Comparative analysis of human, rodent and snake deltavirus replication.

The recent discovery of Hepatitis D (HDV)-like viruses across a wide range of taxa led to the establishment of the Kolmioviridae family. Recent studies suggest that kolmiovirids can be satellites of viruses other than Hepatitis B virus (HBV), challenging the strict HBV/HDV-association dogma. Studying whether kolmiovirids are able to replicate in any animal cell they enter is essential to assess their zoonotic potential. Here, we compared replication of three kolmiovirids: HDV, rodent (RDeV) and snake (SDeV) deltavirus in vitro and in vivo. We show that SDeV has the narrowest and RDeV the broadest host cell range. High resolution imaging of cells persistently replicating these viruses revealed nuclear viral hubs with a peculiar RNA-protein organization. Finally, in vivo hydrodynamic delivery of viral replicons showed that both HDV and RDeV, but not SDeV, efficiently replicate in mouse liver, forming massive nuclear viral hubs. Our comparative analysis lays the foundation for the discovery of specific host factors controlling Kolmioviridae host-shifting.

What to expect after revision shoulder arthroplasty? A comprehensive review of the literature.

The number of shoulder arthroplasties has increased tremendously over the last twenty years, creating a proportional increase in complications rates and revision. Shoulder arthroplasty surgeon should have a clear understanding of the reasons for failure based on the specific index procedure that was performed. The main challenge includes the need for component removal and managing glenoid and humeral bone defects. This manuscript aims to outline the most common indications for revision surgery and treatment options based on a careful and detailed review of the available literature.  This paper should help the surgeon in patient evaluation and selection of the optimal procedure for an individual patient.

BIO-RSA vs. metal-augmented baseplate in shoulder osteoarthritis with multiplanar glenoid deformity: a comparative study of radiographic findings and patient outcomes.

BACKGROUND: Reverse shoulder arthroplasty (RSA) requiring extensive reaming to address severe glenoid bone loss increases the risk of glenoid medialization and baseplate failure. We hypothesized that (1) metal-augmented baseplate prevents the medialization of the joint line and preserves glenoid bone stock similarly to bony increased-offset (BIO)-RSA and (2) bone graft viability and healing in BIO-RSA patients become compromised over time. MATERIALS AND METHODS: Eighty-one patients (83 shoulders) underwent glenoid lateralization with bone (BIO-RSA group, 44) or metal-augmented baseplate (metallic increased-offset [MIO]-RSA group, 39) and a minimum follow-up of 24 months were included. The orientation and direction of glenoid erosion was identified and recorded using computerized 3D planning. Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index were assessed before arthroplasty and at the last follow-up visits. Radiographic changes around the glenoid and humeral components were assessed. Healing and thickness of bone graft were evaluated by predefined criteria. Postoperative global glenoid inclination (ß angle) and retroversion were also measured. RESULTS: Delta scores of active anterior elevation were higher in the MIO-RSA group (P = .027). The differences in the other planes of shoulder motion and in WOOS index scores between the groups were not significant. Preoperative glenoid retroversion was higher in BIO-RSA patients, and glenoid inclination was similar in both groups. Type B2 and B3 glenoids had a posterior-central (91%) and posterior-superior (90%) erosion with a mean posterior humeral head subluxation of 76% and 78%, respectively. The direction of erosion in type E2 and E3 glenoids was posterior-superior, with a mean posterior humeral head subluxation of 74%. The rate of high position of the glenosphere was higher in the BIO-RSA group (P = .022), whereas the values of ß angle and postoperative retroversion were similar in the 2 groups. BIO-RSA group showed radiolucent lines <2 mm around the bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). Incomplete baseplate seating was found in 4 MIO-RSA patients (10%). We found higher rates of humerus condensation lines in MIO-RSA patients (P = .01) and higher rates of cortical thinning and tuberosity resorption in the BIO-RSA group (P = .027 and P = .004, respectively). CONCLUSION: Metal-augmented glenoid is a suitable alternative to BIO-RSA to preserve bone and prevent the medialization of the joint line in arthritic glenoid with multiplanar glenoid deformity. Bone and metal augmentation provided satisfactory clinical outcomes. Bone graft resorption in BIO-RSA patients raise concern about the risk of baseplate loosening and requires further long-term studies.

Shoulder Rehabilitation Exercises With Kinematic Biofeedback After Arthroscopic Rotator Cuff Repair: Protocol for a New Integrated Rehabilitation Program.

BACKGROUND: The recovery of scapular and humeral physiological kinematic parameters, as well as the sensorimotor control of movement, plays a primary role in the rehabilitation process after arthroscopic rotator cuff repair. A highly customized rehabilitation approach is required to achieve this aim. Biofeedback can be a useful tool, but there is poor evidence of its application in the rehabilitation after arthroscopic rotator cuff tear repair. OBJECTIVE: The aim of this paper is to outline an innovative exercise-based rehabilitation program exploiting visual biofeedback for the recovery of patients arthroscopically treated for rotator cuff repair. METHODS: For establishment of the innovative program, a multidisciplinary team involving experts in shoulder surgery, rehabilitation medicine, physical therapy, and biomedical and clinical engineering was formed. Starting from a conventional rehabilitation program, the team selected a set of exercises to be integrated with a biofeedback tool, named the INAIL (National Institute for Insurance against Accidents at Work) Shoulder and Elbow Outpatient program (ISEO program). ISEO is a motion analysis system based on inertial wearable sensors positioned over the thorax, scapula, humerus, and forearm. ISEO can return a visual biofeedback of humerus and scapula angles over time or of the scapula-humeral coordination, with possible overlap of patient-specific or asymptomatic reference values. A set of 12 progressive exercises was defined, divided into four groups based on humerus and scapula movements. Each group comprises 2-4 of the 12 exercises with an increasing level of complexity. Exercises can require the use of a ball, stick, rubber band, and/or towel. For each exercise, we present the starting position of the patient, the modality of execution, and the target position, together with notes about the critical factors to observe. The type of visual biofeedback to adopt is specified, such as the coordination between angles or the variation of a single angle over time. To guide the therapist in customizing the patient's rehabilitation program, a list of operative guidelines is provided. RESULTS: We describe various applications of the ISEO exercise program in terms of frequency and intensity. CONCLUSIONS: An innovative rehabilitation program to restore scapular and humeral kinematics after rotator cuff repair based on kinematic biofeedback is presented. Biofeedback is expected to increase patient awareness and self-correction under therapist supervision. Randomized controlled trials are needed to investigate the potential effect of the exercise-based biofeedback in comparison with conventional rehabilitation programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35757.

Glenoid bone loss in anterior shoulder dislocation: a multicentric study to assess the most reliable imaging method.

PURPOSE: The aim of this multicentric study was to assess which imaging method has the best inter-reader agreement for glenoid bone loss quantification in anterior shoulder instability. A further aim was to calculate the inter-method agreement comparing bilateral CT with unilateral CT and MR arthrography (MRA) with CT measurements. Finally, calculations were carried out to find the least time-consuming method. METHOD: A retrospective evaluation was performed by 9 readers (or pairs of readers) on a consecutive series of 110 patients with MRA and bilateral shoulder CT. Each reader was asked to calculate the glenoid bone loss of all patients using the following methods: best fit circle area on both MRA and CT images, maximum transverse glenoid width on MRA and CT, CT PICO technique, ratio of the maximum glenoid width to height on MRA and CT, and length of flattening of the anterior glenoid curvature on MRA and CT. Using Pearson's correlation coefficient (PCC), the following agreement values were calculated: the inter-reader for each method, the inter-method for MRA with CT quantifications and the inter-method for CT best-fit circle area and CT PICO. Statistical analysis was carried out to compare the time employed by the readers for each method. RESULTS: Inter-reader agreement PCC mean values were the following: 0.70 for MRA and 0.77 for CT using best fit circle diameter, 0.68 for MRA and 0.72 for CT using best fit circle area, 0.75 for CT PICO, 0.64 for MRA and 0.62 for CT anterior straight line and 0.49 for MRA and 0.43 for CT using length-to-width ratio. CT-MRA inter-modality PCC mean values were 0.9 for best fit circle diameter, 0.9 for best fit circle area, 0.62 for anterior straight line and 0.94 for length-to-width methods. PCC mean value comparing unilateral CT with PICO CT methods was 0.8. MRA best fit circle area method was significantly faster than the same method performed on CT (p = 0.031), while no significant difference was seen between CT and MRA for remaining measurements. CONCLUSIONS: CT PICO is the most reliable imaging method, but both CT and MRA can be reliably used to assess glenoid bone loss. Best fit circle area CT and MRA methods are valuable alternative measurement techniques.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up.

BACKGROUND: Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up. MATERIALS AND METHODS: In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated. RESULTS: In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected. CONCLUSIONS: Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries. LEVEL OF EVIDENCE: Level IV-case series.

Implant sonication versus intraoperative tissue sample cultures for Periprosthetic Joint Infection (PJI) of Shoulder Arthroplasty.

Introduction Periprosthetic joint infection (PJI) is the most problematic complications after shoulder arthroplasty. Many diagnostic tools have been identified to find infection, such as hystopatologic examination of tissue sections or cultures of intraoperative tissue. Implant sonication fluid culture showed good results in order to enhance diagnostic accuracy, but literature results are still controversial. Aim of our study is to compare the results of sonication with intraoperative tissue sample cultures. Patients and Methods From February 2016 to January 2018 we performed 102 revisions of Total Shoulder Arthroplasty (TSA) for suspected PJI.  Sixty - five patients respected the criteria for admission to the study. In each case periprostethic specimens were collected and explanted prosthesis were put inside sterile fluid, sonicated and then placed under culture. Results Among the sixty-five patients, 36 were considered as possible, probable or certain infection. Tissue cultures were positive for infection in thirty - four cases (52,3%) and in nineteen cases was found the positivity for Cutibacterium acnes. Sonication fluid cultures were positive in forty cases (61,5%), with a positivity for Cutibacterium acnes in twenty - seven cases. The sensitivities of sonication and tissue cultures for the diagnosis of shoulder PJI were 83.3% and 88,9% (P = 0,08); the specificities were 65.5%  and 93,1% (P < 0.01) respectively. Conclusion Our results suggest that sonication technique had not shown a clear advantage in postoperative shoulder PJI diagnosis, but it's a real aid to detect Cutibacterium acnes. In any case, sensitivity and mostly specificity were higher with  tissue cultures.

A kinematic and electromyographic comparison of a Grammont-style reverse arthroplasty combined with a l'Episcopo transfer compared to a lateralized humeral component reverse for restoration of active external rotation.

PURPOSE: To assess kinematic and electromyographic findings of two designs of reverse total shoulder arthroplasty (RTSA). We tested two hypotheses: (H1) Grammont-style (RTSA) with l'Episcopo tendon transfer gains similar postoperative kinematic findings of a lateralized humeral component RTSA without a tendon transfer; (H2) RTSA with lateralized humeral component induces earlier shoulder muscle activation during shoulder motion compared with standard Grammont prosthesis with l'Episcopo transfer. METHODS: Twenty-five patients with a cuff tear arthropathy, pseudoparalysis, and a positive dropping sign were sequentially included. A Grammont-style RTSA with a l'Episcopo tendon transfer was implanted in 13 patients (medialized humerus and transfer group) and an on-lay curved-stem RTSA in 12 (lateralized humerus group). Constant score; the disabilities of the arm, shoulder, and hand (DASH) score; and active shoulder range of motion (flexion, abduction, external rotation, and internal rotation) were measured pre- and postoperatively. Upper limb kinematic and surface electromyography (EMG) (anterior and posterior deltoid; upper, middle, and lower trapezius; and the upper and lower latissimus dorsi muscles) were recorded during active range of motion. RESULTS: At > 24 months of follow-up, the Constant and DASH scores and active shoulder range of motion improved in both groups (p < 0.0001). Internal rotation was significantly higher in the lateralized humerus group than in the medialized humerus and transfer group (p = 0.004). The dropping sign was found in 0/12 patients in the lateralized humerus group and in 5/13 patients in the medialized humerus and transfer group (p < 0.001). Kinematic findings were similar between groups (p = 0.286). A pattern of earlier muscle activation in the lateralized humerus group was found as compared to the transfer group as follows: (i) posterior deltoid during external rotation (p = 0.004); (ii) upper latissimus dorsi and middle and lower trapezius during flexion (p = 0.004, p = 0.005, and p = 0.042, respectively); (iii) lower latissimus dorsi during abduction (p = 0.016). CONCLUSION: RTSA with a lateralized humeral component provided similar active external rotation restoration to a Grammont-style RTSA with a l'Episcopo procedure in patients with a dropping sign. The posterior deltoid muscle underwent earlier activation during active external rotation in the lateralized humerus RTSA group as compared to the tendon transfer group. Our findings demonstrated the H1 and only partially demonstrated the H2 of the study.

Failed Latarjet procedure: a systematic review of surgery revision options.

BACKGROUND: Revision surgery after the Latarjet procedure is a rare and challenging surgical problem, and various bony or capsular procedures have been proposed. This systematic review examines clinical and radiographic outcomes of different procedures for treating persistent pain or recurrent instability after a Latarjet procedure. METHODS: A systematic review of the literature was performed using the Medline, Cochrane, EMBASE, Google Scholar and Ovid databases with the combined keywords "failed", "failure", "revision", "Latarjet", "shoulder stabilization" and "shoulder instability" to identify articles published in English that deal with failed Latarjet procedures. RESULTS: A total of 11 studies (five retrospective and six case series investigations), all published between 2008 and 2020, fulfilled our inclusion criteria. For the study, 253 patients (254 shoulders, 79.8% male) with a mean age of 29.6 years (range: 16-54 years) were reviewed at an average follow-up of 51.5 months (range: 24-208 months). CONCLUSIONS: Eden-Hybinette and arthroscopic capsuloplasty are the most popular and safe procedures to treat recurrent instability after a failed Latarjet procedure, and yield reasonable clinical outcomes. A bone graft procedure and capsuloplasty were proposed but there was no clear consensus on their efficacy and indication. Level of evidence Level IV Trial registration PROSPERO 2020 CRD42020185090- www.crd.york.ac.uk/prospero/.

Acute elbow dislocation: comparison between magnetic resonance imaging and intra-operative finding of ligament injury.

PURPOSE: The aim of this current study was to assess elbow ligament tears after dislocation using magnetic resonance imaging (MRI) and to correlate any pre-operative imaging with intra-operative findings of elbow ligament tears. METHODS: We prospectively included 32 patients with acute elbow dislocation investigated by MRI at a means of five days from dislocation. A simple elbow dislocation was diagnosed in 14 patients (44%); associated bone injuries were identified in 18 elbows (56%). Surgical repair of elbow ligaments was carried out in 23 patients, and nine cases were treated non-operatively. A blinded MRI evaluation of all 32 elbows was performed by an orthopaedic surgeon (rater 1) and a musculoskeletal radiologist (rater 2). RESULTS: Inter-rater agreement for MRI evaluation of 32 was poor for lateral ulnar collateral ligament (LUCL) tears, fair for radial collateral ligament (RCL), moderate for annular ligament (AL), and fair for ulnar collateral ligament (UCL). All tears were reported as complete by rater 1; 13/32 partial tears were identified by rater 2 (LUCL = 2, RCL = 2, UCL = 9). Correlation between surgical and MRI findings showed good inter-rater agreement for LUCL and AL tears in both raters. Agreement for RCL tear was poor for rater 1 and fair for rater 2; agreement for UCL tear was fair for rater 1 and poor for rater 2. Intra-operative findings showed ten radial head fractures (RHFs) and ten coronoid fractures (CFs). LUCL tears were found in the four cases of type II RHFs and in 3/4 cases of CFs. Bone injuries and ligament tears were not significantly associated. CONCLUSION: MRI scan supported surgeons to identify soft tissue injuries and to address the most suitable surgical approach after acute elbow dislocation. Inter-observer agreement for intra-operative findings was high for LCL complex injuries and poor for UCL.

Pre-operative factors affecting the indications for anatomical and reverse total shoulder arthroplasty in primary osteoarthritis and outcome comparison in patients aged seventy years and older.

BACKGROUND: We evaluated the pre-operative factors affecting anatomical and reverse total shoulder arthroplasty (TSA and RTSA) indications in primary osteoarthritis and compared outcomes in patients aged 70 years and older. METHODS: Fifty-eight patients received a TSA with an all-polyethylene glenoid component (APGC) or an RTSA with/without glenoid lateralization and the same curved short-stem humeral component. Active anterior and lateral elevation (AAE, ALE), internal and external rotation (IR, ER), pain, and the Constant-Murley score (CS) were recorded pre and post-operatively. Pre-operative rotator cuff (RC) fatty infiltration (FI) and modified Walch glenoid morphology were assessed. Humeral and glenoid component radiological outcomes were recorded. RESULTS: RTSA were older than TSA patients (p = 0.006), had lower pre-operative AAE (p < 0.001), ALE (p < 0.001), IR (p = 0.002), pain (p = 0.008) and CS (p < 0.001), and greater supraspinatus FI (p < 0.001). At a mean of 28.8 months, both implants yielded significantly different post-operative scores and similar complication rates. Both groups achieved similar post-operative AAE, ER, and IR; ALE was higher in TSA (p = 0.006); and AAE and ALE delta scores were higher in RTSA (p = 0.045 and p = 0.033, respectively). Radiolucent line rates were higher around the TSA APGC than the RTSA baseplate (p = 0.001). High-grade RC FI adversely affected mobility improvement. Humeral cortical thinning was significantly higher in TSA (p = 0.001). CONCLUSION: RTSA patients were older, had poorer pre-operative active mobility, and had greater RC FI than TSA. Both devices provided good mid-term clinical and ROM improvement.

Shoulder arthroplasty to address the sequelae of anterior instability arthropathy and stabilization procedures: systematic review and meta-analysis.

PURPOSE: Chronic anterior glenohumeral joint instability is a common situation and can lead to progressive cartilage deterioration and ultimately instability arthopathy. Progressive cartilage deterioration can occur despite conservative or surgical treatment and the sequelae of these conditions are often addressed with total shoulder arthroplasty. Aims of the present study were to analyze the available literature to describe the technical aspects of this particular operation and to report outcomes and complication rates. The hypothesis was that shoulder arthropalsty in the sequelae of instability had lower outcomes and higher complication rates than arthroplasties for primary arthritis. METHODS: A systematic review of the literature was performed, in accordance with the PRISMA guidelines. PubMed, Ovid, Cochrane Reviews, and Google Scholar were comprehensively searched using a combination of the following keywords: shoulder arthroplasty, reverse shoulder arthroplasty, dislocation arthropathy, capsulorrhaphy arthropathy and stabilization procedures. RESULTS: Thirteen studies with 365 patients met inclusion criteria. Since 13 patients were lost to follow-up, 352 were reviewed at an average follow-up of 53.4 months. The average Constant-Murley (CM) and American Shoulder and Elbow Society (ASES) scores improved from 35.6 and 35.7 to 72.7 and 77, respectively. The overall complication rate was 25.7% and the reoperation rate was 18.5%. Radiographs at follow-up revealed radiolucent lines on the humerus in 12.4% of cases and radiolucent lines or notching on the glenoid side in 22.7% of cases. The average Methodological Index for Non-randomized Studies Score (MINORS) was 12.9 for non-comparative studies and 21.3 for comparative studies. CONCLUSION: Shoulder arthroplasty to address the sequelae of instability arthropathy and stabilization procedures can be a challenging procedure as a consequence of the distorted anatomy and severe glenohumeral joint pathology. Complication and reoperation rates are higher compared to shoulder arthroplasty for primary glenohumeral joint arthritis; however, the difference is not statistically significant. When reverse shoulder arthroplasties (RSA) were considered as a subgroup and compared to anatomic shoulder replacements (total shoulders and hemiarthroplasties), they showed a lower revision rate.

Isolated displaced type II partial articular radial head fracture: correlation of preoperative imaging with intraoperative findings of lateral ulnar collateral ligament tear.

BACKGROUND: The aim of this study was to determine the lateral ulnar collateral ligament (LUCL) injury associated with isolated radial head fracture (RHF) and the relationship of the ligament injury with the displacement of the fragment-loss of contact-in unstable displaced partial articular RHF in individuals without any history of ulnohumeral dislocation. METHODS: We retrospectively identified 131 consecutive patients who underwent open reduction and internal fixation of isolated closed Mason type II RHF performed at our institution. We identified 3 subsets by the pattern of RHF and the position of the unstable fragment (anterior or posterior) relative to the capitulum humeri: displaced stable (group I), displaced anterior unstable (group II), and displaced posterior unstable (group III). Standard radiographs were obtained preoperatively and postoperatively. The pattern of lateral collateral ligament avulsion and its distribution were inferred from intraoperative records. RESULTS: Preoperative radiographs of the 131 patients showed 101 nonseparated fractures (77%, group I) and 30 unstable fractures (23%). Anterior displacement of the fragment was found in 18 elbows (14%, group II) and posterior displacement in 12 (9%, group III). LUCL avulsion was found in 18 of 30 unstable RHFs (60%) and in 1 of 60 stable RHFs (1.6%). CONCLUSION: RHF is a complex fracture often associated with soft tissue lesions. It is important to determine which structures need to be repaired to avoid complications that could lead to elbow instability. The RHF pattern and classification as stable or unstable can help the surgeon in the identification and treatment of LUCL lesions.

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

PURPOSE: Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component. METHODS: We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient's improvement as a percent of maximal possible improvement (MPI). RESULTS: The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion. CONCLUSIONS: Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.

Assessment of anatomical and reverse total shoulder arthroplasty with the scapula-weighted Constant-Murley score.

AIM OF THE STUDY: To evaluate total (TSA) and reverse total shoulder arthroplasty (RTSA) using the Constant-Murley score (CMS) and the scapula-weighted (SW) CMS, an integrated outcome measure that takes into account the compensatory movements of the scapula. METHODS: Twenty-five consecutive patients, 12 with TSA and 13 with RTSA, underwent kinematic analysis before and after shoulder replacement. Measurements included flexion (FLEX) and abduction (ABD) for the humerus and Protraction-Retraction (PR-RE), Medio-Lateral rotation (ME-LA), and Posterior-Anterior tilting (P-A) for the scapula. They were recorded at baseline (T0) and at six (T1) and 12 months (T2). Reference data were obtained from 31 control shoulders. RESULTS: At T1, differences in CMS and SW-CMS were not significant in either group, whereas values at T2 were significantly lower in RTSA patients (p = 0.310 and p = 0.327, respectively). In TSA shoulders, the compensatory scapular movements in FLEX were all reduced from T0 to T2, whereas P-A was increased in ABD. In RTSA patients, the compensatory scapular movements in FLEX showed a general reduction at T1, with an increase in P-A at T2, whereas in ABD, all increased at T1 and decreased at T2 except for P-A, which did not decrease. DISCUSSION: The SW-CMS showed that the physiological scapulothoracic motion was not restored in TSA and RTSA patients; it may be used as a reference for the gradual progression of deltoid and scapular muscle rehabilitation. CONCLUSIONS: The worse CMS and SW-CMS scores found in RTSA patients at six months may be due to the biomechanics of the reverse prosthesis and to the weakness of deltoid and periscapular muscles.

Functional outcomes and clinical strength assessment after infraspinatus-sparing surgical approach to scapular fracture: Does it really make a difference?

BACKGROUND: Surgical treatment of scapular fractures with posterior approach is frequently associated with postoperative infraspinatus hypotrophy and weakness. The aim of this retrospective study is to compare infraspinatus strength and functional outcomes in patients treated with the classic Judet versus modified Judet approach for scapular fracture. PATIENTS AND METHODS: 20 cases with scapular neck and body fracture treated with posterior approach for lateral border plate fixation were reviewed. In 11 of 20 cases, we used the modified Judet approach (MJ group), and in 9 cases we used the classic Judet approach (CJ group). All fractures were classified according to the AO classification system. At follow-up examinations, patients had X-ray assessment with acromiohumeral distance (AHD) measurement, clinical evaluation, active range of motion (ROM) examination, Constant Shoulder Score, and Disability of the Arm, Shoulder and Hand (DASH) Score. Infraspinatus strength assessment was measured using a dynamometer during infraspinatus strength test (IST) and infraspinatus scapular retraction test (ISRT). RESULTS: Demographic data did not significantly differ between the CJ group and MJ group, except for mean follow-up, which was 4.15 years in the CJ group and 2.33 in the MJ group (p < 0.001). All X-ray examinations showed fracture healing. AHD was significantly decreased in the CJ group (p = 0.006). We did not find significant differences in active ROM between the MJ and CJ groups in the injured arm (p < 0.05). The Constant Score was 75.83 (±14.03) in the CJ group and 82.75 (±10.72) in the MJ group (p = 0.31); DASH Score was 10.16 in the CJ group and 6.25 in the MJ group (p = 0.49). IST showed mean strength of 8.38 kg (±1.75) in the MJ group and 4.61 kg (±1.98) in the CJ group (p = 0.002), ISRT test was 8.7 (±1.64) in the MJ group and 4.95 (±2.1) in the CJ group (p = 0.002). Infraspinatus hypotrophy was detected during inspection in six patients (five in the CJ group and one in the MJ group); it was related to infraspinatus strength weakness in IST and ISRT (p < 0.001). CONCLUSIONS: Infraspinatus-sparing surgical approach for scapular fracture avoids infraspinatus hypotrophy and external-rotation strength weakness. We suggest use of the modified Judet approach for scapular fracture and to restrict the classic Judet approach to only when the surgeon believes that the fracture is not easily reducible with a narrower exposure. LEVEL OF EVIDENCE: Level IV.

Comparison of shoulder replacement to treat osteoarthritis secondary to instability surgery and primary osteoarthritis: a retrospective controlled study of patient outcomes.

PURPOSE: We hypothesized that osteoarthritis developing after instability surgery is radiographically similar to primary arthritis and that arthroplasty provides comparable outcomes in patients with these two types of osteoarthritis. METHODS: Patients with osteoarthritis due to instability surgery (group I) and with primary osteoarthritis (group II) were included. Mean follow-up was 52.6 and 41.6 months, respectively. Hemiarthroplasties (HA) were 32% in group I and 27% in group II; total shoulder arthroplasties (TSA) were 68 and 73% respectively. Outcome measures included active shoulder mobility (anterior elevation [AAE], lateral elevation [ALE], external rotation [ER], and internal rotation [IR]), pain, Constant-Murley score, and Simple Shoulder Test. Pre-operative and post-operative radiographs were taken. Glenoid arthritis was assessed by computed tomography. RESULTS: Participants were 19 in the group I (mean age 44.5 years, 12 males, 7 females) and 30 in the group II (mean age 48.2 years, 28 males, 12 females). Both patient groups had pre-operative concentric arthritis. Group II had higher rates of A2 and B1 glenoids (p = 0.003). A longer interval from stabilization to replacement was associated with lower post-operative IR (p = 0.017) and ALE (p = 0.035). Post-operative ER and IR were higher in group I (p < 0.001 and p = 0.001, respectively). In group I, AFE and ALE were higher in HA than TSA patients (both p = 0.009). The CS and SST score increased significantly in both groups (both p < 0.001). Group II showed significantly greater humeral radiolucency (p = 0.025) and a higher rate of TSA revision to reverse prostheses compared with group I. CONCLUSIONS: Shoulder replacement provides similar clinical and radiographic outcomes in arthritis secondary to instability surgery and in primary osteoarthritis. Posterior glenoid wear is more common in primary osteoarthritis.

Grammont humeral design versus onlay curved-stem reverse shoulder arthroplasty: comparison of clinical and radiographic outcomes with minimum 2-year follow-up.

BACKGROUND: There are few investigations comparing lateralized and medialized reverse total shoulder arthroplasty (RTSA) in patients with cuff tear arthropathy. This study assessed the outcomes of 2 RTSA designs. METHODS: Sixty-eight consecutive cuff tear arthropathy patients (74 shoulders) with a follow-up of at least 24 months received a Grammont or an onlay curved short-stem humeral component, with or without glenoid lateralization; a cementless humeral stem was implanted in >90%. Clinical outcome measures included active range of motion (anterior and lateral elevation, external and internal rotation), pain, and the Constant-Murley score. Radiologic outcomes included radiolucency, condensation lines, cortical thinning, spot weld, loosening and subsidence, and tuberosity resorption for the humeral component and radiolucency, scapular notching, formation of scapular bone spurs, ossifications, and loosening for the glenoid component. RESULTS: Both prostheses provided significant differences between preoperative and postoperative scores and showed a similar complication rate. Scapular fractures were found only in the patients who received the curved short-stem implant. Glenoid bone grafting did not significantly affect clinical scores. Both implants provided similar postoperative shoulder mobility, even though the lateralized curved stem was associated with higher delta scores for external rotation (P = .002) and lower rates of scapular notching (P = .0003), glenoid radiolucency (P = .016), and humeral bone remodeling (P = .004 and P = .030 for cortical thinning and spot weld, respectively). CONCLUSIONS: Medialized and short-stem lateralized RTSA implants provided similar midterm clinical outcomes and range of motion. The curved short stem was associated with higher delta scores for external rotation and a lower rate of radiographic risk factors.

Revision of failed shoulder hemiarthroplasty to reverse total arthroplasty: analysis of 157 revision implants.

BACKGROUND: There remains a paucity of studies examining the conversion of failed hemiarthroplasty (HA) to reverse total shoulder arthroplasty (RTSA). Therefore, the purpose of this study was to examine a large series of revision HA to RTSA. METHODS: A population of 157 patients who underwent conversion of a failed HA to a revision RTSA from 2006 through 2014 were included. The mean follow-up was 49 months (range, 24-121 months). The indications for revision surgery included instability with rotator cuff insufficiency (n = 127) and glenoid wear (n = 30); instability and glenoid wear were associated in 38 cases. Eight patients with infection underwent 2-stage reimplantation. RESULTS: Patients experienced significant improvements in their preoperative to postoperative pain and shoulder range of motion (P < .0001), with median American Shoulder and Elbow Surgeons and Simple Shoulder Test scores of 60 and 6 points, respectively. There were 11 (7%) repeated revision surgeries, secondary to glenoid component loosening (n = 3), instability (n = 3), humeral component disassembly (n = 2), humeral stem loosening (n = 1), and infection (n = 2). Implant survivorship was 95.5% at 2 years and 93.3% at 5 years. There were 4 reoperations including axillary nerve neurolysis (n = 2), heterotopic ossification removal (n = 1), and hardware removal for rupture of the metal cerclage for an acromial fracture (n = 1). At final follow-up, there were 5 "at-risk" glenoid components. CONCLUSION: Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision RTSA from a failed HA. There was a relatively low revision rate, with glenoid loosening and instability being the most common causes.