Christopher Chuinard

Arthroscopic Treatment of Isolated Type II SLAP Lesions Biceps Tenodesis as an Alternative to Reinsertion

Background Overhead athletes report an inconsistent return to their previous level of sport and satisfaction after arthroscopic SLAP lesion repair. Hypothesis Arthroscopic biceps tenodesis offers a viable alternative to the repair of an isolated type II SLAP lesion. Study Design Cohort study; Level of evidence, 3. Methods Twenty-five consecutive patients operated for an isolated type II SLAP lesion between 2000 and 2004 were evaluated at a mean of 35 months postoperatively (range, 24-69). Patients with associated instability, rotator cuff rupture, posterosuperior impingement, or previous shoulder surgery were excluded. Ten patients (10 men) with an average age of 37 years (range, 19-57) had a SLAP repair performed with suture anchors. Fifteen patients (9 men and 6 women) with an average age of 52 years (range, 28-64) underwent arthroscopic biceps tenodesis performed with an absorbable interference screw. Arthroscopic diagnosis and treatment were performed by a single experienced shoulder surgeon, and all patients were reviewed by an independent examiner. Results In the repair group, the Constant score improved from 65 to 83 points; however, 60% (6 of 10) of the patients were disappointed because of persistent pain or inability to return to their previous level of sports participation. In the tenodesis group, the Constant score improved from 59 to 89 points, and 93% (14/15) were satisfied or very satisfied. Thirteen patients (87%) were able to return to their previous level of sports participation following biceps tenodesis, compared with only 20% (2 of 10) after SLAP repair (P = .01). Four patients with failed SLAP repairs underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to their previous level of sports activity. Conclusion Arthroscopic biceps tenodesis can be considered an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation. The results of biceps reinsertion are disappointing compared with biceps tenodesis. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. As the age of the 2 treatment groups differed, these findings should be confirmed by future studies.

Reverse total shoulder arthroplasty after failed rotator cuff surgery

BACKGROUND The purpose is to report the results of reverse shoulder arthroplasty (RSA) after previous failed rotator cuff surgery. MATERIALS AND METHODS A retrospective multicenter study of 42 RSA in 40 patients (mean age, 71 years) with a mean follow-up of 50 months. Thirty shoulders presented with a pseudoparalytic shoulder and 12 with a painful shoulder with maintained active anterior elevation (AAE >or= 90 degrees). RESULTS Five complications (12%) occurred and 2 patients (5%) underwent re-operation. In pseudoparalytic shoulders, AAE increased from 56 degrees to 123 degrees and 7% were disappointed or dissatisfied. In painful shoulders, AAE decreased from 146 degrees to 122 degrees and 27% were disappointed or dissatisfied. DISCUSSION RSA can improve function in patients with cuff deficient shoulders after failure of previous cuff surgery. However, results are inferior to primary RSA. RSA when the patient maintains greater than 90 degrees of preoperative AAE risks loss of AAE and lower patient satisfaction.

The Role of Arthroscopy in Revision of Failed Open Anterior Stabilization of the Shoulder

PURPOSE The purpose of this study was to evaluate the results of revision arthroscopic stabilization after failed open anterior shoulder stabilization. METHODS We studied a retrospective series of 22 consecutive patients with recurrent anterior shoulder instability after open surgical stabilization (12 Latarjet procedures, 4 Eden-Hybinette procedures, 3 open Bankart repairs, and 3 capsular shifts). Failure was associated with a traumatic episode in 12 patients, capsular laxity with persistent Bankart lesions in all patients, and a bone block complication in 13 patients. Labral reattachment and capsuloligamentous retensioning with suture anchors were performed in all cases. An additional rotator interval closure was performed in 4 cases and an inferior capsular application in 12. Bone block screws were removed during arthroscopy in 8 patients because of malpositioning or mobility. Nineteen patients were evaluated at a mean follow-up of 43 months. RESULTS All patients returned to their previous occupations, including 6 cases of work-related injury. Of the patients, 1 (5%) had recurrent subluxation and 2 (11%) had persistent apprehension. The subjective shoulder value was 83% +/- 23%. A good or excellent result was found in 85% of patients according to the Walch-Duplay score and 13 patients (67%) according to the Rowe score. Shoulder pain was found in 6 patients (32%) (4 with light pain and 2 with moderate pain). Of the 5 patients with osteoarthritis before surgery, 3 progressed by 1 stage. CONCLUSIONS Arthroscopic revision of failed open anterior shoulder stabilization provides satisfactory results in a selected patient population. Some persistent pain and osteoarthritis progression remain concerns. The main advantages of the arthroscopic approach are the avoidance of anterior dissection in front of the subscapularis, which places the axillary nerve at risk, and the ability to address the various soft-tissue pathologies encountered. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Effectiveness of revision following linked versus unlinked total elbow arthroplasty

PURPOSE The purpose of this study is to specifically evaluate the implications of unlinked and linked designs on the survivorship of revision surgery. METHODS Between 1972 and 1990, 352 linked and 151 unlinked prostheses were inserted at our institution. One-hundred and twenty-two elbows (24%) underwent subsequent revision: 55 linked (16%) and 67 unlinked (44%). Survivorship of the initial and revision total elbow replacement was calculated using a Kaplan-Meier analysis. Comparisons were made between revisions done after a failed primary linked or unlinked designs. The unlinked revised to a linked device was more reliable than when revised to another unlinked device: 1 year survival 84% compared to 47%. RESULTS Initial survival was 56% at 367 months and 84% at 371 months for the unlinked and linked cohorts, respectively (P < .001). A second revision was required in 12 of the 35 elbows (30%) in the linked cohort and 14 of the 50 elbows (28%) in the unlinked. CONCLUSIONS At our institution, primary linked implants display significantly better long-term survivorship (P < .001) than did the unlinked designs. Unlinked designs are most reliably converted to a linked implant.

Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A Prospective Two-Year Multicenter Study.

BACKGROUND Stemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S. METHODS One hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively. RESULTS One hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components. CONCLUSIONS The study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

CORR Insights®: Conversion of Stemmed Hemi- or Total to Reverse Total Shoulder Arthroplasty: Advantages of a Modular Stem Design

This CORR Insights® is a commentary on the article “Conversion of Stemmed Hemi- or Total to Reverse Total Shoulder Arthroplasty: Advantages of a Modular Stem Design” by Wieser and colleagues available at: DOI: 10.1007/s11999-014-3985-z. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or the Association of Bone and Joint Surgeons®. This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-014-3985-z.

Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture

Reverse shoulder arthroplasty (RSA) has gained wide acceptance for its primary indication, cuff tear arthropathy. The last 5 years, however, has seen the utilization of RSA increase, dramatically, as one of the preferred methods for treating proximal humeral fractures in the elderly. By utilizing surgical techniques that focus on tuberosity reconstruction, excellent results can be see with reverse shoulder replacement for fracture; in fact, RSA for fracture has demonstrated more reliable outcomes than hemiarthroplasty for fracture and is favored in the elderly population.

144 Prise en charge standardisée des luxations du coude associées à une fracture non reconstructible de la tête radiale

Introduction L’objectif etait d’apporter les resultats d’une technique chirurgicale de reconstruction et de stabilisation articulaire dans les luxations posterieures du coude avec fracture non reconstructible de la tete radiale associee ou non a une fracture de la pointe coronoidienne. La mobilisation precoce semble etre le gage d’un bon resultat fonctionnel a condition d’avoir une stabilite articulaire peroperatoire. Patients De juin 2004 a novembre 2006, 14 patients (10 hommes, 4 femmes) presentant une luxation du coude avec fracture non reconstructible de la tete radiale associee ou non a une fracture de la pointe coronoidienne ont beneficie du meme protocole chirurgical. Les fractures de l’apophyse coronoide concernant plus que la pointe de celle-ci n’ont pas ete incluses. L’âge moyen etait de 35 ans. Le recul moyen etait de 12 mois. Methodes Par voie d’abord laterale et apres resection de la tete radiale comminutive, une fixation capsulaire anterieure par ancres resorbables etait pratiquee afin de restaurer la stabilite sagittale. Lorsqu’il existait une fracture de la pointe coronoidienne, celle-ci etait resequee. Puis, un remplacement de la tete radiale etait realise afin de restaurer la stabilite frontale. La fermeture de la voie d’abord laterale etait associee a une reinsertion des epicondyliens lateraux et de l’appareil ligamentaire collateral lateral. Tous les patients ont ete operes sous anesthesie loco regionale et ont beneficies d’un catheter d’analgesie pour la periode postoperatoire. Le protocole de reeducation etait standardise. Les 30 derniers degres de supination et d’extension etaient interdits durant les 3 premieres semaines. La supination etait travaillee en flexion, l’extension etait travaillee en pronation. Resultats Dans tous les cas, la stabilite articulaire peroperatoire a permis d’initier la reeducation en actif des le lendemain de l’intervention. Aucune mesure associee n’a ete necessaire. Un patient a ete reopere precocement pour correction d’une implantation haute de la prothese. Au dernier recul, la mobilite moyenne etait de 129° en flexion, -9° en extension, 72° en pronation et 67,5° en supination. La force de poigne etait de 78 % comparee au cote oppose. Le score fonctionnel de la Mayo Clinic etait de 86/100 en moyenne. Discussion La fixation capsulaire anterieure par voie laterale semble etre une solution efficace et reproductible pour la stabilisation articulaire en association avec le remplacement prothetique de la tete radiale dans les luxations posterieures et posterolaterales du coude avec fracture non reconstructible de la tete radiale associee ou non a une fracture de la pointe coronoidienne.

77 Prothèse d’épaule inversée associée à un transfert du grand dorsal et du grand rond par une voie deltopectorale unique : une nouvelle technique combinée pour un problème d’épaule non résolu

Introduction La perte definitive de l’elevation active et de la rotation externe active observee dans quelques epaules avec une arthrose combinee a un deficit de coiffe des rotateurs constitue un handicap tres penalisant. Des gestes aussi simples que manger, boire, faire sa toilette, se coiffer ou tendre la main deviennent impossibles. Le probleme etait jusqu’a aujourd’hui non resolu : la prothese inversee permet de retablir l’elevation active mais pas la rotation externe qui est meme souvent diminuee apres ce type d’arthroplastie. Le transfert du grand dorsal et du grand rond decrit par l’Episcopo permet de restaurer la rotation externe active. Materiel et Methodes Nous decrivons une nouvelle technique combinant la prothese d’epaule inversee avec un transfert du grand dorsal et du grand rond a travers une voie deltopectorale unique. Cette nouvelle technique combinee a ete utilisee chez 12 patients qui presentaient une perte d’une epaule pseudoparalytique combinee a une perte de la rotation externe active. L’evaluation radiographique preoperatoire a revele une omarthrose de l’epaule associee a une rupture irreparable postero-superieur de la coiffe : les muscles infraspinatus et teres minor etaient tous les deux definitivement atrophies et infiltres de graisse. Resultats Huit patients ont ete suivis avec un recul minimum d’un an. Il n’y avait aucune complication, ni reoperation. Les patients ont beneficie d’un gain moyen de 75° d’elevation active et de 28° de rotation externe. Tous les patients ont regagne le controle du positionnement spatial de leur membre superieur et etaient tres satisfaits du resultat. Les activites quotidiennes – se raser, se brosser les dents, se coiffer, manger, boire ou s’habiller – ont ete retablies suite a l’intervention. Discussion En associant la prothese d’epaule inversee avec un transfert du grand dorsal et du grand rond, il est possible retablir aussi bien l’elevation active que la rotation externe active. L’intervention est techniquement possible a travers une voie deltopectorale unique et peut etre utilisee aussi en cas de reconstruction apres resection tumorale.

35: Arthroscopic revision of failed open anterior stabilization of the shoulder

The purpose of this study is to report the results of arthroscopic Bankart repair following failed open treatment of anterior instability. We performed a retrospective review of twenty-two patients with recurrent anterior shoulder instability (i.e. subluxations or dislocations, with or without pain) after open surgical stabilization. There were seventeen men and five women with an average age of thirty-one years (range, 15–65). The most recent interventions consisted of sixteen osseous transfers (twelve Latarjet and four Eden-Hybinette), three open Bankart repairs and three capsular shifts. The causes of failure were additional trauma in twelve patients and complications related to the bone-block in thirteen (poor position, fracture, pseudarthrosis or lysis). All patients were noted to have distension of the anterior-inferior capsular structures. Labral re-attachment and capsulo-ligamentous re-tensioning with suture anchors was performed in all cases with an additional rotator interval closure in four patients and an inferior capsular plication in twelve patients; the bone block screws were removed in eight patients. At an average follow-up of forty-three months (range, twenty-four to seventy-two months), nineteen patients were evaluated by two independent observers. One patient had recurrent subluxation, and two patients had persistent apprehension. Anterior elevation was unchanged, and loss of external rotation (RE1) was 6°. Nine patients returned to sport at the same level; all patients returned to their previous occupations, including the six cases of work-related injury. Eighty-nine percent were satisfied or very satisfied; the subjective shoulder value (SSV) was 83% ± 23%; the Walch-Duplay, Rowe and UCLA scores were 85 ± 21, 81 ± 23 and 30 ± 7 points respectively. The number of previous interventions did not influence the results. Eight patients (42%) were still painful (six with light pain and two with moderate pain). Arthroscopic revision of open anterior shoulder stabilization gives satisfactory results. The shoulders are both stable and functional. While the stability obtained with this approach is encouraging, our enthusiasm is tempered by some cases of persistent pain.