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

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

Factors that affect external rotation following reverse shoulder arthroplasty: a retrospective multi-centre study on 501 shoulders.

INTRODUCTION: The purpose of this multi-centre study was to assess external rotation in a large cohort following reverse shoulder arthroplasty (RSA) at a minimum follow-up of 2 years, and identify factors that influence postoperative and/or net-improvement of external rotation. METHODS: The authors retrospectively reviewed records of 743 RSAs performed between January 2015 and August 2017 by 16 surgeons that participated in a large national society symposium; 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised with implant exchange, which left 501 available for assessment at 2.0-5.5 years. Pre- and post-operative active forward elevation, active external rotation (ER1), active internal rotation (IR1) and constant score (CS) were collected. Regression analyses were performed to determine associations of patient demographics, surgical and implant parameters, rotator cuff muscles status and radiographic angles with ER1. RESULTS: Multivariable analyses revealed postoperative ER1 decreased with age (ß, - 0.35), increased with lateralisation shoulder angle (LSA) (ß, 0.26), and was better in shoulders operated by the antero-superior (AS) approach (ß, 11.41), but worse in shoulders with absent/atrophic teres minor muscles (ß, - 10.06). Net-improvement of ER1 increased with LSA (ß, 0.39), was better with inlay stems (ß, 8.33) and BIO RSA (ß, 6.22), but worse in shoulders operated for primary OA with rotator cuff (RC) tears (ß, - 16.26), for secondary OA due to RC tears (ß, - 16.06), or for mRCT (ß, - 18.96). CONCLUSIONS: This large multi-centre study revealed that, at a minimum of 2 years following RSA, ER1 improved by 16.1°. Postoperative ER1 was better in shoulders which had normal or hypertrophic teres minor muscles, were operated by the AS approach, or with greater LSA. Net-improvement of ER1 was better in shoulders with inlay stems, with BIO RSA, or with greater LSA, but worse in shoulders with rotator cuff deficiency. LEVEL OF EVIDENCE: IV.

Revision of failed Latarjet with the Eden-Hybinette surgical technique.

INTRODUCTION: The outcomes of the Latarjet procedure for anterior shoulder instability are highly satisfactory although recurrences are possible. Surgical revision is challenging, and often requires an iliac crest bone graft as described by Eden and Hybinette. The aims of our study were to analyze the outcomes of the Eden-Hybinette technique after failed Latarjet procedure, determine the failure and complication rates, and analyze the risk of osteoarthritis. We hypothesized that the Eden-Hybinette technique would yield good outcomes after failed Latarjet procedure. MATERIAL AND METHODS: Retrospective multicenter study (9 hospitals) by the French Shoulder and Elbow Society (SoFEC) involving 46 patients who underwent revision surgery with an Eden-Hybinette procedure after failed Latarjet stabilization. The patients had a minimum follow-up of 1year and the outcomes were evaluated based on the Rowe score, Walch-Duplay score and radiographs. RESULTS: The mean age at the final assessment was 32years. The mean follow-up was 38 months and 86% of patients had a stable shoulder with an overall satisfaction rate of 80%. Postoperatively, the Rowe score averaged 76/100 and the Walch-Duplay score averaged 68/100; 60% of patients had resumed their sports participation. Return to sport was statistically correlated with age (p=0.0001), osteoarthritis (p=0.05) and time elapsed between the two surgical procedures (p=0.0001). The Rowe score was statistically correlated with osteoarthritis (p=0.01). DISCUSSION/CONCLUSION: Our study is one of the largest on the Eden-Hybinette procedure for recurrent anterior shoulder instability. The outcomes at 3years' follow-up were satisfactory in 80% of patients and 86% had stable shoulders. The osteoarthritis rate was low (11%), although the follow-up period was relatively short. LEVEL OF EVIDENCE: IV, non-randomized multicenter retrospective study.

Anterior shoulder instability: the role of advanced shoulder imaging in preoperative planning.

Despite advances in the understanding of anterior shoulder instability, recurrence rates after arthroscopic and open surgery have been reported to be as high as 30%. A successful operative outcome for patients with anterior shoulder instability requires the surgeon to perform a complete preoperative evaluation based on a thorough physical examination and advanced imaging techniques. In addition to the Bankart lesion, the treating surgeon must be aware of other copathologies, such as bony lesions of the glenoid or humeral head, humeral avulsion of the glenohumeral ligament, and articular cartilage defects that can occur in concert with capsular pathology and may necessitate a change in surgical strategy. This article focuses specifically on the osseous, labroligamentous, cartilage, and rotator cuff lesions demonstrated on preoperative imaging that are important to recognize in the preoperative work-up to optimize surgical outcomes for anterior instability.

Preoperative imaging of anterior shoulder instability: diagnostic effectiveness of MDCT arthrography and comparison with MR arthrography and arthroscopy.

OBJECTIVE: The purpose of this article is to assess the diagnostic effectiveness of MDCT arthrography in the preoperative planning of anterior shoulder instability compared with MR arthrography and arthroscopy. SUBJECTS AND METHODS: Shoulder MDCT arthrography and MR arthrography examinations prospectively performed in 40 consecutive patients (30 male and 10 female patients; mean age, 26 years) were independently evaluated by two musculoskeletal radiologists who were blinded to the arthroscopic findings, which represented the reference standard. Sensitivity, specificity, and agreement with arthroscopy were determined for osseous, cartilage, and labroligamentous injuries. RESULTS: In detecting glenoid rim fractures, MDCT arthrography had a sensitivity of 100% (12/12), a specificity of 96% (27/28), and better agreement with surgery (κ = 0.94) than did MR arthrography (κ = 0.74). For the depiction of glenoid cartilage lesions, MDCT arthrography had a sensitivity of 82% (18/22), a specificity of 89% (16/18), and slightly better agreement with surgery (κ = 0.70) than did MR arthrography (κ = 0.66). In identifying anterior labral periosteal sleeve avulsion lesions, MDCT arthrography had a sensitivity of 93% (26/28), a specificity of 100% (12/12), and better agreement with surgery (κ = 0.89) than did MR arthrography (κ = 0.74). For the diagnosis of humeral avulsion of the inferior glenohumeral ligament lesions, MDCT arthrography had a sensitivity and a specificity of 100% (2/2) and better agreement with surgery (κ = 1) than did MR arthrography (κ = 0.79). CONCLUSION: MDCT arthrography showed better accuracy than did MR arthrography in the detection of osseous, cartilage, and labroligamentous injuries related to anterior shoulder instability. Because MDCT arthrography was particularly reliable for the detection of glenoid rim fractures and humeral avulsion of the inferior glenohumeral ligament lesions, which represent crucial findings in the preoperative planning, this technique may beneficially affect treatment by means of selecting the proper surgical treatment.

Orientation of the rotator cuff insertion facets on the humerus: comparison between individuals with intact and torn rotator cuffs.

The purpose of this work has been to compare the orientation of the rotator cuff insertions on the humerus between individuals with intact and torn rotator cuffs, respectively, to look for anatomical factors involved in the pathogenesis of rotator cuff tears. A total of 60 patients evaluated by arthro-computed tomography (CT) were divided into an intact rotator cuff group (31 patients) and a torn rotator cuff group (29 patients). The orientation angles of the lesser humeral tubercle facet and of the superior, middle and inferior facets of the greater humeral tubercle were measured in the sagittal plane between the horizontal line (defined as perpendicular to the diaphysis long axis) and the line tangent to the facet. The orientation angles of the superior and middle facets of the greater humeral tubercle were measured in the coronal plane. The comparison between the two groups showed a significant difference (p=0.009) concerning the orientation of the middle facet of the greater tubercle in the sagittal plane, with a mean angle of 36.0 degrees (S.D., 6.2 degrees) in the intact cuff group versus 31.1 degrees (S.D.,7.2 degrees) in the torn cuff group. There were no other significant differences in regard to the orientation of the facets in the sagittal and coronal planes. A decrease in the dorsal orientation of the middle facet of the greater tubercle, as we observed in the torn rotator cuff group, may reduce the inferior translatory forces generated by the infraspinatus thereby facilitating impingement of the subacromial structures. These additional anatomical data might augment the body of knowledge on rotator cuff pathology.

Sonography of the painful shoulder: role of the operator's experience.

OBJECTIVE: The aim of our study was to determine the role of the operator's experience in the sonographic evaluation of the painful shoulder and to validate assumptions about its technical performance in routine practice. MATERIALS AND METHODS: Two radiologists, respectively standard and expert sonographic operators, independently and prospectively scanned 65 patients with clinical suspicion of rotator cuff lesion. Magnetic resonance arthrography was the reference standard. RESULTS: The sensitivity of the expert ultrasound operator was 95.3% for full-thickness rotator cuff tears (41/43), 70.6% for partial-thickness tears (12/17), 64.3% for intratendinous tears (9/14), 100% for abnormality of the long head of biceps tendon (seven of seven), 88.9% for supraspinatus tendinosis (16/18), 96.4% for subacromial bursa abnormalities (53/55), and 91.7% for acromioclavicular joint osteoarthritis (33/36). The two sonographic operators were in very good agreement about full-thickness rotator cuff tears (kappa = 0.90), supraspinatus tendinosis (kappa = 0.80), abnormalities of the long head of biceps tendon (kappa = 0.84), subacromial bursa abnormalities (kappa = 0.89), and acromioclavicular osteoarthritis (kappa = 0.81). The agreement was only moderate for partial-thickness tears (kappa = 0.63) and intratendinous tears (kappa = 0.57). CONCLUSIONS: Our results show that in moderately experienced hands as in experts' hands, sonography has a low level of interobserver variability for full-thickness rotator cuff tears. Considering partial-thickness and intratendinous rotator cuff tears, our data suggest that interobserver variability is higher.