow-up visit. We evaluated radiographs from the final follow-up visit to look for proximal humeral osteolysis with tuberosity resorption, signs of stress shielding, periprosthetic radiolucent lines, and scapular notching. RESULTS: At a mean follow-up of 9.5 years (5-21), regardless of the fixation method, the RSA procedure helped to improve the CMS and active joint ROM postoperatively, except for internal and external rotation with elbow at side in the press-fit group. Shoulder ROM was significantly better in the group with cemented stems for anterior elevation (P < .001), abduction (P = .006), and external (P = .02) and internal rotation with elbow at side (P = .02). The CMS did not differ between groups. The presence of tuberosity resorption or scapular notching had no effect on the CMS and active ROM in either group. Osteopenia, which was more prevalent in the press-fit group, had no impact on the functional outcome. CONCLUSION: There was no significant difference between groups in the CMS, although the active shoulder ROM was significantly worse in the press-fit group. This difference could be attributed to more frequent tuberosity resorption in this group.

Prevalence of metal hypersensitivity in patients with shoulder pathologies.

BACKGROUND: To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire. METHODS: The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was "reported hypersensitivity to metals," comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips. RESULTS: A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals. CONCLUSIONS: This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.

"Tomydesis" might be a reliable technique for lesions of the long head of the biceps tendon associated with rotator cuff tears: a minimum 6-month prospective clinical follow-up study.

PURPOSE: To compare the clinical outcomes of self-locking T-tenotomy called "tomydesis" to three different techniques of tenodesis for lesions of the long head of the biceps tendon (LHBT) associated with rotator cuff tears. HYPOTHESIS: Tomydesis could provide similar clinical outcomes than the other LHBT tenodesis techniques. METHODS: This prospective multicentre study included 77 patients who underwent rotator cuff repair concomitant with one of four surgical techniques on the LHBT. All patients had a minimum of 6-month follow-up post-operatively. Outcomes were evaluated based on the Constant score, SSV, pain on visual analogue scale, biceps-specific pain and Popeye deformity on photographs. RESULTS: There was no difference for the pain at the biceps muscle belly (p = 0.58), the bicipital groove (p = 0.69) and during resisted supination (p = 0.53), as well as for muscle cramps (p = 0.09), VAS for pain (p = 0.12) and Popeye deformity (p = 0.18). There was more pain in resisted flexion in the tomydesis group (p = 0.032), and significantly better Constant scores and SSV (< 0.001) in the patients who underwent the double lasso loop technique, but non-repairable cuff tears were most frequent in the tomydesis group. CONCLUSIONS: Tomydesis might be a reliable alternative that combines advantages of tenodesis and tenotomy. It should be considered in cases of rotator cuff tears, whose repair and healing are the key for good functional outcomes. LEVEL OF EVIDENCE: II.

Clinical and anatomic results of rotator cuff repair at 10 years depend on tear type.

PURPOSE: Although good short-term and mid-term outcomes are reported for rotator cuff repair, few studies have investigated long-term outcome with clinical and MRI evaluation. The hypothesis was that 10 years following repair of rotator cuff tear, the clinical and anatomic results depend on the extension of the tear. METHODS: The records of all 965 patients who underwent repair of rotator cuff tears in 2003 were retrieved. The patients were reviewed in 2014 for evaluation at a minimum follow-up of 10 years. A total of 511 patients were evaluated clinically, of whom 397 were also evaluated using MRI. There were 289 isolated supraspinatus tears (SS), 94 tears with posterior extension (P), 92 with anterior extension (A) and 36 with anteroposterior (AP) extension. RESULTS: The Constant score had significantly improved from 53.8 ± 14.7 preoperatively to 77.7 ± 12.1 (P < 0.0001) at 10 years, with no significant difference between the four groups. The rate of retear (Sugaya IV, V) was lower in the SS group (19%) and higher in the P (32%) and AP groups (31%). At review, infraspinatus fatty degeneration was significantly greater (Fuchs > 2) in the P (P < 0.001) and AP (P < 0.001) groups and subscapularis fatty degeneration was significantly greater (Fuchs > 2) in the A (P < 0.001) and AP (P < 0.001) groups. The rate of osteoarthritis (Samilson > 2) was significantly higher at 11% (P = 0.001) in the A group. The failure rate was significantly lower (P = 0.044) in the SS group (25%) than the massive rotator cuff tear groups (A, P and AP groups) (35%). Complications occurred in 51 shoulders (10%) and repeat surgery was required in 62 shoulders (12%), with no difference between the four groups. CONCLUSIONS: The long follow-up period of this study, large series of patients and MRI evaluation of tendon repair allowed us to demonstrate that 10 years following rotator cuff tear repair, between 68 and 81% of tendons had healed. These findings are of value in predicting response to surgical treatment. Tears with posterior extension had a higher risk of retear. However, surgical repair appeared to give a good functional outcome whatever the type of tear, despite the overall rate of complications and repeat surgery. LEVEL OF EVIDENCE: IV.

Diagnosis of long head of biceps tendinopathy in rotator cuff tear patients: correlation of imaging and arthroscopy data.

INTRODUCTION: The goal of this prospective study was to assess the reliability of pre-operative cross-sectional imaging for the diagnosis of long head of biceps (LHB) tendinopathy in patients with a rotator cuff tear. METHODS: Cross-sectional imaging with MRI or CT arthrography data from 25 patients operated upon because of a rotator cuff tear between 1 October 2015 and 1 April 2016 was analysed by one experienced orthopaedic surgeon, one experienced radiologist and one orthopaedic resident. The analysis consisted of determining whether the LHB was present, the extrinsic tendon abnormalities (dislocation, tendon coverage) and intrinsic abnormalities (fraying, inflammation, degeneration). These findings were then compared to intra-operative arthroscopy findings, which were used as the benchmark. The interobserver correlation between the three different examiners for the cross-sectional imaging analysis as well as the correlation between the imaging and arthroscopy data were determined. RESULTS: The correlation between the imaging and arthroscopy data was the highest (80%) for the determination of LHB dislocation from the bicipital groove. The other diagnostic elements (subluxation, coverage and tendon degeneration) were difficult to discern with preoperative imaging, and correlated poorly with the arthroscopy findings (45% to 65%). The interobserver correlation was moderate to strong for the diagnosis of extrinsic tendon abnormalities. It was low to moderate for intrinsic abnormalities. CONCLUSION: Except for LHB dislocation, pre-operative imaging is not sufficient to make a reliable diagnosis of LHB tendinopathy. Arthroscopy remains the gold standard for the management of LHB tendinopathy, as diagnosed intra-operatively.

Version Correction via Eccentric Reaming Compromises Remaining Bone Quality in B2 Glenoids: A Computational Study.

BACKGROUND: Version correction via eccentric reaming reduces clinically important retroversion in Walch type B2 glenoids (those with substantial glenoid retroversion and a second, sclerotic neoglenoid cavity) before total shoulder arthroplasty (TSA). Clinically, an increased risk of glenoid component loosening in B2 glenoids was hypothesized to be the result of compromised glenoid bone quality attributable to eccentric reaming. However, no established guidelines exist regarding how much version correction can be applied without compromising the quality of glenoid bone. QUESTIONS/PURPOSES: (1) How does version correction correlate to the reaming depth and the volume of resected bone during eccentric reaming of B2 glenoids? (2) How does version correction affect the density of the remaining glenoid bone? (3) How does version correction affect the spatial distribution of high-quality bone in the remaining glenoid? METHODS: CT scans of 25 patients identified with Walch type B2 glenoids (age, 68 ± 9 years; 14 males, 11 females) were selected from a cohort of 111 patients (age, 69 ± 10 years; 50 males, 61 females) with primary shoulder osteoarthritis who underwent TSA. Virtual TSA with version corrections of 0°, 5°, 10°, and 15° was performed on 25 CT-reconstructed three-dimensional models of B2 scapulae. After simulated eccentric reaming at each version correction angle, bone density (Hounsfield units [HUs]) was analyzed in five adjacent 1-mm layers under the reamed glenoid surface. Remaining high-quality bone (> 650 HUs) distribution in each 1-mm layer at different version corrections was observed on spatial distribution maps. RESULTS: Larger version corrections required more bone resection, especially from the anterior glenoid. Mean bone densities in the first 1-mm bone bed under the reamed surface were lower with 10° (523.3 ± 79.9 HUs) and 15° (479.5 ± 81.0 HUs) version corrections relative to 0° (0°, 609.0 ± 103.9 HUs; mean difference between 0° and 15°, 129.5 HUs [95% CI, 46.3-212.8 HUs], p < 0.001; mean difference between 0° and 10°, 85.7 HUs [95% CI, 8.6-162.9 HUs], p = 0.021) version correction. Similar results were observed for the second 1-mm bone bed. Spatial distribution maps qualitatively showed a decreased frequency of high-quality bone in the anterior glenoid as version correction increased. CONCLUSIONS: A version correction as low as 10° was shown to reduce the density of the glenoid bone bed for TSA glenoid fixation in our computational study that simulated reaming on CT-reconstructed B2 glenoid models. Increased version correction resulted in gradual depletion of high-quality bone from the anterior region of B2 glenoids. CLINICAL RELEVANCE: This computational study of eccentric reaming of the glenoid before TSA quantitatively showed glenoid bone quality is sensitive to version correction via simulated eccentric reaming. The bone density results of our study may benefit surgeons to better plan TSA on B2 glenoids needing durable bone support, and help to clarify goals for development of precision surgical tools.

Humeral version in reverse shoulder arthroplasty affects impingement in activities of daily living.

BACKGROUND: Impingement after reverse shoulder arthroplasty (RSA) has been correlated with implant design and surgical techniques. Previous studies suggested that humeral retroversion can reduce impingement and increase external rotation range of motion (ROM). The purpose of this study was to determine how humeral version affects impingement in activities of daily living (ADLs). MATERIALS AND METHODS: A single surgeon performed virtual RSA on 30 arthritic shoulders that were reconstructed from preoperative computed tomography scans. For each subject, the humeral component was placed into 5 versions: -40°,-20°, 0°, +20°, and +40° (- indicates retroversion, + indicates anteversion). Intra-articular and extra-articular impingement was calculated for 10 ADLs. Impingement-free ROM was also calculated for abduction, forward flexion, scapula plane elevation, and internal/external rotation (standardized tests). Risk of impingement for ADLs was assessed as the collective duration and frequency of impingement across all motions. Frequent impingement sites were identified. RESULTS: For the ADLs, 0° version showed the least amount of impingement. In contrast, 40° retroversion resulted in the largest ROM for the standardized tests (118° ± 19° abduction, 109° ± 16° forward flexion, 111° ± 10° scapula plane elevation, 140° ± 15° internal/external rotation). The site of impingement changed with version: retroversion increased the extra-articular impingement, and anteversion increased the contact between the inferior glenoid and the humeral cup. CONCLUSIONS: Humeral version can significantly affect impingement in RSA. Maximizing ROM in standardized tests may not reduce the risk of impingement during ADLs. Our results showed that an average 0° of version should be preferred, but the large variability among subjects suggested that optimum version may vary among individuals.

Fatty infiltration of stage 1 or higher significantly compromises long-term healing of supraspinatus repairs.

BACKGROUND: Fatty infiltration (FI) compromises outcomes of rotator cuff repairs. Most clinicians consider FI of the infraspinatus, whether it is torn or intact, because it is most rapidly affected. The purpose of this study was to report long-term outcomes of isolated supraspinatus repairs and to determine their associations with FI of the infraspinatus and supraspinatus. METHODS: The records of 182 patients who underwent repair of isolated supraspinatus tears and had preoperative magnetic resonance imaging were retrieved. Of these, 147 patients were evaluated at 10 years' follow-up using the Constant score and magnetic resonance imaging scans. RESULTS: Preoperative FI was greater in the supraspinatus (52% stage ≥1) than in the infraspinatus (29% stage ≥1). The 10-year Constant scores were influenced by FI of the supraspinatus (P = .006) but not of the infraspinatus (P = .422). Multivariable regression confirmed that Constant scores were significantly lower for female patients, repetitive work, and stage 1 and stage 2 FI of the supraspinatus in addition to open surgery. Retear rates (Sugaya types IV-V) were also influenced by FI of the supraspinatus (P = .001) but not of the infraspinatus (P = .979). Shoulders with supraspinatus FI at stages 0, 1, and 2 had retear rates of 10%, 22%, and 31%, respectively. Multivariable regression affirmed that the odds of retears are significantly increased by both stage 1 and stage 2 FI of the supraspinatus. CONCLUSIONS: The Constant scores and retear rates were significantly associated with FI of the torn supraspinatus (stage ≥1) but not of the intact infraspinatus. The authors recommend that rapid surgical intervention be considered, before accumulation of fat, especially for young, active patients.

Effects of the humeral tray component positioning for onlay reverse shoulder arthroplasty design: a biomechanical analysis.

BACKGROUND: Recent shoulder prostheses have introduced a concept of a universal humeral stem component platform that has an onlay humeral tray for the reverse total shoulder arthroplasty (RTSA). No studies have reported how humeral tray positioning can affect the biomechanics of RTSA. MATERIALS AND METHODS: The Newcastle Shoulder Model was used to investigate the biomechanical effect of humeral tray positioning in the Biomet Comprehensive Total Shoulder System (Biomet, Warsaw, IN, USA) RTSA. Five humeral tray configuration positions were tested: no offset, and 5 mm offset in the anterior, posterior, medial, and lateral positions. Superior and inferior impingement were evaluated for abduction, scapular plane elevation, forward flexion, and external/internal rotation with the elbow at the side (adduction) and at 90° of shoulder abduction. Muscle lengths and moment arms (elevating and rotational) were calculated for the deltoid, the infraspinatus, the teres minor, and the subscapularis. RESULTS: Inferior impingement was not affected by the humeral tray position. There was less superior impingement during abduction, scapular plane elevation, and rotation with the shoulder when the tray was placed laterally or posteriorly. The subscapularis rotational moment arm was increased with a posterior offset, whereas infraspinatus and teres minor rotational moment arms were increased with an anterior offset. Very little change was observed for the deltoid elevating moment arm or for its muscle length. CONCLUSION: Positioning the humeral tray with posterior offset offers a biomechanical advantage for patients needing RTSA by decreasing superior impingement and increasing the internal rotational moment arm of the subscapularis, without creating inferior impingement.

Deltopectoral approach for shoulder arthroplasty: anatomic basis.

PURPOSE: The deltopectoral approach is a common surgical procedure for shoulder arthroplasty. Many surgeons are familiar with this procedure, but certain steps are still controversial. This is the case for the management of subscapularis, where surgeons must choose between tenotomy and the lesser tuberosity osteotomy. METHODS: This article is conceived as a toolkit for the inexperienced surgeons, describing our tips and tricks to facilitate final exposure of the glenoid. For experienced surgeons, we analysed the tricky portions of the deltopectoral approach, comparing them with what is classically reported in the literature. RESULTS: We describe an original technic for subscapularis reattachment after lesser tuberosity osteotomy in order to improve its stability. The medial part of the fragment is secondarily sculpted to obtain a step shape, which will be applied against the base of the prosthetic cup in a sort of "corner buttress". CONCLUSIONS: Our work, based on our personal experience, confirms that there is no preferred single deltopectoral approach but, rather, multiple options. When embarking on this "shoulder highway", we encourage surgeons to respect the successive anatomic planes, which we believe is the only way to ensure easy and atraumatic dissection. KEY POINTS: - The safe plane for going around the humeral head and positioning retractors is the plane of the subacromial deltoid bursa. - Always stay close to the bone during capsule release, whether on the humeral or glenoid side. - Never go medially to the conjoint tendon or its deep face.

Evaluation of the role of glenosphere design and humeral component retroversion in avoiding scapular notching during reverse shoulder arthroplasty.

BACKGROUND: Scapular notching is a common observation during radiological follow-up of reverse shoulder arthroplasty. The purpose of this study was to evaluate the effect of glenosphere design and humeral component retroversion on movement amplitude in the scapular plane and inferior scapular impingement. MATERIALS AND METHODS: The Aequalis Reversed Shoulder Prosthesis (Tornier) was implanted into 40 cadaver shoulders. On the glenoid side, 8 different combinations were tested: 36-mm glenosphere: centered (standard), eccentric, with an inferior tilt, or with the center of rotation (COR) lateralized by 5 or 7 mm; and 42-mm centered glenosphere: used alone or with the COR lateralized by 7 or 10 mm. The humeral component was positioned in 0°, 10°, 20°, 30°, and 40° of retroversion. Maximum adduction and abduction were measured when inferior impingement and superior impingement, respectively, were detected. RESULTS: The average increase in abduction amplitude was 10° and inferior impingement occurred 18° later with a 42-mm glenosphere, especially when it was lateralized by 10 mm, relative to a 36-mm centered glenosphere (P < .05). These 2 combinations provided a 28° increase in the movement amplitude in the scapular plane. Positioning of the humeral component in 10° or 20° of retroversion or in anatomical retroversion was most effective at avoiding inferior impingement but had less effect on abduction range of motion (except with the 42-mm glenosphere). CONCLUSION: Our study confirmed published results with various glenosphere designs but was unique in describing the effect of humeral retroversion on scapular impingement. Inferior scapular notching can be most effectively prevented by using large-diameter glenospheres with lateralized COR and by making sure to replicate the patient's native humeral retroversion.

Comprehensive Insights into Chondroblastoma Metastasis: Metastatic Patterns and Therapeutic Approaches.

Chondroblastoma metastasis, though rare, represents a clinically significant and notably important aspect of bone tumors. Understanding its epidemiological characteristics, pathological features, and treatment modalities, despite its infrequency, is imperative for comprehensive patient management. This review aims to elucidate the epidemiology, molecular mechanisms, diagnostic challenges, and therapeutic strategies associated with chondroblastoma metastasis. The patterns, prognostic factors, and treatment outcomes were explored through an analysis of case studies and clinical reports. Notably, we highlighted emerging therapeutic perspectives aimed at improving patient outcomes. To the best of our knowledge, there has been no previous review addressing these matters cumulatively, highlighting a significant gap in the existing scholarly literature. By shedding light on the nuances of chondroblastoma metastasis, this review contributes to the advancement of knowledge in this field and informs clinical decision-making for improved patient care.

Restoration of internal rotation after reverse shoulder arthroplasty may vary depending on etiology in patients younger than 60 ​years of age: a multicenter retrospective study.

BACKGROUND: Reverse shoulder arthroplasty (RSA) offers promising functional outcomes for young patients, yet challenges persist in restoring internal rotation (IR). This study aimed to assess the restoration of IR after RSA in patients younger than 60 years of age and analyze the factors affecting IR recovery. METHODS: A retrospective multicenter study was conducted, examining the functional outcome of patients who underwent RSA, with a minimum follow-up period of 2 years. Two subgroups of patients who underwent primary RSA were analyzed separately with respect to active internal rotation with the elbow at the side (AIR1): "difficult AIR1" and "easy AIR1." RESULTS: The study included 136 patients (overall series) with a mean age of 51.6 years. The overall series showed statistically significant improvement in active range of motion (RoM), pain, and Constant scores, especially with active IR (p â€‹< â€‹0.01). According to etiology, statistically significant improvement (p â€‹< â€‹0.05) in active IR was observed for fracture sequelae, primary osteoarthritis, and rheumatoid arthritis, whereas no statistically significant improvement in IR was observed for tumor, revision, and cuff-tear arthropathy (p â€‹> â€‹0.05). In subgroup analysis, patients with easy AIR1 displayed a statistically significant lower body mass index and better Constant score mobility, as well as improved motion in forward elevation and active IR (p â€‹< â€‹0.05). No statistically significant associations were found between improved IR and prosthetic design or subscapularis repair. Scapular notch, lysis of the graft, and teres minor atrophy were significantly associated with better active IR (p â€‹< â€‹0.05). CONCLUSION: RSA improves active RoM, pain, and functional outcomes in patients aged under 60. However, the degree of improvement in IR may vary depending on several factors and the underlying etiologies. These insights are crucial for patient selection and counseling, guiding RSA optimization efforts. LEVEL OF EVIDENCE: IV.

Better Constant Scores and Active Forward Elevation Using Deltopectoral Versus Anterosuperior Approach for Reverse Shoulder Arthroplasty: Matched Cohort Study.

Purpose: To determine, from a sizable cohort of reverse shoulder arthroplasty (RSA), whether the deltopectoral (DP) or anterosuperior (AS) approach grant better outcomes at a minimum follow-up of 24 months. Methods: The authors reviewed 743 RSAs in patients with primary osteoarthritis (OA) with or without rotator cuff lesions and secondary OA due to rotator cuff tears. The DP approach was used in 540 and the AS approach in 203. Pre- and post-operative constant scores (CSs) and shoulder range of motion were recorded. Results: Of the initial cohort of 743 shoulders, 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised; 540 shoulders were operated using DP approach (73%), of which 22 were revised (4.1%), while 203 were operated using the AS approach (27%), of which 11 were revised (5.4%). Propensity score matching resulted in two groups: 172 shoulders operated by DP approach, and 88 shoulders operated by AS approach. Comparing outcomes of the matched groups at 2 or more years also revealed that, compared to the AS approach, the DP approach resulted in significantly better post-operative CSs (67.3 ± 14.0° vs 60.8 ± 18.3, P = 0.017), active forward elevation (137° ± 27.4° vs 129° ± 29.8; P = 0.031). Conclusion: At 2 or more years following RSA, the DP approach granted significantly better CS (by 6.5 points) and active forward elevation (by 8°) compared to the AS approach. The differences observed are clinically relevant and must be considered to manage patient expectations following RSA and for selecting surgical approach depending on their functional needs. Level of evidence: III, comparative study.

Inter- and intra-observer agreement in arthroscopic assessment of the long head of the biceps.

INTRODUCTION: Long head of the biceps (LHB) pathology is frequent but can be difficult to diagnose. Arthroscopy is the current diagnostic gold-standard. The aim of the present study was to assess inter- and intra-observer agreement in arthroscopic analysis of the LHB. HYPOTHESIS: Agreement in arthroscopic analysis of the LHB is good in the particular case of small rotator cuff tears. MATERIAL AND METHODS: This prospective study included 49 patients operated on between November 1 and November 30, 2017. Seven surgeons were asked to record videos of arthroscopic LHB analysis for Patte-1 small supraspinatus tendon tears. One junior and 2 senior surgeons analyzed the videos independently, studying macroscopic intrinsic and extrinsic LHB aspect. Inter-observer agreement, and intra-observer agreement for the junior surgeon, were analyzed. RESULTS: Inter-observer agreement between the surgeons and intra-observer agreement for the junior surgeon were slight in describing the pathologic aspect of the LHB: respectively, κ=0.254, p<0.038; and κ=0.319, p<0.0019. DISCUSSION: Isolated arthroscopic LHB assessment without clinical or paraclinical input or precise surgical exploration protocol showed slight inter-observer agreement. Analysis and interpretation of LHB aspect should in practice be based on combined clinical, paraclinical and arthroscopic data. LEVEL OF EVIDENCE: III.

Can artificial intelligence help decision-making in arthroscopy? Part 2: The IA-RTRHO model - a decision-making aid for long head of the biceps diagnoses in small rotator cuff tears.

INTRODUCTION: The possible applications of artificial intelligence (AI) in orthopedic surgery are promising. Deep learning can be utilized in arthroscopic surgery due to the video signal used by computer vision. The intraoperative management of the long head of biceps (LHB) tendon is the subject of a long-standing controversy. The main objective of this study was to model a diagnostic AI capable of determining the healthy or pathological state of the LHB on arthroscopic images. The secondary objective was to create a second diagnostic AI model based on arthroscopic images and the medical, clinical and imaging data of each patient, to determine the healthy or pathological state of the LHB. HYPOTHESIS: The hypothesis of this study was that it was possible to construct an AI model from operative arthroscopic images to aid in the diagnosis of the healthy or pathological state of the LHB, and its analysis would be superior to a human analysis. MATERIALS AND METHODS: Prospective clinical and imaging data from 199 patients were collected and associated with images from a validated protocoled arthroscopic video analysis, called "ground truth", made by the operating surgeon. A model based on a convolutional neural network (CNN) modeled via transfer learning on the Inception V3 model was built for the analysis of arthroscopic images. This model was then coupled to MultiLayer Perceptron (MLP), integrating clinical and imaging data. Each model was trained and tested using supervised learning. RESULTS: The accuracy of the CNN in diagnosing the healthy or pathological state of the LHB was 93.7% in learning and 80.66% in generalization. Coupled with the clinical data of each patient, the accuracy of the model assembling the CNN and MLP were respectively 77% and 58% in learning and in generalization. CONCLUSION: The AI model built from a CNN manages to determine the healthy or pathological state of the LHB with an accuracy rate of 80.66%. An increase in input data to limit overfitting, and the automation of the detection phase by a Mask-R-CNN are ways of improving the model. This study is the first to assess the ability of an AI to analyze arthroscopic images, and its results need to be confirmed by further studies on this subject. LEVEL OF EVIDENCE: III Diagnostic study.

Methods of analyzing the long head of the biceps tendon in the management of distal supraspinatus tendon ruptures. Part 2: The role and validation of an arthroscopic exploration protocol of the long head of the biceps tendon.

INTRODUCTION: Inter-observer arthroscopic assessments of the Long head of the Biceps tendon (LHB) injuries, in the absence of predefined instructions, are poorly reproducible. There are several types of LHB injuries, of varying severity, which can make its intraoperative analysis subjective. HYPOTHESIS: The application of a precise arthroscopic exploration protocol, particularly dynamic, associated with an equally precise analysis of the possible tendon lesions, intrinsic or extrinsic, makes it possible to obtain a reproducible analysis of the lesions of the LHB and aid decision-making around its conservation or its resection, in distal supraspinatus tendon ruptures. MATERIAL AND METHODS: This was a prospective, multicenter study including 371 patients with a stage 1 rupture of the supraspinatus tendon, in accordance with the Patte classification. An exploration protocol with intraoperative video recording of the articular portion of the biceps was systematically performed by the operators. It included static intra-articular and extra-articular observation of the LHB, as well as a dynamic intra-articular hook test with mobilization in internal and external rotation, and in anterior elevation. An analysis of the lesion status of the LHB was then made by the principal operator (Op), after defining the various possible lesions: intrinsic or extrinsic. This initial diagnostic assessment was then compared with the analysis made by two independent observers (Obs1, Obs2) based on a replay of the recorded videos. The reliability of agreement was then measured using Cohen's Kappa coefficient (K) and Fleiss' kappa. RESULTS: Two hundred and fifty-seven videos were analyzable. The level of agreement between the two independent observers was strong (K=0.63) for applying the diagnosis of a healthy or pathological biceps. The agreement between the independent observers and the operator was weaker (respectively K Op-Obs1=0.51 - moderate and K Op-Obs2=0.39 - poor). CONCLUSION: The application of a precise protocol for the exploration of the LHB, associated with a previously defined lesion classification, makes it possible to obtain a high rate of agreement for the arthroscopic diagnostic analysis of the LHB. However, arthroscopy cannot be used as the only criterion for deciding which procedure to perform on the LHB. Other clinical and para-clinical factors must be taken into consideration. LEVEL OF EVIDENCE: III; prospective inter-observer series.