The glenoid track concept is insufficient to predict Bankart failures: a computed tomography scan study.

Background: The glenoid track concept identifies patients with "off-track" (engaging) Hill-Sachs lesions (HSLs) as poor candidates for arthroscopic Bankart repair (ABR) due to the high risk of shoulder instability recurrence. Purpose: To retrospectively calculate the glenoid track index, using preoperative computed tomography (CT) scans, in a cohort of patients with failed ABR. We hypothesized that all patients with a failed ABR would have engaging ("off-track") HSLs on preoperative CT scan. Type of Study: CT scan study. Methods: Preoperative CT scan of 45 patients, seen in our facility for failed ABR, was used to retrospectively calculate the glenoid track index. The risk of recurrence was also calculated for each patient using Instability Severity Index Score (ISI-Score) and Glenoid Track Instability Management Score (GTIMS). There were 37 failed isolated ABRs and 8 associated HS remplissage. The mean t age at surgery was 24 years (range, 15-52) and instability recurred at a mean of 29 months postoperative (range, 3-167). Results: Preoperative CT scan imaging identified "off-track" bony lesions in 85% of patients (38/45) and "on-track" lesions in 15% (7/45). No significant differences were noted between the 2 groups (off-track vs. on-track) regarding patient age, hyperlaxity, sports participation, size of HS lesion, or ISI-Score. The mean glenoid bone loss was 15.7% (range, 4-36%) with mean HS width was greater than 20 mm in 66% of CT scans. The preoperative ISI-Score was predictive of failures (>3 points in all patients) with no difference between on-track and off-track patients (6.3 ± 1.7 vs. 6.6 ± 1.7, P = .453). By contrast, the GTIMS did not predict failures as there was a significant difference between GTIMS for on-track and off-track patients (2.1 ± 1.3 vs. 6.6 ± 1.7). Conclusions: The glenoid track concept alone is insufficient to predict Bankart failures: in the present series of failed ABR, 15% of shoulders had "on-track" (non-engaging) lesions on preoperative CT scan. In patients, with "on-track" bony lesions, the ISI-Score is a useful predictive tool to detect patients at risk of failure, while the GTIMS is not.

Hallucination Rates and Reference Accuracy of ChatGPT and Bard for Systematic Reviews: Comparative Analysis.

BACKGROUND: Large language models (LLMs) have raised both interest and concern in the academic community. They offer the potential for automating literature search and synthesis for systematic reviews but raise concerns regarding their reliability, as the tendency to generate unsupported (hallucinated) content persist. OBJECTIVE: The aim of the study is to assess the performance of LLMs such as ChatGPT and Bard (subsequently rebranded Gemini) to produce references in the context of scientific writing. METHODS: The performance of ChatGPT and Bard in replicating the results of human-conducted systematic reviews was assessed. Using systematic reviews pertaining to shoulder rotator cuff pathology, these LLMs were tested by providing the same inclusion criteria and comparing the results with original systematic review references, serving as gold standards. The study used 3 key performance metrics: recall, precision, and F1-score, alongside the hallucination rate. Papers were considered "hallucinated" if any 2 of the following information were wrong: title, first author, or year of publication. RESULTS: In total, 11 systematic reviews across 4 fields yielded 33 prompts to LLMs (3 LLMs×11 reviews), with 471 references analyzed. Precision rates for GPT-3.5, GPT-4, and Bard were 9.4% (13/139), 13.4% (16/119), and 0% (0/104) respectively (P<.001). Recall rates were 11.9% (13/109) for GPT-3.5 and 13.7% (15/109) for GPT-4, with Bard failing to retrieve any relevant papers (P<.001). Hallucination rates stood at 39.6% (55/139) for GPT-3.5, 28.6% (34/119) for GPT-4, and 91.4% (95/104) for Bard (P<.001). Further analysis of nonhallucinated papers retrieved by GPT models revealed significant differences in identifying various criteria, such as randomized studies, participant criteria, and intervention criteria. The study also noted the geographical and open-access biases in the papers retrieved by the LLMs. CONCLUSIONS: Given their current performance, it is not recommended for LLMs to be deployed as the primary or exclusive tool for conducting systematic reviews. Any references generated by such models warrant thorough validation by researchers. The high occurrence of hallucinations in LLMs highlights the necessity for refining their training and functionality before confidently using them for rigorous academic purposes.

Total shoulder arthroplasty for primary glenohumeral osteoarthritis: does posterior humeral subluxation persist after correction of the glenoid version at 5 years minimum?

BACKGROUND: Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. MATERIAL: We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70 ± 9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence. RESULTS: The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ = 0.58) and strong at final follow-up (ρ = 0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P < .05) and retroversion (20° vs. 10° respectively, P < .05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P < .05). CONCLUSION: Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

Revision rotator cuff repair: can a Sugaya III tendon considered to be healed or not.

BACKGROUND: Sugaya et al described a classification system to assess postoperative rotator cuff tendon healing. Although Sugaya I and II tendons can be considered as healed and Sugaya type IV and V can be considered as retorn, the exact status of Sugaya III tendons remains unclear. The objective of this study was to evaluate the impact of Sugaya III tendons on postoperative functional scores in a population of patients undergoing revision rotator cuff repair. METHODS: We retrospectively studied the records of all patients who underwent revision rotator cuff repair in one of 12 different institutions between July 2001 and December 2020. A total of 203 shoulders were included (59% males, mean age: 51 ± 8 years old, mean follow-up 11.5 years [range: 2-28.8 yr]). Fifty-four patients (61% males, mean age 52 ± 6 years old, mean follow-up 14.1 years [range: 10.4-28.8 yr]) had a follow-up ≥10 years (mean 14.1 years [range: 10.4-28.8 yr]) and were included in a long-term follow-up subgroup analysis. Structural integrity of the repaired tendon was evaluated on magnetic resonance imaging at last follow-up. Functional scores, acromiohumeral index (AHI), and progression of fatty infiltration and of osteoarthritis were compared according to Sugaya type. RESULTS: Mean Constant score and mean strength were significantly higher in Sugaya I and II tendons than in Sugaya III (P = .021 and .003) and Sugaya IV and V tendons (P = .07 and .038), but did not differ between Sugaya III and Sugaya IV and V tendons. Mean Subjective Shoulder Value, pain, AHI were significantly higher and fatty infiltration and progression in the Hamada classification were significantly lower in Sugaya I and II tendons and in Sugaya III than in Sugaya IV and V tendons (P < .05), but did not differ between Sugaya I and II and Sugaya III tendons. Similar characteristics could also be observed in the long-term follow-up subgroup. CONCLUSION: Sugaya III tendons after revision rotator cuff repair do not allow restoration of strength thereby impacting the Constant score. However, there seems to be a protective effect of Sugaya III tendons with regard to pain, progression of proximal migration of the humeral head, osteoarthritis, and fatty infiltration, which seems to last at long-term follow-up.

Subjective Shoulder Value for Sport Is a Simple, Reliable, and Valid Score to Assess Shoulder Function in Athletes.

PURPOSE: To validate the subjective shoulder value for sport (SSV-Sport) by measuring its correlation with existing patient-reported outcome measures (PROMs) and defining its psychometric properties. METHODS: Between May 2021 and May 2022, we established 2 patient groups. Group 1 included those (1) aged 18 years or older, who were (2) consulting for the first time for any shoulder condition, (3) regularly participated in sports, and were capable of accessing a questionnaire independently. There were asked to rate their SSV and SSV-Sport at admission and 2 weeks later; they also were asked to answer a questionnaire including other PROMS. Group 2 comprised patients who had (1) undergone shoulder stabilization surgery and had (2) a minimum follow-up period of 6 months. RESULTS: For the shoulder disability patients (group 1, n = 62), there was a strong and significant correlation between SSV-Sport and other PROMs: Quick Disabilities of the Arm, Shoulder and Hand Sport (r = 0.84), Walch-Duplay (r = 0.65), Rowe (r = 0.74), Western Ontario Shoulder Instability (r = 0.78), and SSV (r = 0.75) (P = .0001). The SSV-Sport was reliable at baseline and 2 weeks after (0.91, 95% confidence interval 0.85-0.94), and was responsive to change (P < .001). For the anterior instability patients (group 2, n = 83), SSV was on average 50 points greater than SSV-Sport (29.2 vs 79.4, P < .001) for preoperative values. In both groups, the values of SSV were constantly and significantly higher than the values of SSV-Sport (81.9 ± 21.3 vs 54.8 ± 30.9; P < .001). CONCLUSIONS: The SSV-Sport is an easily administered, reliable, responsive, and valid measure of shoulder function in athletes that is highly correlated with other PROMs. SSV-Sport is better adapted than SSV to quantify pre- and postoperative shoulder deficiency in athletes. LEVEL OF EVIDENCE: Level III, cohort study (diagnosis).

Glenoid lateralization and subscapularis repair are independent predictive factors of improved internal rotation after reverse shoulder arthroplasty.

PURPOSE: Reverse shoulder arthroplasty (RSA) has shown improvement in clinical outcomes for various conditions, although some authors expressed concern about the restoration of active internal rotation (AIR). The current study assesses preoperative and intraoperative predictive factors of AIR in patients having a Grammont-style RSA with a minimum five year follow-up. METHODS: We conducted a retrospective multicentric study, including patients operated on with a 155° Grammont-style RSA for cuff-related pathology or primary osteoarthritis with posterior subluxation or an associated cuff tear. Patients were clinically evaluated at a minimum of five year follow-up. Patients with previous surgery or those who had a tendon transfer with the RSA were excluded. Demographic parameters, BMI, preoperative notes, and operative reports were obtained from medical records. AIR was graded according to the constant score system from 0 to 10. RESULTS: A total of 280 shoulders in 269 patients (mean age at surgery, 74.9 ± 5.9 years) met the inclusion criteria and were analyzed. The average follow-up was 8.1 years (range, 5-16 years). Overall, AIR increased from 4.2 (SD 2.5, range 0 to 10) preoperatively to 5.9 (SD 2.6, range 0 to 10) at final follow-up. At the last follow-up, AIR increased in 56% of cases, was unchanged in 26% and decreased in 18%. In 188 shoulders (67%), internal rotation was functional and allowed patients to reach the level of L3 or higher. Multivariable linear regression found the following preoperative clinical factors predictive of worse AIR after RSA: male gender (ß = -1.25 [-2.10; -0.40]; p = 0.0042) and higher values of BMI (ß = -0.085 [-0.17; -0.0065]; p = 0.048). Two surgical factors were associated with better AIR after RSA: glenoid lateralization with BIO-RSA technique (ß = 0.80 [0.043; 1.56]; p = 0.039) and subscapularis repair (ß = 1.16 [0.29; 2.02]; p = 0.0092). CONCLUSIONS: With a mean of eight year follow-up (5 to 16 years), internal rotation was functional (≥ L3 level) in 67% of operated shoulders after Grammont-style RSA; however, two patients out of ten had decreased AIR after surgery. Male patients and those with higher BMIs had worse AIR, with glenoid lateralization (using the BIO-RSA technique) and subscapularis repair, as they are predictive of increased AIR after RSA. LEVEL OF EVIDENCE: Case series, Level IV.

Three-Dimensional Measurement of Proximal Humerus Fractures Displacement: A Computerized Analysis.

Neer's classification for proximal humerus fractures (PHFs) uses 10 mm and 45° thresholds to distinguish displaced fragments. While this system was originally developed referencing 2D X-rays, fracture displacements occur in three dimensions. Our work aimed to develop a standardized and reliable computerized method for measuring PHF 3D spatial displacements. CT scans of 77 PHFs were analyzed. A statistical shape model (SSM) was used to generate the pre-fracture humerus. This predicted proximal humerus was then used as a "layer" to manually reduce fragments to their native positions and quantify translation and rotation in three dimensions. 3D computerized measurements could be calculated for 96% of fractures and revealed that 47% of PHFs were displaced according to Neer's criteria. Valgus and varus head rotations in the coronal plane were present in 39% and 45% of cases; these were greater than 45° in 8% of cases and were always associated with axial and sagittal rotations. When compared to 3D measurements, 2D methods underestimated the displacement of tuberosity fragments and did not accurately assess rotational displacements. The use of 3D measurements of fracture displacement is feasible with a computerized method and may help further refine PHF analysis and surgical planning.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND: Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear. METHODS: Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months). RESULTS: The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3. CONCLUSION: Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

The reliability of the Neer classification for proximal humerus fractures: a survey of orthopedic shoulder surgeons.

Background: The Neer classification is among the most widely used systems to describe proximal humerus fractures (PHF) despite the poor interobserver agreement. The purpose of this study was to verify whether or not blinded shoulder surgeons and trainees agree with the authors of articles published in the highest impact-factor orthopedic journals. Methods: All articles regarding PHF published between 2017 and 2019 in the top 10 orthopedic journals as rated by impact factor were searched. Articles were included if the authors used the Neer classification to describe at least 1 PHF in the figures. Figures were extracted without the legend, and X-rays ± computed tomography scan images were included when available. An international survey was conducted among 138 shoulder surgeons who were asked to record the Neer classification for each de-identified radiograph in the publications. The type of fracture mentioned in the legend of the published figure was considered as the gold standard. Results: Survey participants agreed with the published article authors in 55% of cases overall (range 6%-96%, n = 35). The most common response disagreed with the article authors in 13 cases (37%), underestimating the number of parts in 11 of 13 cases. The interobserver agreement between the 138 responders was fair (k = 0.296). There was an association between the percentage of concordant answers and greater experience (number of years of shoulder surgery practice) of the responders (P = .0023). The number of parts, the number or type of available imaging modalities, and the geographic origin of participants did not influence the agreement between responders and authors. Discussion: In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of PHF in published manuscripts. Morphologic classification of PHF as the sole basis for treatment algorithms and surgical success should be scrutinized.

Survivorship of Reverse Shoulder Arthroplasty According to Indication, Age and Gender.

Background. The indications for reverse shoulder arthroplasty (RSA) have been widely expanded, but only a few studies report the long-term survival of these implants. Our objective was to report the long-term survivorship of a large series of RSAs implanted for different etiologies. Methods. A retrospective multicenter study including all the RSAs was performed in six shoulder-specialized centers with at least 2 years of follow up. We reviewed 1611 RSAs, operated between 1993 and 2010, including 497 cuff-tear arthropathies (CTA), 239 revision RSAs, 188 massive cuff tears (MCT), 185 fracture sequelae (FS), 183 failed previous cuff repairs (FCR), and 142 primary osteoarthritis (POA). The mean follow-up was 5.6 ± 3.9 years (range 2−20). Results. Overall, 266 RSAs (16.5%) had at least one complication leading to 64 reoperations (4.0%) and 110 revision surgeries (6.8%). The most frequent complications were infection (3.8%), instability (2.8%), and humerus-related complications (2.8%). At 10 years, the survival without revision surgery was 91.0% in primary RSAs and 80.9% in revision RSAs for failed arthroplasty (p < 0.001). In the primary RSA group, MCT and FCR led to 10-year survivals for over 95% but fracture sequelae and tumors had the lowest 10-year survivals (83.9% and 53.1%). Younger patients had a lower 10-year survival. In revision RSAs, male patients had a significantly lower survival than females (72.3% vs. 84.5% at 10 years, p = 0.020). Discussion. Primary RSA for cuff-deficient shoulders or POA leads to a high 10-year survival, but revision RSA or primary RSA for FS and tumors are at high-risk for revision. Surgeons should be aware of high rates of complications and lower survival rates of RSA in younger patients, in males, and in RSAs for revision surgery.

Arthroscopic Latarjet: 2 or 4 Cortical Buttons for Coracoid Fixation? A Case-Control Comparative Study.

BACKGROUND: While 2 screws are traditionally used for coracoid bone block fixation, no gold standard technique has yet been established when using cortical buttons. PURPOSE: To compare anatomic and clinical outcomes of the arthroscopic Latarjet procedure using either 2 or 4 buttons for coracoid bone block fixation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 23 patients with 4-button fixation (group 4B) were matched for age at surgery, sex, and follow-up to 46 patients who had 2-button fixation (group 2B). All patients underwent guided arthroscopic Latarjet (using coracoid and glenoid guides), and a tensioning device was used to rigidify the suture button construct and get intraoperative bone block compression. The primary outcome was assessment of bone block positioning and healing using computed tomography scans performed at 2 weeks and at least 6 months after surgery. The mean ± standard deviation follow-up was 49 ± 7 months (range, 24-64 months). RESULTS: The bone block healing rate was similar in both groups: 91% in group 4B versus 95.5% in group 2B. The transferred coracoid was flush to the glenoid surface in 21 patients (91%) in group 4B and 44 patients (96%) in group 2B (P = .6); it was under the equator in 22 patients (96%) in group 4B and 44 patients (96%) in group 2B (P≥ .99). There was no secondary bone block displacement; the rate of bone block resorption was similar between the groups: 28% in group 4B and 23% in group 2B (P = .71). Patient-reported outcomes, return to sports, and satisfaction were also similar between the groups. The operating time was significantly longer in group 4B (95 vs 75 minutes; P = .009). CONCLUSION: A 4-button fixation technique did not demonstrate any anatomic or clinical advantages when compared with a 2-button fixation technique, while making the procedure more complex and lengthening the operating time by 20 minutes. A 2-button fixation is simple, safe, and sufficient to solidly fix the transferred coracoid bone block. The use of drill guides allows accurate graft placement, while the use of a tensioning device to rigidify the suture button construct provides high rates of bone block healing with both techniques (>90%).

Simulation in shoulder arthroplasty education using three-dimensional planning software: the role of guidelines and predicted range of motion.

AIM: To demonstrate how reverse shoulder arthroplasty (RSA) planning software could be used to improve how the trainees position glenoid and humeral implants and obtain optimal simulated range of motion (ROM). METHODS: We selected four groups of five various level participants: medical student (MS), junior resident (JR), senior resident (SR), and shoulder expert (SE). Thereafter, the 20 participants planned five cases of arthritic shoulders for a RSA on a validated planning software following three phases: (1) no guidelines and no ROM feedback, (2) guidelines but no ROM feedback, and (3) guidelines and ROM feedback. We evaluated the final simulated impingement-free ROM, the choice of the implant (baseplate size, graft, glenosphere), and the glenoid implant positioning. RESULTS: MS planning were significantly improved by the ROM feedback only. JR took the best advantage of both guidelines and ROM in final results. SR planning were less performant than SE into phase 1 regarding flexion, external rotation, and adduction (respectively - 10°, p = 0.03; - 11°, p = 0.003; and - 3°, p = 0,03), but reached similar results into phase 3 (respectively - 2°, p = 0.329; - 4°, p = 0.44; - 2°, p = 0.319). For MS, JR, and SR, we observed a systematic improvement in the agreement over the study course. The glenoid diameter remained highly variable even for SE. Comparing glenoid implant position to SE, the distance error decreased with advancing phases. CONCLUSION: Planning software can be used as a simulation training tool to improve implant positioning in shoulder arthroplasty procedures.

Clinical and radiological outcomes of reverse shoulder arthroplasty for acute fracture in the elderly.

PURPOSE: The goal of this study was to assess the clinical outcomes associated with anatomic healing of the greater tuberosity in patients treated for proximal humerus fractures with reverse shoulder arthroplasty. Our hypothesis was that anatomic healing of the greater tuberosity leads to less complications and better functional outcomes. METHODS: RESULTS: Patients from the GT+ group presented better functional outcomes than the GT- group in all evaluated outcomes. Mean constant score was 61 ± 14 versus 56 ± 15, and the subjective shoulder value (SSV) was 77 ± 14 versus 64 ± 21 (p < 0.001). Forward elevation was 128° ± 28° versus 107° ± 30° and external rotation was 23° ± 17° versus 14° ± 17° (p < 0.001). Twenty patients presented with at least one prosthetic dislocation (7 GT+ vs 13 GT-) while nine patients were revised for humeral loosening (1 GT+ vs 8 GT-). The use of a fracture specific humeral stem was associated with a higher rate of greater tuberosity healing. CONCLUSIONS: Non-anatomic healing of the greater tuberosity was associated with a higher dislocation and humeral loosening rate. Anatomic healing of the greater tuberosity lead to better functional outcomes, less humeral-sided complications, and fewer re-operations.

Risk factors for instability after reverse shoulder arthroplasty.

BACKGROUND: This study aims to identify risk factors related to postoperative instability after reverse shoulder arthroplasty and evaluate the modalities and results of treatments in a large series of patients, with medium to long-term follow-up. METHODS: Retrospective multicenter series of 1035 consecutive Grammont type reverse shoulder arthroplasties implanted between 1992 and 2010. 19.9% had a reverse shoulder arthroplasty with bony lateralization on the glenoid side. Patients were reviewed and radiographed with minimum five years' follow-up. RESULTS: At a mean follow-up of eight years, the overall rate of postoperative instability was 3.0%. Instability was more frequent in case of reverse shoulder arthroplasty for revision surgery, in younger patients, in case of scapular notching, and tuberosity resorption. Lateralized reverse shoulder arthroplasties were associated with a lower instability rate. A reoperation to restore stability was needed in 70% of cases. The improvement in Constant Score was lower in patients with unstable reverse shoulder arthroplasties when compared to stable reverse shoulder arthroplasties. CONCLUSIONS: Younger patients are at higher risk for instability after Grammont type reverse shoulder arthroplasty implantation. Conversely, lateralized reverse shoulder arthroplasties resulted protective. When conservative treatment had failed, shoulder stability can be obtained with reoperation or prosthetic revision (needed in 70% of the cases), but to the price of lower functional results.

Reverse shoulder arthroplasty in rheumatoid arthritis: survival and outcomes.

BACKGROUND: Despite its potential biomechanical advantages, reverse shoulder arthroplasty (RSA) is still considered to be particularly high risk in rheumatoid patients who are osteoporotic and immunodeficient. Our purpose was to report prosthesis survival, complications, and outcomes of RSA in patients with rheumatoid arthritis (RA) at minimum 5-year follow-up. METHODS: We conducted a retrospective multicenter study including 65 consecutive primary RSAs performed in 59 patients with RA between 1991 and 2010. We excluded rheumatoid patients with previous failed anatomic shoulder arthroplasty. Age at surgery averaged 69 years (range, 46-86 years). A structural bone grafting was performed in 18 cases (45%), using the humeral head in 15 cases (BIO-RSA technique), the iliac crest in 2 cases (Norris technique), and an allograft in 1 case. The mean follow-up was 92 months (range, 60-147 months) or until revision surgery. RESULTS: Revision-free survivorship, using Kaplan-Meier curves, was 96% at 7 years. Two patients had revision surgeries for infections, with associated glenoid loosening in 1 case. No humeral loosening was recorded. The mean adjusted Constant score improved from 36% ± 23% preoperatively to 90% ± 26% postoperatively, and mean Subjective Shoulder Value improved from 21% ± 13% to 85% ± 12%, respectively (P < .001). Active anterior elevation increased from 65° ± 43° to 132° ± 27°, active external rotation increased from 10° ± 26° to 22° ± 27°, and internal rotation improved from buttocks to waist (P < .001). Stable fixation of the baseplate was achieved in all cases (including the 6 patients with end-stage RA), and we did not observe bone graft nonunion or resorption. Preoperative radiologic pattern (centered, ascending, or destructive), presence of acromial fractures or tilt (4 cases, 10%), and scapular notching (55%) on final radiographs were not found to influence outcomes or complication rate. Patients with absent/atrophied teres minor had lower functional results. Overall, 95% of the patients were satisfied with the procedure. CONCLUSION: RSA is a safe and effective procedure for the treatment of RA patients, with a low risk of complications and low rate of revision, regardless of the radiologic presentation and stage of the disease. Rheumatoid patients undergoing primary RSA, with or without glenoid bone grafting, can expect a revision-free survival rate of 96% at 7-year follow-up. RSA offers the benefit of solving 2 key problems encountered in rheumatoid shoulders: glenoid bone destruction and rotator cuff deficiency.

Outcomes following revision of the revision total elbow arthroplasty.

BACKGROUND: There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure. METHODS: We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification. RESULTS: We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases. CONCLUSIONS: RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae.

HYPOTHESIS: The aim was to evaluate risk factors for complications, revision, and mid- to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS). METHODS: The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years). RESULTS: The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P = .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P = .003), and a higher revision rate (15% vs. 2%, P = .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P = .026) and with higher rates of postoperative complications (27% vs. 13%, P = .099) and reinterventions (17% vs. 2%, P = .018). CONCLUSION: The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor.

A Population Pharmacokinetic Analysis of Continuous Infusion of Cloxacillin during Staphylococcus aureus Bone and Joint Infections.

Intravenous administration of antibiotics is recommended during the early phase of methicillin-susceptible S. aureus (MSSA) bone and joint infection (BJI). We sought to compare the plasma concentrations of cloxacillin administered alternately by continuous and intermittent infusion (CI and ItI) in patients with MSSA BJI. In this prospective crossover trial, patients were randomly assigned to receive either 3 days of CI (two 75-mg/kg 12-h cloxacillin infusions per day) and then 3 days of ItI (four 37.5-mg/kg 1-h cloxacillin infusions per day) or vice versa. The drug concentration measurement was performed on day 3 of each type of administration at 1, 6, and 11 h and at 1, 2, 3, 4, and 6 h after the beginning of CI and ItI, respectively. We used the nonparametric algorithm NPAG to estimate population pharmacokinetic (PK) parameters. The final model was used to perform pharmacokinetic/pharmacodynamic (PK/PD) simulations and calculate the probabilities of target attainment (PTA) for several ItI and CI dosing regimens. We considered two PK/PD targets of time spent above the MIC for free cloxacillin concentrations (fT>MIC): 50 and 100%. Eighty-four concentrations from 11 patients were analyzed. A two-compartment model adequately described the data. ItI with q6h regimens and short 1-h infusions of 2,000 or 3,000 mg were associated with low PTA, even for the low target (50% fT>MIC) while 3-h infusions and continuous infusions (6 to 12 g/day) were associated with a PTA of >90% for an MIC up to 0.5 mg/liter. These results support the use of prolonged or continuous infusion of cloxacillin in patients with BJI.

Patient-Specific Three-Dimensional-printed Instrumentation for Radius Lengthening Osteotomy by a Volar Approach in Epiphysiodesis Sequelae: A Case Report.

INTRODUCTION: Patient-specific guides are used in the correction of malunion sequelae in adult distal radius fractures. They allow a tridimensional correction of radial glenoid orientation. However, lengthening is small in those indications. Distal radius epiphysiodesis correction is much rarer and patient-specific guide after three-dimensional (3D) planning has never been reported for this indication in the literature. CASE REPORT: We report the case of a 16-year-old teenager with a chronic painful wrist and an ulnar positive variance after a post-traumatic epiphysiodesis sequela of the radius. The radius was 11mm shorter than the ulna. An anatomic reconstruction was decided with a lengthening of the radius. Pre-operative planning and patient-specific guide allowed to control an important radial lengthening, to limit the morbidity of the iliac crest bone graft harvesting, to shape the graft precisely, and to maintain a correct radial glenoid orientation despite the important soft tissue tension. Clinical and radiological results at 6 months showed a complete disappearance of pain, optimal objective and subjective functional scores, and an improvement in the distal ulnar variance (7mm). The teenager went back to sport without limitation or pain. CONCLUSION: 3Dplanning and intraoperative patient-specific guides in radial epiphysiodesis sequelae allow achieving 3D accurate measures of the graft and of the deformation, guiding the position and the orientation of the distal metaphysis cut of the radius, and limiting the morbidity of the iliac graft harvesting. In that case, it allowed restoring the full function of the wrist without remaining pain.