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Bone & Joint Open
Vol. 5, Issue 10 | Pages 851 - 857
10 Oct 2024
Mouchantaf M Parisi M Secci G Biegun M Chelli M Schippers P Boileau P

Aims

Optimal glenoid positioning in reverse shoulder arthroplasty (RSA) is crucial to provide impingement-free range of motion (ROM). Lateralization and inclination correction are not yet systematically used. Using planning software, we simulated the most used glenoid implant positions. The primary goal was to determine the configuration that delivers the best theoretical impingement-free ROM.

Methods

With the use of a 3D planning software (Blueprint) for RSA, 41 shoulders in 41 consecutive patients (17 males and 24 females; means age 73 years (SD 7)) undergoing RSA were planned. For the same anteroposterior positioning and retroversion of the glenoid implant, four different glenoid baseplate configurations were used on each shoulder to compare ROM: 1) no correction of the RSA angle and no lateralization (C-L-); 2) correction of the RSA angle with medialization by inferior reaming (C+M+); 3) correction of the RSA angle without lateralization by superior compensation (C+L-); and 4) correction of the RSA angle and additional lateralization (C+L+). The same humeral inlay implant and positioning were used on the humeral side for the four different glenoid configurations with a 3 mm symmetric 135° inclined polyethylene liner.


The Bone & Joint Journal
Vol. 101-B, Issue 4 | Pages 461 - 469
1 Apr 2019
Lädermann A Schwitzguebel AJ Edwards TB Godeneche A Favard L Walch G Sirveaux F Boileau P Gerber C

Aims

The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years.

Patients and Methods

We retrospectively studied the records of 79 patients (19 men, 60 women; 84 shoulders) aged 70.4 years (21 to 87) treated for aseptic loosening of the glenosphere following RSA. Clinical evaluation included pre- and post-treatment active anterior elevation (AAE), external rotation, and Constant score.


The Bone & Joint Journal
Vol. 100-B, Issue 4 | Pages 485 - 492
1 Apr 2018
Gauci MO Bonnevialle N Moineau G Baba M Walch G Boileau P

Aims

Controversy about the use of an anatomical total shoulder arthroplasty (aTSA) in young arthritic patients relates to which is the ideal form of fixation for the glenoid component: cemented or cementless. This study aimed to evaluate implant survival of aTSA when used in patients aged < 60 years with primary glenohumeral osteoarthritis (OA), and to compare the survival of cemented all-polyethylene and cementless metal-backed glenoid components.

Materials and Methods

A total of 69 consecutive aTSAs were performed in 67 patients aged < 60 years with primary glenohumeral OA. Their mean age at the time of surgery was 54 years (35 to 60). Of these aTSAs, 46 were undertaken using a cemented polyethylene component and 23 were undertaken using a cementless metal-backed component. The age, gender, preoperative function, mobility, premorbid glenoid erosion, and length of follow-up were comparable in the two groups. The patients were reviewed clinically and radiographically at a mean of 10.3 years (5 to 12, sd 26) postoperatively. Kaplan–Meier survivorship analysis was performed with revision as the endpoint.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_20 | Pages 33 - 33
1 Dec 2017
Letissier H Walch G Boileau P Le Nen D Stindel E Chaoui J
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Introduction

Reverse Total Shoulder Arthroplasty (rTSA) is an efficient treatment, to relieve from pain and to increase function. However, scapular notching remains a serious issue and post-operative range of motion (ROM) presents many variations. No study compared implant positioning, different implant combinations, different implant sizes on different types of patient representative to undergo for rTSA, on glenohumeral ROM in every degree of freedom.

Material and Methods

From a CT-scan database classified by a senior surgeon, CT-exams were analysed by a custom software Glenosys® (Imascap®, Brest, France). Different glenoid implants types and positioning were combined to different humerus implant types. Range of motion was automatically computed. Patients with an impingement in initialisation position were excluded from the statistical analysis. To validate those measures, a validation bench was printed in 3D to analyse different configurations.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 224 - 224
1 Dec 2013
Alta T Morin-Salvo N Bessiere C Boileau P
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BACKGROUND:

Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) creates a long-necked scapula, providing the benefits of lateralization. Experience with allogenic bone grafting of the glenoid in shoulder arthroplasty is mainly based on its use with total shoulder arthroplasty (TSA). Therefore, our study objectives were: 1) verify if the use of BIO-RSA together with glenoid surface grafting with allogenic bone would provide similar benefits (clinical and functional) as found with autologous bone, 2) determine if allograft could be a good alternative in the absence of (good quality) autograft bone, and 3) to see if the allograft would incorporate with the native glenoid bone.

METHODS:

We included 25 patients (19 female, 6 male) in this prospective study. Indications for BIO-RSA were: fracture sequalle (n = 9), revisions (n = 11), 4-part humerus fracture (n = 1), rheumatoid arthritis (n = 1) and cuff tear arthropathy (CTA) with poor humeral head bone quality/osteonecrosis (n = 3). Mean (± SD) age 70 ± 11 years (range, 44–86). Clinical evaluation consisted of ROM, Constant scores, patient satisfaction (Subjective Shoulder Value (SSV)) and noted complications. Radiographic and CT scan evaluation consisted of bone graft healing, bone graft resorption/lysis, glenoid component loosening, inferior scapular notching, spur formation and anterior/posterior scapular notching. Mean follow-up was 34 ± 10 months (24–62).


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 223 - 223
1 Dec 2013
Alta T Decroocq L Moineau G Brassart N Favard L Sirveaux F Clavert P Boileau P
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BACKGROUND:

Bony healing of tuberosities around shoulder prostheses is difficult to obtain in the elderly patient. We hypothesized that reattachment of the tuberosities, performed in combination with bone grafting, around a specific reverse shoulder fracture-prosthesis (RSFP) would favour improved tuberosity healing and shoulder mobility in elderly patients with displaced proximal humerus fractures.

METHODS:

We included 49 patients (50 shoulders)(45 female, 4 male) in this prospective study. Mean (± SD) age 80 ± 4 years (range, 70–88). Clinical evaluation consisted of ROM, VAS (pain), Constant scores, patient satisfaction (Subjective Shoulder Value (SSV)) and noted complications. Radiological evaluation consisted of tuberosity healing and component loosening. Mean follow-up 18 ± 8 months (12–39).


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_34 | Pages 225 - 225
1 Dec 2013
Alta T Morin-Salvo N Bessiere C Moineau G Boileau P
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Introduction:

Lateralization of reversed shoulder arthroplasty provides improvement in range of motion and decreases inferior scapular notching. The purpose of this study was to verify if the autologous cancelous bone graft harvested from the humeral head does heal constantly in a large cohort of patients followed for a long time

Methods:

Cohort of 92 consecutive patients operated between 2006 and 2010 with a BIORSA for definitive shoulder pseudoparalysis, secondary to cuff tear arthropathy (CTA) or massive, irreparable cuff tear (MCT). The autogenous cancelous graft was harvested from humeral head in all cases. Eight patients were lost for follow up, and four died before 2 years. The remaining 80 patients underwent clinical, radiographic and CT assessment at a minimum FU of 24 months. Mean age was 73 years. Three independent observers evaluated notching, partial or total glenoid or humeral loosening and viability of the graft. Constant-Murley score, range of motion and subjective shoulder value (SSV) were recorded. The mean follow up was 39 months (range 24–74 months).


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_28 | Pages 40 - 40
1 Aug 2013
Chaoui J Walch G Boileau P
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INTRODUCTION

The glenoid version assessment is crucial step for any Total Shoulder Arthroplasty (TSA) procedure. New methods to compute 3D version angle of the glenoid have been proposed. These methods proposed different definitions of the glenoid plane and only used 3 points to define each plane on the 3D model of the scapula. In practice, patients often come to consultation with their CT-scans. In order to reduce the x-ray dose, the scapulae are often truncated on the inferior part. In these cases, the traditional scapula plane cannot be calculated. We hypothesised that a new plane definition, of the scapula and the glenoid, that takes into account all the 3D points, would have the least variation and provide more reliable measures whatever the scapula is truncated or not. The purpose of the study is to introduce new fully automatic method to compute 3D glenoid version for TSA preoperating planning and test its results on artificially truncated scapulae.

MATERIAL AND METHODS

Volumetric preoperative CT datasets have been used to derive a surface model shape of the shoulder. The glenoid surface is detected and a 3D version and inclination angle of the glenoid surface are computed. We propose a new reference plane of the scapula without picking points on the 3D model. The method is based on the mathematical skeleton of the scapula and the least squares plane fitting. Specific software has been developed to apply the plane fitting in addition the automatic segmentation process. An orthopedic surgeon defined the traditional scapular plane based on 3 points and applied the measures on 12 patients. The manual process has been repeated 3 times and the intra-class correlation coefficient (ICC) was calculated to compare the results with our automatic method. To validate the reliability of the new plane relating to truncated scapulae, we have measured the 3D orientation variation on 37 scapulae. Nine iterations have been applied on each scapula by cutting 5mm of the scapular inferior part.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIV | Pages 90 - 90
1 Oct 2012
Chaoui J Moineau G Stindel E Hamitouche C Boileau P
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For any image guided surgery, independently of the technique which is used (navigation, templates, robotics), it is necessary to get a 3D bone surface model from CT or MR images. Such model is used for planning, registration and visualization. We report that graphical representation of patient bony structure and the surgical tools, inter-connectively with the tracking device and patient-to-image registration, are crucial components in such system. For Total Shoulder Arthroplasty (TSA), there are many challenges. The most of cases that we are working with are pathological cases such as rheumatoid arthritis, osteoarthritis disease. The CT images of these cases often show a fusion area between the glenoid cavity and the humeral head. They also show severe deformations of the humeral head surface that result in a loss of contours. These fusion area and image quality problems are also amplified by well-known CT-scan artefacts like beam-hardening or partial volume effects. The state of the art shows that several segmentation techniques, applied to CT-Scans of the shoulder, have already been disclosed. Unfortunately, their performances, when used on pathological data, are quite poor.

In severe cases, bone-on-bone arthritis may lead to erosion-wearing away of the bone. Shoulder replacement surgery, also called shoulder arthroplasty, is a successful, pain-relieving option for many people. During the procedure, the humeral head and the glenoid bone are replaced with metal and plastic components to alleviate pain and improve function. This surgical procedure is very difficult and limited to expert centres. The two main problems are the minimal surgical incision and limited access to the operated structures. The success of such procedure is related to optimal prosthesis positioning. For TSA, separating the humeral head in the 3D scanner images would allow enhancing the vision field for the surgeon on the glenoid surface. So far, none of the existing systems or software packages makes it possible to obtain such 3D surface model automatically from CT images and this is probably one of the reasons for very limited success of Computer Assisted Orthopaedic Surgery (CAOS) applications for shoulder surgery. This kind of application often has been limited due to CT-image segmentation for severe pathologic cases and patient to image registration.

The aim of this paper is to present a new image guided planning software based on CT scan of the patient and using bony structure recognition, morphological and anatomical analysis for the operated region. Volumetric preoperative CT datasets have been used to derive a surface model shape of the shoulder. The proposed planning software could be used with a conventional localisation system, which locates in 3D and in real time position and orientation for surgical tools using passive markers associated to rigid bodies that will be fixed on the patient bone and on the surgical instruments.

20 series of patients aged from 42 years to 91 years (mean age of 71 years) were analysed. The first step of this planning software is fully automatic segmentation method based on 3D shape recognition algorithms applied to each object detected in the volume. The second step is a specific processing that only treats the region between the humerus and the glenoid surface in order to separate possible contact areas. The third step is a full morphological analysis of anatomical structure of the bone. The glenoid surface and the glenoid vault are detected and a 3D version and inclination angle of the glenoid surface are computed. These parameters are very important to define an optimal path for drilling and reaming glenoid surface. The surgeon can easily modify the position of the implant in 3D aided by 3D and 2D view of the patient anatomy. The glenoid version/inclination angle and the glenoid vault are computed for each postion in real time to help the surgeon to evaluate the implant position and orientation.

In summary, preoperative planning, 3D CT modelling and intraoperative tracking produced improved accuracy of glenoid implantation. The current paper has presented new planning software in the world of image guided surgery focused on shoulder arthroplasty. Within our approach, we propose, to use pattern recognition instead of manual picking of landmarks to avoid user intervention, in addition to potentially reducing the procedure time. A very important role is played by 3D data sets to visualise specific anatomical structures of the patient. The automatic segmentation of arthritic joints with bone recognition is intended to form a solid basis for the registration. The results of this methodology were tested on arthritic patients to prove that it is not just easy and fast to perform but also very accurate so it realises all conditions for the clinical use in OR.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 170 - 170
1 Sep 2012
Alami GB Rumian A Chuinard C Roussanne Y Boileau P
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Purpose

While reverse shoulder arthroplasty (RSA) corrects vertical muscle imbalance, it cannot restore the horizontal imbalance seen in cuff-deficient shoulders with combined loss of active elevation and external rotation (CLEER). We report the medium-term results of the modified latissimus dorsi/teres major tendon transfer (L'Episcopo procedure) associated with RSA, performed via a single deltopectoral approach.

Method

Sixteen CLEER patients underwent the procedure and were followed up at a mean of 49 months (range, 36–70). All patients had lost spatial control of their arm, were unable to maintain neutral rotation, and had abnormal infraspinatus and teres minor muscles on imaging. Outcome measures included Constant score (CS), Subjective Shoulder Value (SSV), and ADLER score (activities of daily living requiring external rotation).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 24 - 24
1 Sep 2012
Favard L Young A Alami G Mole D Sirveaux F Boileau P Walch G
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Purpose

to analyze the survivorship of the RSA with a minimum 10 years follow up.

Patients and Methods

Between 1992 and 1999, 145 Delta (DePuy) RSAs have been implanted in 138 patients. It was a mulicentric study. Initial etiologies were gathered as following: group A (92 cases) Cuff tear arthropaties (CTA), osteoarthritis (OA) with at least 2 involved cuff tendons, and massive cuff tear with pseudoparalysis (MCT); group B (39 cases) -failed hemiarthroplasties (HA), failed total shoulder arthroplasties (TSA), and fracture sequelae; and group C (14 cases) rheumatoid arthritis, fractures, tumor, and instability. Survival curves were established with the Kaplan-Meier technique. Two end-points were retained: -implant revision, defined by glenoid or humeral replacement or removal, or conversion to HA; - a poor clinical outcome defined by an absolute Constant score of less than 30.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 147 - 147
1 Sep 2012
Alami GB Boileau P
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Purpose

While treating fracture sequelae (FS) with unconstrained prostheses has been shown to give inferior or unpredictable outcomes, the literature is still scant regarding their treatment with reverse shoulder arthroplasty (RSA). This study was performed to determine the suitability of RSA as a solution for FS with severe tuberosity malunion/nonunion and rotator cuff dysfunction, and to identify any useful preoperative prognostic factors.

Method

Between 1997 and 2007, RSA was performed in 26 cases for FS of type 4 according to the classification of Boileau et al., previously treated either operatively or nonoperatively. Prior treatment with hemiarthroplasty was an exclusion criteria, as was follow-up of less than two years, leaving 20 patients who had undergone an average of one surgery prior to the index RSA (range, 1–3) and were followed up for a mean of 4.8 years. Preoperatively, the mean global fatty degeneration index (GFDI) was 1.8 (range, 0.7–2.9), and almost half the patients had an atrophic or ruptured teres minor. The mean age at surgery was 70 years (range, 50–91). Clinical evaluation was performed by two independent observers with the help of the Constant score (CS) and Subjective Shoulder Value (SSV).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVIII | Pages 12 - 12
1 Sep 2012
Alami GB Pinedo M Liendo R O'Shea K Boileau P
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Purpose

To describe the geometric variables of the posterosuperior humeral-head (Hill-Sachs) lesion and analyze their relationship with patient clinical variables.

Method

Twenty-eight patients with anteroinferior instability and substantial Hill-Sachs lesions were evaluated using arthro-computer tomography (CT) scans. The images were studied with the OSIRIX software, and the following lesion variables were measured: depth, length, width, volume, surface area, and width/depth ratio. Moreover, the ratio of the humeral heads total volume over the volume under its joint surface was calculated to express the lesions severity as the compromised fraction of the humeral heads articular segment. The above data was statistically analyzed in relation to the total number of instability episodes, the distinction between dislocations and subluxations, and the type of sport played.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 70 - 70
1 Jun 2012
Gazielly D Walch G Boileau P
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Introduction

the aim of this study was to analyse the long-term radiological changes following tsa in order to better understand the mechanisms responsible for loosening.

Material and methods

between 1991 and 2003, in 10 European centers, 611 shoulder arthroplasties were performed for primary osteoarthritis using a third generation anatomic prosthesis with a cemented all-polyethylene keeled glenoid component. Full radiographic and clinical follow-up greater than 5 years was available for 518 shoulders. Kaplan-meier survivorship analysis was performed with glenoid revision for loosening and radiological loosening as end points; clinical outcome was assessed with the constant score, patient satisfaction score, subjective shoulder value and range of movement


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 493 - 493
1 Nov 2011
Zumstein M Lesbats V Trojani C Boileau P
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Purpose of the study: Platelet rich fibrin (PRF) favours proliferation of tenocytes and synthesis of extracellular matrix. The purpose of this study was to demonstrate the technical feasibility of adding a PRF envelope during arthroscopic rotator cuff repair to favour short-term vascularisation of the tendon-trochiter zone vascularization.

Material and method: Twenty patients aged over 55 years with a posterosuperior rotator cuff tear were included in this prospective randomized controlled study. The double strand technique was used for all patients. Patients were selected at random for insertion of a PRF envelope between the tendon and the trochiter. There were thus two groups of ten patients. The SSV, SST, VAS and Constant scores were noted. Vascularization was assessed with Power Doppler ultrasound at 6 weeks and 3 months by an independent operator unaware of the study group.

Results: There were no complications during or after the operations. Postoperatively, all patients increased their SSV, SST, VAS and Constant scores significantly. Vascularization of the tendon-trochiter zone, as assessed by Power Doppler, was significantly higher in the PRF group at 6 weeks. It was unchanged in the two groups at 3 months.

Discussion: Arthroscopic rotator cuff repair with adjunction of a PRF envelope is technically feasible and increases vascularizaton of the tendon-trochiter zone at 6 weeks.

Conclusion: PRF can improve the tendon healing rate for rotator cuff tears.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 509 - 509
1 Nov 2011
Vargas P Pinedo M Zumstein M Old J Boileau P
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Purpose of the study: Posterior fracture-impaction of the humeral head (Hill-Sachs defect or Malgainge notch) is a well-known factor of failure for arthroscopic shoulder stabilisation procedures. Recently, Wolf proposed arthroscopic posterior capsulodesis and tenodesis of the infraspinatus, or what we call in French Hill-Sachs Remplissage (filling). We hypothesised that capsule and tendon healing within the bony defect could explain the efficacy of this arthroscopic technique.

Material and methods: Prospective clinical study of a continuous series. Inclusion criteria:

recurrent anterior instability (dislocation or subluxation);

isolated “engaged” humeral defect;

Bankart arthroscopy and Hill-Sachs remplissage;

arthroCT or MRI at least 6 months after surgery.

Exclusion criteria:

associated bone loss in the glenoid;

associated rotator cuff tear.

Twenty shoulders (20 patients) met the inclusion and exclusion criteria and underwent Hill-Sachs remplissage. Four orthopaedic surgeons evaluated independently the soft tissue healing in the humeral defect. Mann-Whitney analysis was used to search for a link between rate of healing and clinical outcome.

Results: Filling of the humeral defect reached 75 to 100% in 16 patients (80%°; it was 50–75% in 4 patients. Healing was never noted less than 50%. The short-term clinical outcome (mean follow-up 11.4 months, range 6–32) showed an excellent results as assessed by the Constant score (mean 92±8.9 points) and the Walch-Duplay score (91 points). The subjective shoulder value (SSV) was 50% preoperatively and 89% at last follow-up. There were no cases of recurrent instability. This study was unable to establish a relationship between minor healing and less favourable clinical outcome.

Discussion: This study confirmed our hypothesis that arthroscopic Hill-Sachs remplissage provides a high rate of significant healing in a majority of patients. Capsule and tendon healing in the humeral defect yields significant shoulder stability via at least two mechanisms:

prevention of defect engagement on the anterior border of the glenoid and

posterior force via improved muscle and tendon balance in the horizontal plane.

Further mid- and long-term results will be needed to establish a confirmed correlation between healing and clinical outcome.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 495 - 495
1 Nov 2011
Balestro J Trojani C Daideri G Boileau P
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Purpose of the study: Palliative treatment for unreparable rotator cuff tears by intra-articular resection of the long head of the biceps provides demonstrated satisfactory results. We hypothesized that associated acromioplasty could be deleterious.

Material and method: We conducted a case-control study comparing 24 tenotomies or tenodeses of the long head of the biceps with 24 tenotomies or tenodeses of the long head of the biceps associated with acromioplasty. All patients had an unreparable tear of the rotator cuff. Full-thickness tear of the subscapularis or Hamada and Fukuda radiological stage 3 or 4 tear were exclusion criteria. The two groups were matched for weighted Constant score, Hamada and Fukuda stage, type of tear of the infraspinatus and subscapularis, overall fatty infiltration grade, and follow-up. After the physical examination, we compared the four items of the Constant score, the absolute and weighted score, active anterior elevation, pain score on a visual analogue scale (VAS), and the subjective shoulder score. All patients were examined by a clinician unaware of the group at last follow-up (mean 51 months).

Results: The two groups were comparable preoperatively except for the fatty infiltration index which was higher in the acromioplasty group. At 51 months follow-up, active anterior elevation was statistically lower in the acromioplasty group (145 versus 170). The absolute and weighted Constant scores were lower in the acromioplasty group (p< 0.05). There was no difference for pain and the subjective shoulder score (67 versus 71). Four patients in the acromioplasty group required revision total shoulder arthroplasty versus two in the group without acromioplasty.

Discussion: Association of acromioplasty with intra-articular resection of the long head of the biceps for palliative treatment of unreparable rotator cuff tears is deleterious for elevation and reduces overall shoulder function. Even though acromioplasty provides good short-term results for average-sized tears, outcome is less satisfactory for massive tears and deteriorates over time. In addition, as described by Wiley, acromioplasty can induce a pseudoparalytic shoulder in patients with unreparable tears.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 510 - 510
1 Nov 2011
Boileau P Mercier N Roussanne Y Old J Moineau G Zumstein M
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Purpose of the study: The purpose of this study was to determine the feasibility and reproducibility of a new arthroscopic procedure combining a Bristow-Latarjet lock with Bankart reinsertion of the lambrum.

Material and methods: Forty-seven consecutive patients with significant bone defects in the glenoid and a deficient capsule were treated arthroscopically: arthroscopic Bankart had failed in six. The procedure was performed exclusively arthroscopically using a special instrumentation: after its osteotomy and identification of the axiallary nerve, the coracoids was passed through the subcapular muscle with its tendon; the block was fixed on the scapular neck after 90° lateral rotation so as to prolong the natural concavity of the glenoid. Anchors and sutures were then used to refix the capsule and the labrum onto the glenoid border, leaving the block in an extra-articular position. Follow-up included a physical examination and standard x-rays at 45, 90 and 180 days; 31 patients had a postoperative scan. Three independent operators read the images.

Results: The procedure was completed arthroscopically in 41 of 47 patients (8%); conversion to a deltopectoral approach was required for six patients (12%). The axillary nerve was successfully identified in all shoulders. The block had a subequatorial position in 98% (46/47 shoulders) and equatorial in one. The block was tangent to the surface of the glenoid in 92% (43/47), lateral in one (2%) and too medial (> 5mm) in three (6%). One patient presented an early fracture of the block and five patients exhibited block migration; there was a partial lysis of the block in two patients. The final rate of nonunion of the block was 13% (6/47). Fractures, migrations and non-unions were related to technical errors: screws too short (unicortical) and/or poorly centred in the block.

Conclusion: Our results show that arthroscopic transfer of the coracoids to the scapular neck is a safe and successful operation. The rate of correctly positioned healed blocks was equivalent or superior to conventional techniques. The complications observed show that the arthroscopic block technique is difficult with a long learning curve.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 524 - 524
1 Nov 2011
Pelegri C Moineau G Roux A Pison A Trojani C Frégeac A de Peretti F Boileau P
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Purpose of the study: Optimal management of proximal fractures of the humerus remains a subject of debate. We conducted a prospective epidemiological study to identify injuries encountered, determine the reproducibility of reference classifications and their pertinence for therapeutic decision making.

Material and methods: All patients presenting a proximal fracture of the humerus admitted to a teaching hospital from November 2007 to November 2008 were included using a standardised computer form. A CT-scan was obtained if necessary. Fractures were classified by three senior observers (CP, GM, AR) according to the Neer and AO classifications.

Results: Two hundred forty-seven fractures were collected in 75 men (30%) and 172 women (70%), mean age 66 years (18–97). There were 112 fractures on the dominant side (45%). Two patients had vessel injury and one an associated injury of the brachial plexus. One patient had an isolated injury to the axillary nerve. According to the Neer classification which describes 15 types of fractures, there was little or no displacement or 38% of the fractures and 97.5% of the fractures were classified within six groups: little or no displacement, surgical neck, trochiter fracture alone or with anterior dislocation, 3 or 4 fragment fractures. Using the nine subtypes of the AO classification, there were 58 A1, 55 A2, 42 A3, 43 B1, 9 B2, 5 B3, 14 C1, 18 C2 and 3 C3. Groups A and B included 88% of the fractures. Regarding the CT-scan, obtained in 40% of patients, changed the radiographic interpretation in six cases. Interobserver reproducibility was good. Orthopaedic treatment was given for 203 patients (82%). Operations were: fixation of the tuberosities (n=7), anterograde nailing (n=29), hemiarthroplasty (n=6), reversed prosthesis (n=2).

Discussion: This distribution of fractures of the proximal humerus corresponds well with data in the literature. Good quality x-rays can provide adequate classification without a CT-scan for the majority of patients. The classification systems currently used are quite exhaustive although the distribution in the subgroups is not homogeneous.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 569 - 569
1 Nov 2011
Old J Boileau P Pinedo M Vargas P Zumstein M
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Purpose: The “Hill-Sachs Remplissage” (HSR) is a procedure used in the treatment of anterior shoulder instability associated with an engaging Hill-Sachs (HS) defect. It consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon within the defect. There is currently no evidence that the capsule and tendon heal in the humeral bone defect. Our hypotheses were

that the capsulotenodesis heals in the HS defect and fills at least 50% of its area; and,

that limitation of range of motion compared to the non-operated shoulder would be minimal.

Method: Prospective clinical study. Inclusion criteria:

recurrent anterior shoulder instability;

engaging HS lesion.

Exclusion criteria:

glenoid bone loss;

rotator cuff tear.

Twenty-nine patients underwent an arthroscopic Bankart repair plus HSR. Clinical assessment at a mean follow up of 13.1 months (range 6 to 32 months) consisted of a structured interview and detailed physical examination including range of motion compare to the contralateral shoulder and instability signs. Range of motion was analyzed in two groups according to length of follow-up, Group 1 with less than 12 months follow-up (14 patients); and Group 2 with greater than 12 months follow-up (15 patients). Either a CT arthrogram (25 patients) or an Arthro-MRI (2 patient) was performed at a minimum of six months postoperatively. Four orthopaedic surgeons analyzed the images independently to determine the percentage of healing of the capsulotenodesis.

Results: There was no recurrence of instability at the latest follow-up. There was no statistically significant deficit in forward elevation in either group. Group 1 patients had statistically significant mean deficits as compared to the contralateral side of 15 degrees of external rotation in adduction (ER1), 15 degrees of external rotation at 90 degrees of abduction (ER2), and 1.1 points of internal rotation in adduction according to the Constant score system (ER1). Group 2 patients had statistically significant mean deficits of 4 degrees of ER1 and 11 degrees of ER2, with no significant difference in IR1. There was healing of the capsulotenodesis within the bone defect in all twenty-seven patients. The bone defect was filled more than 75% of its surface in 22 of 29 patients (76%). The remaining seven had between 50 and 75% filling (24%). There was no defect filling of less than 50% in this study.

Conclusion: We demonstrated greater than 50% HS defect filling in all patients in our series after an arthroscopic “Hill-Sachs Remplissage” and filling > 75% in 22 of 29 (76%). Modest deficits of external rotation were demonstrated at greater than 12 months follow-up. While these results suggest that the technical goal of HS defect filling is achievable, longer term studies are necessary to establish whether there is an association between the rate of healing, the functional impairment of external rotation and clinical outcomes.