Publications by authors named "Lionel Neyton"

46 Publications

Anterior Shoulder Instability Part I-Diagnosis, Nonoperative Management, and Bankart Repair-An International Consensus Statement.

Arthroscopy 2021 Jul 29. Epub 2021 Jul 29.

Sports Surgery Clinic, Dublin, Ireland.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability.

Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

Results: The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors.

Conclusion: Overall, 84% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization.

Level Of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.07.022DOI Listing
July 2021

Anterior Shoulder Instability Part II-Latarjet, Remplissage, and Glenoid Bone-Grafting-An International Consensus Statement.

Arthroscopy 2021 Jul 29. Epub 2021 Jul 29.

Sports Surgery Clinic, Northwood Avenue, Santry Demesne, Dublin 9, D09 C523, Dublin, Ireland.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability.

Methods: A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

Results: The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation.

Conclusion: Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage.

Level Of Evidence: Level V: expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.07.023DOI Listing
July 2021

Anterior Shoulder Instability Part III-Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up-An International Consensus Statement.

Arthroscopy 2021 Jul 29. Epub 2021 Jul 29.

Sports Surgery Clinic, Dublin, Ireland.

Purpose: The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability.

Methods: A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.

Results: The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction.

Conclusion: Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up.

Level Of Evidence: Level V, expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.07.019DOI Listing
July 2021

Intra- and intersession reliability and agreement of the Unilateral Seated Shot-Put Test outcome measures in healthy male athletes.

BMC Sports Sci Med Rehabil 2021 Jul 6;13(1):72. Epub 2021 Jul 6.

Laboratoire Interuniversitaire de Biologie de la Motricité EA 7424, Université de Lyon, UFRSTAPS, 27-29 Boulevard du 11 Novembre 1918, 69622, Villeurbanne Cedex, France.

Background: The Unilateral Seated Shot-Put Test (USSPT) consists of pushing an overweight ball as far as possible to assess upper extremity power unilaterally and bilateral symmetry. Literature however reports various body positions and upper limb pushing patterns to perform USSPT, demanding to provide additional guideline to achieve overweight ball push. This study therefore aimed at assessing the reliability and agreement of USSPT outcome measures when pushing an overweight ball in a horizontal direction.

Methods: Twenty-seven healthy male athletes performed two sessions, one week apart, of three unilateral pushes per upper limb using a 3-kg medicine ball, for which the distances were measured. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimum detectable change at a 95 % confidence level (MDC) and coefficient of variation (CV) were assessed for the pushing distances based on one, two or three trials per side to produce two outcome measures: the pushing distance per limb and USSPT Limb Symmetry Index (LSI) when dividing pushing distance of the dominant side by that of the non-dominant side.

Results: The most reliable pushing distance per limb was obtained when averaging three pushing distances, normalized by body mass with the exponent 0.35. The mean USSPT LSI was 1.09 ± 0.10 for the first session and 1.08 ± 0.10 for the second session, highlighting good reliability and agreement (ICC = 0.82; SEM = 0.045; MDC = 0.124; CV = 5.02 %).

Conclusions: When the overweight ball is pushed in a horizontal direction, averaging the distances of three trials for both the dominant and non-dominant limbs is advised to provide the most reliable USSPT distance per limb and USSPT LSI.
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http://dx.doi.org/10.1186/s13102-021-00301-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261983PMC
July 2021

The S-STARTS Test: Validation of a Composite Test for the Assessment of Readiness to Return to Sport After Shoulder Stabilization Surgery.

Sports Health 2021 Apr 9:19417381211004107. Epub 2021 Apr 9.

Background: The time elapsed since surgery is the primary criterion for allowing athletes to return to sport after shoulder stabilization surgery using the Latarjet procedure. The objective assessment of shoulder functional status through the return-to-sport continuum demands a scoring instrument that includes psychological and physical dimensions. This study aimed to statistically validate the Shoulder-SanTy Athletic Return To Sport (S-STARTS) score in patients who have undergone primary shoulder stabilization surgery.

Hypothesis: The S-STARTS score fulfils the criteria for statistical validation for assessing return-to-sport readiness after shoulder stabilization surgery.

Study Design: Diagnostic study.

Level Of Evidence: Level 4.

Methods: Fifty patients and 50 controls completed the Shoulder Instability-Return to Sport after Injury questionnaire and performed 4 physical performance tests, from which 8 outcome measures were extracted to provide a composite score, named S-STARTS, according to a scoring procedure. The statistical validation of the S-STARTS score was based on construct validity, discriminant validity, sensitivity to change, internal consistency, reliability, agreement, and feasibility.

Results: The 8 components of the S-STARTS score provided additional information (0.01 ≤ || ≤ 0.59). The S-STARTS score exhibited good reliability (intraclass coefficient of correlation [3,k] = 0.74), no ceiling or floor effects, and high discrimination and sensitivity to change. The S-STARTS score was significantly lower in patients than in controls (13.5 ± 3.8 points vs 16.1 ± 2.7 points, respectively; < 0.001). A significant increase was reported between 4.5 and 6.5 months postoperatively (12.8 ± 2.3 points vs 17.2 ± 2.4 points, respectively; < 0.001).

Conclusions: The S-STARTS score meets statistical validation criteria for the assessment of shoulder functional status after shoulder stabilization surgery using the Latarjet procedure.

Clinical Relevance: Using an S-STARTS score-based assessment to monitor an athlete's progression through the return-to-sport continuum may help clinicians and strength and conditioning coaches in return-to-sport decision-making.
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http://dx.doi.org/10.1177/19417381211004107DOI Listing
April 2021

Adjusting Implant Size and Position Can Improve Internal Rotation After Reverse Total Shoulder Arthroplasty in a Three-dimensional Computational Model.

Clin Orthop Relat Res 2021 01;479(1):198-204

E. G. Huish, L. Neyton, G. Walch, Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.

Background: Efforts during reverse total shoulder arthroplasty (RSA) have typically focused on maximizing ROM in elevation and external rotation and avoiding scapular notching. Improving internal rotation (IR) is often overlooked, despite its importance for functional outcomes in terms of patient self-care and hygiene. Although determinants of IR are multifactorial, it is unable to surpass limits of bony impingement of the implant. Identifying implant configurations that can reduce bony impingement in a computer model will help surgeons during preoperative planning and also direct implant design and clinical research going forward.

Questions/purposes: In a CT-modeling study, we asked: What reverse total shoulder arthroplasty implant position improves the range of impingement free internal rotation without compromising other motions (external rotation and extension)?

Methods: CT images stored in a deidentified teaching database from 25 consecutive patients with Walch A1 glenoids underwent three-dimensional templating for RSA. Each template used the same implant and configuration, which consisted of an onlay humeral design and a 36-mm standard glenosphere. The resulting constructs were virtually taken through ROM until bony impingement was found. Variations were made in the RSA parameters of baseplate lateralization, glenosphere size, glenosphere overhang, humeral version, and humeral neck-shaft angle. Simulated ROM was repeated after each parameter was changed individually and then again after combining multiple changes into a single configuration. The impingement-free IR was calculated and compared between groups. We also evaluated the effect on other ROM including external rotation and extension to ensure that configurations with improvements in IR were not associated with losses in other areas.

Results: Combining lateralization, inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion resulted in a greater improvement in internal rotation than any single parameter change did (median baseline IR: 85° [interquartile range 73° to 90°]; combined changes: 119° [IQR 113° to 121°], median difference: 37° [IQR 32° to 43°]; p < 0.001).

Conclusion: Increased glenosphere overhang, varus neck-shaft angle, and humeral anteversion improved internal rotation in a computational model, while glenoid lateralization alone did not. Combining these techniques led to the greatest improvement in IR.

Clinical Relevance: This computer model study showed that various implant changes including inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion can be combined to increase impingement-free IR. Surgeons can employ these currently available implant configurations to improve IR when planning and performing RSA. These findings support the need for further clinical studies validating the effect of implant configuration on resultant IR.
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http://dx.doi.org/10.1097/CORR.0000000000001526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899712PMC
January 2021

Modified L'Episcopo tendon transfer for isolated loss of active external rotation.

J Shoulder Elbow Surg 2020 Dec 9;29(12):2587-2594. Epub 2020 Jun 9.

Departments of Orthopaedic Surgery & Shoulder/Elbow Surgery, The Rothman Institute-Thomas Jefferson, Philadelphia, PA, USA.

Background: Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation.

Methods: A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up.

Results: Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%).

Conclusion: In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.
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http://dx.doi.org/10.1016/j.jse.2020.03.031DOI Listing
December 2020

Shoulder functional status in rugby union players with and without history of shoulder problems.

Phys Ther Sport 2020 Sep 2;45:71-75. Epub 2020 Jul 2.

Université de Lyon, Université Lyon 1, Laboratoire Interuniversitaire de Biologie de la Motricité - EA 7424, UFRSTAPS, 27-29 boulevard du 11 novembre 1918, 69622, Villeurbanne Cedex, France.

Objectives: To assess the effects of (1) rugby union practice, (2) history of injury managed nonoperatively, and (3) history of injury managed operatively on shoulder functional status in male rugby union players.

Design: Cross sectional study.

Setting: Clinical.

Participants: 86 male athletes were assigned into four groups: multisport athletes, rugby union players without shoulder problems, with history of shoulder injury managed nonoperatively and with history of shoulder injury managed operatively.

Main Outcome Measures: SI-RSI questionnaire, maximal isometric glenohumeral internal and external rotator strength, unilateral seated shot put test, upper quarter Y balance test.

Results: Healthy players presented higher internal (p = 0.03) and external (p = 0.04) rotator strength than multisport athletes. History of shoulder injury managed nonoperatively did not impair physical abilities but limited player's psychological readiness (p < 0.001). After 4.5-months, shoulder stabilization surgery impaired maximal muscle strength and upper quarter body stability and mobility (p < 0.001 for all).

Conclusions: The shoulder functional status in rugby union player presented increased glenohumeral rotator strength when compared to non-collision sport athletes. In rugby union players, psychological concerns remained in the long-term after a shoulder injury managed nonoperatively, and psychological and physical readiness seemed not be reached at 4.5 months postoperatively to respond to rugby union practice demand.
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http://dx.doi.org/10.1016/j.ptsp.2020.06.014DOI Listing
September 2020

Shoulder Hemiarthroplasty After Previous Pectoralis Major Transfer for Irreparable Subscapularis Tear: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0322

1Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Unité de l'épaule, Lyon, France 2Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 3MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.

Case: A 30-year-old woman with an irreparable subscapularis tear presented with persistent painful anterior instability despite several open and arthroscopic stabilization procedures. A pectoralis major tendon transfer (PMTT) was performed. The patient subsequently developed progressive glenohumeral arthritis over the next 10 years, ultimately necessitating shoulder arthroplasty.

Conclusions: PMTT provides valuable anterior soft-tissue reconstruction stabilization for subscapularis insufficiency in a multioperated shoulder. Ten years later, the transfer was found to be intact and managed like a native subscapularis during anatomic shoulder replacement, thus avoiding a reverse arthroplasty in a young patient.
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http://dx.doi.org/10.2106/JBJS.CC.19.00322DOI Listing
February 2021

Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients.

J Shoulder Elbow Surg 2020 Jun 4;29(6):1206-1213. Epub 2019 Dec 4.

Centre Orthopédique Santy, Hôpital Privé Jean Mermoz Ramsay GDS, Lyon, France.

Introduction: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure.

Methods: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications.

Results: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up.

Conclusions: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.
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http://dx.doi.org/10.1016/j.jse.2019.09.039DOI Listing
June 2020

The Arthroscopic "Montgolfier Double-Row Knotless" Rotator Cuff Repair Technique.

Arthrosc Tech 2019 Jul 6;8(7):e669-e674. Epub 2019 Jun 6.

Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopedique Santy, Lyon, France.

Contemporary arthroscopic double-row suture anchor rotator cuff repairs have superior biomechanics compared with prior iterations. Numerous techniques have been described, but consensus regarding value has yet to be established. We describe an effective and easily reproducible technique: the arthroscopic "Montgolfier double-row" repair technique. This knotless construct has an evenly distributed, load-sharing, radially oriented suture limb configuration much like the envelope cables of a Montgolfier hot-air balloon, its namesake. Other advantages include the ability to apply manual, progressive and calculated tension on each suture limb and easy intraoperative modification depending on tear size, shape, and delamination, as well as tissue tension and quality. Future studies are needed to validate the biomechanics and clinical outcomes of this technique.
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http://dx.doi.org/10.1016/j.eats.2019.02.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713846PMC
July 2019

Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under.

J Shoulder Elbow Surg 2019 Sep 13;28(9):1666-1673. Epub 2019 Jun 13.

Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.

Background: Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy.

Methods: A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined.

Results: A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA.

Conclusion: In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.
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http://dx.doi.org/10.1016/j.jse.2019.03.006DOI Listing
September 2019

Intrarater reliability and agreement of a modified Closed Kinetic Chain Upper Extremity Stability Test.

Phys Ther Sport 2019 Jul 24;38:44-48. Epub 2019 Apr 24.

Université de Lyon, Laboratoire Interuniversitaire de Biologie de la Motricité - EA 7424, UFRSTAPS, 27-29 boulevard du 11 novembre 1918, 69622, Villeurbanne Cedex, France. Electronic address:

Objectives: To assess the reliability of a modified procedure for Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST).

Design: Intra- and intersession reliability and agreement; SETTING: Clinical.

Participants: Twenty-seven asymptomatic athletes.

Main Outcome Measures: The modifications (m-CKCUEST) in CKCUEST procedure consisted in hand spacing at one half arm-span, and to complete the three regular-series of 15 s exertion by performing a fourth 1-min series during which the number of touches was counted every 15 s. The intra- and intersession reliability and agreement were assessed for the numbers of touches in order to produce two outcome measures: m-CKCUEST score and muscular endurance index.

Results: The most reliable m-CKCUEST score was obtained when averaging the numbers of touches of the second and third sets (Intraclass Coefficient of Correlation(3,k); ICC = 0.92). Good reliability was found for muscular endurance index computed when dividing the one-half number of touches counted during the last 30 s of 1-min set, by the m-CKCUEST score calculated above (ICC = 0.86).

Conclusions: The m-CKCUEST allowed the production of two reliable outcome measures, which assessed the upper limb stability and the muscular endurance. Such outcomes may be used in a follow-up to assess performance or rehabilitation level.
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http://dx.doi.org/10.1016/j.ptsp.2019.04.017DOI Listing
July 2019

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older.

J Shoulder Elbow Surg 2019 Sep 28;28(9):e304-e312. Epub 2019 Apr 28.

Centre Orthopédique Santy, Hôpital Privé Jean Mermoz Ramsay GDS, Lyon, France.

Background: The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization.

Methods: A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations.

Results: Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients.

Conclusions: The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.
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http://dx.doi.org/10.1016/j.jse.2019.02.004DOI Listing
September 2019

The "Double Lasso-Loop" Technique Used for Arthroscopic Proximal Biceps Tenodesis.

Arthrosc Tech 2019 Mar 18;8(3):e291-e300. Epub 2019 Feb 18.

Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.

Disorders of the long head biceps tendon are among the most challenging of shoulder problems to diagnose and manage. In this Technical Note, we introduce an arthroscopic technique for proximal biceps tenodesis high in the groove at the articular margin of the humeral head using a single anchor and 2 self-cinching loops followed by 5 alternating half-hitches to secure the construct. This method is simple and enables stable fixation of the biceps tendon.
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http://dx.doi.org/10.1016/j.eats.2018.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475644PMC
March 2019

Three-dimensional characterization of the anteverted glenoid (type D) in primary glenohumeral osteoarthritis.

J Shoulder Elbow Surg 2019 Jun 23;28(6):1175-1182. Epub 2019 Jan 23.

Roth/McFarlane Hand and Upper Limb Center, St Joseph's Health Care, Western University, London, ON, Canada.

Background: The Walch classification describes glenoid morphology in primary arthritis. As knowledge grows, several modifications to the classification have been proposed. The type D, a recent modification, was defined as an anteverted glenoid with or without anterior subluxation. Literature on the anteverted glenoid in primary osteoarthritis is limited. The purpose of this study, therefore, was to analyze the anatomic characteristics of the type D glenoid on radiographs and computed tomography (CT).

Methods: The shoulder arthroplasty databases from 3 institutions were examined to identify patients with primary glenohumeral osteoarthritis and glenoid anteversion (≥5°), with or without anterior subluxation. The type D study cohort consisted of 18 patients (3% of the osteoarthritis cohort) and was a mean of 70 years old, with 11 women and 7 men. All radiographs were reviewed, and computed tomography Digital Imaging and Communications in Medicine (National Electrical Manufacturers Association, Rosslyn, VA, USA) data were analyzed on validated 3-dimensional imaging software. Rotator cuff fatty infiltration, glenoid measurements (anteversion and inclination), and humeral head subluxation according to the scapular plane were determined.

Results: In the study cohort, the mean glenoid anteversion was 12° (range, 5°-24°), the mean inclination was 0°, and the mean anterior subluxation was 38% (range, 6%-56%). Eight patients (44%) had a biconcave glenoid with a posterosuperiorly positioned paleoglenoid and an anteroinferiorly positioned neoglenoid, and 10 patients had a monoconcave glenoid. Fatty infiltration of the rotator cuff muscles never exceeded Goutallier stage 2.

Conclusion: The type D glenoid is an addition to the original Walch classification and is characterized by glenoid anteversion (≥5°), anteroinferior humeral head subluxation, and absence of severe subscapularis fatty infiltration.
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http://dx.doi.org/10.1016/j.jse.2018.09.015DOI Listing
June 2019

Postoperative radiographic findings of an uncemented convertible short stem for anatomic and reverse shoulder arthroplasty.

J Shoulder Elbow Surg 2019 Apr 22;28(4):715-723. Epub 2018 Nov 22.

Centre Orthopedique Santy, Lyon, France.

Background: Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA.

Methods: There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio.

Results: At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014).

Conclusions: The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.
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http://dx.doi.org/10.1016/j.jse.2018.08.037DOI Listing
April 2019

Should clinicians integrate the findings of 's 2018 placebo-controlled subacromial decompression trial into clinical practice?

BMJ Open Sport Exerc Med 2018 4;4(1):e000454. Epub 2018 Oct 4.

Department of Orthopaedic Surgery and Sports Medicine, Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint-Grégoire, France.

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http://dx.doi.org/10.1136/bmjsem-2018-000454DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196955PMC
October 2018

Grammont Award 2018: Scapular fractures in reverse shoulder arthroplasty (Grammont style): prevalence, functional, and radiographic results with minimum 5-year follow-up.

J Shoulder Elbow Surg 2019 Feb 18;28(2):260-267. Epub 2018 Sep 18.

Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.

Background: Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up.

Materials And Methods: We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views.

Results: Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points).

Conclusions: Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture.
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http://dx.doi.org/10.1016/j.jse.2018.07.004DOI Listing
February 2019

Increased scapular spine fractures after reverse shoulder arthroplasty with a humeral onlay short stem: an analysis of 485 consecutive cases.

J Shoulder Elbow Surg 2018 Dec 8;27(12):2183-2190. Epub 2018 Aug 8.

Ramsey Générale de Santé Hôpital Privé Jean Mermoz, Lyon, France.

Background: Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients.

Methods: A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture.

Results: A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P < .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion.

Conclusion: Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.
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http://dx.doi.org/10.1016/j.jse.2018.06.007DOI Listing
December 2018

Arthroscopic Latarjet Techniques: Graft and Fixation Positioning Assessed With 2-Dimensional Computed Tomography Is Not Equivalent With Standard Open Technique.

Arthroscopy 2018 07 19;34(7):2032-2040. Epub 2018 May 19.

Clinique Générale Annecy, Annecy, France.

Purpose: To analyze graft and fixation (screw and EndoButton) positioning after the arthroscopic Latarjet technique with 2-dimensional computed tomography (CT) and to compare it with the open technique.

Methods: We performed a retrospective multicenter study (March 2013 to June 2014). The inclusion criteria included patients with recurrent anterior instability treated with the Latarjet procedure. The exclusion criterion was the absence of a postoperative CT scan. The positions of the hardware, the positions of the grafts in the axial and sagittal planes, and the dispersion of values (variability) were compared.

Results: The study included 208 patients (79 treated with open technique, 87 treated with arthroscopic Latarjet technique with screw fixation [arthro-screw], and 42 treated with arthroscopic Latarjet technique with EndoButton fixation [arthro-EndoButton]). The angulation of the screws was different in the open group versus the arthro-screw group (superior, 10.3° ± 0.7° vs 16.9° ± 1.0° [P < .001]; inferior, 10.3° ± 0.8° vs 15.7° ± 0.9° [P < .0001]). The angulation of the EndoButtons was 5.7° ± 0.5°; this was different from that of open inferior screws (P = .003). In the axial plane (level of equator), the arthroscopic techniques resulted in lateral positions (arthro-screw, 1.5 ± 0.3 mm lateral [P < .001]; arthro-EndoButton, 0 ± 0.3 mm lateral [P < .0001]) versus the open technique (0.9 ± 0.2 mm medial). At the level of 25% of the glenoid height, the arthroscopic techniques resulted in lateral positions (arthro-screw, 0.3 ± 0.3 mm lateral [P < .001]); (arthro-EndoButton, 0.7 ± 0.3 mm lateral [P < .0001]) versus the open technique (1.0 ± 0.2 mm medial). Higher variability was observed in the arthro-screw group. In the sagittal plane, the arthro-screw technique resulted in higher positions (55% ± 3% of graft below equator) and the arthro-EndoButton technique resulted in lower positions (82% ± 3%, P < .0001) versus the open technique (71% ± 2%). Variability was not different.

Conclusions: This study shows that the position of the fixation devices and position of the bone graft with the arthroscopic techniques are statistically significantly different from those with the open technique with 2-dimensional CT assessment. In the sagittal plane, the arthro-screw technique provides the highest positions, and the arthro-EndoButton technique, the lowest. Overall, the mean position of the bone block with the open Latarjet technique in the axial plane is slightly medial to the joint line, as recommended. Conversely, with the arthroscopic techniques, the bone grafts are more lateral with a slight overhang. The main differences are observed in the dispersion of the values (more extreme positions) with the arthro-screw technique, given the acknowledged limitations. Despite the statistical significance, the clinical significance of these differences is yet unknown.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2018.01.054DOI Listing
July 2018

Short-term radiographic results of a cemented polyethylene keeled glenoid component with varying backside radiuses of curvature.

J Shoulder Elbow Surg 2018 May 29;27(5):839-845. Epub 2017 Dec 29.

Department for Shoulder Surgery, Centre Orthopédique Santy, Lyon, France.

Background: This study analyzed the radiographic results of a cemented all-polyethylene keeled glenoid component available in different sizes and multiple backside radiuses of curvature.

Methods: The study group consisted of 118 cases (114 patients). There were 63 women and 51 men. Mean age at the time of arthroplasty was 68 years (range, 51-85 years). True anterior-posterior radiographs obtained postoperatively and at the final follow-up were analyzed for implant seating and the occurrence of radiolucent lines. Glenoid morphology and fatty infiltration of the rotator cuff muscles were examined using computed tomography scans. Mean follow-up was 38 months (range, 24-70 months).

Results: The mean radiolucent line score after surgery was 0.54 points (range, 0-3 points), and 90% had no or only 1 radiolucent line. At the final follow-up, the mean score was 1.06 points (range, 0-3 points), and 74% had no or only 1 radiolucent line. The score increased significantly over time (P < .001). No component was at risk for loosening. No correlation was found between patient age, sex, hand dominance, glenoid morphology, or fatty infiltration of the rotator cuff muscles and the occurrence of radiolucent lines.

Conclusion: In the short-term, the glenoid component analyzed in this study showed promising radiographic results, with a low number of radiolucent lines without failure. However, the mean radiolucent line score increased significantly over time, and long-term observations are necessary to confirm a possible advantage compared with older component designs.
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http://dx.doi.org/10.1016/j.jse.2017.10.026DOI Listing
May 2018

Can a Drill Guide Improve the Coracoid Graft Placement During the Latarjet Procedure? A Prospective Comparative Study With the Freehand Technique.

Orthop J Sports Med 2017 Oct 20;5(10):2325967117734218. Epub 2017 Oct 20.

Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, Lyon, France.

Background: One of the factors that can affect the success of the Latarjet procedure is accurate coracoid graft (CG) placement.

Hypothesis: The use of a guide can improve placement of the CG and screw positioning in the sagittal and axial planes as compared with the classic open ("freehand") technique.

Study Design: Cohort study; Level of evidence, 2.

Methods: A total of 49 patients who underwent a Latarjet procedure for the treatment of recurrent anterior shoulder instability were prospectively included; the procedure was performed with the freehand technique in 22 patients (group 1) and with use of a parallel drill guide during screw placement in 27 patients (group 2). All patients underwent a postoperative computed tomography scan with the same established protocol. The scans were used to evaluate and compare the position of the CG in the sagittal and axial planes, the direction of the screws (α angle), and overall contact of the graft with the anterior surface of the glenoid after the 2 surgical techniques.

Results: The CG was placed >60% below the native glenoid equator in 23 patients (85.2%) in group 2, compared with 14 patients (63.6%) in group 1 ( = .004). In the axial plane, the position of the CG in group 2 patients was more accurate (85.2% and 88.9% flush) at the inferior and middle quartiles of the glenoid surface ( = .012 and .009), respectively. Moreover, with the freehand technique (group 1), the graft was in a more lateral position in the inferior and middle quartiles ( = .012 and .009, respectively). No differences were found between groups 1 and 2 regarding the mean α angle of the superior (9° ± 4.14° vs 11° ± 6.3°, = .232) and inferior (9.5° ± 6° vs 10° ± 7.5°, = .629) screws. However, the mean contact angle (angle between the posterior coracoid and the anterior glenoid surface) with the freehand technique (3.8° ± 6.8°) was better than that of the guide (8.55° ± 8°) ( = .05).

Conclusion: Compared with the classic freehand operative technique, the parallel drill guide can ensure more accurate placement of the CG in the axial and sagittal planes, although with inferior bone contact.
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http://dx.doi.org/10.1177/2325967117734218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5652655PMC
October 2017

Classification of full-thickness rotator cuff lesions: a review.

EFORT Open Rev 2016 Dec 13;1(12):420-430. Epub 2017 Mar 13.

Southern Oregon Orthopedics, Medford, Oregon, USA.

Rotator cuff lesions (RCL) have considerable variability in location, tear pattern, functional impairment, and repairability.Historical classifications for differentiating these lesions have been based upon factors such as the size and shape of the tear, and the degree of atrophy and fatty infiltration. Additional recent descriptions include bipolar rotator cuff insufficiency, 'Fosbury flop tears', and musculotendinous lesions.Recommended treatment is based on the location of the lesion, patient factors and associated pathology, and often includes personal experience and data from case series. Development of a more comprehensive classification which integrates historical and newer descriptions of RCLs may help to guide treatment further. Cite this article: Lädermann A, Burkhart SS, Hoffmeyer P, et al. Classification of full thickness rotator cuff lesions: a review. 2016;1:420-430. DOI: 10.1302/2058-5241.1.160005.
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http://dx.doi.org/10.1302/2058-5241.1.160005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367545PMC
December 2016

Is the two-dimensional computed tomography scan analysis reliable for coracoid graft positioning in Latarjet procedures?

J Shoulder Elbow Surg 2017 Aug 31;26(8):e237-e242. Epub 2017 Mar 31.

French Society of Arthroscopy, Paris, France.

Background: The aim of the study was to develop a computed tomography (CT)-based measurement protocol for coracoid graft (CG) placement in both axial and sagittal planes after a Latarjet procedure and to test its intraobserver and interobserver reliability.

Methods: Fifteen postoperative CT scans were included to assess the intraobserver and interobserver reproducibility of a standardized protocol among 3 senior and 3 junior shoulder surgeons. The evaluation sequence included CG positioning, its contact area with the glenoid, and the angle of its screws in the axial plane. The percentage of CG positioned under the glenoid equator was also analyzed in the sagittal plane. The intraobserver and interobserver agreement was measured by the intraclass correlation coefficient (ICC), and the values were interpreted according to the Landis and Koch classification.

Results: The ICC was substantial to almost perfect for intraobserver agreement and fair to almost perfect for interobserver agreement in measuring the angle of screws in the axial plane. The intraobserver agreement was slight to almost perfect and the interobserver agreement slight to substantial regarding CG positioning in the same plane. The intraobserver agreement and interobserver agreement were both fair to almost perfect concerning the contact area. The ICC was moderate to almost perfect for intraobserver agreement and slight to almost perfect for interobserver agreement in analyzing the percentage of CG under the glenoid equator.

Conclusion: The variability of ICC values observed implies that caution should be taken in interpreting results regarding the CG position on 2-dimensional CT scans. This discrepancy is mainly explained by the difficulty in orienting the glenoid in the sagittal plane before any other parameter is measured.
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http://dx.doi.org/10.1016/j.jse.2016.12.067DOI Listing
August 2017

The Hidden Lesion of the Subscapularis: Arthroscopically Revisited.

Arthrosc Tech 2016 Aug 15;5(4):e877-e881. Epub 2016 Aug 15.

Ramsay, Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.

The "hidden lesion" refers to a tear of the subscapularis in the presence of an intact biceps pulley or rotator interval. Visualization of these tears during open surgery is difficult, yet even with the advancement of arthroscopy, visualization can still be challenging. Incomplete visualization of the subscapularis could lead to failure to diagnose a tear of the tendon and subsequently hinder results after shoulder surgery. With the advancement of arthroscopy, a technique to identify these hidden lesions is needed to avoid inferior results. We describe an arthroscopic technique to visualize, diagnosis, and repair these tears when clinically indicated. Implementing this technique in the setting of suspected subscapularis tendon injury can provide complete visualization of the tendon insertion.
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http://dx.doi.org/10.1016/j.eats.2016.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5040480PMC
August 2016

Arthroscopic Distal Clavical Resection Using "Vis-à-Vis" Portal.

Arthrosc Tech 2016 Jun 27;5(3):e667-70. Epub 2016 Jun 27.

Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy, Lyon, France.

Arthroscopic distal clavicle resection has become an increasingly popular procedure in orthopaedics, and various techniques have been published. Many of the arthroscopic distal clavicle resection techniques that have been reported require visualization from the lateral portal with an anterior working portal to perform the resection. While these techniques have reported high success rates, there is often difficulty in viewing the entire acromioclavicular joint from the 2 standard arthroscopic portals (lateral and anterior). This is due to the medial edge of the acromion blocking the ability to visualize the most superior and posterior portions of the distal clavicle. We propose a technique for arthroscopic distal clavicle resection using an accessory anterior portal.
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http://dx.doi.org/10.1016/j.eats.2016.02.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5021634PMC
June 2016

What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears?

Clin Orthop Relat Res 2015 Sep 12;473(9):2959-66. Epub 2015 Jun 12.

Saint-Grégoire Private Hospital Center, Saint-Grégoire Cedex, France.

Background: Few studies define the clinical signs to evaluate the integrity of teres minor in patients with massive rotator cuff tears. CT and MRI, with or without an arthrogram, can be limited by image quality, soft tissue density, motion artifact, and interobserver reliability. Additionally, the ill-defined junction between the infraspinatus and teres minor and the larger muscle-to-tendon ratio of the teres minor can contribute to error. Therefore, we wished to determine the validity of clinical testing for teres minor tears.

Question/purposes: The aim of this study was to determine the accuracy of commonly used clinical signs (external rotation lag sign, drop sign, and the Patte test) for diagnosing the teres minor's integrity.

Methods: We performed a prospective evaluation of patients referred to our shoulder clinic for massive rotator cuff tears determined by CT arthrograms. The posterosuperior rotator cuff was examined clinically and correlated with CT arthrograms. We assessed interobserver reliability for CT assessment and used three different clinical tests of teres minor function (the external rotation lag sign, drop sign, and the Patte test). One hundred patients with a mean age of 68 years were available for the analysis.

Results: The most accurate test for teres minor dysfunction was an external rotation lag sign greater than 40°, which had a sensitivity of 100% (95% CI, 80%-100%) and a specificity of 92% (95% CI, 84%-96%). External rotation lag signs greater than 10° had a sensitivity of 100% (95% CI, 80%-100%) and a specificity of 51% (95% CI, 40%-61%). The Patte sign had a sensitivity of 93% (95% CI, 70%-99%) and a specificity of 72% (95% CI, 61%-80%). The drop sign had a sensitivity of 87% (95% CI, 62%-96%) and a specificity of 88% (95% CI, 80%-93%). An external rotation lag sign greater than 40° was more specific than an external rotation lag sign greater than 10° (p < 0.001), and a Patte sign (p < 0.001), but was not more specific than the drop sign (p < 0.47). There was poor correlation between involvement of the teres minor and loss of active external rotation.

Conclusions: Clinical signs can predict anatomic patterns of teres minor dysfunction with good accuracy in patients with massive rotator cuff tears. This study showed that the most accurate test for teres minor dysfunction is an external rotation lag sign and that most patients' posterior rotator cuff tears do not lose active external rotation. Because imaging is not always accurate, examination for integrity of the teres minor is important because it may be one of the most important variables affecting the outcome of reverse shoulder arthroplasty for massive rotator cuff tears, and the functional effects of tears in this muscle on day to day activities can be significant. Additionally, teres minor integrity affects the outcomes of tendon transfers, therefore knowledge of its condition is important in planning repairs.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1007/s11999-015-4392-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523548PMC
September 2015

Comma sign-directed repair of anterosuperior rotator cuff tears.

Arthrosc Tech 2014 Dec 1;3(6):e695-8. Epub 2014 Dec 1.

Shoulder Unit, Centre Orthopédique Santy, Lyon, France.

The comma sign was described as an arthroscopic landmark to identify the torn subscapularis stump to mobilize and repair the tendon in anterosuperior rotator cuff tears. It was hypothesized that it is composed of the humeral attachments of the superior glenohumeral and coracohumeral ligaments. This arthroscopic finding has since become accepted orthopaedic nomenclature pathognomonic for subscapularis tears and a key component of subscapularis tear classification. We propose an alternative theory of the pathoanatomy of the comma sign in anterosuperior rotator cuff tears and present the technique of comma sign-directed repairs of combined subscapularis and supraspinatus lesions. After appropriate releases, tendon-to-tendon repair of the distal-superior aspect of the comma sign to the upper border of the remnant subscapularis results in anatomic re-creation of the intra-articular portion of the torn subscapularis with concomitant reduction of the anterior leading edge of the supraspinatus and reconstitution of the rotator cable complex. A tension-free, single-anchor subscapularis repair is then performed to secure the tendon to the lesser tuberosity. After subscapularis repair, the supraspinatus that was previously retracted to the glenoid rim takes the appearance of a crescent-type tear that is easily approximated to its anatomic insertion.
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http://dx.doi.org/10.1016/j.eats.2014.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314558PMC
December 2014

The "comma sign": an anatomical investigation (dissection of the rotator interval in 14 cadaveric shoulders).

Surg Radiol Anat 2015 Sep 17;37(7):793-8. Epub 2015 Jan 17.

Centre Orthopédique Santy, Unité épaule, 24, Avenue Paul Santy, 69008, Lyon, France.

Purpose: The aim of the present study was to describe the precise anatomy of the so-called "Comma Sign" which has been observed during arthroscopy in retracted subscapularis (SSC) tears.

Methods: Fourteen fresh cadaveric shoulders were prepared to obtain an articular view comparable to arthroscopic posterior portal view. A step-by-step dissection was carried out to verify the presence of any anatomic structure inserting directly on the lateral margin of the SSC tendon. A sequential detachment of the superior gleno-humeral ligament (SGHL), the coraco-humeral ligament (CHL), and the SSC tendon from their bony humeral insertions was performed. Under intra-articular and extra-articular view, the SSC and its connections with the supraspinatus (SS), the SGHL and the CHL were evaluated.

Results: The detachment of the CHL and the SGHL from the humerus did not reveal any structure directly inserted on the superior-lateral margin of the SSC tendon. However, when the SSC tendon was excised from the lesser tuberosity and pulled medially, a bundle of fibers, which inserted directly onto its superior-lateral edge, was constantly observed.

Conclusions: We constantly found an effective link between the superior-lateral corner of the SSC tendon and a bundle of fibers coming from SS and CHL. It became visible only after medial traction of the detached SSC. This structure yields the "Comma Sign" in subscapularis tendon tears.
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http://dx.doi.org/10.1007/s00276-015-1420-0DOI Listing
September 2015
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