Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study.

From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH.

A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012).

The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation.

Purpose: Shoulder pain in the young athlete is often a diagnostic challenge. It is our experience that this pain can be related to a so-called “unstable painful shoulder” (UPS), defined as instability presenting in a purely painful form, without any history of instability but with anatomical (soft tissue or bony) ‘roll-over’ lesions. The objectives are to describe the epidemiology and diagnostic criteria and to report the results of surgical treatment.

Method: A prospective review was performed of 20 patients (mean age 22 ± 8 years). Inclusion criteria: a painful shoulder and “roll-over lesions” on imaging or at surgery. Exclusion criteria: a dislocation/subluxation; associated pathology; previous shoulder surgery.

Results: Most patients were male (60%), athletes (85%) and involved the dominant arm (80%). All patients denied a feeling of instability and only complained of deep, anterior pain. Most had a history of trauma (80%). All patients had rehabilitation without success and 30% had subacromial injections. All had to stop sports. Most (85%) had anterior or inferior hyperlaxity. All had pain with an anterior apprehension test and relieved by relocation test. ‘Roll-over’ lesions included: labrum detachment (90%), capsular distension (75%), HAGL lesion (10%), glenoid fracture (20%) or Hill-Sachs (40%). Time from symptoms to surgery was 25 ± 23 months. All patients had arthroscopic treatment. Mean follow-up was 38 ± 14 months. Eighteen patients (90%) were very satisfied/satisfied. None had pain at rest, but one (5%) had pain with apprehension test. There was no change in elevation, external or internal rotation (p> 0.05). There were no cases of instability. Rowe and Duplay scores improved (p< 0.05).

Conclusion: Instability of the shoulder can present in a purely painful form, without any history of dislocations or subluxations. Diagnosis can be difficult, and should be suspected in young patients and athletes. Most patients have deep anterior pain and pain with apprehension test. ‘Roll-over’ lesions are necessary to confirm the diagnosis. Arthroscopic repair is effective.

Purpose: Comparer la technique de réparation de la coiffe des rotateurs par haubanage tendineux en simple rangée aux techniques transosseuse et double-rangée par rapport à la surface et la pression de contact à l’interface tendon-os, et la force de rupture.

Method: Pour tester la pression et la surface de contact, les techniques de réparation ont été faite sur 2 spécimens cadavériques (tête humérale et sus-épineux) chaque. Un film Prescale pressure-sensing a été interposé entre les tendons et l’os pendant 2 minutes avec une tension de 120N sur les tendons. Les films ont été numérisés pour l’analyse avec le logiciel ImageJ. La force de rupture a été testé sur un modèle Sawbones d’humérus proximal. Des tendons synthétiques en fibre de nylon et polyesther dans du silicone ont été créés pour les propriétés d’un tendon proportionnellement à la rigidité du Sawbones. La force a été appliquée à 135° jusqu’à rupture sur 2 montages par technique de réparation. La suture transosseuse utilisait 2 fils Orthocord dans 2 tunnels transosseux. La suture double rangé a été faite avec 2 ancres Spiralok médialement et 2 ancres Versalok latéralement avec des fils Orthocord. Le haubanage tendineux a été fait avec 2 ancres Panalok RC latéralement dans la zone corticale.

Results: La surface de contact du haubanage de 17mm2 était significativement plus basse que de la suture transosseuse à 48mm2 (p=0.002) et double-rangée à 86mm2 (p=0.001). La différence entre transosseux et double rangée était significative (p=0.029). La pression de contact du haubanage de 0.353MPa était significativement plus basse que de la suture transosseuse à 0.441MPa (p=0.002) et double-rangée à 0.567MPa (p=0.003). La différence entre transosseux et double rangée était significative (p-0.029). La force de rupture du haubanage de 106N était significativement plus basse que de la suture transosseuse à 249N (p=0.03) et double-rangée à 316N (p=0.04). La différence entre transosseux et double rangée n’était pas significative.

Conclusion: Le haubanage tendineux ne reproduit pas l’empreinte anatomique du sus-épineux sur la grande tubérosité ni une pression de contact adéquate en plus d’avoir une force de rupture plus faible. Malgré son coût plus élevé, la suture par double rangée est supérieure à la technique transosseuse ou simple rangée.

Recurrence represents the leading complication of arthroscopic anterior shoulder stabilization. Even with modern suture anchor techniques, a recurrence rate of between 5 to 20% persists; emphasizing that arthroscopic Bankart repair cannot apply to all patients and selection must be done. Numerous prognostic factors have already been reported, but strict observance would eliminate almost all patients from arthroscopic Bankart repair. We hypothesised that clinical and radiological risk factors could be present and identifiable in the normal outpatient visit, and they could be integrated into a severity score

A case-control study was undertaken, comparing patients identified as failures after arthroscopic Bankart repair (i.e, recurrent instability) with those who had a successful result (i.e., no recurrence). Recurrence was defined as any new episode of dislocation or any subjective complains of subluxation. During a four-year period one hundred and thirty-one consecutive patients with recurrent anterior shoulder instability, with or without shoulder hyperlaxity, were operated by the senior shoulder surgeon with an arthroscopic suture anchor technique and followed for a minimum of two years. Patients were excluded if concomitant pathology, including multidirectional instability, were present. Bony lesions were not excluded. A complete pre and postoperative questionnaire, physical exam, and anteroposterior x-ray were recorded. Mean follow-up was 31.2 months (range, twenty-four to fifty-two months).

Nineteen patients had a recurrent anterior instability (14.5%). Preoperative evaluation demonstrated that age below twenty years old, involvement in athletic competition, participation in contact or forced-overhead sports, presence of shoulder hyperlaxity, Hill-Sachs lesion visible on AP external X-ray, and loss of inferior glenoid sclerotic contour on AP x-ray were all factors related to increased recurrence. These factors were integrated in an Instability Severity Index Score and tested retrospectively on the same population. Patients with a score of six or less had a recurrence risk of 10% and those over six had a recurrence risk of 70% (p< 0.001).

This study proved that a simple scoring system based on factors of a preoperative questionnaire, physical exam, and anteroposterior x-ray can help the surgeon to select patients who would benefit from arthroscopic stabilization with suture anchors and those for whom an open surgery, like the Latarjet procedure, is a better option.