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.

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.

Purpose: We hypothesized that lateralization of the RSA, with a glenoid bone graft taken from the osteotomised humeral head, would prevent those problems without increasing torque on the glenoid component by keeping the center of rotation within the glenoid. The objectives of this study were to describe the results of the first 12 patients that underwent a bony increased-offset RSA (BIO RSA).

Method: Thirty-six shoulders in 34 consecutive patients with cuff tear arthritis (mean age 72 years, range 52–86 years) received a BIO RSA, consisted of a RSA incorporating an autogenous humeral head bone graft placed beneath the glenoid baseplate. A baseplate with a lengthened central peg (+25 mm) was inserted in the glenoid vault, securing the bone graft beneath the baseplate and screws. All patients underwent clinical and radiographic (computed tomography) review at a minimum 1-year follow-up.

Results: All patients were satisfied or very satisfied and all had no or slight pain. Mean active elevation increased from 72° to 142° (p< 0.05), external rotation from 10° to 18° (p< 0.05) and internal rotation from L4 to L3 (p> 0.05). Constant Score improved from 27 to 63 points (p< 0.05). The Subjective Shoulder Value (SSV) increased from 27% to 73% (p< 0.05). Radiographically, the graft healed to the native glenoid in all cases and no graft resorption under the baseplate was observed. Complications included one patient with scapular notching (stage 1) and one patient with previous radiotherapy had a deep infection. No postoperative instability, and no glenoid loosening were observed.

Conclusion: The use of an autologous bone graft harvested from the humeral head can lateralize the center of rotation of a RSA while keeping the center of rotation at the glenoid bone-prosthesis interface. The clinical advantages of a BIO RSA are a decrease in scapular notching, enhanced stability and mobility, and improved shoulder contour while keeping the center of rotation at the glenoid bone-prosthesis interface. This bony lateralization allows maintenance of the principles of Grammont and seems to be more appropriate than prosthetic lateralization. These promising early results of this novel procedure warrant further investigation.

Purpose: Fractures involving both the shaft of the femur and the proximal portion of the femur are uncommon. In a meta-analysis of cases reported between 1951 and 1985, Alho recorded 659 cases where a wide range of management strategies were used. We report here a homogeneous series of 17 patients treated with ascending locked anterograde nailing.

Material: This series of 17 patients were young (mean age 36 years). These eleven men and six women were all victims of high-energy trauma; 12 had multiple fractures. The shaft fracture involved the middle third in 15 patients, the lower third in two; the shaft fracture was open in six cases. The proximal fracture was transcervical in nine patients (7 B21, 1 B22, 1 B23) and trochanteric in six (A A32, 1 A31, 2 A12, 2 A33).

Methods: The fracture was reduced under fluorescent guidance on the orthopaedic table in the supine position followed by anterograde nailing with ascending proximal locking in the axis of the neck using a Russel and Taylor reconstruction nail. The osteosynthesis was performed on day 0 in eleven patients, during the first week in three and later in three.

Results: Results are reported for 17 patients. There was one early superficial suppuration which healed favourable after local care. Two shaft fractures exhibited nonunion and were revised to decorticalise the graft. The cervical fracture exhibited early displacement in one patient who underwent revision on day 15; bone healing did not ensue and a total hip arthroplasty was implanted at ten months. All the other fractures healed within three to five months after the first-intention treatment. The long-term follow-up has revealed one case of cephalic necrosis at five years which has required a total hip arthroplasty.

Discussion: These double fractures involving the proximal femur and the shaft of the femur account for 1 to 5% of the femur fractures reported in the literature. They are observed in young victims of high-energy trauma, often associated with other multiple injuries. Diagnosis is not always easy to establish since there may be little or no displacement of the proximal fracture, which may be recognised secondarily after standard nailing (2 out of 17 cases).

The trochanteric fractures are generally easier to diagnose and reduce, and usually heal well. The shaft fractures are more often displaced and readily comminutive, sometimes open, having absorbed the greater part of the trauma energy. These fractures heal like ordinary shaft fractures. Neck fractures are often seen in the lower portion with a vertical fracture line, with or without displacement.

Using a single centromedullary nail for the osteosynthesis of both fractures is an attractive solution. The proximal fracture must however be carefully reduced with percutaneous pins before attempting nail insertion. The postoperative period is generally uneventful. Problems may be encountered if the cervical fracture cannot be perfectly reduced, in which case two separate fixations would be preferable.