Anatomy of the biceps brachii osseous footprint: study of 100 radii and literature review.

Biceps brachii (BB) tendon rupture is frequent in young males and may require surgical repair. Non-anatomic reinsertion leads to loss of strength in supination. The main aim of the present study was to describe the anatomy of the osseous footprint of the distal BB tendon. The dimensions of the footprint of the distal BB insertion were analyzed in 100 dry cadaver radii, using MicroScribe 3D software. Insertion area, assimilated to an ellipse, was calculated from 4 points (medial, lateral, cranial and caudal) determining the two axes of the ellipse. Mean footprint length, width and area were 18 mm (range, 7-24 mm), 9 mm (range, 4-15 mm), and 129 mm2 (range, 46-266 mm²), respectively. Intra- and inter-observer correlation coefficients were satisfactory: κ = 0.75 and κ = 0.7, respectively. The present study reported BB footprint dimensions in 100 radii, providing a basis to guide surgical treatment of distal BB tendon rupture. Non-anatomical restoration of the BB tendon footprint leads to poorer clinical and biomechanical results; precise knowledge of the footprint is necessary for anatomical repair.

Shoulder arthrodesis in brachial plexus palsy.

Long considered as the ultimate surgery for limb salvage in case of brachial plexus palsy, shoulder fusion has seen its indications reduced with the development of more numerous and multiple tendon transfers. This option remains valid and should always be suggested first because of its reliable effects on pain and function. However, it is a demanding surgery, the position of the fusion remains difficult to determine and the complication rate is not negligible.

The position of the upper limb during shoulder arthroscopy does not affect the distance between axillary nerve and glenoid.

PURPOSE: The segment of the axillary nerve (AxN) near the glenoid rim is at risk of iatrogenic lesion during arthroscopic procedures. We hypothesize that the distance between the AxN and the glenoid rim is not modified by the patient's positioning. The primary objective was to compare the position of the AxN with the inferior glenoid rim in lateral decubitus or in beach chair and positions of the upper limb. METHODS: Sixteen shoulders were dissected in beach chair position with the shoulder in neutral rotation. Needle one was placed in the axillary nerve where it was the closest with the inferior glenoid rim. In lateral decubitus with traction and 70° of abduction needle two was placed in the AxN at the closest with the inferior glenoid rim. The glenoid rim was marked with a needle at 6 o'clock. In beach chair position, the distance between needle one and the glenoid needle was measured for six positions. In lateral decubitus, measures were done for two positions of abduction. In lateral decubitus with 70° of abduction, the distance between needle two and the glenoid needle was also measured. RESULTS: The mean distance between AxN and the inferior glenoid rim was 14.4 mm in reference position in beach chair. The results showed the absence of difference between the positions during surgery except for lateral decubitus with 70° of abduction. CONCLUSION: Our study showed that the position of the shoulder during arthroscopic procedures cannot take away the AxN from the inferior glenoid rim. LEVEL OF EVIDENCE: Level IV-basic science study.

Innervation of flexor hallucis longus muscle: an anatomical study for selective neurotomy.

BACKGROUND: The aim of the study was to describe the innervation of flexor hallucis longus (FHL) and obtain its surgical coordinates to facilitate selective neurotomy. MATERIALS AND METHODS: Fifteen embalmed lower limbs of adults were studied. Anatomical dissections to isolate the innervating branches of FHL were performed. Distance between the supplying nerve of FHL, including both its origin and termination, and the medial malleolus were obtained, providing anatomical coordinates beneficial for surgery. RESULTS: In all cases, FHL was innervated by only one branch, which originated from the tibial nerve. Mean distance between the medial malleolus and the nervous branch origin was 21.39 ± 3.05 cm. Mean distance between the medial malleolus and the nervous branch termination was 12.7 ± 1.59 cm. Length of the nervous branch innervating FHL was proportional to the length of the leg, measuring 8.69 ± 2.45 cm. All nerves were located 15-17.4 cm above the medial malleolus. CONCLUSIONS: This anatomical study traced valuable surgical coordinates useful for performing selective peripheral neurotomy on the nerve branch innervating the FHL.

Popeye sign: Tenodesis vs. self-locking "T" tenotomy of the long head of the biceps.

INTRODUCTION: Treatment of long head of the biceps lesions is controversial. A new technique of self-locking "T" tenotomy was developed in our department in 2013. HYPOTHESIS: The main objective of the present study was to assess onset of Popeye sign after "T" tenotomy, with comparison to long head of the biceps tenodesis. MATERIAL AND METHODS: A continuous retrospective study included 180 patients with long head of the biceps lesion, either isolated or associated with rotator cuff tear. RESULTS: 130 underwent "T" tenotomy (group A), and 50 tenodesis (group B). Mean age was 57.9 years (range, 23-88 years) in group A and 50.8 years (range, 20-66 years) in group B. At last follow-up, 27.7% of patients in group A and 24% in group B showed Popeye sign (P=0.616), after equivalence test and adjustment on age and occupational activity. Bicipital groove pain was more frequent in the tenodesis group (44% versus 25.4%; P=0.025). DISCUSSION: Self-locking "T" tenotomy did not significantly differ from tenodesis in onset of Popeye sign or clinical results, and showed better postoperative course. LEVEL OF EVIDENCE: IV, retrospective study.

Glenoid exposure in total shoulder arthroplasty.

Glenoid exposure is agreed to be a difficult step, but is also a key step in total shoulder arthroplasty, both anatomic and reverse. It conditions unhindered use of the ancillary instrumentation and thus correct glenoid component positioning. The main stages comprise arthrotomy, by opening the rotator cuff, humeral head cut, and inferior glenohumeral release, enabling shifting of the humerus and good exposure of the glenoid cavity. The two main approaches are deltopectoral and anterosuperior transdeltoid. Using the deltopectoral approach, arthrotomy is performed through the subscapularis muscle, by various techniques. This approach enables extensive inferior glenohumeral release and thus an approach to the inferior apex of the glenoid cavity, which is a key area for glenoid implant positioning. The main drawbacks are postoperative shoulder instability and limited access to the posterior part of the glenoid in case of significant retroversion. Moreover, subscapularis healing is uncertain, which can impair the clinical outcomes, with risk of glenoid component loosening. Advantages, on the other hand, include the fact that it can be implemented in all cases, even the most difficult ones, and that the deltoid muscle is respected. The transdeltoid approach has the advantage of being simple, providing direct exposure of the glenoid cavity through a rotator cuff tear after passing through the deltoid. It is therefore especially indicated for reverse prosthesis in case of rotator cuff tear, and in traumatology. However, the approach to the inferior part of the glenoid cavity can be restricted, with insufficient exposure and a risk of glenoid component malpositioning (superior tilt). The preoperative assessment is essential, to detect at-risk situations such as severe stiffness and anticipate difficulties in glenoid exposure.

Painful posterior shoulder instability: Anticipating and preventing failure. A study in 25 patients.

BACKGROUND: Painful posterior shoulder instability (PPSI) is the least common of the three clinical patterns of posterior shoulder instability. PPSI is defined as pain combined with anatomical evidence of posterior instability but no instability events. MATERIAL AND METHOD: We studied a multicentre cohort of 25 patients with PPSI; 23 were identified retrospectively and had a follow-up of at least 2 years and 2 patients were included prospectively. Most patients engaged in sports. RESULTS: All 25 patients underwent surgery, which usually consisted in arthroscopic capsulo-labral reconstruction. The outcome was excellent in 43% of patients; another 43% had improvements but reported persistent pain. The pain remained unchanged or worsened in the remaining 14% of patients. Causes of failure consisted of a missed diagnosis of shoulder osteoarthritis with posterior subluxation, technical errors, and postoperative complications. The main cause of incomplete improvement with persistent pain was presence of cartilage damage. CONCLUSION: Outcomes were excellent in patients who were free of cartilage damage, bony abnormalities associated with posterior instability (reverse Hill-Sachs lesion, erosion or fracture of the posterior glenoid), technical errors, and postoperative complications.

Outcomes of capsulolabral reconstruction for posterior shoulder instability.

BACKGROUND: Surgical treatment of isolated posterior shoulder instability-a rare and often misdiagnosed condition-is controversial because of poor outcomes. Failure of physical therapy in symptomatic young athletes requires capsulolabral reconstruction or bone block procedures. The goal of this study was to report the outcomes of patients who have undergone surgical capsulolabral reconstruction and to look for risk factors that contribute to failure of this procedure. MATERIAL AND METHOD: We analyzed the outcomes of 101 patients who underwent capsulolabral reconstruction: 83 included retrospectively, 18 included prospectively. The procedures were performed alone or in combination with capsular shift, labral repair, closure of the rotator interval and notch remplissage. The primary endpoint was failure of the procedure, defined as recurrence of the instability and/or pain. We also determined the outcomes based on specific (Walch-Duplay, modified Rowe) and non-specific (Constant, resumption of activities) scores of shoulder instability. RESULTS: The results were satisfactory despite a high failure rate: 35% in the retrospective cohort with 4.8±2.6 years' follow-up and 22% in the prospective cohort with 1.1±0.3 years' follow-up. The various outcome scores improved significantly. Ninety-two percent of patients returned to work and 80% of athletes returned to their pre-injury level of sports. Eighty-five percent of patients were satisfied or very satisfied after the surgery. No risk factors for failure were identified; however, failures were more common in older patients, those who underwent an isolated procedure and those who had unclassified clinical forms. CONCLUSION: Treatment of posterior shoulder instability by capsulolabral reconstruction leads to good clinical outcomes; however, the recurrence rate is high. LEVEL OF EVIDENCE: 4 - retrospective study.

Posterior shoulder instability: Prospective non-randomised comparison of operative and non-operative treatment in 51 patients.

BACKGROUND: The management of posterior shoulder instability remains controversial. Consequently, for a symposium on this topic, the French Arthroscopy Society (SFA) conducted a prospective multicentre study comparing outcomes of operative and non-operative treatment. OBJECTIVE: To compare outcomes after operative versus non-operative treatment of posterior shoulder instability. HYPOTHESIS: The surgical treatment of posterior shoulder instability may achieve better clinical outcomes than non-operative treatment in selected patients. MATERIAL AND METHODS: Fifty-one patients were included prospectively then followed-up for 12months. Three groups were defined based on the clinical presentation: recurrent dislocation or subluxation, involuntary instability or voluntary instability that had become involuntary, and shoulder pain with instability. Of the 51 patients, 19 received non-operative therapy involving a three-step rehabilitation programme and 32 underwent surgery with a posterior bone block, labral repair and/orcapsule tightening, or bone defect filling. At inclusion and at last follow-up, the Subjective Shoulder Value (SSV), Rowe score, Walch-Duplay score, and Constant score were determined. RESULTS: The preliminary results after the first 12 months are reported here. In the non-operative and operative groups, the Constant score was 78 versus 87, the Rowe score 64 versus 88, and the Walch-Duplay score 69 versus 82, respectively. These differences were statistically significant (P<0.05). DISCUSSION: To our knowledge, this study is the first comparison of non-operative versus operative treatment in a cohort of patients with documented posterior shoulder instability. Outcomes were better with operative treatment. However, this finding remains preliminary given the short follow-up of only 1 year. LEVEL OF EVIDENCE: III, case-control study.

Clinical outcomes of posterior bone block procedures for posterior shoulder instability: Multicenter retrospective study of 66 cases.

BACKGROUND: The posterior bone block procedure is a well-known treatment option for posterior shoulder instability. The goal of this retrospective multicenter study was to evaluate the clinical and radiological outcomes of this procedure. MATERIAL AND METHODS: The study cohort consisted of 66 patients (55 men, 11 women) with an average age of 27.8 years who were evaluated clinically and radiologically using a standardized questionnaire after posterior bone block surgery. RESULTS: The Constant score significantly improved postoperatively (P<0.0001). The postoperative Walch-Duplay score was 81.5. The Rowe score was 86.5 points. The pain level (VAS) was significantly reduced after this procedure (P<0.0001). Eighty-five percent of patients were satisfied or very satisfied with the outcome. CONCLUSION: This multicenter study of 66 patients shows that the posterior bone block procedure is an effective technique with good subjective and objective outcomes; however, the possibility of complications cannot be ignored. CLINICAL STUDY: Level of evidence IV.

Posterior shoulder instability managed by arthroscopic acromial pediculated bone-block. Technique.

In posterior shoulder instability (recurrent dislocation, involuntary posterior subluxation or voluntary subluxation that has become involuntary), surgery may be considered in case of failure of functional treatment if there are no psychological contraindications. Acromial bone-block with pediculated deltoid flap, as described by Kouvalchouk, is an alternative to iliac bone-block, enabling triple shoulder locking by the blocking effect, the retention hammock provided by the deltoid flap and posterior capsule repair. Arthroscopy allows shoulder joint exploration and diagnosis of associated lesions, with opening and conservation of the posterior capsule; it greatly facilitates bone-block positioning and capsule reinsertion. The present report describes the procedure in detail. LEVEL OF EVIDENCE: Technical note.

Posterior interosseous nerve to the superficial branch of the ulnar nerve transfer at the distal third of the forearm through a single anterior approach: Anatomical feasibility study.

The purpose of this study was to determine in a cadaver model, whether transfer of the posterior interosseous nerve (PIN) to the superficial branch of the ulnar nerve (SBUN) by a single approach was feasible. The experiment was carried out on five fresh cadavers. The ulnar nerve was split into its motor branches and the SBUN. The PIN was collected behind the interosseous membrane and sutured to the SBUN on its anterior surface. All sutures were tensionless and technically possible with the PIN's diameter being at least 50% of the SBUN's diameter in all cases. Our results demonstrate that PIN to SBUN transfer through a single anterior approach is feasible in a cadaver model.

Cadaver study of anatomic landmark identification for placing ankle arthroscopy portals.

BACKGROUND: Arthroscopy-assisted surgery is now widely used at the ankle for osteochondral lesions of the talus, anterior and posterior impingement syndromes, talocrural or subtalar fusion, foreign body removal, and ankle instability. Injuries to the vessels and nerves may occur during these procedures. OBJECTIVE: To determine whether ultrasound topographic identification of vulnerable structures decreased the risk of iatrogenic injuries to vessels, nerves, and tendons and influenced the distance separating vulnerable structures from the arthroscope introduced through four different portals. HYPOTHESIS: Ultrasonography to identify vulnerable structures before or during arthroscopic surgery on the ankle may be useful. MATERIAL AND METHOD: Twenty fresh cadaver ankles from body donations to the anatomy institute in Strasbourg, France, were divided into two equal groups. Preoperative ultrasonography to mark the trajectories of vessels, nerves, and tendons was performed in one group but not in the other. The portals were created using a 4-mm trocar. Each portal was then dissected. The primary evaluation criterion was the presence or absence of injuries to vessels, nerves, and tendons. The secondary evaluation criterion was the distance between these structures and the arthroscope. RESULTS: No tendon injuries occurred with ultrasonography. Without ultrasonography, there were two full-thickness tendon lesions, one to the extensor hallucis longus and the other to the Achilles tendon. Furthermore, with the anterolateral, anteromedial, and posteromedial portals, the distance separating the vessels and nerves from the arthroscope was greater with than without ultrasonography (P=0.041, P=0.005, and P=0.002), respectively; no significant difference was found with the anterior portal. DISCUSSION: Preoperative ultrasound topographic identification decreases the risk of iatrogenic injury to the vessels, nerves, and tendons during ankle arthroscopy and places these structures at a safer distance from the arthroscope. Our hypothesis was confirmed. LEVEL OF EVIDENCE: IV, cadaver study.

Experimental validation of the GNRB® for measuring anterior tibial translation.

INTRODUCTION: The objective of this study was to validate the technique used to measure anterior tibial translation in cadaver knees using the GNRB® device by comparing it with the gold standard, the OrthoPilot® navigation system. HYPOTHESIS: Simultaneous measurement of anterior tibial translation by the GNRB® and the OrthoPilot® in the chosen experimental conditions will result in significant differences between devices. MATERIAL AND METHODS: Five fresh frozen cadavers were used. The knee was placed in 20° flexion. Four calibrated posterior-anterior forces (134N to 250N) were applied. For each applied force, the anterior tibial translation was measured simultaneously by both devices. Two conditions were analyzed: anterior cruciate ligament (ACL) intact and ACL transected. The primary criterion was anterior tibial translation at 250N. The measurements were compared using a paired Student's t-test and the correlation coefficient was calculated. Agreement between the two methods was determined using Bland-Altman plots. Consistency of the measurements was determined by calculating the intraclass correlation coefficient. RESULTS: For all applied forces and ligament conditions, the mean difference between the GNRB® and the navigation system was 0.1±1.7mm (n.s). Out of the 80 measurements taken, the difference between devices was less than ±2mm in 66 cases (82%). There was a strong correlation, good agreement and high consistency between the two measurement methods. DISCUSSION: The differences between the measurements taken by the GNRB® and the navigation system were small and likely have no clinical impact. We recommend using the GNRB® to evaluate anterior knee laxity. LEVEL OF EVIDENCE: II controlled laboratory study.

Preliminary clinical outcomes of Latarjet-Patte coracoid transfer by arthroscopy vs. open surgery: Prospective multicentre study of 390 cases.

BACKGROUND: The Latarjet-Patte procedure consisting in transfer and screw fixation of the coracoid process to the anterior glenoid is a treatment of reference for anterior shoulder instability. Over time, surgical innovations translated into a number of improvements and, in late 2003, an arthroscopically assisted variant of the procedure was described. OBJECTIVE: To evaluate and compare clinical outcomes of the modified Latarjet-Patte procedure performed by open surgery, arthroscopy with screw fixation, or arthroscopy with endobutton fixation. MATERIAL AND METHOD: A total of 390 patients who underwent surgery to treat anterior shoulder instability between March 2013 and June 2014 were included and divided into three groups depending on whether they were managed using open surgery with screw fixation, arthroscopy with screw fixation, or arthroscopy with endobutton fixation. Clinical findings were recorded pre-operatively then 6 months post-operatively and at last follow-up (mean, 27.7 months). Range of motion and apprehension test (arm in external rotation at 0°, 90°, and 140° of abduction) were assessed and the Walch-Duplay and modified Rowe scores were determined. RESULTS: Motion range restriction was minimal with all three techniques, and motion range continued to improve throughout follow-up. Apprehension in external rotation was noted at 90° of abduction in 11% of cases and at 140° of abduction in 4% of cases. The mean total Walch-Duplay score improved from 46 pre-operatively to 90.6 and the mean total modified Rowe score from 46 pre-operatively to 91.1. By statistical analysis, external rotation at 90° of abduction and internal rotation at 0° of abduction were better after open surgery, but the differences were of limited clinical significance. Recurrence was noted in 3.3% of cases, nerve injury in 0.8%, and infection in 1.5%. CONCLUSION: In this study, the three techniques produced similar clinical outcomes, with a stable shoulder and no joint stiffness.

Is anterior glenoid bone block position reliably assessed by standard radiography? A cadaver study.

BACKGROUND: Standard radiography with an antero-posterior view and Bernageau's glenoid profile view is the method most widely reported in the literature to assess coracoid bone block position and fusion. OBJECTIVE: The aim of this cadaver study was to determine whether the antero-posterior and Bernageau's radiographs provide a reliable and reproducible evaluation of the position of a coracoid bone block and its fixation screws. METHOD: An isolated scapula showing no evidence of osteoarthritis or other abnormalities was used. The coracoid process was transferred to the anterior glenoid rim. Fixation was with two slightly diverging malleolar screws, chosen of different sizes for ease of identification. Computed tomography (CT) was performed as the reference imaging technique. The standard radiographs were then obtained, using fluoroscopy to accurately position the scapula for the antero-posterior and Bernageau's views. This position was defined as 0°, and radiographs were taken at angles of 5°, 10°, and 15° in all three planes. All radiographs were taken during a single session to ensure that the distance separating the tube from the scapula remained unchanged. The images were exported to OsiriX for analysis. We measured the angles formed by the screws and the glenoid surface, as well as bone block position and overhang. Finally, we used 1-mm thick disks to evaluate bone-to-bone contact. RESULTS: No correlations were found between values by CT and by standard radiography (both views) for the screw angles or overhang. A space≤1mm between the neck of the scapula and the bone block was not visible on the standard radiographs in any of the positions. CONCLUSION: Standard radiography does not provide an accurate analysis of bone block position or bone-to-bone contact. CT is needed to assess bone block and screw position and bone-to-bone contact. LEVEL OF EVIDENCE: Level III.