Purpose of the study: The purpose of this work was to report the clinical outcomes observed after great pectoral transfer (clavicular head in 8 cases and sterna head in 7) behind the coracoids for irreparable subscapular tears.

Material and method: This was a retrospective analysis of 15 patients, mean age 57 years, with retracted subscapular tears with fatty degeneration grade 3 or greater, associated with a supspinatus tear for 12 cases. The Constant score was not pre and postoperatively. The lift-off test was positive in all patients. The clavicular head (n=8) and the sterna head (n=7) were positioned under the coracoids and fixed with anchors in the trochin using the double row technique. Biceps tenodesis was associated in 12 cases. Immobilisation was maintained for six weeks in neutral rotation with passive mobilization immediately postop and active rehabilitation after the sixth week.

Results: At mean 24 months follow-up (range 12–50), nine patients were very satisfied, three were satisfied, and three were disappointed; one patient had revision with a reverse prosthesis due to anteroposterior instability; one patient developed an infection after a haematoma and retained an elevation deficit and a painful shoulder. The gain was 11 points (2.66 to 13.6 ([p< 0.001]) for pain and 4.5 points (3.2 to 7.7 [p< 0.001]) for force. The gain was non significant for active elevation (7 points) and external rotation (6 points). The lift-off test was negative in 11 of the 15 shoulders. There was no significant difference between the two pectoral heads. This series is limited by the small number of shoulders.

Discussion: Greater pectoral transfer for unreparable tears of the subscapularis improves force and reduces pain. However, compared with data in the literature, outcome is not different if the entire muscle is used or if only the sterna or clavicular heads are used, whether inserted anteriorly or posteriorly on the coracoids.

Purpose of the study: A multicentric study involving ten centres of shoulder surgery collected a retrospective series of 45 patients treated for infection of a total shoulder arthroplasty.

Material and methods: Mean age was 68 years (range 28–88) with 2/3 male. The initial indication was excentred joint degeneration (37%), centred degeneration (5%), necrosis (7%), fracture (34%), excentration without degeneration (12%), rheumatoid disease (5%). The implants were a reversed total prosthesis (59%), a hemiprosthesis (26%), a total anatomic prosthesis (15%). Nineteen patients (46%) had a ‘naive’ shoulder at implantation of the first prosthesis, including 70% without any specific medical condition: 30% fracture (hemiprosthesis) and 50% reversed total prosthesis.

Results: The infection developed immediately after implantation in 76% of the shoulders (abnormal pain, hematoma, early collection, inflammatory scar, early fistula). The preoperative Constant score (26 points) showed pain at 4, function at 8, mobility at 12, and force at 2. Osteolysis was noted in 30%. The infection lasted less than 3 months before revision in 27%, 3 to 12 months in 68%, and more than 12 months in 5%. Blood tests were normal in two patients. Staphylococcus epidermidis was isolated in 29%, Propioni bacterium acne in 31%, and these two germs in 5%, but no germ was identified in 24%. There was no loosening in 69% of the cases, making the revision invasive. A one-phase procedure was performed in 31% of patients and a two-phase procedure in 25%. Repeated wash-outs were performed in 25%. A reversed prosthesis was implanted at revision in 87% of the shoulders. These revisions produced a 22% complication rate and 27% were revised for repeated wash-outs, instability or definitive en bloc resection. An infectious disease specialist was called in for 75% of patients; a two-drug i.v. regimen for 10 days was instituted followed by oral antibiotics for 3 months. Outcome was assessed with more than 24 months follow-up for 26 patients. The Constant score at review was 47 points (pain 12, function 12, mobility 20, force 4).

Discussion: Seventy-seven percent of the patients were considered cured at more than 2 years. The two-phase surgery, undertaken when the infection had lasted 3 to 12 months (40%) or more than 12 months (60%), gave a Constant score at 51% and 100% cure. The one-phase option undertaken for infections lasting less than 3 months (40%) or 3 to 12 months (60%) gave a Constant score at 46% and 50% cure. Simple wash-out required 60% revision (repeated wash-out, or implant replacement) and 67% cure. In the event of complications after revision, the cure rate was 67%. In all, only 6% of the patients were dissatisfied.

Purpose: The goal of this retrospective study was to analyze the results of each kind of reoperation used in rotator cuff retear.

Materials and Methods: 38 rotator cuff retear were reoperated. 18 female and 20 male with a mean age was 57(range 40 to 73 years). Initial tear were repaired by open surgery with a procedure of trans osseous reinsertion in 26 cases. Arthro CT Scan, confirmed the recurrent tear and evaluated the size, number of tendon involved and the global fatty degeneration index (GFDI) of the muscle.The size of the retear was smaller in 9 patients, same in 5 and bigger in 23 with always a decreasing of the GFDI from 0.83 to 1.60. The mean time of reoperation was 29 months(range 1 to 120). We performed 14 trans osseous reinsertion, 6 latero lateral tendinous suture, 3 resection reinsertion, 5 deltoid flap, 3 latissimus dorsi flap, 4 reversed prosthesis, one arthrodesis, one subscapularis flap and one debridment for acute infection. A biceps tenodesis were performed in 20 cases.

Results: Results were evaluated with a mean follow-up of 33 months (range 5 to 145). The constant’s score improved from 46(22 to 68) preoperatively to 67(40–95) post operatively with a decreasing of the GFDI in 0.83 to 1.60. The best results were obtained with a trans osseous reinsertion (Constant’s score 70; gain 40%) and latero lateral tendinous suture(Constant’s score 78; gain 37%). However, the gain higher was obtained with the reversed prosthesis(Constant’s score 57;gain 88%).

Discussion and Conclusion: Arthro CT Scan is a good way to diagnose a recurrent rotator cuff tear and to choose the type of new operation when shoulder still painfull. The final result is higher if it is possible to do a transosseous reinsertion for a small retear with a good trophicity of the muscle (GFDI lower). However for pseudo paralytic shoulder, reversed prosthesis can improved the constant’s score from 34 to 64 with a restoration of a good elevation. Latissimus dorsi flap (deltoid and subscapularis flap) are usefull for painrelief but the improvement of motion is less.

Glenoid component loosening is a concern in long term outcome of total shoulder arthroplasty. Unfortunately revision of glenoid loosening remains very challenging regarding bone reconstruction and reimplantation of a glenoid component. A new design metal-back component (Arrow™) seems to get the procedure easier and lead to higly best clinical and radiological results than prior technics.

It is a retrospective study of 34 patients operated on for isolated aseptic glenoid component loosening between 1997 and 2007. Glenoid bone loss based on a new classification was rated in 5 degrees. All patients were reviewed at a mean follow up of 34 months (from 12 to 89). Pre and post operatively Constant score and SST have been evaluated. Fluoroscopic views and CT scan have been performed for radiologic assesment.

Mean delay for revision surgery was 58 months (from 28 to 134 months). 16 patients underwent only bone graft reconstruction. 18 patients underwent both bone reconstruction and glenoid implant reimplantation.

Autolog bone graft (iliac crest) was used in 19 cases, allograft bone in 5 cases, and both autolog and dried bone substitutes in 10 cases. The glenoid component was an uncemented metal-backed in 11 cases, and a polyethylene cemented in 2 cases. The new metal-backed bone ingrowth component is composed with a keel and a winglet securing bone graft fixation and implant stability. For the all cohort Constant score improves of 21 points (from 35 to 56). Gain of pain and active motion is statiscally significative (p< 0.005).Patients who underwent reimplantation of a new glenoid component had a higher clinical result (Constant score: 66) than those who underwent only a bone graft reconstruction (Constant score: 52) in term of pain and active forward elevation as well (p< 0.001). At maximum follow up (32 months) no radiolucent lines or loosening of the new glenoid component was noted. Patients who underwent only bone reconstruction showed a mild glenoid erosion due to subsidence and resorption of cancellous auto or allograft bone.

Revision of glenoid component depends on the glenoid bone stock specially about posterior defect. The use of cortical autolog bone graft and new metalback component allows better glenoid reconstruction, secure the stabiliy of the new gle and yields to goods clinical results restoring painless shoulder and function. Reimplantation of a glenoid component becomes an adequate procedure for total shoulder arthroplasty revision

The goal of this retrospective study was to evaluate the result of this technique proposed as initial treatment (group 1: 17 cases) or after a failure of repairing cuff (group 2: 7 cases).

Materials and Methods: Eleven females and thirteen males with an average age of fifty six years were available for this study. Initial rupture was always massive (2 tendons, retracted to the glenoid level), superior and posterior(20 cases) with superior lesion of the subscapularis in 4 cases. An ascension of the humeral head was found in 18 cases. Degree of fatty degeneration evaluated with CT arthrogram was 3.45 for the supra spinatus and 3.25 for the infra spinatus. The latissimus dorsi was harvested with axillary approach and released from the angle of the scapula to be able to cover the humeral head. Coraco acromial arch was preserved. Abduction splint was maintained 6 weeks.

Results: The average follow up was 21 months(12/48). For the 24 patients Constant score was improved from 34,6 to 55,6(+21): a significant improvement of forward active elevation from 98° to 153 (+55°) but a little improvement of external rotation from 23 to 33 (+10°). The best results were obtained in group 1: constant score progressed from 34 to 58 (+24) with an increasing of 66° (98 to 164°) of forward active elevation and 13°(22 to 35°) of external rotation. Results of group 2 are less: Constant score progressed from 36 to 51(+15), forward elvevation 33°(96 to 129°) and 3° (27 to 30°) of active external rotation. 2 failures caused by a rupture of the transfer. Painrelief was obtained in 90% but any improvement of strength.

Discussion and Conclusion: Ours results indicate that latissimus dorsi transfer improves range of motion, pain, function and patient satisfaction with irreparable rotator cuff tear. We recommend to use it for pseudoparalytic and painfull shoulder, with a persistent acriomo humeral space, after failure of rehabilatation, for young patient. A stable humeral head with a good subscapularis without previous operation are good pronostic factors.

Aims: The revision of hemi or total arthroplasty represents a difficult challenge for a shoulder surgeon. The purpose of this study was to report the results of a retrospective series of 30 reverse prosthesis.

Materials and Methods: 17 patients were female, 13 were male; the mean age was 68 (45–84). 14 patients had at least 2 surgeries before the arthroplasty. Of the failed arthroplasties, 26 were hemiarthroplasties and 4 were total shoulder arthroplasties. The indication for the revision of hemiarthroplasty were: 10 migration of the tuberosities, 7 secondary rotator cuff tears, 5 were stiff, 2 glenoiditis,, one humeral loosening and one sepsis. The indication for the revision of total arthroplasty were 3 loosenning of the glenoïd component and 2 secondary rotator cuff tear with a superior ascension of the humeral head. The rotator cuff was always irreparable. We used mainly a deltopectoral approach. During the removing of the humeral component and the cement, 6 fractures of the diaphysis occurred treated by cerclage. A bone graft was used at the level of the glenoïd (3) and of the humerus (4). We implanted 19 Delta and 11 Arrow reverse prosthesis. The patients were reviewed clinically using the Constant score with a mean follow up 3 years (range 1–5 years).

Results: The Constant score improved from 20 (6–39) pre operatively to 55 (44–87) post operatively. Shoulder flexion increased from 45 (20–100) pre operatively to 100 degrees (90–160) post operatively. Pain was improved from 3/15 to 13,66/15 post operatively. The worse results were obtained for the patients who were multioperated before the first arthroplasty. Four patients were reoperated: 2 for dislocations and two for material dysfunction(glenosphere). 6 patients were disappointed, 18 were satisfied and 6 patients were very satisfied subjectively with the procedure. No difference in term of clinical results between Delta and Arrow except no glenoid notch occurred with Arrow prosthesis.

Discusssion and conclusion: After a failure of an hemi or total arthroplasty, if the cuff is no functional or no reparable, reverse prosthesis is currently the best salvage procedure. Bone glenoid stock and deltoid muscle are the limited factors. Surgical tips and tricks should be known before to do this difficult operation. Others procedures can be discussed: reconstruction of the coracoacromial arch, gleno-humeral arthrodesis, deltoïd flap or latissimus dorsi flap and others semi-contrained prosthesis. Patients who had pseudo-paralytic painfull shoulder, without stiffness after an arthroplasty with less than 2 previous operations represent our best results.

Does the pre-operative range of active anterior elevation alter the outcome of reverse shoulder prosthesis? A review of 96 cases.

Aims: The aim of this retrospective study was to analyse the results of reverse shoulder prosthesis in massive, irreparable rotator cuff tears in terms of the preoperative active anterior elevation (AAE).

Materials and Methods: This was a retrospective study of 96 reverse shoulder prostheses in patients with a mean age of 74 years, and with an average follow-up of 30 months. We divided the patients into three groups for the purposes of the study. Group 1 had an AAE less than 60° (n=51); group 2 had an AAE between 60 and 120° (n=39); group 3 had an AAE above 120° (n=6). The majority had off-centre arthritis with a Fukuda Hamada classification of IV or V (n=77); only 19 fell within classes I, II or III. We excluded patients who had previously had a failed anterior cuff repair or arthroplasty and those with a diagnosis of rheumatoid arthritis.

Results: There was no significant difference in constant score between the three groups based on preoperative AAE: group 1: 63.50; group 2: 65.05; group 3: 65.16. Analysis of the 96 reverse prostheses in relation to the Fukuda Hamada classification also showed no difference: types I, II and III had a constant score of 64.37; types IV and V a score of 63.68. However, the improvement in AAE (I), rotation (RE1 and RI) and in power was significantly greater in shoulders with pseudoparalysis (p< 0.001): group 1: I = 71.43%; group 2: I = 33.48%; group 3: I = 3.03%. The degree of improvement of the pseudoparalytic shoulders (group 1) was influenced by the Fukuda Hamada classification (p< 0.01): 77.78% for stages I, II and III compared with 69% for stages IV and V.

Discusssion and conclusion: This retrospective study confirms that the reverse shoulder prosthesis is a beneficial treatment for massive, irreparable cuff tears in older patients with shoulder psuedoparalysis. Its use is debatable if the preoperative AAE is over 120°, in which case hemiarthroplasty may be a better option. The benefit of the reverse prosthesis is greatest in the shoulder with pseudoparalysis, no glenohumeral arthritis (Fukuda I, II or III), and no previous surgical intervention.

Purpose of the study: The aim of this biomechanical study was to assess the performance of the deltoid muscle in the absence of a rotator cuff using different models for shoulder prosthesis.

Material and methods: A computer model reproducing the three dimensions of the glenohumeral joint was use to analyze the force of the deltoid muscle during abduction movements in shoulders devoid of a rotator cuff. The three heads of the deltoid were analyzed in order to determine the most effective level of muscle tension. The lever arm of the deltoid was measured from 0–90° abduction. Using this 3D model, we simulated implantation of six different models of reversed prostheses in order to assess the biomechanical situation which would be the most favorable for the deltoid. Performance of the normal deltoid was compared with the performance of the deltoid after implantation of an anatomic prosthesis and after implantation of an reversed prosthesis. Several variables were studied: medial offset of the center of rotation, lateral offset of the humerus, lengthening of the deltoid muscle.

Results: Optimal deltoid performance (especially from 60–90° abduction) was observed if the center of rotation was offset medially and the humerus was offset laterally and lowered. A 10% increase in the length of the muscle fibres increased muscle performance 18%. Exaggerated lateral offest of the humerus increased deltoid performance between 30 and 60° abduction but lost its beneficial effect at 90° abduction. From 15° abduction, a scapular notch appeared when the humerus was off set medially. This could be avoided if the humerus was offset laterally with a less medial center of rotation. Beyond 150° abduction, superior impingement appeared irrespective of the type of prosthesis.

Discussion and conclusion: This biomechanical study proved the superiority of reversed prostheses compared with anatomic prostheses for massive rotator cuff tears. Medial offset of the center of rotation reduced shear forces on the glenoid. Lateral offset of the humerus increase via a pulley effect the lowering force of the deltoid. Lowering the humerus pulled on the muscle fibers of the deltoid and increased their performance. Dosing these three variables with an appropriate («ideal») design for the reversed prosthesis would optimize deltoid performance in patients with deficient rotator cuffs.

Purpose of the study: This retrospective analysis was conducted to study the gain provided by a latissimus dorsi flap used as first-intention treatment (group 1) or secondary treatment after prior failure (group 2) for irreparable rotator cuff tears.

Material and methods: This series included ten women and nine men, mean age 58 years (range 42-64). The initial tear was a massive (> 5 cm) posterosuperior tear in 16 patients and extended to the upper third of the infra-scapularis in three. Surgery was undertaken because of persistent pain and limited joint motion despite rehabilitation. A subacromial impingement was noted in 15/20 shoulders on the arthroscan and fatty degeneration was noted as grade 3.31 on average for the supraspinatus and 3.1 for the infraspinatus (Goutallier and Bernageau classification). The latissimus dorsi flap was harvested via the superolateral approach and fixed with anchors in the superior border of the infrascapularis and on the trochiter after avivement. Tendon stumps were sutured to the medial part of the aproneurotic sheath of the latissimus dorsi.

Results: Overall outcome and outcome in group 1 patients (14 shoulders) and group 2 patients (five shoulders) were noted. Mean follow-up was 19.72 months (range 12–48). The overall Constant score progressed from 33.10 to 54.9 with a mean gain of 53° for elevation (98–151°) and 11° for external rotation (21.5–32.1°). For group 1, the Constant score progressed from 31 (15/51) to 58 (40/75) with a mean gain of 37° elevation (121–155°) and 13° external rotation (22.8–35°). For group 2, the Constant score progressed from 33 to 52 (40/75) with a mean gain of 32° elevation (88–120°) and 6° external rotation (18–24°). Pain improved from 6.3 to 11.8 on the Constant score.

Discussion and conclusion: Used as a first intention treatment for massive irreparable cuff tears with fatty degeneration scored greater than grade 3, the latissimus dorsi flap provides better results than when it is used after failure of a prior procedure. Results are good for pain relief and active elevation (45°) but modest for external rotation (6–13°) and zero for force. The two failures and the two cases of only fair subjective outcome were in group 2. We reserve the procedure for painful pseudo-paralytic shoulders in subjects aimed less than 60 years who do not respond to prolonged rehabilitation.

Purpose: The purpose of this work was to determine whether the position of the coracoid block used for surgical stabilisation of the shoulder using the Patte procedure has an influence or not on persistent postoperative apprehension.

Material and methods: Forty patients, mean age 26 years (19–37) operated on by the same surgeon (PV) were reviewed retrospectively at mean 40 months (24–60). Instability was expressed by dislocation (70%), subluxation (20%), or both (10%). Hyperlaxity was not found in any of the patients. The same surgical technique was used in all cases: subscapular discision along the axis of the fibres and fixation of the coracoid block using a single cortical lag screw (4.5 mm) with a washer. Radiological assessment at review included a three-quarter AP view in rotation and a glenoid lateral view (Bernageau). The height of the block was measured from the equator of the glenoid and lateral position in relation to the glenohumeral joint line (medial, flush, lateral).

Results: The block was always in an inferior position, flush in 70%, medial in 22% and slightly overhanging in 8%. Twenty percent of the patients experienced persistent apprehension for extreme abduction and external rotation; only one patient with a flush block reported apprehension compared with seven among patients with a medial block. There were two cases of recurrent dislocation and two episodes of subluxation in the patients with a medial block; none required revision. Function was assessed with the DASH: mean score was 6.7 for the entire series, 10 for patients with a medial block and 4.2 for those with flush blocks.

Conclusion: This retrospective analysis emphasises the difficulty and the necessity of rigorous technique to obtain an “ideal” position of the coroacoid block. When the technique is perfectly performed in patients with posttraumatic chronic instability without hyperlaxity, apprehension disappears with little risk of recurrence.

Aims:The purpose of this study was to evaluate the results obtained with a reversed shoulder prosthesis in cuff tear arthropathy. Materiels and methods: 37 inverted Delta 3 prosthesis were performed on 35 patients between 1995 and 1999. The average age was 74 years old (64–87). Majority were female. A pre-operative standard x-rays and CT scan assessed bone stock of the glenoid and trophicity of the deltoid.we performed a preacromial approach to obtain an excellent exposition of the glenoid. Rotator cuff were founded non reconstructable (34 cases) and in 3 cases non functionnal with fatty muscle degeneration. Results: Functionnal results were assessed using Constant score. The mean follow up was 32 months (18–70). Constant score was improved from 21,65 (8–45) in pre operative to 62,09 (35–75) in post operative. Forward flexion increased from 33 degrees (0–80) to mean 120 degrees (60–150). The operative mean value for pain was 2 and it was reduced to a mean value of 13,9 (15 = painless). 90% of the patients were satisfied and returned to their daily activities. Complications occurred 5 times: one post operative dislocation, one neuroalgodystrophy, one loosening of the glenoid component and 2 infections. Conclusion: Inverted Delta 3 prosthesis represents a successful choice for cases of irreparable rotator cuff and gleno-humeral arthritis with an excellent deltoid and a good glenoid bone stock. But it is also a salvage procedure after a failure of a non constrained prosthesis which restored stability and improved function in all patients.

Purpose: Surgical prosthetic treatment of excentred degeneration of the shoulder joint has long been limited to simple humeral prostheses. Inverted total shoulder arthroplasty (ITSA) using the Grammont system appears to provide real improvement. What is the comparative outcome? Does the Grammont prosthesis give constant results? Is the simple humeral prosthesis still indicated for selected cases? In order to respond to these questions, we reviewed 84 patients who had undergone surgery between 1986 and 2000 for implantation of 52 simple humeral prostheses (mean follow-up 7.1 years) and 32 ITSA (mean follow-up 4.3 years).

Material and methods: Between 1986 and 1995, all patients with excentred degeneration of the shoulder joint were treated with a simple humeral prosthesis (36 cases). Between 1995 and 2000, either ITSA or simple humeral prosthesis (16 cases) was used. For the ITSA, indications were limited to excentred degeneration in patients aged over 70 years with a painful pseudoparalytic shoulder or contraindication for a simple prosthesis (alteration of the acromiocorocoid vault or the subscapular area). Simple prostheses were used either when an ITSA could not be implanted (patient too young, overly deteriorated glenoid, deltoid insufficiency) or when there was a preferential indication (excentred degeneration in young patients < 65 years, preservation of active motion, Favard type 1 or 2 glenoid…).

Results: For the simple humeral prosthesis series (1986–1995): the Constant score improved from 16.4 preoperatively to 489.6 postoperatively; radiographically there were one humeral loosening, three superior migrations, and three glenoid degenerations; three revision procedures were required. For the ITSA: the Constant score improved from 14.2 preoperatively to 61.6 postoperatively; radiographically there was one humeral loosening; 32% glenoid alterations in Nérot grades 3 and 4; one revision procedure was required. For the later simple humeral protheses (1995–2000): the Constant score improved from 18.2 preoperatively to 56.4 postoperatively (60.2 excluding cases with a simple prosthesis due to contraindication of an ITSA); radiologically there were one superior migration and two glenoid deteriorations.

Discussion: For a given indication, the results with the ITSA were better than with the simple prosthesis (p < 0.001). However, excluding salvage procedures where the ITSA could not be used, simple prostheses inserted for precise indications provided results nearly equivalent to the ITSA (p < 0.05) with less uncertainty concerning the future. For us, the inverted total shoulder prosthesis and the simple humeral prosthesis share indications for surgical repair of excentred degeneration of the shoulder joint.

Purpose: Injury to the clavicle is a rare cause of outlet syndrome. We report eight cases to determine the diagnostic and therapeutic features and report outcomes.

Material and methods: This series of eight patients (five women and three men), mean age 48 years (11)70) sufferred from pain irradiating to the upper limb with paraesthesia in the ulnar teritorry of the hand together with diminished muscle force. The diagnosis was established 23.1 months (mean, range 1–10 years) after the initial comminutive mid-third fracture. The displaced bone which was treated orthopaedically. Standard x-rays revealed: four deformed calluses, two atrophic nonunions, one fracture with a vertical fragment (rapid osteosynthesis performed to avoid acute plexus compression) and finally one resection of the mid third (secondary to osteitis). The electromyogram confirmed the diagnosis, generally with compression of a secondary anteromedial trunk. 3D reconstruction scans (measurement of the costo-cleidal space) were obtained.

Results: Pain disappeared the day after surgery as did the paraesthesia in seven out of eight patients. The clavicle healed in 13 to 18 months.

Discussion: Different mechanisms can cause compression of the brachial plexus after displaced comminutive fracture of the clavicle. Different therapeutic modalities have been proposed. The outlet syndrome should be considered following displaced fractures of the mid third of the clavicle in patients presenting pain irradiating to the upper limb. The diagnosis is confirmed by electromyography. Proper analysis of the clavicle is obtained with 3D CT scan allowing adapted surgical treatment.

Purpose: The hand-to-forehead test is a new subjective and objective test for anterior shoulder instability. This test is performed preoperatively under general anaesthesia and involves a quantifiable patient-controlled apprehension test and an objective quantitative test of anterior stability.

Material and methods: Between January 1998 and April 2000, 135 patients (97 men and 38 women), mean age 25 years, age range 16–40 years, candidates for surgery for anterior instability of the shoulder (115 Latarget, 14 Bankart, 6 capsular shift) were tested. A control group of 300 candidates free of any shoulder disorder for other surgery were also tested.

Results: the Apprehension test was positive in 95 of the operated patients and negative in 40. Mean angle was 160° (90–180°). The test was always negative in patients with an underlying hyperlaxity (18 patients). The test was positive in 20 controls and negative in 270. Test sensitivity was 72%, specificity 92.5%, positive predictive value 42%, (prevalence 1.5%) and negative predictive value 86%. Reproducibility was 80%. The objective test was positive in 125 of the operated patients and negative in 10. The value was 2++ in 55% of the cases. In the control group, the objective test was positive in 28 and negative in 272. The sensitivity of the objective test was 95%, specificity 90%, positive predictive value 55% and negative predictive value 95%. Reproducibility was 92%.

Discussion: The purpose of the hand-to-forehead test is to express the instability as perceived by the patient and to exteriorise anterior laxity without reproducing true anterior displacement. Excepting cases with underlying hyperlaxity, this test does not appear to be inflenced by different injuries subsequent to recurrent anterior dislocation. (no significant difference between glenoid bone lesions, Broca lesions or Malgaigne notches).

Conclusion: This new test provides a reliable objective assessment of anterior instability of the shoulder using a quantifiable combination of classical apprehension and laxity tests. It is a supplementary diagnostic tool for difficult cases and a useful aid for pre- and postoperative evaluation of these patients.

Purpose: We report the long-term outcome after treatment of scaphoid nonunion using a graft harvested on the anterior aspect of the radius and vascularised with the anterior carpus artery.

Material and methods: We treated 72 patients, 11 women and 61 men. Mean age was 31.4 years (15–61) and mean delay from initial fracture of the scaphiod to treatment of nonunion was 22 months (4–120 months). Twenty-seven patients had had prior tratments (11 Mati-Russe, 16 screw fixations). Alnot classification was 40 grade 2A, 28 grade 2B and 4 grade 3A. the patients were generally treated as out-patients under locoregional anaesthesia. A single approach was needed. After reduction and fixation of the scaphoid, the graft was harvested from the anterior aspect of the radius and inserted in the bone gap, usually fixed with a temporary pin. A palmar brace was maintained until bone healing.

Results: Bone healing was achieved in 66 patients (91.6%). Mean delay to healing was 9.8 weeks (6–24). Pain relief was achieved in all patients; 59 were completely pain free. Mean flexion improved from 45° to 56° and mean extension from 54° to 65°. Muscle force improved from 50% to 90% of the healthy side. There were three cases of reflex dystrophy, two cases of styloid radial osteoarthritis and three cases of postoperative stiffness requiring secondary arthrolysis. Functional outcome was excellent in 46 patients, good in 13, fair in 9 and poor in 4.

Discussion: The vascularised graft advocated by Judet as early as 1964 has proven its efficacy for repeated nonunions of the scaphoid. In our series, there was a direct correlation between the grade of the nonunion and the final outcome, the best results being obtain for grade 2A.

Conclusion: Use of a bone graft vascularised with the anterior carpus artery only requires on approach, and provides a high rate of bone healing. We recommend this method for first line treatment of nonunion of the scaphoid.

Purpose: Revision of a humeral prosthesis or a total shoulder arthroplasty is a difficult therapeutic challenge. The purpose of this work was to report our experience in a retrospective series of 19 inverted Grammont prostheses implanted during revision procedures.

Material and methods: The series included 11 women and eight men, mean age 66.8 years (45–84). Nine patients had already undergone at least two procedures before the revision of their prosthesis. There were 19 revisions of humeral prostheses and four revision total shoulder arthroplasties. Causes leading to revision of the humeral prostheses were: infection one patient, secondary cuff tears six patients, anterosuperior dislocation of the prosthesis five patients, and stiff and painful shoulders three patients. For the total shoulder arthroplasties, three required revision for a loosened glenoid implant and two for secondary cuff tears with ascension of the humeral head. The same access was used as for the first procedure in most of the cases (deltopectoral or anterolateral approach). The rotator cuff was torn and retracted, or fibrous and non-functional. Ablation of the humeral implant and the cement led to fracture (error or infection) in six cases requiring cerclage for fixation. A complementary bone graft was needed in three cases at the glenoid level in three and at the humeral level in three others.

Results: The Constant score at mean follow-up of 36.4 months (12–60) was 55.07 (44–87) a clear improvement over the initial 13.87 (6–39) before revision. The score was less favourable for patients with several operations before revision. Mean anterior elevation was 29.33° (20–100) pre-operatievely and reached 118.67° (90–160) postoperatively. The pain score was 3/15 preoperatively and13.66/15 postoperatively.

Discussion: Other alternatives may be indicated in salvage situations with an unreparable cuff and a pseudo-paralytic shoulder: rectus or deltoid flaps, reconstruction of the acro-miocoracoid arch and glenohumeral arthrodesis.

Conclusion: The inverted Grammont prosthesis appears to be a useful salvage technique, particularly when the acro-miocoracoid arch is destroyed and the cuff is unreparable. The best chances of success are observed for revision of hemiarthroplasties of a pseudo-paralytic shoulder with complete passive mobility and an anterosuperior dislocation of the humeral prosthesis head.