Treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and screw plate.

In 2020, the most common treatment for presumed aseptic non-union of the humeral shaft seems to be decortication, often associated with bone autografting, and stabilized by a screw plate. We propose to evaluate an original technique of rigid osteosynthesis combining intramedullary nailing and screw plate. Between January 2004 and January 2020, 45 patients underwent treatment of presumed aseptic non-union of the humeral shaft by osteosynthesis combining intramedullary nailing and a screw plate. The minimum radio-clinical follow-up was one year postoperatively. The series included 19 men and 26 women with a mean age of 53 years (range 19-84 years). Bone consolidation was achieved in 43 patients, a rate of 95.5%. Comparing patients who achieved bone consolidation with the two failed consolidations did not reveal any statistically significant factor. Interobserver agreement was almost perfect (k=0.93) for the use of the RUST for humeral shaft fractures treated with intramedullary nailing and screw plate. In our study, the treatment of presumed aseptic non- union of the humeral shaft with an osteosynthesis combining intramedullary nailing and screw plate gives, with 95.5% of bone consolidation, results equal to or even superior to the different treatments currently described in the literature.

Humeral metastasis as the only recurrence of a 5-year resected gastrointestinal stromal tumor: a case report.

INTRODUCTION: Gastrointestinal stromal tumors represent the most frequently encountered primary mesenchymal tumors. Whereas the liver and the peritoneum are known to be the preferential metastasis sites, no therapeutic standard has yet been established for the management of bone metastases because of their very low incidence. We report a unique example of a single humerus metastasis of a jejunal gastrointestinal stromal tumor. CASE PRESENTATION: We report the case of a 72-year-old European woman whose jejunal gastrointestinal stromal tumor was resected in 2013 and treated during the following 3 years with imatinib (400 mg daily). In 2018, she developed a single humeral bone lesion that was identified as a gastrointestinal stromal tumor metastasis. After 7 months of imatinib intake, reconstructive surgery was performed. Pathologists confirmed the satisfactory histological regression and assessed the complete tumor resection. The patient is still on imatinib maintenance therapy, with no recurrence reported so far. She fully recovered the upper limb function after following an appropriate rehabilitation program. DISCUSSION: Current literature and published case reports indicate that bones are one of the rarest locations of gastrointestinal stromal tumor metastasis (about 1%), with occurrence mainly in the spine. Patients initially diagnosed with gastrointestinal stromal tumor of the small intestine and stomach are more likely to suffer from bone metastasis, compared with other gastrointestinal stromal tumor locations. The median overall survival rate is higher for patients with isolated bone metastasis compared with those having liver metastasis. Metastasis occurs on average 4 years after the primary, but it may take up to 20 years, emphasizing the need for long-term clinical and radiological monitoring. Although specific guidelines for such cases have not yet been established, we suggest that a multimodal concerted approach involving surgery or radiotherapy associated with tyrosine kinase inhibitor intake should be considered. CONCLUSION: Bones are one of the rarest locations of gastrointestinal stromal tumor metastasis. A multidisciplinary collaboration was set up to allow conservative surgery of our patient after several months of imatinib treatment. A year and a half later, the patient is still in complete remission. This specific case supports the concept of an intermediate stage between local and oligometastatic disease that should be managed with a curative aim, as much as possible.

Evaluation of arthroscopic skills with a virtual reality simulator in first-year orthopaedic residents.

PURPOSE: This study of residents' initial performance was performed to determine which factors predisposed residents for success in demonstrating the best arthroscopic skills. METHODS: Each orthopaedic first-year resident was officially invited to take part in a one hour evaluation on a VirtaMed™ ArthroS™ simulator. On the FAST module, the Periscoping exercise was chosen to test for use of angled optics. The Shoulder Module was chosen to test their ability to extract intra-articular foreign bodies using the Catch the Stars exercise. The variables such as time, camera alignment, camera path length, and grasper path length were analysed. Residents completed a questionnaire prior to the evaluation. Their results were analysed according to gender, orientation assessment, and surgical history. RESULTS: A total of 34 women and 82 men were included in the study. In the Periscoping exercise, a significant difference between women and men in the time variables was noticed (275 ± 82 and 195 ± 71; p < 0.00001) and camera path length (207 ± 60 and 170 ± 66; p = 0.00094). For the Catch the Stars exercise, there was a significant difference between women and men for the time values (249 ± 114 and 201 ± 99; p = 0.01246) and grasper path length (290 ± 130 and 229 ± 108; p = 0.00493). After multivariate analysis, no influence of self-assessed spatial perception (p=0.1), number of arthroscopic procedures (p=0.39), or laparoscopic procedures (p=0.43) to which they had already assisted was found. CONCLUSIONS: This study shows a significant difference in skills regarding spatial recognition and triangulation related to gender at the beginning of specialization training. It also demonstrates that male medical students are more attracted by surgical departments during their medical training.

Evidence-based MR imaging follow-up strategy for desmoid-type fibromatosis.

OBJECTIVES: To propose a follow-up strategy for desmoid-type fibromatosis (DF) based on tumor growth behavior and the signal on T2-weighted MRI. METHODS: We retrospectively reviewed 296 MRI studies of 34 patients with histologically proven DF. In each study, tumor volume and T2 signal relatively normal striated muscle were assessed. Volume variation and monthly growth rates were analyzed to determine lesion growth behavior (progressing versus stable/regressing lesions). Growth behavior was correlated with T2 signal, tumor location, ß-catenin status, treatment strategy, and follow-up duration. Interobserver variability of volume measurements and interobserver measurement variation ratio were assessed. RESULTS: There were 25 women and 9 men with a mean age of 39.9 ± 19 (4-73) years. Mean follow-up time in the patients included was 55 ± 41 (12-148) months. In progressing lesions, the mean average monthly growth ratio was 10.9 ± 9.2 (1.1-42.5) %. Interobserver variability of volume measurements was excellent (ICC = 0.96). Mean interobserver measurement variation ratio was 20.4 ± 23.6%. The only factor correlated with tumor growth behavior was T2 signal ratio (p < 0.0001). Seventeen out of 34 (50%) patients presented a signal change over the threshold of 1 during follow-up. There were five occurrences of secondary growth after a period of stability with a mean delay until growth of 38.2 ± 44.2 (17-116) months. CONCLUSION: DF growth rate was quantitatively assessed. A threshold for volume variation detection was established. DF growth behavior was significantly related to T2 signal. An evidence-based follow-up strategy is proposed. KEY POINTS: • In progressing desmoid fibromatosis, the mean average monthly growth ratio was 10.9 ± 9.2%. • Lesions with muscle/tumor T2 signal ratios lower than 1 tended to be stable or regress over time. • Given the interobserver measurement variability and MRI in-plane spatial resolution, a variation higher than 42.6% in tumor volume is required to confirm punctual progression.

Intravoxel incoherent motion MRI for the initial characterization of non-fatty non-vascular soft tissue tumors.

PURPOSE: To compare the capabilities of intravoxel incoherent motion (IVIM) to those of monoexponential diffusion-weighted imaging for differentiating benign from malignant non-vascular, non-fatty soft tissue tumors (NVSFSTT). MATERIAL AND METHODS: A total of 64 patients with 64 histologically confirmed soft-tissue tumors were retrospectively included. There were 23 men and 41 women with a mean age of 52±17 (SD) (range: 18-92 years). IVIM parameters, including molecular diffusion restriction coefficient (ADCtrue), perfusion fraction, and tissue perfusion related coefficient were compared to mean monoexponential ADC (ADCstd) values. Two readers calculated all parameters, which were compared to histopathological findings that were used as standard of reference. RESULTS: The overall performance of ADCtrue and ADCstd was similar for the benign-malignant differentiation of NFNVSTT with accuracies ranging from 73% to 75% for both readers (P=0.3). Interobserver reproducibility was considered excellent for both ADCstd and all IVIM parameters (ICC=0.81-0.96). When myxoid tumors were excluded from morphological analysis, an increase in sensitivity of 16-21% of ADCtrue was observed, with no changes in specificity values. The use of perfusion related IVIM parameters in association with ADCtrue did not improve tumor characterization. CONCLUSION: The use of IVIM parameters does not improve the characterization of NVNFSTT by comparison with conventional monoexponential ADC calculation.

Surgery in reference centers improves survival of sarcoma patients: a nationwide study.

BACKGROUND: NETSARC (netsarc.org) is a network of 26 sarcoma reference centers with specialized multidisciplinary tumor boards (MDTB) aiming to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and expert pathological review are mandatory for sarcoma patients nationwide. In the present work, the impact of surgery in a reference center on the survival of sarcoma patients investigated using this national NETSARC registry. PATIENTS AND METHODS: Patients' characteristics and follow-up are prospectively collected and data monitored. Descriptive, uni- and multivariate analysis of prognostic factors were conducted in the entire series (N = 35 784) and in the subgroup of incident patient population (N = 29 497). RESULTS: Among the 35 784 patients, 155 different histological subtypes were reported. 4310 (11.6%) patients were metastatic at diagnosis. Previous cancer, previous radiotherapy, neurofibromatosis type 1 (NF1), and Li-Fraumeni syndrome were reported in 12.5%, 3.6%, 0.7%, and 0.1% of patients respectively. Among the 29 497 incident patients, 25 851 (87.6%) patients had surgical removal of the sarcoma, including 9949 (33.7%) operated in a NETSARC center. Location, grade, age, size, depth, histotypes, gender, NF1, and surgery outside a NETSARC center all correlated to overall survival (OS), local relapse free survival (LRFS), and event-free survival (EFS) in the incident patient population. NF1 history was one of the strongest adverse prognostic factors for LRFS, EFS, and OS. Presentation to an MDTB was associated with an improved LRFS and EFS, but was an adverse prognostic factor for OS if surgery was not carried out in a reference center. In multivariate analysis, surgery in a NETSARC center was positively correlated with LRFS, EFS, and OS [P < 0.001 for all, with a hazard ratio of 0.681 (95% CI 0.618-0.749) for OS]. CONCLUSION: This nationwide registry of sarcoma patients shows that surgical treatment in a reference center reduces the risk of relapse and death.

Glenoid loosening and migration in reverse shoulder arthroplasty.

AIMS: The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years. PATIENTS AND METHODS: We retrospectively studied the records of 79 patients (19 men, 60 women; 84 shoulders) aged 70.4 years (21 to 87) treated for aseptic loosening of the glenosphere following RSA. Clinical evaluation included pre- and post-treatment active anterior elevation (AAE), external rotation, and Constant score. RESULTS: From the original cohort, 29 shoulders (35%) were treated conservatively, 27 shoulders (32%) were revised by revision of the glenosphere, and 28 shoulders (33%) were converted to hemiarthroplasty. At last follow-up, conservative treatment and glenoid revision significantly improved AAE, total Constant score, and pain, while hemiarthroplasty did not improve range of movement or clinical scores. Multivariable analysis confirmed that conservative treatment and glenoid revision achieved similar improvements in pain (glenoid revision vs conservative, beta 0.44; p = 0.834) but that outcomes were significantly worse following hemiarthroplasty (beta -5.00; p = 0.029). CONCLUSION: When possible, glenoid loosening after RSA should first be treated conservatively, then by glenosphere revision if necessary, and last by salvage hemiarthroplasty Cite this article: Bone Joint J 2019;101-B:461-469.

CT arthrography of the intra-articular long head of biceps tendon: Diagnostic performance outside the labral-bicipital complex.

PURPOSE: The purpose of this study was to determine the performance of CT arthrography for the diagnosis of intra-articular long head of biceps (LHB) tendon intrinsic lesions using arthroscopy findings as standard of reference. MATERIAL AND METHODS: CT arthrography studies of 98 patients (55 men, 43 women; mean age 54.8±12.7 [SD] years [range: 16-77 years]) were retrospectively evaluated by two radiologists independently. Per operative arthroscopic images and surgical reports were retrospectively reviewed by a shoulder-specialist surgeon. Based on the analysis of arthroscopic images and the surgical reports, the LHB tendon was classified as normal (continuous with uniform tendon thickness), tendinopathy/partial rupture (focal change in tendon thickness and contour irregularities) and total rupture (total loss in tendon continuity). Imaging results were compared to those of surgery that served as standard of reference. Interobserver agreement was assessed. RESULTS: At arthroscopy, the LHB tendon was classified as normal in 38/98 (38.8%) patients, tendinopathic in 51/52 (52%) and totally ruptured in 9/98 (9.2%). The sensitivity and specificity of CT arthrography for the diagnosis of LHB tendinopathy were respectively 74% (95%CI: 60%-85%) and 93% (95%CI: 80%-99%) for reader 1 and 79% (95% CI: 67%-89%) and 95% (95% CI: 83%-99%) for reader 2. The sensitivity and specificity for the diagnosis of LHB tendon total ruptures were 100% (95%CI: 66%-100%) and 93% (95%CI: 86%-98%) for both readers. Interobserver agreements for the identification of the LHB tendon tendinopathy and total ruptures were excellent (kappa values of 0.94 and 0.96, respectively). CONCLUSION: CT arthrography demonstrates good sensitivity and excellent specificity for the detection of intra-articular LHB tendinopathy and tear.

Assessment of a press-fit proximal femoral modular reconstruction implant (PFMR®) at 14.5 years. A 48-case series with a disturbing rate of implant fracture.

INTRODUCTION: The PFMR® proximal femoral modular reconstruction implant (Protek, Sulzer Orthopedics, Switzerland) is a straight modular stem in sanded titanium with press-fit anchorage, intended to achieve spontaneous bone reconstruction following Wagner's principle. The aim of the present study was to analyze long-term clinical and radiological outcome. MATERIAL AND METHOD: A single-center retrospective study included 48 PFMR stems implanted in 47 patients between 1998 and 2002. Results in this series were previously reported at 7 years' follow-up. Clinical assessment used PMA and Harris scores. Radiologic assessment focused on stem stability and osseointegration, and bone stock following Le Béguec. RESULTS: Twenty-three patients were seen at a mean 14.5 years' follow-up (13 deceased, 11 lost to follow-up), including 1 with bilateral implants, i.e., 24 stems. PMA and Harris scores, stem stability and osseointegration and bone stock were stable with respect to the 7-year findings. Radiology found 7 stem fractures in the Morse taper, i.e., in 29% of implants. Two of these cases required femoral implant replacement; 5 were asymptomatic. DISCUSSION AND CONCLUSION: Long-term outcome for PFMR stems was clinically and radiologically satisfactory for the 16 patients free of mechanical complications. The Morse taper fracture rate was high, and higher than reported elsewhere. The usual risk factors for implant fracture were not found in the present series. The modular design of the press-fit revision implant is its weak point; monoblock implants should be used in patients with good life-expectancy. LEVEL OF EVIDENCE: IV (retrospective 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.

Analysis of four-fragment fractures of the proximal humerus: the interest of 2D and 3D imagery and inter- and intra-observer reproducibility.

The treatment of the four-part fractures of the proximal humerus remains a therapeutic challenge. The decision-making is based on preoperative criteria concerning the displacement of the fracture, the stability of the fracture and the risk of avascular necrosis of the humeral head. The aim of this study was to analyse the inter- and intra-observer reproducibility of those criteria previously described by Hertel. Three observers analysed three times 20 radiologic files comprising 2D X-rays, 2D CT scan and 3D reconstructions for the intra-observer study, and an expert committee was used to assess the inter-observer reproducibility. The Kappa coefficient was used to measure agreement. The Kappa coefficient founded poor to moderate agreement for the majority of the criteria after the 2D X-ray analysis. This coefficient was improved with the use of 2D CT scan and 3D reconstructions, in particular for the medial hinge assessment, the humeral head fracture and the metaphyseal extension. The reproducibility of the criteria described by Hertel on 2D X-rays is at least moderate. Reproducibility could be considerably improved by associating 2D scans and 3D reconstruction, in particular for the criteria related to prognosis for the vascularisation of the humeral head.

Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases.

INTRODUCTION: No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other. MATERIAL AND METHODS: This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN). RESULTS: After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group. CONCLUSION: If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area. LEVEL OF EVIDENCE: IV, retrospective study.

Developments in imaging methods used in hip arthroplasty: A diagnostic algorithm.

BACKGROUND: Several imaging modalities can be used to diagnose complications of hip prosthesis placement. Despite progress in these imaging techniques, there are, as yet, no guidelines as to their respective indications. METHODS: We formed a panel of experts in fields related to prosthesis imaging (radiology, nuclear medicine, orthopedic surgery) and conducted a review of the literature to determine the value of each modality for diagnosing complications following hip replacement. RESULTS: Few recent studies have investigated the benefits related to the use of the latest technical developments, and studies comparing different methods are extremely rare. CONCLUSIONS: We have developed a diagnostic tree based on the characteristics of each imaging technique and recommend its use. Computed topography was found to be the most versatile and cost-effective imaging solution and therefore a key tool for diagnosing the complications of hip replacement surgery.

Influence of fixation with two vs. three screws on union of arthroscopic tibio-talar arthrodesis: Comparative radiographic study of 111 cases.

BACKGROUND: Ankle arthrodesis is a treatment of choice for advanced tibio-talar disease unresponsive to conservative treatment. Using arthroscopy to perform this procedure minimises soft-tissue trauma while providing similar outcomes to those of open surgery. Union rates have ranged across studies from 85% to 100%. The objective of this study was to assess the potential influence on union of the number of screws used for arthrodesis fixation. HYPOTHESIS: The working hypothesis was that using three screws for arthrodesis produced a higher union rate than did using only two screws. MATERIAL AND METHODS: This single-centre retrospective comparative study included 111 cases of arthroscopic ankle arthrodesis (in 108 patients) carried out between February 1994 and October 2012. The number of screws was two in 75 cases and three in 36 cases. Union was assessed on radiographs taken 2, 6, and 12months postoperatively. RESULTS: Mean age at surgery was 55.8years. After 12months, union was achieved in 87.4% cases overall. The non-union rate was 16% with two screws and 5.6% with three screws. Three-screw fixation was associated with a significantly higher rate of union of the medial gutter after 6months and of the lateral gutter after 12months. DISCUSSION: Our findings support the use of three screws for fixation of arthroscopic tibio-talar arthrodesis. Adding a third screw seems associated with a lower risk of non-union and a shorter time to union. These effects can be ascribed to greater stability of the construct. LEVEL OF EVIDENCE: Level IV, retrospective study.

Two-stage total hip arthroplasty for complex pelvic abnormalities: Example of hip arthrodesis conversion with concomitant treatment of pelvic and acetabular non-union.

Hip prosthesis implantation requires a stable pelvic foundation, which may be lacking in patients with complex pelvic abnormalities (e.g., arthrodesis conversion, tumour excision, or revision with large bony defects). Many reconstructive options exist for these situations, but their outcomes vary with the initial amount of bone loss and with the technique used. We describe a two-stage arthroplasty technique (acetabular cup first, then femoral stem) and report its use in a case of arthrodesis conversion with concomitant treatment of pelvic and acetabular non-union. Clinical and radiological outcomes after 5 years are reported. This procedure can be adapted to the most complex cases of pelvic reconstruction.

Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study.

INTRODUCTION: Complex 4-part fractures of the proximal humerus are one of the most difficult fractures to manage. For several years, reverse total arthroplasty (RSA) has been proposed as an alternative to hemiarthroplasty (HA) when internal fixation is insufficient. The goal of this study was to compare the short and intermediate term results of these 2 different types of arthroplasty. MATERIALS AND METHODS: In a retrospective, multicenter study, 57 HA and 41 RSA were reviewed after a follow-up of at least 2 years. The clinical evaluation was based on the absolute and adjusted Constant scores, Simple shoulder value (SSV) and the quick-DASH scores. The radiological assessment included standard radiological tests. RESULTS: After a mean follow-up of 39 months, the RSA group had a significantly higher adjusted Constant score than the HA group (83% vs 73%, respectively P=0.02). However, there was no significant difference in the absolute Constant score, the quick-DASH or the SSV scores. Active anterior elevation was better in the RSA group, while internal rotation was better in the HA group (130° vs 112°, P=0.01; sacrum vs L3, P=0.03). There was no significant difference in external rotation (28° vs 23°, P=0.31). The rate of complications was higher in the HA group than in the RSA group (24% vs 10%, P=0.01). The radiological rate of union of the greater tuberosity was similar in both groups (70%) and scapular notching was found in 23% of the RSA group. CONCLUSION: The short and intermediate term clinical outcomes are better with RSA than with HA. The complication rate is higher with HA. Nevertheless, scapular notching occurred in more than 20% of patients with RSA, suggesting that care should be taken when using this prosthesis in young, active patients.

Four-part fractures treated with a reversed total shoulder prosthesis: Prospective and retrospective multicenter study. Results and complications.

INTRODUCTION: The reversed shoulder prosthesis is becoming the gold standard for cases of complex fracture of the proximal humerus after 70 years of age. MATERIAL AND METHODS: The French Society of Orthopaedic and Traumatology Surgery (SOFCOT) conducted a prospective and retrospective multicenter study to evaluate the results of the reversed shoulder prosthesis implanted in patients with a four-part fracture in nine centers. In the retrospective study (n=41 patients, 78 years of age, 14% ASA grade 3, 21% associated fractures) and in the prospective study (n=32 patients, 79 years of age, 37% ASA grade 3, 21% associated fractures) evaluation by independent surgeons was conducted to measure the QuickDASH score, the Constant score, the SSV (subjective shoulder value), and complications to correlate these measurements with radiological results. RESULTS: In both studies, use of an autograft (75%) to perform an osteosuture of tuberosities (90%) and no postoperative immobilization (75%) were similar. In the retrospective study at 39 months (range: 24-62 months) of follow-up, the QuickDASH reached 28 (range: 0-59), the Constant scores (raw Constant=57, weighted Constant=83.4%), and SSV 75 (range: 35-100). Complications after the 1st month (7%) were nonunion or ossifications. In the prospective study at 11 months (range: 5-16.5 months) of follow-up, the QuickDASH reached 40 (range: 1-75), the Constant scores 50 (raw Constant) and 74.6% (weighted Constant), and SSV 69 (range: 10-100). Complications after the 1st month (21%) were stiffness and dislocation, with two patients who underwent revision surgery. In both studies, early complications reached 6% (palsy, dislocation). CONCLUSION: This double (retrospective and prospective) study confirms the good results with a low level of complications of the reversed implant in cases of fracture but with osteosuture of tuberosities.

How to determine the bone mineral density of the distal humerus with radiographic tools?

INTRODUCTION: The aim of this study was to investigate three methods of prediction of the bone quality of the distal humerus: dual-energy X-ray absorptiometry (DEXA), Ct-Scan and plain radiographs. MATERIALS AND METHODS: The bone mineral density (BMD) of 21 cadaveric distal humerus was determined using DEXA at two levels. Then a CT-scan and anteroposterior radiographs were taken. The cancellous density was estimated with the CT-scan. The cortico-medullar index (CMI) was calculated as cortical thickness divided by total bone thickness on AP views. RESULTS: A significant positive correlation was found between the BMD of the epiphysis and the CMI of r = 0.61. The mean BMD of the distal humerus was 0.559 g/cm(2). Male specimens showed a significantly higher BMD than females. The mean CMI of diaphysis was 1.431 and the mean BMD of the metaphysis region was 0.444 g/cm(2). DISCUSSION: More than a direct evaluation of the bone density with a CT-scan, the CMI of the distal humerus diaphysis is a predictor of the bone quality of the distal humerus. This should be of great help for the surgeon's decision making in case of fracture of the distal humerus, as open Reduction and Internal Fixation (ORIF) of fractures of the distal humerus can lead to failure due to poor bone quality. LEVEL OF EVIDENCE: Basic Science Study, Anatomic Cadaver Study.