Scientific Program

01 - Rotator Cuff

Moderators :
Jeno Kiss (Hungary)
Christophe Lévigne (France)

Failed rotator cuff repair - what are the reasons in arthroscopic and open repair ?
A Hedtmann (Hamburg - GERMANY)
Purpose
Structural non-healing after RC repair in the majority of patients does not necessarily lead to a bad clinical result. The purpose of this investigation is to find reasons for clinical failure in arthroscopic and open rotator cuff surgery.
Material and Methods
We retrospectively analyzed the files of a continously feeded databank with failed shoulder operations from 1995 to 2010. One of the inclusion criteria was
Re-operation (open or arthroscopic) in our hospital with arthroscopy.
Results
We found 216 cases of previous open and 48 cases of arthroscopic rotator cuff repair with bad results. In the open group, 61,6 % had a complete recurrent tear, in the arthroscopic group 81,3 % . The primary defect was smaller /greater than the original one in the open group in 60,9 % vs. 39,1 % and in 43,6 % vs. 54,4 % in the arthroscopic group. A symptomatic long head of biceps with structural lesion was present in 31.5 % of the open and 29.2 % of the arthroscopic group.
A non-adequate subacromial decompression (false plane of resection, too wide resection, insufficient bony resection) was found in 36.1 % of the open and in 39,6 % of the arthroscopic group. Symptomatic AC arthritis was found in 36.1 % of the open group and in 29.2 % of the arthroscopic group. A false ACJ resection was found in 5.1 % of open and 8.3 % of the arthroscopic group.We found an average of 2.43 failures/complications in the open group and in the arthroscopic group 2.75 per patient.
All re-tears of the RC in the open group occured in the classic manner laterally at the insertion site of the RC. In contrast, 25.6 % of the re-tears after arthroscopic repair occured medially to the anatomic neck.
ConclusionBeside structural non-healing of the cuff, there is high rate of technical failures of subacromial decompression and ACJ procedures. A high number of cases with so called failed rotator cuff tear obviously becomes or stays symptomatic due to other reasons than missing structural healing of the cuff.

Natural history of rotator cuff tears: a clinical and radiological evaluation after conservative treatment
A de Carli , A Ciompi, RM Lanzetti, A Vadala, C Iorio, A Ferretti (Rome - ITALY)
Purpose
The natural history of rotator cuff tears is not well known. The aim of this study was to analyze the clinical and radiological evolution of non-operatively managed rotator cuff tears.
Material and Methods
Thirty-eight patients conservatively treated after a diagnosis of rotator cuff documented by MRI (T0-MRI), were enrolled in this study. At T0 there were 19 full-thickness tears (group C), 12 partial-articular (group A) and 7 partial-bursal (group B) cuff tears. At follow-up, all patients underwent clinical examination and a new MRI (T1).
Results
The mean follow-up was 62 months. According to T0-MRI diagnosis (group A, B or C), we found a significant trend in group B toward a complete tear in 6 cases (85.7%) (p = <0.001), while this percentage was only 25% in group A (3 cases). Moreover, patients of groups B and C showed a significant evolution of : cuff tear size (group B : p = <0.05 ; group C : p = <0.001) ; fatty-infiltration and muscle-atrophy (group B : p = <0.05 ; group C : p = <0.001) ; medial tendon retraction (group B : p = <0.03 ; group C : p = <0.001). In group A we found a significant evolution only in regard to fatty-infiltration and muscle-atrophy (p = 0.02 and p = 0.014 respectively). Simple Shoulder Test and Constant Score results did not correlate to the radiological evolution.
Conclusion
Patients with a T0 diagnosis of complete or bursal cuff tear showed significant clinical worsening, while most patients with articular tears remained unchanged. In patients of groups B and C, the number of tendons, tear size, medial tendon retraction, fatty infiltration and muscle atrophy significantly worsened by final follow-up.

Change of fatty degeneration of the supraspinatus following rotator cuff repair as measured by occupation ratio
JH Oh , SW Chung, SH Kim, JY Kim, YH Kim, BW Song (Gyeonggi-Do - KOREA, REPUBLIC OF, Seoul - KOREA, REPUBLIC OF)
Purpose
To evaluate the change of fatty degeneration (FD) of the supraspinatus muscle after surgical repair.
Material and Methods
One hundred ninety-one patients with full-thickness rotator cuff tears who underwent both preoperative MRI and postoperative multidetector CT (MDCT) at a mean of 13.2 ±4.8 months after operation were enrolled in this study (mean age, 59.7± 7.9 years). We measured FD of the supraspinatus using MR T1-weighted images and MDCT by calculating the occupation ratio using Photoshop CS3 software, and after defining FD improvement as more than a 10% increase in occupation ratio and FD aggravation as more than a 10% decrease. We evaluated the differences in various clinal factors between the FD improvement group and the FD aggravation group. Further, we assessed the association between FD change and cuff integrity after surgical cuff repair.
Results
Fatty degeneration, quantified as occupation ratio, was significantly improved from 0.49 ±0.17 preoperatively to 0.53 ±0.16 postoperatively (p < 0.001), and the number of patients whose FD improved by more than 10% was 81 of 191 patients (42.4%). FD improved regardless of age, retraction length, or preoperative occupation ratio, however, the proportion of unhealed cuffs was significantly higher in the FD aggravation group (16 of 33 patients, 48.5%) compared with the FD improvement group (18 of 81 patients, 22.2% ; p = 0.007).
Conclusion
Unlike previous suggestions that the FD of rotator cuffs is an irreversible phenomenon, FD of the supraspinatus measured by occupation ratio was improved in a large proportion of the cases (42.4%) postoperatively, regardless of age, retraction length, or preoperative occupation ratio. However, in patients with unhealed cuffs, the FD became worse postoperatively.

Anabolic steroids prevent muscle damage caused by rotator cuff tendon tear – An experimental study in rabbits
C Gerber , DC Meyer, KM Nuss, M Farshad (Zurich - SWITZERLAND)

Purpose
Following chronic tear of their tendon, rotator cuff muscles undergo retraction, atrophy and fatty infiltration. These changes are inevitable, considered irreversible and limit the potential of successful repair of musculotendinous units. It was the purpose of this study to test the hypothesis that administration of anabolic steroids can diminish these muscular changes following experimental supraspinatus tendon release in the rabbit.
Material and Methods
The supraspinatus tendon was experimentally released in 20 New Zealand rabbits. Musculotendinous retraction was monitored over a period of 6 weeks. The seven animals in group I had no additional intervention, 6 animals in group II had local and seven animals in group III had systemic administration of nandrolone deconate during six weeks of retraction. Two animals (in group III) developed a postoperative infection and were excluded from the analysis. At the time of sacrifice, in-vivo muscle performance as well as radiologic and histologic muscle changes were investigated.
Results
Supraspinatus retraction was significantly higher in group I (1.8±0.2 cm) than in group II (1.5±0.3 cm, p = 0.044) or III (1.2±0.3 cm, p = 0.001). The reduction in radiological cross sectional area, as a measure for atrophy, was significant in groups I (p = 0.013) and II (p = 0.030), not in group III (p = 0.149). Histologically, there was no fatty infiltration in the treated groups II (p = 1.000) and III (p = 0.812), but in the untreated group I (p = 0.0312). The work of the respective muscle during one standardized contraction with supramaximal stimulation decreased in groups I (p = 0.056) and II (p = 0.0528), and also but less so in group III (p = 0.23).
Conclusion
This is the first documentation of partial prevention of important muscle alterations after retraction of the musculotendinous unit caused by rotator cuff tear. Nandrolone deconate administration in the post tendon release phase prevented fatty infiltration of the supraspinatus muscle and reduced functional muscle impairment caused by myo-tendinous retraction.

A clinical and anatomical randomized study of immediate passive motion versus immobilization after arthroscopic supraspinatus repairs
P Clavert , J Arndt, P Mielcarek, JF Kempf (Strasbourg - FRANCE)
Purpose
Rehabilitation after cuff repair must allow function restitution without affecting cuff healing. The purpose of this coutinous randomized study was to compare clinical and anatomical outcomes after 2 protocols of rehabilitation following supraspinatus repair : immediate passive motion versus immobilization.
Material and Methods
We observed 100 patients, mean age 55 years, who underwent an arthroscopic full-thickness supraspinatus tear repair. Post-operative rehabilitation was randomized between « immediate passive motion » or « immobilization » during the first six weeks. A clinical evaluation was performed for 92 patients with a mean follow-up of 16 months (range of motion, Constant score) and a CT-arthrogram for 82 patients between 6 and 28 months after surgery.
Results
Mean Constant score improved from 46.1 preoperatively to 73.9 at follow-up (p<0.001). The rotator cuff was watertight in 48 out of 82 patients. Better range of motion and function restitution at follow-up were noted after passive motion : mean passive external rotation at 58.7° versus 49.1° (p = 0.011), mean passive forward elevation at 172,4° versus 163,3° (p = 0,094), mean Constant score at 77.6 versus 69.7 (p = 0.045). The rate of stiffness and frozen shoulder was higher after immobilization. CT-arthrography found a normal healed tendon in 25.6% of the patients after passive motion versus 35.9% after immobilization, an intratendinous addition image in 30.2% versus 25.6%, a minor leak in 20.9% versus 23.1%, and a recurrent tear in 23.3% versus 15.4% (p = 0.669). The rate of watertight cuff was 55.8% after passive motion versus 61.5% after immobilization (p = 0.382).
Conclusion
The protocol of rehabilitation wich can give the best tendon healing without shoulder stiffness have not been established yet. Our results promoted the use of an early passive motion : functional results after this protocol of rehabilitation were better, without statistically difference on the tendon healing. However, the optimal protocol may reside somewhere between both.

A clinical and anatomical randomized study of immediate passive motion versus immobilization after arthroscopic supraspinatus repairs
P Clavert , J Arndt, P Mielcarek, JF Kempf (Strasbourg - FRANCE)

Purpose
Rehabilitation after cuff repair must allow function restitution without affecting cuff healing. The purpose of this coutinous randomized study was to compare clinical and anatomical outcomes after 2 protocols of rehabilitation following supraspinatus repair : immediate passive motion versus immobilization.
Material and Methods
We observed 100 patients, mean age 55 years, who underwent an arthroscopic full-thickness supraspinatus tear repair. Post-operative rehabilitation was randomized between « immediate passive motion » or « immobilization » during the first six weeks. A clinical evaluation was performed for 92 patients with a mean follow-up of 16 months (range of motion, Constant score) and a CT-arthrogram for 82 patients between 6 and 28 months after surgery.
Results
Mean Constant score improved from 46.1 preoperatively to 73.9 at follow-up (p<0.001). The rotator cuff was watertight in 48 out of 82 patients. Better range of motion and function restitution at follow-up were noted after passive motion : mean passive external rotation at 58.7° versus 49.1° (p = 0.011), mean passive forward elevation at 172,4° versus 163,3° (p = 0,094), mean Constant score at 77.6 versus 69.7 (p = 0.045). The rate of stiffness and frozen shoulder was higher after immobilization. CT-arthrography found a normal healed tendon in 25.6% of the patients after passive motion versus 35.9% after immobilization, an intratendinous addition image in 30.2% versus 25.6%, a minor leak in 20.9% versus 23.1%, and a recurrent tear in 23.3% versus 15.4% (p = 0.669). The rate of watertight cuff was 55.8% after passive motion versus 61.5% after immobilization (p = 0.382).
Conclusion
The protocol of rehabilitation wich can give the best tendon healing without shoulder stiffness have not been established yet. Our results promoted the use of an early passive motion : functional results after this protocol of rehabilitation were better, without statistically difference on the tendon healing. However, the optimal protocol may reside somewhere between both.

Partial articular-sided supraspinatus tear: a comparison between transtendon repair and tear completion and repair
A Castagna , S Gumina, M Borroni, G Delle Rose, M Conti, R Garofalo (Milano - ITALY, Roma - ITALY, Bari - ITALY)

Purpose
Partial articular sided supraspinatus tear is a common type of rotator cuff tear, often cause of pain generally nocturne and real or apparent weakness of the rotator cuff. Different ways of treatment have been proposed, but in case of repair of the lesion it's not clear whether transtendon repair or complete/repair the tear is better. The purpose of this study is to compare the clinical and subjective difference between these two techniques in two homolougus groups.
Material and Methods
74 patients with a partial tear of the supraspinatus confirmed with arthroscopy were randomized in two groups of 37 patients each. The first group (A) was treated with a transtendon repair while the second group (B) was treated with a completion of the tear and a formal repair. Both groups were treated with arthroscopic techniques and all the patients were revaluated at a minimum follow up of two years with Constant score (CS) and Visual Analogic Scale (VAS).
Results
In group A the Constant score improved by a mean value of 25.15 (from 62.45 to 87.61) and VAS score of a mean value of 3.48 (from 8.85 to 5.37). In group B the Constant score improved by a mean value of 29.02 (from 57.82 to 86.85) and VAS score of a mean value of 3.67 (from 9.1 to 5.4). The data are similar but analyzing the subgroup of the Constant Score, we noticed that the improvement was higher in both group for the Activities of Daily Living and that in Group B the improvement in strength was higher than in Group A.
Conclusion
We conclude that a repair in partial articular-sided supraspinatus tear provide good results in term of function and pain regardless the technique of repair.
But the completion and the repair of the tear provide better results in strength than a transtedon repair.

Mayday Shoulder Score: Validation of a patient based questionnaire for rotator cuff disorders
A Iossifidis , C Petrou (London - UNITED KINGDOM)

Purpose
The purpose of this study was to validate the Mayday Shoulder Score (MSS). It is an 11-item, patient-based shoulder self-assessment questionnaire, evaluating patients presenting with rotator cuff disorders.
Material and Methods
119 patients completed the Mayday Shoulder score (patient based) and the Constant score (doctor based), preoperatively and 6 months following arthroscopic rotator cuff repair. The MSS consists of two categories, pain and activities of daily living. The results of the two scores were compared and the data were analyzed to assess the reliability, validity and responsiveness of the MSS. Forty patients were selected randomly to assess test-retest reliability. Statistical analysis was performed using the Statistical Package of the Social Sciences. The critical level for significance was chosen at p < 0.05.
Results
Reliability analysis revealed a test-retest Pearson\'s correlation coefficient of 0.96 (95% CI, 0.92-0.98) showing that the MSS was highly consistent on different occasions. Internal consistency analysis revealed a Cronbach alpha of 0.93 suggesting that items are interdependent and homogeneous in terms of the construct they measure Construct validity tests revealed that the correlation coefficient between the total MSS and Constant score were 0.782 and 0,737 preoperatively and postoperatively respectively (p < 0.0005) indicating a very strong correlation between the 2 questionnaires. The MSS also showed a very high responsiveness to clinical change (p<0.0005).
Conclusion
The Mayday Shoulder Score is a patient-based device that can be incorporated into a busy clinical practice and provides a quick, reliable, valid and practical measure of outcome for rotator cuff disorders.


02 - Shoulder Fractures

Moderator :
J Garret (France),
R Hertel (Switzerland)

Early functional results of the reverse shoulder prosthesis for acute fracture in elderly are improved by tuberosity healing
F Sirveaux , F Wein-Remy, D Block, J Sedaghatian, O Roche, D Molé (Nancy - FRANCE)

Purpose
The reverse shoulder arthroplasty (RSA) is used in acute fracture in elderly people to avoid complications of hemiarthroplasty related to tuberosity healing. The goal of this study was to analyze the influence of tuberosity healing after RSA for fracture. We hypothesized that the healing of the greater tuberosity should improve the early clinical results.
Material and Methods
62 patients (av. Age 79 years) have been operated by implanting a RSA through a superolateral approach with tuberosities fixation and supra-spinatus removal. All of them participated in an early rehabilitation program. The patients available for functional evaluation (active mobility, Constant score) at a minimum FU of 6 months were included. The tuberosities healing were assessed on X-rays at last FU.
Results
We noticed 4 complications : one acromial fracture, one traumatic humeral shaft fracture, one infection and one early glenoid component loosening. 47 cases were included. At a mean FU of 30 months, the active anterior elevation averaged 120 degrees and the mean Constant score was 55 points. 89% were painfree. The rate of greater and lesser tuberosity healing were respectively 85% and 98%. The greater tuberosity healing influenced significantly the active external rotation recovery (-4 versus 10 degrees), the constant score (41 versus 57 points) and the active elevation (88 versus 124 degrees).
Conclusion
The tuberosity fixation does not compromize an early rehabilitation program. The healing of the greater tuberosity is necessary for the recovery in active external rotation. It improves significantly the active mobility in elevation and the functional results.

Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review
S Brorson , JV Rasmussen, LH Frich, BS Olsen, A Hrobjartsson (Copenhagen - DENMARK, Odense - DENMARK)

Purpose
To systematically review clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in intraarticular fractures (OTA Type C) of the proximal humerus.
Material and Methods
We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently.
Results
Twelve studies and 282 Type C fractures were included. Results were categorised according to the type of study and synthesized qualitatively. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range 4-33%), screw perforations (range 5-20%), loss of fixation (range 3-16%), impingement (range 7-11%) and infections (range 4-19%). Reoperation rate ranged from 6 to 44%.
Conclusion
Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in OTA Type C fractures.

Hemiarthroplasty versus non-operative treatment of displaced 4-part proximal humeral fractures in elderly patients. a randomized controlled trial
P Olerud , L Ahrengart, S Ponzer, J Saving, J Tidermark (Stockholm - SWEDEN)

Purpose
The aim of the study was to report the 2-year outcome after a displaced 4-part fracture of the proximal humerus in elderly patients randomized to treatment with a hemiarthroplasty (HA) or non-operative treatment.
Material and Methods
We included 55 patients, mean age 77 (58 to 92) years, 86% being women. Follow-up examinations were done at 4, 12 and 24 months. The main outcome measures were health-related quality of life (HRQoL) according to the EQ-5D and the DASH and Constant scores.
Results
At the final 2-year follow-up the HRQoL was significantly better in the HA group compared to the non-operative group, EQ-5D index score 0.81 compared to 0.65 (p = .02). The results for DASH and pain assessment were both in favor of the HA group, DASH score 30 versus 37 (p = .25) and pain according to VAS 15 versus 25 (p = .17). There were no significant differences regarding the Constant score or range of motion (ROM). Both groups achieved a mean flexion of approximately 90-95° of and a mean abduction of 85-90°. The need for additional surgery was low : 3 patients in the HA group and 1 patient in the non-operative group.
Conclusion
The results of the study demonstrated a significant advantage in quality of life in favor of HA as compared to non-operative treatment in elderly patients with a displaced 4-part fracture of the proximal humerus. The main advantage of HA appeared to be less pain. However, despite the use of a modern fracture prosthesis and an appropriate surgical technique with a low reoperation rate, there were no differences in ROM.


Interest of the tuberosities reinsertion in complex shoulder fractures treated by reversed prosthesis
D Gallinet , A Adam, N Gasse, S Rochet, L Obert (Besançon - FRANCE)
Purpose
Reversed prosthesis in complex shoulder fractures is now a common practice. Unfortunately, the shelf life of the implants constrain the use for old people and the loss of rotations induced by the suppression of the tuberosities is responsible for handicap in daily life of our patients, how old there are. The purpose of this study was to evaluate the advantage of tuberosities reinsertion on the functional result after reversed prosthesis for complex shoulder fracture.
Material and Methods
Forty-two patients on fifty-four operated was retrospectively reviewed by an independent evaluator. The mean age of the population was seventy-six years and the patients were reviewed at mean follow-up of twenty-three months. Twenty-eight patients have benefit of tuberosities reinsertion by the Boileau's technique described for hemiarthroplasties, the supraspinatus was systematically removed. The tuberosities were totally removed in the fourteen other cases. All patients have benefit of prosthesis radio. Two groups were defined. In the group one we find the patients with an anatomic consolidation of the tuberosities around the reversed prosthesis. In the group two, we find the patients with mal-union, and non-union of the tuberosities or absence of tuberosities reinsertion.
Results
2/3 of the tuberosities reinserted have consolidated in anatomic position. So we found eighteen patients in the group one and twenty-two in the group two. All the mobilities were statistically better in the group one, especially in the sector of rotations, along with the constant score and the Dash Score. All items of the constant score were statistically improved in the group one, except the pain that was comparable. However the rate of radiological scapular notch was similar in the two groups (70%).
Conclusion
What was envisaged by a lot of authors is verified by this study : the tuberosities reinsertion enables to regain rotations and also to ameliorate significantly the quality of life of our patients. The rate of anatomic tuberosities consolidation is correct (66%) for the mean age of the population. But this rate must be probably improved by the development of reversed prosthesis especially dedicated to traumatology. Unfortunately this study is not enabling to decrease the limit age of implantation, commonly fixed at 70 years old, because of scapular notch percentage in the two groups. To conclude, we can maintain by this study that we must reinsert the tuberosities in complex shoulder fractures treated by reversed prosthesis. The excision of the tuberosities is not recommended.

Risk factors for clinical outcome of fractures to the proximal humerus
F Domaszewski , M Gregori, H Binder, C Fialka (Vienna - AUSTRI
A)
Purpose
Fractures to the proximal humerus represent the third most frequent fracture in the elderly population and the incidence has considerably increased during the last fifty years. Several risk factors are known to favour the appearance of fractures to the proximal humerus. It is still not known which risk factors predict a negative therapeutic outcome independent of operative or non-operative treatment.
Material and Methods
Over a period of twelve months, 188 consecutive patients (66 men, 122 women, average 65 years) with fractures of the proximal humerus were included in a prospective study design, independent of fracture type and non-operative or operative treatment. After the patients' affirmation a standardised questionnaire was used to collect epidemiological data. This questionnaire evaluated 30 different general medical risk factors. Radiologic and clinical examinations were performed 3 and 6 month after trauma, using plain x-ray and the Individual Relative Constant Score. The objective was the investigation of therapy-independent risk factors, which lead to negative therapeutic outcome of fractures to the proximal humerus. A negative therapeutic outcome was defined as Individual Relative Constant Score < 70%.
Results
Six months after trauma 61 patients (23 male, average 70 years) showed poor therapeutic outcome with an Individual Relative Constant Score <70% (Group A), with menopause (36/61), Body Mass Index >25 (35/61 patients) and intake of β-blocker (26/61) as most frequent risk factors. 127 patients with good clinical outcome and an Individual Relative Constant Score >70% (Group B) had menopause (75/127), Body Mass Index >25 (62/161) and intake of proton pump inhibitors (47/127) as most frequent risk factors. The comparison of both groups showed higher incidence of Body Mass Index >25 (10,2%), chronic alcoholism (10,1%) and intake of β-blocker (9,5%) in Group A with poor therapeutic outcome.
Conclusion
The prevalence of the described risk factors is a prognostic factor for poor clinical outcome. Obesity, chronic alcoholism and β-blocker medication are risk factors which lead to poor shoulder function, independent of fracture type or treatment modality.

Complications after Locking Plate Fixation of Fractures of the Proximal Humerus
C Gerber , C Spross, H Grehn, B Jost (Zurich - SWITZERLAND, Chur - SWITZERLAND)

Purpose
Locking plates for open reduction and internal fixation (ORIF) of proximal humerus fractures are widely used. An increasing number of patients with complications has been referred to our institution in recent years. This study is a report of these cases
Material and Methods
From 2003 to 2010 all patients treated with complications after ORIF of proximal humeral fractures with locking plates were prospectively collected and retrospectively analyzed. In patients necessitating revision surgery the clinical outcome was assessed with the Constant Score (CS), the radiographic evolution with standardized radiographs.
Results
121 patients (mean age 59 years) with complication(s) after primary locking plate ORIF were included. The complications observed were : initial malreduction, malunion, avascular necrosis, nonunion and infection. Glenohumeral perforation of head screws was seen in 83 patients with (partial) destruction of the glenoid in 40 patients. 107 patients needed revision surgery, anatomical hemi- or total shoulder arthroplasty (n = 37) improved the mean CS from 27 to 49 points and reverse shoulder arthroplasty (n = 29) from 20 to 44 points after a mean of 24 months (p < 0.05). For 6 patients only hemiarthroplasty was possible as a salvage procedure due to glenoid destruction by perforated screws.
Discussion
Most complications were major and more than 50% needed revision arthroplasty. Complete destruction of the glenoid by locking screws was the most devastating and previously almost unseen complication. ORIF of proximal humerus fractures with locking plates should be carried out with the awareness that at least one large referral center observes an intimidating number of often severe complications using this technique

Complications after Locking Plate Fixation of Fractures of the Proximal Humerus
C Gerber , C Spross, H Grehn, B Jost (Zurich - SWITZERLAND, Chur - SWITZERLAND)

Purpose
Locking plates for open reduction and internal fixation (ORIF) of proximal humerus fractures are widely used. An increasing number of patients with complications has been referred to our institution in recent years. This study is a report of these cases
Material and Methods
From 2003 to 2010 all patients treated with complications after ORIF of proximal humeral fractures with locking plates were prospectively collected and retrospectively analyzed. In patients necessitating revision surgery the clinical outcome was assessed with the Constant Score (CS), the radiographic evolution with standardized radiographs.
Results
121 patients (mean age 59 years) with complication(s) after primary locking plate ORIF were included. The complications observed were : initial malreduction, malunion, avascular necrosis, nonunion and infection. Glenohumeral perforation of head screws was seen in 83 patients with (partial) destruction of the glenoid in 40 patients. 107 patients needed revision surgery, anatomical hemi- or total shoulder arthroplasty (n = 37) improved the mean CS from 27 to 49 points and reverse shoulder arthroplasty (n = 29) from 20 to 44 points after a mean of 24 months (p < 0.05). For 6 patients only hemiarthroplasty was possible as a salvage procedure due to glenoid destruction by perforated screws.
Discussion
Most complications were major and more than 50% needed revision arthroplasty. Complete destruction of the glenoid by locking screws was the most devastating and previously almost unseen complication. ORIF of proximal humerus fractures with locking plates should be carried out with the awareness that at least one large referral center observes an intimidating number of often severe complications using this technique

Predicting failure after surgical fixation of proximal humerus fractures
C Hengg (Innsbruck - AUSTRIA)

Purpose
Several studies reported high failure rates after internal fixation of proximal humerus fractures (PHF). Loss of reduction and screw cut-out are the most common reasons for revision surgery. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable PHF.
Material and Methods
Two different surgical techniques (PHILOS locking plate and Humerusblock) were compared in overall 67 patients. Local cancellous BMD (CT based) of the uninvolved side, age, sex and various other potential risk factors were examined. Postoperatively the anatomical reconstruction was assessed, especially of the medial hinge. Bone implant insufficiencies leading to consecutive mal- or nonunion were assessed.
Results
Failure occurred in 13 patients (19,4%). These were significantly older and had lower local BMD values (t-test, p < 0.05). Anatomic reduction and restoration of the medical cortical support were significantly less frequent in this group (Fisher's Exact-test, p < 0.05). Thus, the following four parameters were defined as risk factors : age > 63 years, local BMD < 95 mg/cm3, no anatomic reduction, no restoration of the medial cortical support. Failure rate significantly increased with the number of risk factors (Chi-square test, p < 0.05) up to 85.7% in patients with four risk factors.
Discussion
Local BMD and the patients' age as well as intraoperative anatomic reduction and restoration of the medial cortical support are essential for successful surgical fixation of PHF. If the surgeon is not able to achieve intrinsic stability of the fracture by meticulous anatomic reduction and restoration of the medial cortical support in this situation, adjustments such as augmentation or primary arthroplasty might be considered due to the high risk for failure.

Predicting failure after surgical fixation of proximal humerus fractures
C Hengg (Innsbruck - AUSTRIA)

Purpose
Several studies reported high failure rates after internal fixation of proximal humerus fractures (PHF). Loss of reduction and screw cut-out are the most common reasons for revision surgery. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable PHF.
Material and Methods
Two different surgical techniques (PHILOS locking plate and Humerusblock) were compared in overall 67 patients. Local cancellous BMD (CT based) of the uninvolved side, age, sex and various other potential risk factors were examined. Postoperatively the anatomical reconstruction was assessed, especially of the medial hinge. Bone implant insufficiencies leading to consecutive mal- or nonunion were assessed.
Results
Failure occurred in 13 patients (19,4%). These were significantly older and had lower local BMD values (t-test, p < 0.05). Anatomic reduction and restoration of the medical cortical support were significantly less frequent in this group (Fisher's Exact-test, p < 0.05). Thus, the following four parameters were defined as risk factors : age > 63 years, local BMD < 95 mg/cm3, no anatomic reduction, no restoration of the medial cortical support. Failure rate significantly increased with the number of risk factors (Chi-square test, p < 0.05) up to 85.7% in patients with four risk factors.
Discussion
Local BMD and the patients' age as well as intraoperative anatomic reduction and restoration of the medial cortical support are essential for successful surgical fixation of PHF. If the surgeon is not able to achieve intrinsic stability of the fracture by meticulous anatomic reduction and restoration of the medial cortical support in this situation, adjustments such as augmentation or primary arthroplasty might be considered due to the high risk for failure.

Surgically Treated Humeral Shaft Fractures Following Shoulder Arthroplasty
M Frankle (Tampa - UNITED STATES)

Purpose
The limited literature that exists on surgical treatment of periprosthetic humerus fractures excludes patients with reverse implants. The purpose of this study is to describe the surgical treatment of periprosthetic fractures and report on their outcomes.
Material and Methods
From 1998-2010 (37) patients with existing prostheses-18 anatomic and 19 reverse anatomic-were surgically treated for humerus fractures at one institution. Of these, 17 were treated with open reduction & internal fixation (ORIF) and 18 with a stem revision (two intra-operative fracture cases were excluded). An attempt was made to classify each fracture. Radiographic union, complication rates, range of motion, and functional scores were reported.
Results
Fractures treated with ORIF healed at 6.8 months (range 3.25-12) and 8/17 patients required an allograft strut. Average ASES score was 41.5 (range 1.67-80) at most recent follow-up of 21.8 months (range 4-84).Fractures treated with a long-stemmed revision healed at 8.0 months (range 3.5-13.5) and 15/18 patients required an allograft strut. Average ASES score was 56.5 (range 35-85) at most recent follow-up of 43.7 months (range 4-152).Additionally, 8/18 in this group could not be classified by any existing periprosthetic fracture classification system. There were 16 total complications, six of which required re-operation.
Discussion
Union occurred in 94% of patients, 66% required a structural allograft, and 17% required re-operation. Half of the patients in this study required long-stemmed revisions due to loose humeralcomponents. Fractures occurring around a well fixed stem can be successfully treated with primary ORIF, with or without allograft. Existing classification systems may not adequately describe and allow for proper management of periprosthetic fractures. The surgeon must be prepared to manage these difficulties with extensile approaches, revision long-stemmed components, structural allograft, cables, and locked plating systems-

More information interferes observer agreement in the categorization of proximal humerus fractures
C Torrens , X Piqueres, E Cassart, R Goberna, A Rosales, JM Mora (Barcelona - SPAIN)

Purpose
The aim of this study is to evaluate concordance and reproducibility in the characterization of proximal humeral fractures when analyzed by complete CT scan/x-ray versus only axial view CT scan/x-ray.
Material and Methods
6 observers analyzed 153 fractures twice. 22 characteristics were checked divided into five groups : cephalodiaphyseal relationship (CDR), tuberodiaphyseal relationship, cephalotuberosity relationship, humeral head and cephaloglenoid relationship and Fracture fragment description. In each reading exam two groups were set which differ in the CT scan projection views analyzed. First group consisted in complete CT and AP/Y scapula view x-ray (Group 1) ; and second group was formed by only axial view CT scan and AP/Outlet x-ray (Group 2). To perform the descriptive statistical analysis, the Kappa Index was used.
Results
In almost all the categories studied Group 2 scored better than Group 1, as far as concordance and reproducibility is concerned. Just displacement between lesser tuberosity and diaphysis tends to improve with complete CT-scan (p<0,001). Specialists (median G2 0,50 ; G1 0,34) ) agreed more than no specialists (median G2 0,33 ; G1 0,25) in the CDR with both radiological studies. Intraobserver-agreement Kappa values were moderate to substantial in most categories observed (group 2 : 0,17-0,65 ; group 1 : 0,32-0,73).
Conclusion
Analysis of proximal humeral fractures with a complete set of images of the CT scan provides worst agreement than analysis done just with the axial view. Observer's agreement improves when describing the cephalodiaphyseal pattern of the fracture. More experienced surgeons achieved better reliability and reproducibility in all settings.

Optimization of tuberosity sutures in hemiartroplasties for proximal humeral fractures. Tailoring sutures depending on cuff forces
F Santana , A Casals, J Amat, M Vinagre, C Torrens (Barcelona - SPAIN)

Purpose
Test a tuberosity suture design (Tension band) and compare it to the suture types currently in use by analysing the relative motion of the bone segments.
Material and Methods
Three large left synthetic sawbones® humerus were used. A custom device was constructed to allow a reproducible hemiarthroplasty biomechanics. Three different configurations were performed : 1) standard technique (ST), 2) Boileau specific fracture technique (Tornier ®) (BWT) and 3) tension band suture (TB) that sutures supraspinatus and subscapular following its tension lines. Each configuration was cycled 60 times between the neutral 100º glenohumeral abduction, 45º external and 45º internal rotation simulating one-hour passive physiotherapy. Motion was also performed after resecting one centimetre of anterior supraspinatus tendon to recreate fracture conditions. Micro movement was recorded through ATI Multi-Axis Force/Torque Sensor. U Mann-Whitney and Wilcoxon were used for statistical analysis.
Results
Movement registered with standard technique : 1,07 mm mean displacement value between shaft and greater tuberosity (S-G), 2,07 mm between shaft and lesser tuberosity (S-L) and 0,29 mm between lesser and great tuberosity (L-G). Movement registered with Boileau technique : 0,29 mm mean S-G, 1,82 S-L and 0,34 displacement value. Tension band technique diminished this measures to 0,13 S-G, 0,64 S-L and 0,16 L-G. Tension band also reduced displacement when making a 1 cm torn at the anterior part of supraspinatus ; from 0,18 to 0,11 in S-G, 1.08 to 0,49 in S-L and 0,34 to 0,14 in L-G. Tension band suture was significantly superior to others techniques either with an intact rotator cuff (8.5 TB 6.1 BWT, 5.7 ST, p<0.001) or with a torn rotator cuff (8.8 TB, 7.0 BWT, p<0.001).
Conclusion
Tension band concept reduces the displacement of optimal tuberosity position while glenohumeral motion when compared to other suture techniques. In those cases when the supraspinatus is partially lost because of fracture conminution, the tension band also significantly improves stability of the fragments.

03 - Basic Science Session


Moderator :
A Farron (Switzerland),
S Frostick (United Kingdom)

Biomechanical Evaluation of Trans-Osseous Rotator Cuff Repair: Do Anchors Really Matter?
M Salata , EC Lin, EF Shewman, BJ Cole, NN Verma, AA Romeo (Chicago, Il - UNITED STATES)

Purpose
The purpose of this study is to compare the initial biomechanical properties of 4 RCR techniques : Arthroscopic trans-osseous equivalent repair using suture anchors (TOE), traditional trans-osseous repair (TO), trans-osseous using the ArthroTunneler (AT) (Tornier, Edina, MN) and ArthroTunneler with X-Box suture configuration (ATX).
Material and Methods
27 human cadaveric shoulders were dissected down to supraspinatus and randomized via bone density into one of four repair groups (TOE, TO, AT, ATX). Tensile testing was conducted in 30° of abduction, and involved an initial preload, cyclic loading, and pull to failure. Elongation during testing was measured using optical tracking. Data was statistically assessed using ANOVA with a Tukey post-hoc test for multiple comparisons.
Results
The TOE repair demonstrated a significantly higher mean failure load (558.5 N ± 122.9) than the TO (325.3 N ± 79.9), AT (269.3 N ± 75.4), and ATX (388.5 N ± 92.6) repairs (p<.05). The TOE repair also demonstrated a significantly lower cyclic elongation (5.9% ± 3.3%) than the TO (13.7% ± 7.4%), AT (14.8% ± 8.5%), and ATX (11.7% ± 5.3%) repairs over the course of the cyclic testing (p<.05). There was no significant difference between repair groups in elongation or stiffness during maximum load-to-failure, in excursion during the first cycle of cyclic testing, or in average secant stiffness of last 5 cycles. Failure modes were : TOE - tendon (4), anchor pull-out (2) ; TO - suture (5), bone (n = 2) ; AT - bone (3), tendon (2), suture (1) ; ATX - tendon (n = 7).
Discussion
This study demonstrates that anchorless repair techniques using trans-osseous sutures only resulted in lower failure loads than a repair model utilizing anchors in aTOE construct. Changing to an X-Box suture configuration increased the construct failure load, although not significantly so.

Surgical planes of the glenoid: a Three Dimensional CT-scan study
T Verstraeten , E Deschepper, B de Coninck, S Walravens, M Jacxsens, L de Wilde (Gent - BELGIUM)

Purpose
There is no consensus on which glenoid plane should be used in total shoulder arthroplasty. Nevertheless, anatomical reconstruction of this plane is imperative for the longevity of a total shoulder arthroplasty.
Material and Methods
Three-Dimensional reconstruction CT-scans were performed on 152 healthy shoulders. Four different glenoid planes, each determined by three surgical accessible bony reference points, are determined.The first two are triangular planes, defined by the most anterior and posterior point of the glenoid and respectively the most inferior point for the Saller's Inferior plane and the most superior point for the Saller's Superior plane. The third plane is formed by the best fitting circle of the superior tubercle and the most anterior and posterior point at the distal third of the glenoid (Circular Max). The fourth plane is formed by the best fitting circle of three points at the rim of the inferior quadrantsof the glenoid (Circular Inferior). We hypothesized that the plane with a normal distribution, narrowest variability and best reproducibility would be the most suitable surgical glenoid plane.
Results
All four planes behave normally. The humeral center of rotation is identically positioned for both the Circular Max and Circular Inferior plane (X = 91.71/X = 91.66 p = 0.907 and Y = 90.83/Y = 91.7 p = 0.054) and different for the Saller's Inferior and Saller's Superior plane (p < 0.001). The Circular Inferior plane has the lowest variability to the coronal scapular plane (p<0.001).
Conclusion
This study provides arguments to use the Circular Inferior glenoid plane as preferred surgical plane of the glenoid.

Genetic Profiles Of Changes Underlying Different Sized Human Rotator Cuff Tendon Tears
S Chaudhury (Oxford - UNITED KINGDOM)

Purpose
There is increasing evidence for a multi-stage model of rotator cuff (RC) tendon tears, wherein healing is affected by tear size. This study aimed to gain greater insight into size related tear pathogenesis by analyzing gene expression profiles from normal, small and massive RC tears.
Material and Methods
The genetic profiles of 28 human RC tendons were analyzed using microarrays representing the entire genome. 11 massive and 5 small torn RC tendon specimens were obtained from tear edges intraoperatively, and compared to 12 age matched normal controls. Semiquantitative real-time polymerase chain reaction (RT-PCR) and immunohistochemistry were performed for validation.
Results
Key gene changes included upregulation of aggrecan in massive tendon tears (p < 0.05 and > 2-fold change). Matrix metallopeptidases (MMP) -3,-10,-12,-13,-15, -21,-25 and a disintegrin and metallopeptidase (ADAMs) -12,-15,-22 were significantly upregulated in tears. Aggrecan was upregulated in massive tendon tears but not in small tears. Amyloid was downregulated in both tear groups. Small tears also involved upregulation of BMP-5. As part of the chemotaxis pathway, IL-3,-10,-13,-15,-18 were upregulated in tears, whereas downregulation of IL-1,-8,-11,-27, was seen.
Discussion
The gene profiles of normal, small and massive RC tear groups suggested they are biologically distinct groups. This study has identified a number of novel pathways which suggest that RC tear pathogenesis is contributed to by ECM remodeling genes, chemotaxis genes, aggrecan and amyloid. These genes may potentially have a role as biomarkers of failure. Modulating these ECM pathways may be a useful treatment strategy for improving clinical outcomes.

Do the Signaling Pathways in Osteoarthritis Differ Between Weightbearing and Non-weightbearing Joints? A Mass Spectrometry Study of the Shoulder and Knee Proteome
JP Wanner , R Shree Subbaiaih, Y Shishani, M Miyagi, R Gobezie (Cleveland - UNITED STATES)
Purpose
Osteoarthritis (OA) is a significant cause of pain and disability which is characterized by cartilage degeneration, pathologic changes in the subchondral bone, and irritation of the synovium. Mass spectrometry-based proteomics is an evolving technique which has been successfully used to directly analyze large numbers of proteins quantitatively in SF. The purpose of this study was to examine the proteome of SF in osteoarthritic shoulders and knees in order to determine if the signaling pathways in weight-bearing (knee) vs non-weighbearing joints is similar as we have hypothesized.
Material and Methods
A cross-sectional study of 17 patients with early OA (n = 5), patients with late OA (n = 5), and control individuals (n = 7) was conducted. Depletion of high abundant proteins from the SF was achieved using an Agilent High Capacity Multiple Affinity Removal Spin Cartridge. The resulting low abundant proteins were qualitatively and quantitatively analyzed in each of the experimental groups and compared to the pooled control samples using 18O labeling and subjecting the samples to LC-MS/MS. The 16O/18O ratio of each peptide was calculated using software developed in-house for this purpose. One sample independent t-tests with multiple-testing correction (p<0.05 with Bonferroni correction), as well as one-way and two-way ANOVA statistical methods were used to identify proteins with differential expression scores that generate low p-values (p ≤0.05). The differentially expressed proteins were analyzed by DAVID and Ingenuity software in comparison with the proteome of the osteoarthritic knee.
Results
Acute phase signaling pathway, coagulation pathway and complement system pathway were all enhanced in the late osteoarthritic shoulder when compared to the controls. The network analysis showed changes in lipid metabolism in the early shoulder proteome while skeletal disorders and connective tissue disorder were pronounced in the late shoulder proteome. Comparison of the shoulder proteome of this study and the previously reported knee proteome demonstrates that the mechanisms contributing to the pathophysiology are similar in both. However, it should be noted that energy metabolism was shown to be higher in the shoulder proteome when compared to the knee.
Conclusion
Pathway analysis confirms the gradual deterioration of the shoulder joint as the disease progresses. The ingenuity platform identifies strong wound signaling in both shoulder and knee arthritis suggesting that the disease manifestation is similar in both the joints. It is interesting to note that the signature of an unresolving wound in the synovial fluid of subjects with OA is consistent with chronic meniscal damage that is present in these subjects. Further investigation is being carried out to identify pathological pathways unique to the shoulder and knee.

Relationship between Pullout strength of Screws and Bone Mineral Density in the Proximal Humeral Head
M Yamada , T Yamaji, H Yamada (Nagoya - JAPAN, Toyoake - JAPAN)

Purpose
Operative treatment for proximal humeral fractures in elderly patients has several problems due to osteoporosis. To get stable fixation with screws we analyzed the relationship between bone mineral density and screws pull out strength in proximal humeral head.
Material and Methods
We examined 10 cadavers proximal humeral heads ; male 6, female 4, mean age 85 yr. (76-90).7 region of interests (ROI) were analysed ; 1 : 30 degrees above surgical neck at subchondral bone, 2 : 60 degrees above surgical neck at subchondral bone, 3 : greater tubercle, 4 : medial side of surgical neck, 5 : lateral side of surgical neck, 6 : 1 cm inside of ROI 1, 7 : 1 cm inside of ROI 2.
To evaluate the pull out strength, 2 cannulated screws were inserted at ROI 1 and 7 and load test was performed by universal material machine (INSTRON 5582).
Results
Each region of BMD values (g/cm2) were ; 1 : 0,243, 2 : 0.144, 3 : 0.096, 4 : 0.086, 5 : 0.007, 6 : 0.092, 7 : 0.027. BMD of ROI 1 was significantly higher than other ROI. Pull out strength (N) of screws were ; 1 : 296.6, 7 : 92.6. Pull out strength of ROI 1 was significantly higher than 7.
Conclusion
Within the proximal humeral head, BMD value at 30 degree above surgical neck region was significantly higher than other regions. And also pull out strength of screw in this region was significantly higher than center of proximal humeral head. Above results indicate screw should be inserted in 30 degrees above surgical neck at the subchondral bone to get better fixation at the fracture side.

Biomechanical considerations preventing the stripping of the head socket in titanium locking screws in a generic pre-contoured locking plate clavicle fixation system
G Tamvakopoulos , K Brister, J Buchanan (London - UNITED KINGDOM, Hastings - UNITED KINGDOM)

Purpose
Pre-contoured titanium locking plates (Accumed) is a popular fixation option for clavicle fractures. The fixation device often requires removal after evident union, since it leads to local irritation. Stripping of the screw heads leads to difficulty removing these plates and increases the risk of complication in an area of important anatomical structures. The aim of this study was to determine the factors leading to stripping of screw heads in titanium locking plates.
Material and Methods
Twelve separate tests on each screw were performed, as well as hardness measurements on the plate using the Vickers Material hardness test machine. Hardness measurements were taken on both coated and non-coated sections to determine the effect of the applied coating. The company-provided driver-bit was used to tighten by hand the screws onto the plate. The driver-bit and screws were examined under microscope to study the contact effect. A digital micrometer was used to measure all contact faces.
Results
The hexagonal screwdriver bit was twice the hardness of both screws. The clavicle plate was 2/3 the hardness of the screws, making the screw threads more likely to achieve good compression on the plate but more difficult for the screw to be removed. There was 0.1 mm difference between the driver-bit and the screw head. 'Camming out' was observed by the driver-bit in to the socket during tightening.
Conclusion
The difference in fit lead to limited contact during rotation of the driver creating increased pressures at loading points. This in combination with the difference in hardness of the two materials and the limited access of the medially placed screws because of the position of the head-and-neck leads to 'camming out' or stripping of the screw head.

Rotator cuff tendon blood flow in a sheep model – a comparison of single- vs. double-row repairs
B Marquardt , N Dedy, G Hausschild, S Meier, J Steinbeck, D Liem (Muenster - GERMANY)

Purpose
Double-row suture anchor repair of rotator cuff tears has been shown to be superior to single-row techniques with regard to footprint reconstruction, load to failure and tendon-to-bone contact pressures. We hypothesized that anchor repair can impair intratendinous blood flow and that the greater contact pressure of double-row techniques would compromise blood flow to a higher degree than single-row repair in an in-vivo-sheep model.
Material and Methods
18 sheep underwent detachment and immediate anchor repair of the infraspinatus tendon using either an arthroscopic Mason-Allen suture or a double-row suture-bridge technique. Tendon blood flow was measured using laser Doppler flowmetry before detachment, immediately after repair and 12 weeks thereafter. Six regions of interest were measured, three at the lateral aspect of the footprint and three at the medial aspect.
Results
Immediately after repair, tendon blood flow decreased significantly in both repair groups when compared to the native tendons (P = .004). At 12 weeks, a significant increase in flow was observed in both repair groups when compared to the measurements immediately after repair (P = .016). There was no significant difference between the two repair groups at any point in time when mean values of all regions of interest were analyzed. Subgroup analysis of flow data showed that blood flow over the medial aspect of the footprint immediately after repair was significantly lower in the double-row group (P = .047).
Conclusion
Suture anchor repair compromises tendon blood flow immediately after repair regardless of the technique, but flow appears to recover within 12 weeks. A statistically significant difference between the repair groups could not be demonstrated, although a trend was noted towards a greater reduction of tendon blood flow over the medial aspect of the footprint after double-row repair.

Relationship between the medial offset of the proximal humerus and the destabilizing action of the middle deltoid during elevation: A numerical sensitivity study
PO Lemieux , N Hagemeister, P Tétreault, N Nuño (Montréal - CANADA)

Purpose
During the early phase of elevation, the middle deltoid has a superior destabilizing (shear) action, which appears to be more or less significant among individuals. The origin of this variability is unknown but a potential explanation may lie in the geometry of the proximal humerus. Indeed, the medial offset (distance between the metaphyseal axis and the centre of rotation) has shown to directly interfere with the line of action of the middle deltoid. Using a numerical simulation, the present study looked for a relationship between extreme medial offsets observed in normal shoulders and the destabilizing action of the middle deltoid during elevation.
Material and Methods
Following the terminology of the ISB, an elevation in the plane of the scapula (0 to 135°) was simulated with the shoulder model from the AnyBody Modeling System (AnyBody Technology A/S, Aalborg, Denmark). The variability of the medial offset of the proximal humerus was covered using data from anthropometric studies (minimum - 0 mm, average - 7 mm and maximum - 14 mm). While the average offset was used as a reference, three biomechanical parameters of the middle deltoid were studied (moment arm, activation and shear forces) by being averaged over the entire range of motion.
Results
Throughout elevation, the minimum medial offset lateralized the middle deltoid, disrupting its moment arm (-11%), activation (+18%) and superior shear force (+40%), with respect to the average offset. Conversely, the maximum medial offset medialized the middle deltoid, disrupting its moment arm (+9%), activation (-30%) and superior shear force (-30%). For all the medial offsets, the highest superior shear force of the middle deltoid occured before 45° and decreased afterwards.
Discussion
In the present study, a variation of the medial offset has a marked influence on the destabilizing action of the middle deltoid. A large medial offset lateralizes the middle deltoid, thereby reducing its superior shear force throughout elevation, with a greater overall influence during the early phase of elevation (0 to 45°). The Anybody simulation tool used in this study appears to be promising to establish links between shoulder morphology and stability. Such a tool could help explain the pathophysiology of common shoulder dysfunctions related to cuff disease and arthritis, or may help improving prosthetic design.

Overuse Trainning increase mechanoreceptors in supraspinatus tendon of rats SHR
A Pochini , B Ejnisman, N Viviane, S Han, MT Seixas, M Cohen (São Paulo - BRAZIL)

Purpose
introduction - The presence of mechanoreceptors in tendon after overuse activities can be a further step to learn about tendinopathy and oversuse. Studies of tendons mechanoreceptors in rats are rare.
Material and Methods
methods - We studied 12 isogenic SHR rats which underwent an overuse protocol consisting of an hour per daily session of treadmill running at a speed of 17 mmin, 5 timesweek for 4 months.
Results
results - Supraspinatus tendons were evaluated with immunohistochemistry using S100 protein antibodies and histological protocol. Supraespinatus tendons at the end of 4 months of overuse protocol had a high number of media mechanoreceptors 4.3 than controls 0,6. Conclusion
conclusion - The overexpression of s100 protein antibody in overuse activities maybe could represent a adaptative effort to tendon before the tear.

Adipose-derived stem-cell therapy for rotator cuff ruptures.
C Encinas , R Barco Laakso, S Antuña Antuña, M Garcia-Arranz, MT Carrascal (Madrid - SPAIN)

Purpose
Healing rates of the rotator cuff remain low despite new repair strategies. Enhancement in the biology of the repaired tendon seems necessary because healing occurs through scar tissue formation with diminished mechanical properties. The local use of stem-cell therapy is hypothesized to improve the mechanical strength of the repaired rotator cuff.
Material and Methods
24 BDIX rats underwent bilateral detachment of the supraspinatus tendon from the greater tuberosity and were randomized into one of three groups : tendon repair with a modified mattress suture through a transosseous tunnel (group 1), tendon repair with addition at the repair site of a fibrin sealant (group 2) and tendon repair with addition at the repair site of 2 x 106 of adipose-derived stem-cells in a fibrin sealant carrier (group 3). The animals were euthanized at 4 and 8 weeks after repair. The proximal humeri, scapulae and supraspinatus muscle was dissected free and placed in a syringe with PMMA cement. The specimens were tested in an electro-mechanic tension machine to determine the load to failure, deformity, stiffness and absorbed energy.
Results
Mean load to failure (N) was 12.83 (group 1), 11.57 (group 2) and 11.72 (group 3) at 4 weeks (p = 0.67) and 15.11 (group 1), 15.94 (group 2) and 14.35 (group 3) at 8 weeks (p = 0.88). At 4 and 8 weeks there were no differences between the groups for any of the rest of studied parameters.
Discussion
The addition of ASC did not improve the mechanical properties of the rotator cuff at the studied time points. The reasons for failure are analysed.

04 - Miscellaneous

Moderator :
F Sirveaux (France),
E Wiedemann (Germany)

Proprioception and neuromuscular control evaluation after arthroscopic capsular release of frozen shoulder – minimum 2 year follow-up observation
J Fabis , R Rzepka (Lodz - POLAND)
Purpose
The purpose of this study was evaluation of selected proprioception and neuromuscular control parameters in group of patients after arthroscopic capsular release of frozen shoulder.
Material and Methods
There were 27 patients (20 women, 7 men) operated on due to frozen shoulder, av. Age : 54,1 years, arthroscopic antero-inferior capsulo-ligamentous resection by punch was performed in 4 patients and in 23 cases it was combine with postero-inferior one. Including criteria for patients were : min.2 yrs follow-up, no pain. Evaluation was done with Biodex System 3, uninvolved (UNIV) and involved (INV) limbs were compared. Proprioception parameters assessed : active (APS) and passive (PPS) position sense of GLH joint in external (ER) and internal (IR) rotation, each tested with 3 repetitions in 30° of ER and IR. The Wilcoxon was used (p<0.05).
Results
There were not statistically significant differences between INV and UNIV sides in AROM and PROM. Statistically significant difference between INV and UNIV sides in APS and PPS tests in ER (APS ave. Diff : INV : 6,61°, UNIV : 5,39°, PPS ave. Diff : INV : 5,41, UNIV : 3,93).The isokinetic evaluation showed statistically significant differences between INV and UNIV limbs at tested speeds (60°/s and 180°/s) in : time to peak torque (60°/s : INV : 501,5msec, UNIV : 447,8msec, ave.diff. : 53,7 ; 180°/s : INV : 424,8msec, UNIV : 329,6msec, ave.diff : 95,2).
Conclusion
There is statistically significant deficit in proprioception in both APS and PPS tests in ER and neuromuscular control parameters for ER 2 yrs after arthroscopic capsular release of frozen shoulder.These results can imply additional information relevant for rehab directed toward proprioception reeducation and neuromuscular control after capsulo -ligamentous resectionTo our knowledge there is no data concerning the impact of capsular release of frozen shoulder on proprioception and neuromuscular control. Our study reveals that resection of the capsulo-ligamentous complex influences proprioception and neuro-muscular control.

Excellent long-term outcomes of arthroscopic capsular release for frozen shoulder
H Le Lievre , G Murrell (Sydney - AUSTRALIA)

Purpose
Arthroscopic capsular release for frozen shoulder has potential complications including iatrogenic chondral injury and recurrence of stiffness. Whilst there is long-term data regarding non-operative treatment, and good short-term (two years or less) outcomes following a release for idiopathic frozen shoulder, little is known about the long-term outcomes (five years or more) of arthroscopic capsular release. This study aimed to determine the long-term outcomes of arthroscopic capsular release for idiopathic frozen shoulder.
Material and Methods
A cohort of patients with idiopathic frozen shoulder who had a circumferential arthroscopic gleno-humeral joint capsular release for idiopathic frozen shoulder by a single surgeon were assessed using patient-ranked pain and shoulder functional Likert scores and examiner-ranked range of motion preoperatively and at 1, 6, 12, 24, 52 weeks and at 7 years post surgery.
Results
At a mean follow-up of seven years, 43 patients (49 shoulders) demonstrated continued significant relief of pain frequency and severity in comparison to initial presentation (p < 0.001) and one year follow-up (p < 0.001). There was significant improvement in shoulder function, stiffness and difficulty completing activities (p < 0.01). Shoulder motion improved (p < 0.001) and was comparable to the contralateral shoulder. There were no complications.
Conclusion
Patients with idiopathic frozen shoulder who had an arthroscopic capsular release had early significant improvements in shoulder range of motion, pain frequency and severity and function. These improvements were maintained and/or enhanced at seven years. There were no complications in the short or long term. In contrast to that reported for non-operative treatment, shoulder range of motion at seven years was equivalent to the contralateral shoulder.

A prospective analysis of 179 SLAP 2 Repairs: Outcomes and factors associated with failure and revision
M Provencher , F Mccormick, C Dewing, D Solomon (Coronado - UNITED STATES, San Diego - UNITED STATES, San Francisco - UNITED STATES)

Purpose
To prospectively determine the clinical outcomes of the arthroscopic surgical treatment of Type 2 SLAP tears in a young, active patient population, and to elucidate factors associate with failure of treatment.
Material and Methods
A total of 209 patients with mean age of 31.6 (range, 18 to45) over a 4-year period with a SLAP tear were prospectively enrolled. Two sports/shoulder trained orthopaedic surgeons performed SLAP 2 repair with between 1 to 2 anchors (mean 1.6 anchors) and vertical suture construct. At a mean of 40.4 months (range 26-62months), a total of 179 patients underwent a comprehensive preoperative and postoperative assessment with WOSI, ASES, SANE, and physical examination of range of motion. In addition, a failure analysis was conducted to determine variables associated with failure.
Results
Out of the 179 patients, there were a total of 56 patients (31.2%) failures, 48 have undergone revision surgery to a biceps tenodesis (in 40), tenotomy (in 4), and debridement (in 4). The mean preoperative scores (WOSI = 54%, SANE = 50%, ASES = 65) improved to postoperative scores (WOSI = 82%, SANE = 85%, ASES = 88). However, in those that had failed, the mean scores were not statistically different from preoperative scores. The mean postoperative range of motion was 150 degrees of flexion, 145 abduction, and 60 external rotation at the side, and was much less in those that had failed the procedure. Advanced age within the cohort (>36) was associated with a statistical increase in failure.
Conclusion
Repairs of SLAP 2 lesions remain a challenge. This study demonstrated that over 31% of the patients had failed, with a high revision rate. Those over the age of 36 were associated with a higher chance of failure

Arthroscopic Biceps Tenodesis Compared to Repair of Isolated Type II SLAP Lesions in Patients Over 35 Years of Age
PJ Denard , A Lädermann, SS Burkhart (San Antonio - UNITED STATES, Geneva - SWITZERLAND)

Purpose
The purpose of this study was to compare arthroscopic biceps tenodesis with repair of isolated type II superior labrum anterior and posterior (SLAP) lesions in patients over the age of 35.
Material and Methods
We identified isolated type II SLAP lesions surgically managed over a five-year period. Minimum two-year follow-up was available for 22 patients who underwent repair (Group 1), and for 15 patients who underwent a primary biceps tenodesis (Group 2). The mean age at the time of surgery was 45.2 + 5.5 years in group 1, and 52.0 + 8.0 years in group 2.
Results
In group 1, functional outcome improved from baseline to final follow-up by American Shoulder and Elbow Surgeons (ASES) (47.5 to 87.4 ; p < .0001) and University of California, Los Angeles (UCLA) scores (18.5 to 31.2 ; p < .0001). In group 2, similar findings were observed for ASES (43.4 to 89.9 ; p < .0001) and UCLA scores (19.0 to 32.7 ; p < .0001). There was no difference in functional outcome between the groups (ASES, p = .2395 ; UCLA, p = .6046). Full range of motion recovery was delayed by nearly 3 months in group 1 compared to group 2 (p = .0631). In group 1, 77.3% of patients were both satisfied and returned to normal activity, compared to 100% in group 2 (p = .0673). Two patients in group 1 required a secondary capsular release.
Discussion
In the current study, individuals over the age of 35 with an isolated type II SLAP lesion had a shorter postoperative recovery, a more predictable functional outcome, and a higher rate of satisfaction and return to activity with a biceps tenodesis compared to repair. Based on our observations, biceps tenodesis is preferable to repair for isolated type II SLAP lesions in non-overhead athletes over the age of 35

A randomized study of the effectiveness of suprascapular nerve block in patient satisfaction and outcome after arthroscopic subacromial decompression
HC Jeske- , F Hoffmann, C Dallapozza, J Oberladstaetter, F Kralinger, M Wambacher (Innsbruck - AUSTRIA, Rosenheim - GERMANY)
Purpose
The purpose of this study was to evaluate the efficiency of the suprascapular
nerve (SSN) block in pain reduction after arthroscopic subacromial decompression (ASD) operations and its influence on patient satisfaction. Furthermore, we wanted to evaluate if better perioperative pain management could positively influence postoperative shoulder function.
Material and Methods
In this prospective, randomised, double-blinded clinical trial, three groups of
10 patients - each with 15 participants - were treated with SSN block (10 ml Ropivacaine 1%), placebo, or a subacromial infiltration of local anaesthesia (20 ml Ropivacaine 1%). Preand postoperative pain was evaluated using a visual analogue scale. Functional outcome was measured by Constant Murley Scoring, and patient satisfaction measured anecdotally at interview two days, two weeks and six weeks after surgery.
Level of evidence : Clinical level I study.
Results
The SSN group reported significantly lower levels of postoperative pain, required
significantly less analgesics, had better range of motion (ROM) and had higher levels of postoperative satisfaction in comparison to the subacromial infiltration group and placebo group.
Conclusion
Patients treated with SSN blocks experienced overall less pain, which led to a
decreased need of analgesics in comparison to the subacromial infiltration and the placebo group. Further, the SSN-blocked group achieved a better postoperative range of motion (ROM) and were significantly more satisfied after surgery.

The safe zone for avoiding suprascapular nerve injury: an anatomical study on 500 dry scapulae
S Gumina , P Albino, M Giaracuni, S Carbone, V Arceri (Rome - ITALY)

Purpose
Suprascapular nerve injury may be a complication during shoulder arthroscopy. Our aim was to verify the reliability of the existing data, assess the differences between scapulae in the two genders and in the same subject, obtain a safe zone useful to avoid iatrogenic nerve lesions, and analyze the existing correlations between the scapular dimensions and the safe zone.
Material and Methods
We examined five hundred dried scapulae, measuring six distances for each one, referring to the scapular body, glenoid and the course of the suprascapular nerve, also catalogued according to gender and side. Differences due to gender were assessed comparing mean ± sd of each distance in males and females ; paired t-test was used to compare distances deriving from each couple. Successively we calculated our safe zone and Pearson's correlation.
Results
We found non-significant differences between the right and left distances deriving from each couple ; differences due to gender were stated. We defined three kinds of safe zones referring to : 500 scapulae ; males (139 scapulae) and females (147 scapulae). The correlation indexes calculated between the axis of the scapular body and glenoid and the posterosuperior distance (referring to the suprascapular nerve) were0.624,0.694,0.675, 0.638 ; while those with the posterior distance were0.230,0.294,0.232,0.284.
Discussion
Knowledge of the safe zone, for avoiding suprascapular nerve injury, is important ; gender and specific scapular dimensions should be evaluated since they influence the dimensions of the safe zone. The linear predictors should be used to obtain specific values of the posterosuperior limit in each patient.

The evaluation of sensory function for the patients of suprascapular nerve palsy
H Ikegami , K Ogawa, N Matsumura, Y Toyama (Tokyo - JAPAN)

Purpose
Ajmani and Horiguchi reported a cutaneous branch of the suprascapular nerve supplying the proximal-lateral one-third of the arm. There is, however, no paper that reports the relationships between clinical symptoms and sensory disturbance in the patients of suprascapular nerve palsy. We report the usefulness of the evaluation of sensory function for suprascapular nerve palsy.
Material and Methods
We treated 83 patients of suprascapular nerve palsy from 1985 to 2010. To study the usefulness of evaluating sensory function, we investigate the clinical progress and the results of the sensory disturbance in 30 cases of suprascapuar nerve palsy in which the sensory tests were done more than two times. As the sensory function, we evaluated vibration thresholds, pain, light touch, and the sensation of heat and cold.
Results
In all the cases, we found atrophy of infraspinatus muscle, dullness around the shoulder joint, tenderness at the entrapment point. Twelve cases had ganglion treated by puncture. We excised ganglion in eight cases. We diagnosed 18 cases without ganglion cysts as neuralgic amyotrophy from the characteristic clinical progress and electromyography. We did decompression of the suprascapular nerve by a trapezius-splitting surgical approach. In the tests for evaluating sensory function, there are no cases with abnormal vibration thresholds. There are 26 cases with hypalgesia and hypothermesthesia in the region of posterior axillary pouch and 25 cases with hypaesthesia in the same area.
Discussion
The evaluation of sensory function for the patients of suprascapular nerve palsy is useful for follow-up of this palsy, because this is non-invasive, inexpensive, and sensitive comparing with MRI and electromyography.

05 - Miscellaneous

Moderator :
A Castagna (Italy), E Servien (France)

4D CT scans improve pre-operative planning in Snapping Scapular Syndrome
SN Bell , TDW Alta, JA Coghlan, JM Troupis (Melbourne - AUSTRALIA, Amsterdam - NETHERLANDS)
PurposeThe 4 dimensional CT scan provides a moving 3D image in real time of the scapula snapping over the chest wall. The study was to determine if this aids the clinician in defining the size and area of the scapular bone to be removed arthroscopically in patients with 'Snapping Scapular Syndrome'.
Material and Methods
From January 2009 - January 2011 nine consecutive patients with Snapping Scapular Syndrome were included. In six patients, (mean age 21±5 years) conservative treatment failed. These patients were positioned prone and demonstrated their snapping motion during the 7 seconds duration of the scan. The 4D CT machine, scans a 16 cm volume with one 360° rotation. Therefore, multiple rotations (each acquired within 0.3 seconds) will result in recording of motion. This ability to perform CT fluoroscopic assessment allows a 3D reconstruction of the scapulothoracic joint, its' movements and the dynamic area of impingement of the scapula on the surrounding structures.
Results
The scan showed in one case not only snapping of the superior medial angle of the scapula on the 2nd rib, but also extra bone impinging on the 3rd rib. Another case showed no real impingement but movement of the 2nd and 3rd rib by a tethering structure and a third case demonstrated impingement of the lateral third of the clavicle on the 2nd rib.
The scans improved delineation of the amount, and position, of the scapular bone that needed to be removed.
Conclusion
Images provided by this new 4D CT scan offer greater pre-operative insight on the pathology in each individual patient with Snapping Scapular Syndrome and improve the efficacy of bone removal.


Bilateral Scapulothoracic Arthrodesis Does Not Reduce Respiratory Function in Patients with Facioscapulohumeral Muscular Dystrophy
P Boileau , A Pison, C Trojani, K O'shea, S Sacconi, C Desnuelle (Nice - FRANCE)

Purpose
Facioscapulohumeral muscular dystrophy (FSHD) is characterized by the weakness of the scapular fixator muscles and scapular instability associated to functional limitation of shoulder movements and chronic pain. The aims of this study are to evaluate the effect of bilateral scapulothoracic arthrodeses (STA) on : 1) shoulder function, 2) bone consolidation, 3) respiratory capacity.
Material and Methods
We evaluated 10 bilateral STA performed on 5 genetically confirmed FSHD female patients (mean age : 38 years). Fixation of the scapula was obtained with metallic cerclages passed around the ribs ; a tubular plate was placed along the medial border of the scapula and an iliac crest bone graft was added. Shoulder function was evaluated before surgery and at last follow-up. Bone consolidation was evaluated by thoracic CT-scan. Spirometry measured respiratory functions before surgery and at different time-points of the follow-up. The mean follow-up was 49 months (2 to 10 years).
Results
Two patients experienced transitory surgical complications : 1 rib fracture and 1 regressive pleural effusion. At last follow-up, shoulder active elevation (mean values : +46°) and shoulder abduction (mean values : +22°) were significantly improved ; internal and external rotations were conserved. Shoulder function was also improved (mean values : +37 points on Constant Score, +46% on SSV). Moreover, chronic pain was clearly reduced (mean values : -5 point on pain VAS). All patients were very satisfied. Bone fusion was complete in 9 cases and partial in one. Bilateral surgery did not affect respiratory function significantly. The results did not deteriorate with time.
Conclusion
Bilateral STA improved significantly shoulder function and motion, chronic pain, quality of life and cosmetics in all FSHD patients without reducing their respiratory function. Bone fusion was regularly obtained and is crucial for long lasting results in these patients with a long life expectancy.

Incidence of associated intra-articular shoulder injuries, diagnosed during the arthroscopic assisted treatment of acute AC joint dislocations
F Montoya , T Kruppa, P Magosch, P Habermeyer, S Lichtenberg (Heidelberg - GERMANY)
Purpose
Purpose : The purpose of this study was to evaluate the incidence of intra-articular shoulder lesions diagnosed during an arthroscopic assisted treatment of acute acromio-clavicular (AC) joint injuries.
Material and Methods
43 patients (38 males, 9 females), average age 37.2 years (17-59 years) with an acute AC joint dislocation (Rockwood type III, 4 ; type IV, 2 ; type V, 37), were operated on an arthroscopic assisted technique. No patient had shoulder pain before the trauma. Associated intra-articular shoulder lesions were diagnosed and treated. The intraoperative findings were prospectively documented in a database. The operation report and the database were retrospectively assessed in order to evaluate the incidence of associated intra-articular lesions.
Results
Seventeen patients (39.5%) were diagnosed with associated intra-articular shoulder injuries : 8 (18.6%) SLAP lesions ; 1 (2.3%) supraspinatus tendon complete tear, 7 (16.3%) supraspinatus tendon partial tears, 3 (6.9%) subscapularis tendon partial tears, 1 (2.3%) supraspinatus/subscapularis tendons partial tear, 1 (2.3%) supraspinatus/subscapularis tendons complete tear ; 2 (4.6%) LHBT partial ruptures ; 4 (9.3%) lesions of the biceps pulley system ; and 1 (2.3%) humeral head chondral lesion. Patients with associated rotator cuff tears were significantly older than patients without them, 46.5 years versus 32 years (p = 0.001).
Conclusion
Associated intra-articular shoulder lesions were commonly diagnosed and treated when an arthroscopic assisted AC joint reconstruction/stabilization was performed. Nearly 40% of the patients showed additional lesions of the shoulder joint. In 30% of the cases a lesion of the rotator cuff was observed, especially in patients older than 46 years. Considering the prominent clinical signs of an acute AC joint dislocation, clinical and imaging diagnosis may be difficult to perform for associate lesions. Therefore diagnostic shoulder arthroscopy could play an important role in the detection and treatment of them.

Complication of the clavicle hook plate
X Wu (Shanghai - CHINA
)
Purpose
To discuss the clinical characteristic of the unstable medial clavicle fracture and its treatment.
Material and Methods
Eleven medial clavicle fractures were treated during the period from January 2007 to August 2009. 10 were male, with the mean age of 44.5 years .The medial clavicle fracture is defined by the Edinburgh classification that is located one-fifth of the medial part of the clavicle. The separation of the bone ends larger than 10 mm using 3D CT measurement was considered as severely displaced. The unstable medial clavicle fracture was defined as meeting at least one of the three criteria (1) with the ipsilateral scapular fracture, (2) as a part of the segmental clavicle fracture, (3) severely displaced. One medial clavicle fractures was accompanied by the scapular neck fracture, one with the acromion fracture. Three medial clavicle fractures were a part of the segmental clavicle fractures, two with the middle third clavicle fracture, and the other with the distal clavicle fracture along with the ipsilateral scapular fracture. Six were severely displaced.Eight of them were treated by the open reduction and internal fixation. . Seven were treated by ORIF with 3.5 mm reconstructed locking plate.The medial clavicle fracture with the ipsilateral acromion fracture was treated by two 3.5 mm volar T-locking plates. The rest three cases were treated conservatively because of the severe associated injury.
Results
All the patients were followed for a mean time of 15 months (15-18m).The fractures were united anatomically in the surgical group with one plate breakage .The mean Constant score for the last follower up were 94 for the surgery cases .Two fractures in the conservative group were malunited and the rest one was nonunion..
Conclusion
The surgical treatment is strongly recommended to the unstable medial clavicle fractures .The locking plate can be an alternative choice in these cases.

COMPARISON OF AUTOLOGOUS BONE GRAFT VS DEMINERALISED BONE MATRIX (DBX) IN TREATMENT OF MIDSHAFT CLAVICLE NON-UNION
P Mestha , A Singh, M Pimple, A Tavakkolizadeh, J Sinha (London - UNITED KINGDOM)

Purpose
Clavicle mid-shaft fracture non-union is usually addressed surgically with open reduction internal fixation (ORIF), and augmentation with autologous bone graft (ABG) or other bone substitutes. This study aims to compare the outcome between ABG and Demineralised Bone Matrix (DBX).
Material and Methods
This is a retrospective study of 30 patients with mid shaft clavicle fracture non-union treated with ORIF and augmented with ABG or (DBX) between 2000 and 2010. Of these, 20 were in bone graft group while 10 in the DBX group. Most fractures, 27 out of 30 were initially managed conservatively, while three had failed primary fixation. Two belonged to bone graft and one to DBX group. The mean age for the bone graft group was 39.4 years (range 30-74 yeas), and DBX group was 42.1 years (range 24-78 years). The exclusion criteria were open fractures, fractures with neurovascular deficit or septic non-unions. The results were compared clinically, radiologically and through satisfaction scores.
Results
The union rate in both groups were comparable with 18 out of 20 in bone graft group, and 9 out of 10 in DBX group achieving union. One of the non-unions in the bone graft group required re-plating with ossigraft, leading to union. The other two, one belonging to each group, were asymptomatic with fibrous non-union with full range of shoulder movement. Both patients declined further surgery. The median time to radiological union was 6 months (range 3-9 months) in both groups. Of the cases that could be contacted, 90% of DBX group and 70% of bone graft group rated their function as excellent and would consider having the surgery again if required.
Conclusion
To conclude, Clavicle non-unions augmented by DBX have at least as good a union rate as autologous bone graft without the associated donor site morbidities, and hence can be considered as an alternative option.

Development and Validation of a Score to Assess Functional External Rotation Deficit: the ADLER score (Activities of Daily Living utilizing External Rotation)
P Boileau , AP Rumian, G Alami, K O'shea, B Melis, Y Roussanne (Nice - FRANCE, Montpellier - FRANCE)

Purpose
When the infraspinatus and teres minor are absent or fatty-infiltrated, no other muscle can provide active external rotation (aER) and attempts at shoulder elevation result in the forearm swinging in uncontrollably towards the trunk. The purpose of this study was to develop and validate a score that objectively quantifies the functional deficit in Activities of Daily Living (ADLs) requiring aER.
Material and Methods
Score development had 3 stages : (1) Identification of patients with absent aER- inability to maintain neutral shoulder rotation in adduction + positive hornblower's sign + absent/fatty-infiltrated infraspinatus and teres minor on imaging. (2) Item determination - patient interviews generated a list of ADLs that were difficult to perform in the absence of aER (3) Score validation -prospective evaluation of 56 patients undergoing Latissimus Dorsi-Teres Major tendon (LD/TM) transfer, using pre- and post-operative scoring using the ADLER score and correlating it with other validated scores (Constant score, Simple Shoulder Test).
Results
The ADLER score has 10 items : Brushing hair, Shaving/applying make-up, Brushing teeth, Getting dressed, Filling a glass from a bottle (whilst seated), Bringing a full glass to the mouth, Eating soup with a spoon, Shaking someone's hand/opening a door, Holding a telephone to the ear, Writing/typing/playing the piano. Each item was scored between 0 and 3 : 0 impossible, 1 very difficult, 2 somewhat difficult, 3 not difficult at all. All activities should be performed without flexing the neck or the trunk and without first abducting the elbow (ie, without a hornblower's sign). After LD/TM transfer, the ADLER score improved from a mean of 13 to 24 points and correlated closely with other scores whilst being more sensitive to improvements in aER.
Conclusion
The ADLER score is a useful, validated tool to help identify patients who may benefit from tendon-transfer procedures and assess their treatment outcomes.

Motion analysis of acromioclavicular joint using 3D in-vivo shoulder model
YS Yoo (Seoul - KOREA, REPUBLIC OF)

Purpose
The aim of this study was to determine the AC motion and change in length and tension of the coracoclavicular ligament at shoulder abduction using a three dimensional finite element model.
Material and Methods
The right shoulder of 5 living subjects was scanned with a high resolution CT scanner at 0°, 80° and 180° of knee flexions. Several modeling programs were used to simulate AC motion. Finite element model of conoid and trapezoid ligament was constructed and put into each footprint. The tension and length change of each ligament during shoulder abduction were assessed.
Results
The distal clavicle translated posteriorly and rotated internally with respect to medial acromion at 80o of shoulder abduction (1.1±0.3 cm and 24.4±9.1o). With 180o of shoulder abduction, the rotational gap between distal clavicle and medial acromion increased (36.8 ±12.1o), The virtual lengths of conoid ligament increased at 0o to 180o of shoulder abduction (0.9±0.2 cm to 1.3±0.4 cm), meanwhile, those of trapezoid ligament is constant at 0o to 80o (1.6±0.8 cm to 1.5±0.7 cm) and deceased at 80o to 180o (1.5±0.7 cm to 1.1±0.4 cm) of abduction. With a progression of shoulder abduction, finite element model of conoid ligament is seriously stretched more than 30% of its original length.
Conclusion
The results of this study suggest that distal clavicle has a wide range of motion during shoulder abduction, which do not support the concept of synchronous motion with scapula. The conoid and trapezoid ligaments showed a reciprocal function during shoulder abduction with their different tension pattern. The length and tension vs abduction angle data obtained has the potential to suggest that conoid and trapezoid ligament should be reconstructed separately and no trial is recommended for AC fixation in patient with AC dislocation~

Motion analysis of acromioclavicular joint using 3D in-vivo shoulder model
YS Yoo (Seoul - KOREA, REPUBLIC OF)

Purpose
The aim of this study was to determine the AC motion and change in length and tension of the coracoclavicular ligament at shoulder abduction using a three dimensional finite element model.
Material and Methods
The right shoulder of 5 living subjects was scanned with a high resolution CT scanner at 0°, 80° and 180° of knee flexions. Several modeling programs were used to simulate AC motion. Finite element model of conoid and trapezoid ligament was constructed and put into each footprint. The tension and length change of each ligament during shoulder abduction were assessed.
Results
The distal clavicle translated posteriorly and rotated internally with respect to medial acromion at 80o of shoulder abduction (1.1±0.3 cm and 24.4±9.1o). With 180o of shoulder abduction, the rotational gap between distal clavicle and medial acromion increased (36.8 ±12.1o), The virtual lengths of conoid ligament increased at 0o to 180o of shoulder abduction (0.9±0.2 cm to 1.3±0.4 cm), meanwhile, those of trapezoid ligament is constant at 0o to 80o (1.6±0.8 cm to 1.5±0.7 cm) and deceased at 80o to 180o (1.5±0.7 cm to 1.1±0.4 cm) of abduction. With a progression of shoulder abduction, finite element model of conoid ligament is seriously stretched more than 30% of its original length.
Conclusion
The results of this study suggest that distal clavicle has a wide range of motion during shoulder abduction, which do not support the concept of synchronous motion with scapula. The conoid and trapezoid ligaments showed a reciprocal function during shoulder abduction with their different tension pattern.
The length and tension vs abduction angle data obtained has the potential to suggest that conoid and trapezoid ligament should be reconstructed separately and no trial is recommended for AC fixation in patient with AC dislocation~

The pectoralis major footprint: an anatomic description of its insertion site
EA Figueiredo , BB Terra, G Monteiro, ADC Pochini, CV Andreoli, B Ejnisman (São Paulo - BRAZIL)

Purpose
The correct repair of the pectoralis major tendon requires an accurate identification of its insertion on the humerus. In the absence of residual fiber at its insertion, surgical treatment requires knowledge of its anatomical relationships in the proximal humerus. This study aimed to describe the insertion of the pectoralis major tendon as well as measuring its distance to adjacent anatomical structures.
Material and Methods
We dissected 18 shoulders from nine fresh cadavers. The pectoralis major tendon was identified and its insertion site at humerus. The dimensions of the footprint were measured superior to inferior, as well as medial to lateral, by a single observer. We also measured the distance from the top edge of the tendon of pectoralis major to the follow structures : the apex of the humeral head, the apex of the greater tuberosity, lateral border of the conjoint tendon, axillary nerve in the quadrangular space, musculocutaneous nerve in passage through coracobrachialis muscle, the apex of coracoid process and lateral epicondyle.
Results
The mean length of proximal to distal was 80.28 mm (73-89) and from lateral to medial of 6.28 mm (5-7). The average distances from the apex of the pectoralis major to the following structures were : apex of the humeral head 58.5 mm (56-62), greater tuberosity 51.4 mm (51-53), conjoint tendon 12.28 mm (8 -16), axillary nerve 22.8 mm (18-25), musculocutaneous nerve 33.8 mm (30-36), coracoid process 68.14 mm (62-70) and the lateral epicondyle 226.85 mm (210-240).
Discussion
Rupture of the pectoralis major is an uncommon lesion in the shoulder, but its prevalence has increased in recent years, especially in military and weightlifters. The literature concerning this subject is scarce and this paper can help surgeons to perform a better surgical treatment of the pectoralis major rupture.

Getting the balance right between the operative and non-operative management of shoulder injuries – the proprioceptive effect of immobilisation
E Cullen , K Sibartik, R Conroy, H Mullett (Dublin - IRELAND)

Purpose
Shoulder immobilisation is a common non-operative treatment option for many upper limb injuries in Orthopaedics. Bipedal posture and balance in the human is maintained by a closed loop proprioceptive series of sensory inputs and motor outputs. Our hypothesis is that immobilisation of a unilateral upper limb extremity deleteriously affects this proprioceptive feedback loop and may not be the optimal treatment option for many patients.
Material and Methods
We determined a power analysis, the statistical requirements and received ethics approval prior to the commencing this project. Sixty healthy volunteer adults were then selected and divided into two groups. The groups were divided by their age into those under thirty and over fifty years old with a male to female ratio of one in each group. Each volunteer had an interval assessment pre and post shoulder immobilisation to determine a clinical significance. This case controlled the cohort. Sensory organisation, motor control and adaptation responses were measured in the study and control analyses in the two groups.
Results
Balance is significantly affected by wearing a shoulder immobilisation device in both groups (P<0.001) with no significant difference between male and female volunteers across the groups. Summated equilibrium analyses show a higher fall risk in the older age group (43.82%) compared to healthy volunteers under thirty years (28.17%).
Conclusion
Shoulder immobilisation is a conservative non-operative treatment option for many upper limb injuries. This study shows that shoulder immobilisation is not a risk free intervention in healthy volunteers. Statistically, there is a higher fall risk in those aged over fifty. Research to date has proven that concomitant factors predispose an older population to more significant injuries following a simple fall - is the optimal treatment option surgery in appropriate cases to reduce the length of upper limb immobility in the future ?

High Prevalence of Early Cyst Formation in the Dominant Shoulder of High Performance Junior Elite Javelin Throwers, but not in Junior Elite Volleyball Players: A Basis for a Preventive Shoulder Training?
K Beitzel , KI Beitzel, J Zandt, S Buchmann, AB Imhoff, PU Brucker (Munich - GERMANY)
Purpose
A PSI (posteriorsuperior impingement) is frequently seen in the dominant shoulder of adult competitive volleyball and javelin athletes. However, there is a lack of clinical and imaging-based data in a-/oligo-symptomatic junior elite athletes, even though basic approaches for injury prevention should specifically start and focus on this age group. The aim of this study was to evaluate clinical and imaging-based shoulder findings bilaterally in high performance overhead athletes.
Material and Methods
30 healthy junior elite athletes competing at national and international levels were included. Two groups were composed of 16 male volleyball players and 14 male javelin throwers. The mean age (±SD) of the volleyball and the javelin group was 16.9 (±1.0) and 17.6 (±0.8) years, respectively. No major trauma or surgery of the both shoulders were found in medical history. All subjects underwent prospective interviews, clinical examination, and shoulder scoring systems (ASES, Rowe Score). A special attention was paid to the GIRD and external rotation in 90° abduction. Bilateral shoulder imaging data were performed using a native 3T-MRI.
Results
Clinical evaluation demonstrated any specific shoulder pathologies and all subjects had high mean ASES and Rowe score >96 points. A GIRD (glenohmeral internal rotation deficit) of 16.9 (±11.1) ° was found in the volleyball and 9.3 (±9.5) ° in the javelin athletes. The external rotation gain measured 15.0 (±12.5) ° in the dominant shoulders of the volleyball vs. 10.7 (±10.1) ° in the javelin athletes. MRI revealed bony cysts >3 mm at the insertion area of the footprint of the rotator cuff in 71.4% of the dominant shoulders of the javelin athletes compared to only 14.3% in the non-dominant shoulder. In contrast, only 12.6% of the volleyball players had these cyst formations in their dominant and 6.3% in their non-dominant shoulders.
Discussion
A high percentage of a-/oligosymptomatic junior elite athletes already demonstrate structural changes in their dominant shoulders. This is commonly known for adult overhead athletes, but now firstly observed in this young athletic group. The results indicate a high prevalence of GIRD in both groups with more intense occurrence in the volleyball group. MRI indicated osseous signs of overloading especially in the javelin group. This may be caused by repetitive microtrauma due to eccentric loading. Therefore, specific preventive training programs may be dicussed.

05 - Miscellaneous

Moderator :
A Castagna (Italy),
E Servien (France)

 

4D CT scans improve pre-operative planning in Snapping Scapular Syndrome
SN Bell , TDW Alta, JA Coghlan, JM Troupis (Melbourne - AUSTRALIA, Amsterdam - NETHERLANDS)

Purpose
The 4 dimensional CT scan provides a moving 3D image in real time of the scapula snapping over the chest wall. The study was to determine if this aids the clinician in defining the size and area of the scapular bone to be removed arthroscopically in patients with 'Snapping Scapular Syndrome'.
Material and Methods
From January 2009 - January 2011 nine consecutive patients with Snapping Scapular Syndrome were included. In six patients, (mean age 21±5 years) conservative treatment failed. These patients were positioned prone and demonstrated their snapping motion during the 7 seconds duration of the scan. The 4D CT machine, scans a 16 cm volume with one 360° rotation. Therefore, multiple rotations (each acquired within 0.3 seconds) will result in recording of motion. This ability to perform CT fluoroscopic assessment allows a 3D reconstruction of the scapulothoracic joint, its' movements and the dynamic area of impingement of the scapula on the surrounding structures.
Results
The scan showed in one case not only snapping of the superior medial angle of the scapula on the 2nd rib, but also extra bone impinging on the 3rd rib. Another case showed no real impingement but movement of the 2nd and 3rd rib by a tethering structure and a third case demonstrated impingement of the lateral third of the clavicle on the 2nd rib. The scans improved delineation of the amount, and position, of the scapular bone that needed to be removed.
Conclusion
Images provided by this new 4D CT scan offer greater pre-operative insight on the pathology in each individual patient with Snapping Scapular Syndrome and improve the efficacy of bone removal.

Bilateral Scapulothoracic Arthrodesis Does Not Reduce Respiratory Function in Patients with Facioscapulohumeral Muscular Dystrophy
P Boileau , A Pison, C Trojani, K O'shea, S Sacconi, C Desnuelle (Nice - FRANCE)

Purpose
Facioscapulohumeral muscular dystrophy (FSHD) is characterized by the weakness of the scapular fixator muscles and scapular instability associated to functional limitation of shoulder movements and chronic pain. The aims of this study are to evaluate the effect of bilateral scapulothoracic arthrodeses (STA) on : 1) shoulder function, 2) bone consolidation, 3) respiratory capacity.
Material and Methods
We evaluated 10 bilateral STA performed on 5 genetically confirmed FSHD female patients (mean age : 38 years). Fixation of the scapula was obtained with metallic cerclages passed around the ribs ; a tubular plate was placed along the medial border of the scapula and an iliac crest bone graft was added. Shoulder function was evaluated before surgery and at last follow-up. Bone consolidation was evaluated by thoracic CT-scan. Spirometry measured respiratory functions before surgery and at different time-points of the follow-up. The mean follow-up was 49 months (2 to 10 years).
Results
Two patients experienced transitory surgical complications : 1 rib fracture and 1 regressive pleural effusion. At last follow-up, shoulder active elevation (mean values : +46°) and shoulder abduction (mean values : +22°) were significantly improved ; internal and external rotations were conserved. Shoulder function was also improved (mean values : +37 points on Constant Score, +46% on SSV). Moreover, chronic pain was clearly reduced (mean values : -5 point on pain VAS). All patients were very satisfied. Bone fusion was complete in 9 cases and partial in one. Bilateral surgery did not affect respiratory function significantly. The results did not deteriorate with time.
Conclusion
Bilateral STA improved significantly shoulder function and motion, chronic pain, quality of life and cosmetics in all FSHD patients without reducing their respiratory function. Bone fusion was regularly obtained and is crucial for long lasting results in these patients with a long life expectancy.

Incidence of associated intra-articular shoulder injuries, diagnosed during the arthroscopic assisted treatment of acute AC joint dislocations
F Montoya , T Kruppa, P Magosch, P Habermeyer, S Lichtenberg (Heidelberg - GERMANY)

Purpose
Purpose : The purpose of this study was to evaluate the incidence of intra-articular shoulder lesions diagnosed during an arthroscopic assisted treatment of acute acromio-clavicular (AC) joint injuries.
Material and Methods
43 patients (38 males, 9 females), average age 37.2 years (17-59 years) with an acute AC joint dislocation (Rockwood type III, 4 ; type IV, 2 ; type V, 37), were operated on an arthroscopic assisted technique. No patient had shoulder pain before the trauma. Associated intra-articular shoulder lesions were diagnosed and treated. The intraoperative findings were prospectively documented in a database. The operation report and the database were retrospectively assessed in order to evaluate the incidence of associated intra-articular lesions.
Results
Seventeen patients (39.5%) were diagnosed with associated intra-articular shoulder injuries : 8 (18.6%) SLAP lesions ; 1 (2.3%) supraspinatus tendon complete tear, 7 (16.3%) supraspinatus tendon partial tears, 3 (6.9%) subscapularis tendon partial tears, 1 (2.3%) supraspinatus/subscapularis tendons partial tear, 1 (2.3%) supraspinatus/subscapularis tendons complete tear ; 2 (4.6%) LHBT partial ruptures ; 4 (9.3%) lesions of the biceps pulley system ; and 1 (2.3%) humeral head chondral lesion. Patients with associated rotator cuff tears were significantly older than patients without them, 46.5 years versus 32 years (p = 0.001).
Conclusion
Associated intra-articular shoulder lesions were commonly diagnosed and treated when an arthroscopic assisted AC joint reconstruction/stabilization was performed. Nearly 40% of the patients showed additional lesions of the shoulder joint. In 30% of the cases a lesion of the rotator cuff was observed, especially in patients older than 46 years. Considering the prominent clinical signs of an acute AC joint dislocation, clinical and imaging diagnosis may be difficult to perform for associate lesions. Therefore diagnostic shoulder arthroscopy could play an important role in the detection and treatment of them.

Complication of the clavicle hook plate
X Wu (Shanghai - CHINA)

Purpose
To discuss the clinical characteristic of the unstable medial clavicle fracture and its treatment.
Material and Methods
Eleven medial clavicle fractures were treated during the period from January 2007 to August 2009. 10 were male, with the mean age of 44.5 years .The medial clavicle fracture is defined by the Edinburgh classification that is located one-fifth of the medial part of the clavicle. The separation of the bone ends larger than 10 mm using 3D CT measurement was considered as severely displaced. The unstable medial clavicle fracture was defined as meeting at least one of the three criteria (1) with the ipsilateral scapular fracture, (2) as a part of the segmental clavicle fracture, (3) severely displaced. One medial clavicle fractures was accompanied by the scapular neck fracture, one with the acromion fracture. Three medial clavicle fractures were a part of the segmental clavicle fractures, two with the middle third clavicle fracture, and the other with the distal clavicle fracture along with the ipsilateral scapular fracture. Six were severely displaced.Eight of them were treated by the open reduction and internal fixation. . Seven were treated by ORIF with 3.5 mm reconstructed locking plate.The medial clavicle fracture with the ipsilateral acromion fracture was treated by two 3.5 mm volar T-locking plates. The rest three cases were treated conservatively because of the severe associated injury.
Results
All the patients were followed for a mean time of 15 months (15-18m).The fractures were united anatomically in the surgical group with one plate breakage .The mean Constant score for the last follower up were 94 for the surgery cases .Two fractures in the conservative group were malunited and the rest one was nonunion..
Conclusion
The surgical treatment is strongly recommended to the unstable medial clavicle fractures .The locking plate can be an alternative choice in these cases.

COMPARISON OF AUTOLOGOUS BONE GRAFT VS DEMINERALISED BONE MATRIX (DBX) IN TREATMENT OF MIDSHAFT CLAVICLE NON-UNION
P Mestha , A Singh, M Pimple, A Tavakkolizadeh, J Sinha (London - UNITED KINGDOM)

Purpose
Clavicle mid-shaft fracture non-union is usually addressed surgically with open reduction internal fixation (ORIF), and augmentation with autologous bone graft (ABG) or other bone substitutes. This study aims to compare the outcome between ABG and Demineralised Bone Matrix (DBX).
Material and Methods
This is a retrospective study of 30 patients with mid shaft clavicle fracture non-union treated with ORIF and augmented with ABG or (DBX) between 2000 and 2010. Of these, 20 were in bone graft group while 10 in the DBX group. Most fractures, 27 out of 30 were initially managed conservatively, while three had failed primary fixation. Two belonged to bone graft and one to DBX group. The mean age for the bone graft group was 39.4 years (range 30-74 yeas), and DBX group was 42.1 years (range 24-78 years). The exclusion criteria were open fractures, fractures with neurovascular deficit or septic non-unions. The results were compared clinically, radiologically and through satisfaction scores.
Results
The union rate in both groups were comparable with 18 out of 20 in bone graft group, and 9 out of 10 in DBX group achieving union. One of the non-unions in the bone graft group required re-plating with ossigraft, leading to union. The other two, one belonging to each group, were asymptomatic with fibrous non-union with full range of shoulder movement. Both patients declined further surgery. The median time to radiological union was 6 months (range 3-9 months) in both groups. Of the cases that could be contacted, 90% of DBX group and 70% of bone graft group rated their function as excellent and would consider having the surgery again if required.
Conclusion
To conclude, Clavicle non-unions augmented by DBX have at least as good a union rate as autologous bone graft without the associated donor site morbidities, and hence can be considered as an alternative option

Development and Validation of a Score to Assess Functional External Rotation Deficit: the ADLER score (Activities of Daily Living utilizing External Rotation)
P Boileau , AP Rumian, G Alami, K O'shea, B Melis, Y Roussanne (Nice - FRANCE, Montpellier - FRANCE)

Purpose
When the infraspinatus and teres minor are absent or fatty-infiltrated, no other muscle can provide active external rotation (aER) and attempts at shoulder elevation result in the forearm swinging in uncontrollably towards the trunk. The purpose of this study was to develop and validate a score that objectively quantifies the functional deficit in Activities of Daily Living (ADLs) requiring aER.
Material and Methods
Score development had 3 stages : (1) Identification of patients with absent aER- inability to maintain neutral shoulder rotation in adduction + positive hornblower's sign + absent/fatty-infiltrated infraspinatus and teres minor on imaging. (2) Item determination - patient interviews generated a list of ADLs that were difficult to perform in the absence of aER (3) Score validation -prospective evaluation of 56 patients undergoing Latissimus Dorsi-Teres Major tendon (LD/TM) transfer, using pre- and post-operative scoring using the ADLER score and correlating it with other validated scores (Constant score, Simple Shoulder Test).
Results
The ADLER score has 10 items : Brushing hair, Shaving/applying make-up, Brushing teeth, Getting dressed, Filling a glass from a bottle (whilst seated), Bringing a full glass to the mouth, Eating soup with a spoon, Shaking someone's hand/opening a door, Holding a telephone to the ear, Writing/typing/playing the piano. Each item was scored between 0 and 3 : 0 impossible, 1 very difficult, 2 somewhat difficult, 3 not difficult at all. All activities should be performed without flexing the neck or the trunk and without first abducting the elbow (ie, without a hornblower's sign). After LD/TM transfer, the ADLER score improved from a mean of 13 to 24 points and correlated closely with other scores whilst being more sensitive to improvements in aER.
Conclusion
The ADLER score is a useful, validated tool to help identify patients who may benefit from tendon-transfer procedures and assess their treatment outcomes.

Motion analysis of acromioclavicular joint using 3D in-vivo shoulder model
YS Yoo (Seoul - KOREA, REPUBLIC OF)

Purpose
The aim of this study was to determine the AC motion and change in length and tension of the coracoclavicular ligament at shoulder abduction using a three dimensional finite element model.
Material and Methods
The right shoulder of 5 living subjects was scanned with a high resolution CT scanner at 0°, 80° and 180° of knee flexions. Several modeling programs were used to simulate AC motion. Finite element model of conoid and trapezoid ligament was constructed and put into each footprint. The tension and length change of each ligament during shoulder abduction were assessed.
Results
The distal clavicle translated posteriorly and rotated internally with respect to medial acromion at 80o of shoulder abduction (1.1±0.3 cm and 24.4±9.1o). With 180o of shoulder abduction, the rotational gap between distal clavicle and medial acromion increased (36.8 ±12.1o), The virtual lengths of conoid ligament increased at 0o to 180o of shoulder abduction (0.9±0.2 cm to 1.3±0.4 cm), meanwhile, those of trapezoid ligament is constant at 0o to 80o (1.6±0.8 cm to 1.5±0.7 cm) and deceased at 80o to 180o (1.5±0.7 cm to 1.1±0.4 cm) of abduction. With a progression of shoulder abduction, finite element model of conoid ligament is seriously stretched more than 30% of its original length.
Conclusion
The results of this study suggest that distal clavicle has a wide range of motion during shoulder abduction, which do not support the concept of synchronous motion with scapula. The conoid and trapezoid ligaments showed a reciprocal function during shoulder abduction with their different tension pattern. The length and tension vs abduction angle data obtained has the potential to suggest that conoid and trapezoid ligament should be reconstructed separately and no trial is recommended for AC fixation in patient with AC dislocation~

The pectoralis major footprint: an anatomic description of its insertion site
EA Figueiredo , BB Terra, G Monteiro, ADC Pochini, CV Andreoli, B Ejnisman (São Paulo - BRAZIL)

Purpose
The correct repair of the pectoralis major tendon requires an accurate identification of its insertion on the humerus. In the absence of residual fiber at its insertion, surgical treatment requires knowledge of its anatomical relationships in the proximal humerus. This study aimed to describe the insertion of the pectoralis major tendon as well as measuring its distance to adjacent anatomical structures.
Material and Methods
We dissected 18 shoulders from nine fresh cadavers. The pectoralis major tendon was identified and its insertion site at humerus. The dimensions of the footprint were measured superior to inferior, as well as medial to lateral, by a single observer. We also measured the distance from the top edge of the tendon of pectoralis major to the follow structures : the apex of the humeral head, the apex of the greater tuberosity, lateral border of the conjoint tendon, axillary nerve in the quadrangular space, musculocutaneous nerve in passage through coracobrachialis muscle, the apex of coracoid process and lateral epicondyle.
Results
The mean length of proximal to distal was 80.28 mm (73-89) and from lateral to medial of 6.28 mm (5-7). The average distances from the apex of the pectoralis major to the following structures were : apex of the humeral head 58.5 mm (56-62), greater tuberosity 51.4 mm (51-53), conjoint tendon 12.28 mm (8 -16), axillary nerve 22.8 mm (18-25), musculocutaneous nerve 33.8 mm (30-36), coracoid process 68.14 mm (62-70) and the lateral epicondyle 226.85 mm (210-240).
Discussion
Rupture of the pectoralis major is an uncommon lesion in the shoulder, but its prevalence has increased in recent years, especially in military and weightlifters. The literature concerning this subject is scarce and this paper can help surgeons to perform a better surgical treatment of the pectoralis major rupture.

Getting the balance right between the operative and non-operative management of shoulder injuries – the proprioceptive effect of immobilisation
E Cullen , K Sibartik, R Conroy, H Mullett (Dublin - IRELAND)

Purpose
Shoulder immobilisation is a common non-operative treatment option for many upper limb injuries in Orthopaedics. Bipedal posture and balance in the human is maintained by a closed loop proprioceptive series of sensory inputs and motor outputs. Our hypothesis is that immobilisation of a unilateral upper limb extremity deleteriously affects this proprioceptive feedback loop and may not be the optimal treatment option for many patients.
Material and Methods
We determined a power analysis, the statistical requirements and received ethics approval prior to the commencing this project. Sixty healthy volunteer adults were then selected and divided into two groups. The groups were divided by their age into those under thirty and over fifty years old with a male to female ratio of one in each group. Each volunteer had an interval assessment pre and post shoulder immobilisation to determine a clinical significance. This case controlled the cohort. Sensory organisation, motor control and adaptation responses were measured in the study and control analyses in the two groups.
Results
Balance is significantly affected by wearing a shoulder immobilisation device in both groups (P<0.001) with no significant difference between male and female volunteers across the groups. Summated equilibrium analyses show a higher fall risk in the older age group (43.82%) compared to healthy volunteers under thirty years (28.17%).
Conclusion
Shoulder immobilisation is a conservative non-operative treatment option for many upper limb injuries. This study shows that shoulder immobilisation is not a risk free intervention in healthy volunteers. Statistically, there is a higher fall risk in those aged over fifty. Research to date has proven that concomitant factors predispose an older population to more significant injuries following a simple fall - is the optimal treatment option surgery in appropriate cases to reduce the length of upper limb immobility in the future ?

High Prevalence of Early Cyst Formation in the Dominant Shoulder of High Performance Junior Elite Javelin Throwers, but not in Junior Elite Volleyball Players: A Basis for a Preventive Shoulder Training?
K Beitzel , KI Beitzel, J Zandt, S Buchmann, AB Imhoff, PU Brucker (Munich - GERMANY)

Purpose
A PSI (posteriorsuperior impingement) is frequently seen in the dominant shoulder of adult competitive volleyball and javelin athletes. However, there is a lack of clinical and imaging-based data in a-/oligo-symptomatic junior elite athletes, even though basic approaches for injury prevention should specifically start and focus on this age group. The aim of this study was to evaluate clinical and imaging-based shoulder findings bilaterally in high performance overhead athletes.
Material and Methods
30 healthy junior elite athletes competing at national and international levels were included. Two groups were composed of 16 male volleyball players and 14 male javelin throwers. The mean age (±SD) of the volleyball and the javelin group was 16.9 (±1.0) and 17.6 (±0.8) years, respectively. No major trauma or surgery of the both shoulders were found in medical history. All subjects underwent prospective interviews, clinical examination, and shoulder scoring systems (ASES, Rowe Score). A special attention was paid to the GIRD and external rotation in 90° abduction. Bilateral shoulder imaging data were performed using a native 3T-MRI.
Results
Clinical evaluation demonstrated any specific shoulder pathologies and all subjects had high mean ASES and Rowe score >96 points. A GIRD (glenohmeral internal rotation deficit) of 16.9 (±11.1) ° was found in the volleyball and 9.3 (±9.5) ° in the javelin athletes. The external rotation gain measured 15.0 (±12.5) ° in the dominant shoulders of the volleyball vs. 10.7 (±10.1) ° in the javelin athletes. MRI revealed bony cysts >3 mm at the insertion area of the footprint of the rotator cuff in 71.4% of the dominant shoulders of the javelin athletes compared to only 14.3% in the non-dominant shoulder. In contrast, only 12.6% of the volleyball players had these cyst formations in their dominant and 6.3% in their non-dominant shoulders.
Discussion
A high percentage of a-/oligosymptomatic junior elite athletes already demonstrate structural changes in their dominant shoulders. This is commonly known for adult overhead athletes, but now firstly observed in this young athletic group. The results indicate a high prevalence of GIRD in both groups with more intense occurrence in the volleyball group. MRI indicated osseous signs of overloading especially in the javelin group. This may be caused by repetitive microtrauma due to eccentric loading. Therefore, specific preventive training programs may be dicussed.

ICL 1: Treatment of proximal humerus fractures: what's new?

Moderator : F Gohlke (Germany)

Understanding the fracture type?Patient related outcome parameters: injury patterns, age and bone quality?
H Resch (Salzburg - AUSTRIA)

Indications for conservative or surgical treatment? How to make the decision
R Emery (London - UNITED KINGDOM)

Treatment options: minimal invasive, nailing, plating? Evidence based superiority of certain procedures?
R Hertel (Bern - SWITZERLAND)

Reverse TSR: does it improve the results in acute fracture arthroplasty
F Sirveaux (Nancy - FRANCE)

Failures of fractures treatment: common types, how to avoid and how to solve problems.
F Gohlke (Wuerzburg - GERMANY)

ICL 2: Nerve entrapment around the elbow

Moderator : F van Glabbeek (Belgium)

Clinical anatomy of the nerves around the elbow joint
F van Glabbeek (Wilrijk - BELGIUM)

Ulnar nerve entrapment around the elbow joint
S Antuña (Madrid - SPAIN)

Radial-, medial and subcutaneous nerve entrapment around the elbow joint
P Mansat (Toulouse - FRANCE)

ICL 3: Subscapularis tears, from small to irreparable: how and when to treat?

Moderator : L Lafosse (France)

Introduction
L Lafosse (Annecy - FRANCE)

Subscapularis anatomy
P Golano

Arthroscopic repair of small and medium subscapularis tear
R Brzoska (Bielsko-Biala - POLAND)

Arthroscopic versus open repair of large subscapularis tears
P Kasten (Dresden - GERMANY)

Irreparable subscapularis tear: what to do?
C Gerber (Zurich - SWITZERLAND)

Conclusion
L Lafosse (Annecy - FRANCE)

Bone Insufficiency in shoulder instability

Moderator : WJ Willems (Netherlands)

Introduction and classification of glenoid and humeral effects
J Willems (Amsterdam - NETHERLANDS)

Biomechanics of bone deficiency in shoulder instability
E Itoi (Sendai - JAPAN)

Hill-Sachs lesions: when and how to treat
C Gerber (Zurich - SWITZERLAND)

Arthroscopic bone block grafting in glenoid defects
E Taverna (Mendrisio - SWITZERLAND)

Arthroscopic Latarjet procedure
L Lafosse (Annecy - FRANCE)

Open Latarjet procedure
C Levigne (Lyon - FRANCE)

06 - Shoulder Arthroplasty

Moderator : L Favard (France), F Gohlke (Germany)

Prospective multicentric study of a continuous series of 50 Reverse Total Shoulder Arthroplasties (RTSA) with a minimum follow-up of four years
M Scarlat , M Gonzalvez, E Baulot, F Handelberg, C Hugues (Toulon - FRANCE, Dijon - FRANCE, Bruxelles - BELGIUM, Lille - FRANCE)

Purpose
Prospective study of a new RTSA used in clinical applications since 2006. The glenosphere have a lowered axis of rotation providing physiologic adduction. We hypothesized that this design will result in better ranges of motion and less.
Material and Methods
50 patients had surgery in 5 centers. The Constant score, strength, everyday activities and comfort were assessed periodically with a minimum follow-up of fourty-eight months. Radiological follow-up was performed with standard views. . Fifty patients (82% females, 62% operated on the dominant side) were prospectively followed. None was lost of view. The patients were assessed by an independent examiner. The indication for RTSA was arthritis with an eccentric head 40%, arthritis with a centered head 14%, fractures 4%, necrosis 4%, other pathologies including revision surgery 28%. The preoperative score 28,9% (19 to 64%). Complications include two early and one late dislocations within one year. The average Constant score was 62 with improvement in the arm strength, comfort (12.6 / 15), activity (8 / 10) and mobility (7.8 / 10.).
Results
Fifty patients (82% females, 62% operated on the dominant side) were prospectively followed. None was lost of view. The patients were assessed by an independent examiner. The indication for RTSA was arthritis with an eccentric head 40%, arthritis with a centered head 14%, fractures 4%, necrosis 4%, other pathologies including revision surgery 28%. The preoperative score 28,9% (19 to 64%). Complications include two early and one late dislocations within one year. The average Constant score was 62 with improvement in the arm strength, comfort (12.6 / 15), activity (8 / 10) and mobility (7.8 / 10.). The radiological study reported the absence of a notching phenomenon (96% of patients with stage 0 and 4% depending Nerot stage 1). A spur was found at 2 years in 18% of cases (14% and 4% small spur) 78% of cases had no spur.
Conclusion
The radiological study reported the absence of a notching phenomenon (96% of patients with stage 0 and 4% depending Nerot stage 1). A spur was found at 2 years in 18% of cases (14% and 4% small spur) 78% of cases had no spur.The implant is well tolerated clinically with a satisfactory radiological and clinical follow-up. This design seems to diminish the conflict at the lower edge of the glenoid, resulting in no notching and improved mobility in all the cases.

Survivorship of the reverse shoulder arthroplasties (RSA) with a minimum follow up of 10 years
L Favard , G Alami, A Young, F Sirveaux, P Boileau, G Walch (Tours - FRANCE, Nice - FRANCE, Lyon - FRANCE, Nancy - FRANCE)

Purpose
to analyze the survivorship of the RSA with a minimum 10 years follow up.
Material and Methods
Between 1992 and 1999, 145 Delta (DePuy) RSAs have been implanted in 138 patients. Initial etiologies were gathered as following : group A (92 cases) - Cuff tear arthropaties (CTA), and massive cuff tear with pseudoparalysis (MCT) ; group B (39 cases) - failed hemiarthroplasties (HA), failed total shoulder arthroplasties (TSA) ; and group C (14 cases) - varied. Two end-points were retained : implant revision, defined by glenoid or humeral replacement or removal, or conversion to HA ; a poor clinical outcome defined by an absolute Constant score of less than 30.
Results
At the time of review, 47 patients had died with their prosthesis in place and 30 were lost to follow-up. There were 12 revisions. The survival curve to prosthetic removal showed an overall survivorship of 92% at 10 years. Segmentation according to etiology showed a 97% survivorship for group A and 88% for group B This difference was not significant. The survival curve to a Constant score of less than 30 showed an overall survivorship of 90% at 10 years. Segmentation according to etiology showed a significant difference at 10 years in favor of group A (92%) compared to group B (86%) with a break of the curve after 9 years for group B.
Discussion
Our results show that the overall survivorship to removal is good even 10 years after implantation, in particular if it had been implanted for CTA, OA, or MCT. However, functional results did deteriorate progressively after 9 years). Therefore, extreme caution must be observed in relation to the indications for reverse shoulder arthroplasty, especially in younger patients.

Glenoid Loosening and Failure in Total Shoulder Arthroplasty: Is Revision with a Reverse Shoulder Arthroplasty a Reliable Option?
B Melis , N Bonnevialle, C Lévigne, L Favard, G Walch, P Boileau (Nice - FRANCE, Toulouse - FRANCE, Lyon - FRANCE, Tour - FRANCE)

Purpose
Aseptic glenoid loosening and failure in total shoulder arthroplasty (TSA) are often associated with glenohumeral instability, rotator cuff tears and glenoid bone loss. Our purpose was to evaluate if, in these cases, revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option.
Material and Methods
Retrospective multicenter cohort study of 37 consecutive TSA revised by RSA for aseptic glenoid loosening or failure. The indication for TSA was primary osteoarthritis in 22 cases, post-instability osteoarthritis in 3, sequela of fracture in 3, rheumatoid arthritis in 2 and miscellaneous in 7 cases. Mean age of patients at revision was 71 years (range, 52 to 82). Rotator cuff tears were associated in 24 cases, subscapularis insufficiency in 29, and prosthetic instability in 13. Glenoid bone deficiency was present in all cases and a bone graft was performed in 29. All patients were reviewed clinically and radiologically at a mean follow-up of 47 months (range, 24 to 104).
Results
At last follow-up, the average Constant score increased from 24 à 55 pts (p<0,0001) and active anterior elevation from 68° à 121° (p<0,0001) ; 22 of the 29 associated bone grafts were incorporated in the glenoid. Three patients had to be re-revised because of recurrent glenoid loosening, 3 because of prosthetic anterior instability and 2 because of humeral subsidence. The RSA had been converted to a hemiarthroplasty in one case and a resection arthroplasty was performed in one other.
Conclusion
Revision of glenoid loosening or failure with a RSA is a reliable therapeutic option, which allows : 1) to reconstruct the glenoid bone stock by fixing the bone graft with the help of the baseplate and screws and 2) to solve the problem of soft tissue insufficiency and prosthetic instability. However, the rate of complications and re-revision is high.

The "bone Collar-And-Tie" (bCAT) technique: A New Solution to Restore Tuberosity Position and Cuff Tension in Reverse Shoulder Prosthesis for Complex Proximal Humeral Fractures
R Russo , F Cautiero, M Ciccarelli, G Pizzi, G Della Rotonda (Napoli - ITALY)

Purpose
The reverse shoulder prosthesis (RSP) has been proposed as an alternative to conventional surgery for elderly patients with complex proximal fractures. However, the results are controversial and the functional outcome poor particularly as regards restoration of extra-rotation and abduction of the shoulder. To address this problem, we have devised a new technique, designated " bone collar-and-tie " (bCAT) technique, to associate with RSP surgery.
Material and Methods
The bCAT technique consists in using the fractured humeral head, appropriately modeled, positioned collar-like around the prosthesis and under the tuberosities. This bone support functions mechanically and biologically to relieve cuff tension thereby improving shoulder rotations and promoting healing of tuberosities. Between 2005 and 2010, 34 patients (mean age 73.8 years ; range 68-95) were treated with a reverse prosthesis for a complex proximal humeral fracture. In 18 of these patients, the bCAT technique was associated with RSP surgery
Results
Sixteen patients were available for follow-up (mean 14 months). Seven patients underwent conventional RSP surgery (group A) and 9 underwent RSP surgery associated with the bCAT procedure (group A). As shown in the Table below, movement was much better in group B than in group A. Similarly, the Constant score was much higher in group B than in group A.
Average motion outcome
Group A
RSP surgery
7 patients
Group B
bCAT-associated RSP
9 patients
Abduction
109.4°
138°
Anterior elevation
125°
160°
Extra-rotation in RE1
14°
35°
Intra-rotation
Sacrum
L2-L3
Constant score (mean)
67.8
90
Conclusion
The results of this study suggest that the bCAT technique can improve the outcome of RSP surgery. Further studies on larger populations are required to verify our preliminary report.

Reverse Shoulder-Allograft Composite Prosthesis for Reconstruction following Severe Proximal Humeral Bone Loss
D Doherty , TB Edwards, H Elkousy, D O'Connor, A Rodriguez-Santiago, G Gartsman (Houston - UNITED STATES)

Purpose
Whether due to fracture, tumor resection, or prosthetic failure, extensive proximal humeral bone loss is often a difficult scenario to manage. The introduction of the reverse shoulder prosthesis successfully addresses the limitations of shoulder arthroplasty when rotator cuff insertions are lost. However, proximal humeral bone loss may remain problematic when implanting a reverse prosthesis due to the potential for instability or prosthetic loosening. The purpose of this study is to report our experience using allografts in conjunction with the reverse shoulder prosthesis in treatment of patients with severe proximal humeral bone loss.
Material and Methods
A prospective database of 284 patients receiving reverse shoulder arthroplasty was queried, and 13 patients were identified who received an allograft and had a minimum of one year follow up (avg : 25 months). Clinical charts, radiographs, and patient surveys were included in our analysis. Pre and post-operative results, including ASES scores, Constant scores, and active mobility were compared using paired t-tests.
Results
Statistically significant improvements (p<0.05) were seen in all Constant scores, forward flexion, and abduction. ASES score improved from 56.3 preoperatively to 62.0 at follow up. This population had an average of 69.9 mm of proximal humeral bone loss. Four patients reported a subjective grade of very satisfied post operatively, 4 reported satisfied, 2 reported dissatisfied, and 3 reported very dissatisfied. Despite improvements in most functional outcomes, the complication rate was high, as four patients experienced radial nerve palsy, two patients experienced multiple recurrent dislocations, two patients experienced acromion fractures, and two patients developed infections, one of which required removal of the prosthesis.
Discussion
The use of an allograft in the setting of reverse shoulder arthroplasty seems to carry a high rate of postoperative complications. Management of extensive proximal humeral bone loss remains a difficult clinical scenario for which the optimal management has yet to be adequately elucidated. Further research into the use of allografts to minimize complications seems to be warranted.

Reverse prosthesis associated to a transfer of the teres maior and latissimus dorsi.What can we expect on rotations?A prospective study of 17 cases
N Ivaldo (Acqui Terme - ITALY
)
Purpose
We have examined 17 patients who received a reverse prosthesis associated to a transfer of the teres maior and latissimus dorsi, using a single delto-pectoral approach.Our pourpose was to evaluate results on active external rotation, possible loss of internal rotation, and overall complication rate of this combined procedure.
Material and Methods
This surgical procedure was performed in patients with eccentric arthropaty or significant rotator cuff injury, in which the function of the teres minor was absent or significantly compromised. Therefore, the active external rotation was totally lost. The average age at the moment of the operation was 71 years and the female/male ratio was 12/17 with a follow-up of 30 months. The Constant Score, not weighed for sex and age, was used for the clinical evaluation.
Results
The final score improved from 34 to 65 points. The active elevation improved from 93° to 142° (+49°), the functionality from 4.6/10 (sternum level) to 8.8 points (overhead level). The score relative to the active external rotation improved from 3.5 to 7.6 points. The external rotation in adduction improved by 17° (from -12° to +5°), whereas the external rotation evaluated at 90° of abduction (or at least at the max reachable level of abduction) improved by 32° (from +8° to +40°). A significant decrease in the average internal rotation occurred (L2 during preop evaluation and at gluteus level during final control ). No infections or dislocations were observed in this series. However, we had two patients who had one transient and one persistent neurological disorder in the form of paresthesia, and muscular hypotrophy both involving the ulnar nerve area.
Conclusion
The combined procedure of reverse prosthesis and latissimus dorsi transfer allows for a partial recovery of the external rotation without exposing the patient to a high risk of complications. The loss of internal rotation at follow up is pronounced, thus the transfer should be avoided when the contralateral shoulder shows a significant restriction of this movement.

Wear-induced loss of mass in reversed total shoulder arthroplasty with conventional and inverted bearing materials
G Kohut , F Dallmann, U Irlenbusch (Fribourg - SWITZERLAND, Mörsdorf/Thür - GERMANY, Arnstadt - GERMANY)

Purpose
The notching phenomenon is frequently observed after reversed total shoulder arthroplasty (RTSA). While its clinical relevance is debated, some concern may be raised regarding its effect on bone loss on the scapula. In order to avoid the abutment of a polyethylene (PE) part against the scapula, some prosthetic designs feature an inverted pairing of materials (inverted bearing-RTSA = IB-RTSA) : the glenosphere is made of PE and the epiphysis is metallic.
Since metal (CoCr) and polyethylene (UHMWPE) switched their positions on IB-RTSA, the question raises whether the tribological behaviour of the system would then be different. The present report addresses this question.
Material and Methods
The tribological wear of four pairs of conventional and IB-RTSA components was tested on wear simulators, up to 500'000 cycles with maximum loads of 1000 N.
As for comparison, the mechanical loss of mass due to different stages of inferior notching was calculated on a CAD device, based on observations on retrieved specimens.
Results
After 500.000 cycles the mean amount of wear of the polyethylene components was
-9.78 mg for the pairing UHMWPE Glenosphere / CoCr Inlay respectively -8.40 mg for the pairing CoCr Glenosphere / UHMWPE Inlay.
Calculated loss of mass due to inferior notching : On a +0 mm inlay, the calculated loss of mass ranges from 51.7 mg to 611.8 mg, depending on the depth of abrasion. On a +6 mm inlay, the numbers are 154.2 mg to 1478.7 mg.
Conclusion
The amount of tribological PE wear does not differ significantly between conventional and IB-RTSA. In both situations, the tribological PE wear represents only a small percentage of the loss of mass that would be due to mechanical inferior notching with PE-Inlays.

07 - Rotator cuff

Moderator : J Bruguera (Spain), A Schneeberger (Switzerland)

Use of Platelet- and Leucocyte-Rich Fibrin (L-PRF) improves early vascularization but does not affect late rotator cuff tendon healing: A prospective randomized controlled study
MA Zumstein , AP Rumian, K O'shea, CE Thélu, V Lesbats, P Boileau (Nice - FRANCE)

Purpose
Leukocyte platelet-rich plasmas (L-PRP's) and pure platelet-rich fibrins (P-PRF's) didn't improve the anatomical healing rate up to now. There is a potential advantage of leukocyte platelet-rich fibrin (L-PRF) that has a solid matrix and can store and deliver growth factors up to 28 days. We hypothesized that arthroscopic rotator cuff repair with L-PRF results in better vascularization of the bone tendon unit and in a higher watertight healing rate and better tendon quality at 12 months follow up than without L-PRF.
Material and Methods
Thirty-five prospective randomized patients underwent arthroscopic rotator cuff repair for the treatment of chronic posterosuperior rotator cuff tears. In seventeen patients, leukocyte platelet-rich fibrin (L-PRF) was added in between the tendon and the bone. All patients were prospectively followed clinically and radiographically. Vascularization was measured with Power Doppler ultrasonography at 6 weeks and 3 months, anatomic watertight healing, tendon thickness and tendon quality was measured using MR arthrography.
Results
A double row technique was used in all patients. The mean SSV, SST and adjusted Constant increased significantly in both groups from pre- to postoperatively, but with no difference between the groups. Although early vascualrization of the operated tendon-bone insertions was significantly higher in the L-PRF group than in the control group (9.8 vs 5.8, p = 0.015 at 6 weeks ; 7.2 vs 4.6 at 3 months), there was no difference in anatomical healing rate (13/ 17 in the L-PRF ; 14/18 in the control group). Tendon thickness (5.3 mm vs. 6.0 mm) and tendon quality (Sugaya III) were not different in either group at 12 months.
Conclusion
Arthroscopic rotator cuff repair with application of leukocyte platelet-rich fibrin (L-PRF) yields higher early vascularization response without a beneficial effect in terms of anatomical healing rate, tendon thickness, tendon quality, and the functional results of the shoulder.

Platelet Rich Plasma (PRP) in Arthroscopic Rotator Cuff Repair. A Prospective RCT Study, 2 years Follow-up
P Randelli , P Arrigoni, A Aliprandi, V Ragone, P Cabitza (Milano - ITALY)

Purpose
Hypothesis : Local application of autologous PRP improves tendon healing in patients undergone arthroscopic rotator cuff repair. Study design : Prospective, randomized, controlled, double blind study ; Level of evidence, 1. Considering an alpha level of 5%, a power of 80%, 22 patients for group are needed.
Material and Methods
Fifty-three patients who undergone a shoulder arthroscopy for the repair of complete rotator cuff tear, were randomly divided into two groups (block randomization procedure) : a treatment group (N = 26) who received an intra-operative application of PRP in combination with an autologous thrombin component and a control group (N = 27). Patients were evaluated with Validated outcome score. An MRI was performed in all case at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. Results
The two groups were omogeneous. Pain score in treatment group was lower than control group at 3, 7, 14 and 30 days after surgery (p< 0,05). Strenght in External Rotation (dynamometer), SST, UCLA and Constant scores in treatment group were significantly higher than control group at 3 months after surgery (SER : 3 ±1,6kg versus 2,1±1,3kg ; SST : 8,9±2,2 versus 7,1±2,7 ; UCLA : 26,9±3 versus 24,2±4,9 ; Constant : 65±9 vs 57,8±11 ; p< 0,05). There was no difference between the two groups after 6, 12 and 24 months.The MRI follow-up showed no significant difference in the healing rate. In the subgroup of stage 1 and 2 tears, with less retraction and more prone to the effect of a biological therapy, SER in PRP group were significant higher at 3, 6, 12 and 24 months post-op. (p< 0,05).
Conclusion
The results of our study showed autologous PRP reduced pain in the first months post-op and promoted quicker healing. Long-term results of subgroups of stage 1 and 2 tears suggest PRP effectively affected cuff rotator healing.

Local application of autologous platelet rich plasma with fibrin at the repair site of completely reconstructed massive rotator cuff tears: A prospective randomized clinical trial
JM Martinez , JM Sanchez-Marquez, R Barco, S Antuña (Madrid - SPAIN)

Purpose
The objective of this study was to evaluate the influence of Platelet Rich Plasma with Fibrin (PRP-F) on the functional outcome and integrity of the repair in patients with massive rotator cuff tears treated arthroscopically.
Material and Methods
A prospective, blinded, randomized clinical trial was performed on 28 patient (22 females, 6 males) with a mean age of 65 years (range, 53 to 77) undergoing complete arthroscopic repair of a massive rotator cuff tear. Patients with partial repairs were excluded. In 14 patients, 6 ccs of PRP-F (vivostat®) were locally applied to the repair site. In 14 patients no addition of PRP-F was performed. All patients were clinically and radiographically examined at a minimum of 1 year after the operation. Functional outcome was evaluated with the Constant score. The integrity of the repair was assessed with an arthro-MRI.
Results
There were no reported complications. Globally, the constant score improved from 45 pts (range, 25 to 65) to 64 pts (range, 20 to 79) (P<0.001). 26 patients were satisfied with their outcome. There was not any statistically significant difference in the preoperative (46 vs 43 pts ; P = 0.37) or postoperative constant score (61 vs 68 ; p = 0.125) between the control group and the PRP-F group. On the arthro-MRI, 19 of the 28 patients (68%) had a large full-thickness re-tear : 10 shoulders in the PRP-F group and 9 shoulders in the control group, with no differences between both groups.
Conclusion
Local application of PRP-F to the repair site of fully reconstructed massive rotator cuff tears does not improve either the clinical outcome or the healing rate of the tendons.

The Effect of Platelet Rich Plasma and Two Different Application Methods of Platelet Rich Plasma on Rotator Cuff Healing: A Biomechanical Animal Study
A Ersen , M Demirhan, AC Atalar, M Kapicioglu (Istanbul - TURKEY)

Purpose
The goal of this study was to evaluate the effect of Platelet Rich Plasma and two different application methods of PRP on rotator cuff healing.
Material and Methods
Supraspinatus tendons of forty-eight mature male Wistar-Albino rats were detached from insertion on humerus. The animals are divided into four different protocols : (1) no repair (2) primary repair (3) Repair plus PRP application with injection to tendon-bone interface (4) Repair plus PRP application with sponge carrier to tendon-bone interface. The animals were sacrified at eight weeks and ten rotator cuffs from each group underwent biomechanical testing while two rotator cuffs were evaluated with histologic analysis.
Results
The specimens from the groups with PRP application (Groups 3-4) had significantly greater load to failure rates 11.8±5.5 N and 11.6±3.9 (p<0.05) and stiffness (p<0.05) than the control specimens from group 1 and 2 without PRP application 3.5±2.3 N and 1.6±0.75 N, respectively. No significant difference was detected between the groups with two PRP application methods. Histologic evaluation showed a fibrovascular tissue in the interface between tendon and bone however there is no significant difference among four groups. Conclusion
The application of Platelet Rich Plasma, independent of the application method, resulted significantly improved biomechanical properties at the rotator cuff tendon-bone interface which we assume due to high concentration of platelet derived growth factors. The type of application, injection or through a sponge carrier, did not influence the effect of PRP on rotator cuff healing.

Single-Incision vs. Double-Incision Technique for Latissimus Dorsi Transfer
HC Jeske- , F Kralinger, M Wambacher, C Dallapozza, M Tauber, H Resch (Innbruck - AUSTRIA, Innsbruck - AUSTRIA, Munich - GERMANY, Salzburg - AUSTRIA)

Purpose
In current surgical practice, irreparable posterosuperior rotator cuff ruptures are treated with a latissimus dorsi transfer using a double-incision technique. This study compares functional outcome after using conventional double-incision and a new single-incision delto-pectoral approach for latissimus dorsi transfer.
Material and Methods
44 patients with irreparable posterosuperior rotator cuff ruptures refractory to physiotherapeutic treatment received a latissimus transfer. 23 patients were treated using a single delto-pectoral incision, 21 patients with conventional (tendon harvest without bone chip) double-incision surgical approach. All patients had full-thickness tears of at least two complete tendons, and all had fully functioning deltoid and subscapularis muscles. Preoperative loss of muscle function was clinically assessed and verified by magnetic resonance tomography.
Level of evidence : Consecutive clinical level II-2 study.
Results
The postoperative functional outcome measured by Constant-Murley Score (CMS) increased significantly (p<0.001) compared to preoperative functional outcome in both groups. The postoperative absolute CMS and CMS-subscores scores were similar for both surgical approaches. However, the increase gained (preoperative vs. Postoperative functional scores) in CMS, ROM and activities of daily life were higher (p<0.001) using a single-incision delto-pectoral approachcompared to the conventional double-incision.
Conclusion
In conclusion, the single-incision technique provided similar functional end result compared with conventional double-incision technique. The gain in absolute CMS, ROM and Activities of daily life values was significantly higher in the single incision group. The single-incision delto-pectoral approach seems to provide comparable result with less invasiveness and the option for simultaneous arthroplasty, if needed.

Arthroscopic controlled and bone tunnel fixation of latissimus dorsi transfer for massive irreparable cuff tears. Results of a multicenter prospective study
J Grimberg , J Kany, P Valenti, J Garret, LD Duranthon, VK Chang (Paris - FRANCE, Saint Jean - FRANCE, Lyon - FRANCE, Hawai - UNITED STATES)

Purpose
Latissimus dorsi (LD) transfer for massive irreparable posterosuperior cuff tears has been usually described as successful in many studies. Some authors advocate reinforcement of the tendon as unsufficient tendon thickness may explain some unsatisfying reported results. . Our purpose was to evaluate a technique with arthroscopic assisted transfer and fixation of the LD tendon in a bone tunnel in the humeral head in terms of clinical and magnetic resonance imaging (MRI) results through a prospective multicenter study.
Material and Methods
Inclusion criterium was : massive irreparable posterosuperior cuff tear. Exclusion criteria were : excentrated omarthrosis, deltoïd palsy, irreparable subscapularis tear. All patients were preoperativly and postoperativly clinically evaluated with Constant score and single shoulder value (SSV) score and had preoperative MRI or CT scan. Patients were asked to have a one year postoperative MRI.
Results
49 patients were included in the study. Mean age at time of surgery was 59,4 (31-73). 26 patients had already been operated (1 to 6 times). Mean preoperative Constant score was 36,8 (14-58), preoperative SSV score was 26,6 % (5-50). No patient was lost to follow-up ; Mean followup was 21,2 months (12-42). Mean postoperative Constant score was 63,6 (35-81), mean postoperative SSV score was 68,6 % (25-90), 39 patients were satisfied or very satisfied ; 5 were disapointed, 5 were not satisfied. Some factors had no influence on the clinical results : age > or < 65, sex, type of work, (manual or light), preoperative mobility in active anteflexion < 90° or > 90°, zone of fixation of the tendon on the greater tuberosity (superior or posterior). Some factors had pejorative effects : preoperative surgery, worker's compensation. 44 patients had a one year postoperative MRI, 41 had an intact transfer, 3 had a ruptured tendon.
Conclusion
Through this first multicenter prospective study, tubulisation and fixation of the LD tendon in a bone tunnel in the humeral head with arthroscopic assistance seems to give good clinical and MRI results comparable to usual technique with anchor fixation.

Long Term Outcome After Failure of Healing after Rotator Cuff Repair- Minimum 10 year Follow Up
L Galatz , ES Paxton, S Teefey, N Dahiya, J Keener, K Yamaguchi (St. Lous, Mo - UNITED STATES, St. Louis, Mo - UNITED STATES)

Purpose
Little information exists regarding the long term outcome of shoulders after structural failure of rotator cuff repair. Early clinical improvement at a 2 year follow up was previously reported in 18 patients following arthroscopic repair of massive rotator cuff tears despite a 94% failure of healing. The purpose of this study is to report the 10 year follow up of these patients with known early structural failures of rotator cuff repairs.
Material and Methods
15 of 18 (83%) of patients were available for follow up at a minimum of 10 years. The patients were evaluated clinically using the American Shoulder and Elbow Score (ASES), Simple Shoulder Test (SST), Visual Analogue Scale (VAS) pain score, and Constant Score. Additionally, patients were assessed radiographically and ultrasonographically.
Results
The average age was 75 years, 10 men, 5 women. The ASES average score was 81.2 (range, 50-95) and the VAS average was 2.0 (range, 1-4), both unchanged from 2 years. The average SST was 9.4 (range, 6-12) and the average age-adjusted Constant Score was 75.3 (range, 58.7-97.5). Two patients underwent another surgical procedure- 1 arthroplasty, 1 revision repair. Of the remaining 13, 85% had radiographic progression of joint degeneration, 3 Hamada grade 2, 5 Hamada grade 3, and 3 Hamada grade 4 (2-4a and 1-4b). Ultrasound confirmed persistence of all tears seen at 2 years.
Conclusion
Early clinical improvements and pain relief after cuff repair of massive tears persist at long term follow up of 10 years despite early structural failure of repair. Shoulders had a high rate of progression of radiographic degeneration, yet only 2 underwent subsequent surgical procedures. These results demonstrate that healing is not critical for long term satisfactory results in older patients.

Natural history of asymptomatic rotator cuff tears - a longitudinal study of clinical, sonographic and MRI findings
S Moosmayer , R Tariq, M Stiris, HJ Smith (Bærum - NORWAY, Oslo - NORWAY)

Purpose
Fifty asymptomatic rotator cuff tears were followed over 3 years. We wanted to find out whether these tears remain asymptomatic, and whether development of symptoms would be related to a progression of tear size, muscle atrophy or fatty degeneration.
Material and Methods
Fifty individuals with a full-thickness rotator cuff tear on sonography and MRI in a shoulder with no present or earlier pain, an ASES score > 90 points and normal examination findings at baseline were included. After 3 years clinical, sonographic and MRI re-examination was performed.
Results
Eighteen (36 %) of 50 initially asymptomatic tears developed symptoms during follow-up. Decrease on the ASES scale for newly symptomatic tears was 30 points compared to 0 points for still asymptomatic tears (p < 0.0005). Increasing tear size and muscle atrophy were significantly associated to the development of symptoms but only in subjects in whom the study shoulder was combined with a pain free contralateral shoulder. In this subgroup (n = 28), tear size progression at follow-up was 0.6 mm in still asymptomatic subjects compared to 6.4 mm in newly symptomatic subjects (p = 0.001). Of 10 newly symptomatic subjects 5 had developed serious supraspinatus atrophy during follow-up compared to only 1 of 14 still asymptomatic subjects. (OR : 13.0 ; p = 0.04).
Discussion
Our results suggest that asymptomatic rotator cuff tears are at risk to become clinically relevant. Once detected, they should be followed clinically and by imaging to allow early therapeutic intervention. Progression of tear size and muscle atrophy was positively associated to the development of symptoms. This may indicate a causal relationship. The condition of the contralateral shoulder influenced the study results.

Relationship of rotator cuff tears, shoulder pain and functional loss in a normal population
H Oag , A Nichols, M Daines, A Kiran, N Arden, A Carr (Oxford - UNITED KINGDOM)

Purpose
This study describes the prevalence of pain, functional loss and rotator cuff tears (RCTs) in a general population cohort.
Material and Methods
The Chingford cohort is a 19-year old longitudinal population study comprising 1003 women aged between 44 and 67 at baseline. To date 183 consecutive subjects (366) shoulders have been interviewed about their shoulders. Myometric strength assessment and high-definition ultrasound examination (US) have been performed on all shoulders. Additionally pain thresholds and perceptions of pain have been tested using quantitative sensory testing (QST) and a number of validated questionnaires, including the illness attitudes scale and the pain detect score.
Results
The population prevalence of at least one full-thickness RCT was 24%, with 19% being unilateral and 5% bilateral. The distribution of symptoms across the 366 shoulders is shown in table 1
Number (N)
Normal tendon (on US)

Abnormal tendon-bone interfaces

Partial-thickness tears
Full-thickness tears (≤2cm)
Full-thickness tears (>2cm)
Shoulders
206 (56%)
73 (20%)
34 (9%)
24 (7%)
29 (8%)

Pain
47 (23%)
26 (36%)
10 (29%)
7 (29%)
16 (55%)
Functional loss
49 (24%)
26 (36%)
13 (38%)
7 (29%)
14 (48%)
Pain and functional loss
32 (16%)
20 (28%)
7 (21%)
4 (17%)
12 (41%)
Asymptomatic
138 (68%)
40 (56%)
18 (53%)
14 (58%)
11 (38%)
Table 1 : Distribution of symptoms across the different stages of tendon pathology
The pain and functional loss was significantly greater in the abnormal tendon-bone attachment group, and the full-thickness RCT (greater than 2 cm) group, compared to those with no abnormality on high-definition ultrasound examination.
Discussion
In a unique normal population-cohort study significant pain and/or loss of function was found in 48% of shoulders with high-definition US abnormalities of the tendon. High-definition US has allowed us to identify a group of tendons with an abnormality at the tendon bone interface. The pain and functional loss increases at this stage and then only further increases once a tear is greater than 2 cm. However over 50% remain asymptomatic.

Ultrasound changes after rotator cuff repair – is supraspinatus tendon thickness related to pain?
L Tham , L Briggs, G Murrell (Sydney - AUSTRALIA)

Purpose
The purpose of this study was to determine whether there are changes after rotator cuff repair thickness, anatomical footprint, tendon vascularity, subacromial bursa, capsular thickness, and whether tendon and bursal thickness correlate with pain.
Material and Methods
Fifty-one patients completed a pain questionnaire and had their shoulders scanned by the same sonographer with a GE Logiq 9 using a standardised protocol at 1 week, 6 weeks, 3 months and 6 months post arthroscopic rotator cuff repair.
Results
Forty-four of the 51 rotator cuff repairs were intact at 6 months. At 6 weeks, the repaired tendon thickness mean (SD) was 4.2 (0.9) mm and increased to 4.6 (0.8) mm at 6 months - similar to the contralateral un-injured side. There was a significant increase in bursal thickness at 1 week [2.0 (0.8) mm] compared with the contralateral shoulder [0.8 (0.4) mm] ; which decreased at each time point so that by 6 months it was 0.7 (0.5) mm (p < 0.001). The width of the anatomical footprint increased from 7.0 (2.0) mm at 1 week to 9.2 (1.5) mm at 6 months (p < 0.001). Vascularity of the tendon decreased from mild at 1 week, to none at 6 months (p < 0.001). At 1 week there was a significant increase in the ipsilateral posterior capsule thickness 2.3 (0.8) mm, which gradually decreased to 1.3 (0.6) mm at 6 months (p < 0.001). There was no correlation between tendon thickness or bursal thickness with pain.
Conclusion
(1) After supraspinatus repair, the tendon thickness increased only 10% between 6 weeks and 6 months. (2) The width of the anatomical footprint of the repaired supraspinatus was 30% narrower at 1 week and gradually increased over 6 months to be comparable with the contralateral un-injured shoulder. (3) Bursal thickness and tendon vascularity increased significantly compared with the contralateral shoulder at 1 week post surgery and then gradually decreased over 6 months. (4) Joint capsule thickness increased following rotator cuff repair and then normalised by 6 months.

08 - Elbow

Moderator : S Antuña (Spain), R Lille

Eleven-year experience with the Coonrad-Morrey total elbow arthroplasty: Mid-term results.
P Mansat , AS Coutié, N Bonnevialle, M Rongières, M Mansat, P Bonnevialle (Toulouse - FRANCE)

Purpose
Clinical and radiographic results of the Coonrad-Morrey total elbow arthroplasty (TEA) were reviewed with 5-year average follow-up.
Material and Methods
91 patients (100 TEA) were reviewed with 2 years minimum follow-up - 17 men and 74 women of 63 years average age (22-90). Etiologies were : rheumatoid arthritis (45), trauma (33) - 18 acute distal humeral fractures, 10 nonunion, and 5 posttraumatic arthritis-, revision (16), and others (6).
Results
At 5 years average follow-up (2-11), Mayo score increased from 30 to 85 points (30-100) (p<0.01). Better results were observed in rheumatoid arthritis (90 points) compared to trauma (80 points) or revisions (80 points) (p<0.01). Postoperative extension/flexion extended from 28° (0-90) to 130° (0-155), with an arc of rotation of 138° (0-180) without significant difference according to etiology. DASH score reached 40 points (0-97). Radiolucencies were found in 20 cases around the humeral component (4 complete) and around the ulnar component (6 complete). Bushing wear was observed in 21 cases, moderate in 15 and severe in 6. There were 37 complications, of which 13 required a revision surgery. In 3 cases the prosthesis has to be removed to treat a deep infection, and in another 3 cases the prosthesis has to be changed on both side in one case, and only at the ulna in 2 cases. At follow-up, 94 prostheses were still in place.
Discussion
The Coonrad-Morrey total elbow arthroplasty allows treating a large spectrum of etiologies with satisfactory results. The rate of complication remains high even if the rate of implant revision stays low and seems to decrease with the last version of the implant. However, increase incidence of lucent lines around the ulnar component with follow-up and bushing wear are of concern.
Revision Total Elbow Arthroplasty with the Semi Constrained Coonrad-Morrey Total Elbow Arthroplasty
HC Plaschke , T M. Thillemann, AK Belling Soerensen, B Sanderhoff Olsen (Copenhagen - DENMARK, Aarhus - DENMARK)
Purpose
In this retrospective case series we evaluated the short- to medium-term results after Coonrad-Morrey revision total elbow arthroplasty (TEA).
Material and Methods
We retrospectively included a consecutive series of revision TEA performed at our institution from 2004-2010. At mean follow-up of 29 months patients were clinically evaluated using the Mayo Elbow Performance Score (MEPS), and radiographically we evaluated standard elbow anterior-posterior and lateral radiographs. Patient reported outcome measures were performed using the Oxford Elbow Score (OES) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH).
Results
18 primary TEAs and 2 revision TEAs were revised in 19 patients. Mean age at revision was 65.8 years. Median time of implant survival for primary prosthesis was 115 months. Revisions were performed due to infection (1), loosening (15), periprosthetic fracture (2), mechanical failure (1) and maltraction (1). Mean postoperatively MEPS was 79. All patients were satisfied with the operative result. Mean DASH at follow-up was 48 and mean OES was 58, 66 and 53 for function, pain and psychosocial dimension respectively. Mean preoperatively flexion/extension range of motion (ROM) was 79 degrees and improved to 111 degrees at follow-up (P<0.0001). There were two cases of radiolucent line, however, none of the implants were clinically loose. In one case deep infection led to a new revision. Five patients had ulnar nerve paraesthesia at follow up.
Conclusion
Results after revision TEA using the Coonrad-Morrey prosthesis are acceptable with low short to midterm failure rate. Revision improves both range of motion and pain scores and in the present study results are comparable to previously published studies with mean MEPS of 79. Two cases of radiolucent line are of concern and needs attention. The treatment can be recommended as a good option for failed TEA.

Long term results of the Mopyc prosthesis in non reconstructible radial head fractures
JP Pequignot (Nice - FRANCE)

Purpose
To evaluate the clinical and radiographic results of a modular osteointegrated implant with a pyrocarbon cupula in the treatment of non-reconstructible radial head fractures with ligament instability in the elbow, at over 5 years of follow-up.
Material and Methods
12 patients were reviewed with an average follow-up of 6.5 years (8 to 5 years). There were 2 women and 10 men, aged 46 years old on average. In 3 cases, treated secondarily, the initial lesions were Essex-Lopresti syndromes. The patients were evaluated by an independent operator and the help of Broberg-Morrey and MEPS scores. All measurements (range of motion and strength) were digitally recorded.
The radiological follow-up took into account the fixation of the radial stem and the behaviour of the capitellum as regards its pyrocarbon head.
Results
From a clinical viewpoint, we noted 11 excellent and good results and 1 fair.
The X-rays showed that the stem of the radial head was perfectly integrated in all cases and resorption below the femoral neck (stress-shielding) had stabilized after 2 years. Remodelling of the capitellum was related to pre-existing osteo-chondral damage to the capitellum and, for the Essex-Lopresti syndromes, the implant's residual hyperpression.
Conclusion
At over 5 years of follow-up the results of the Pyrocarbon modular radial head prosthesis with an osteointegrated titanium stem (MoPyc) are both promising and stable over time. The stem was perfectly osteointegrated. Tolerance of the capitellum was good thanks to the adjusted substitution of the radial head allowed by the prosthesis' modularity and rigorous surgical technique. When there is remodelling of the capitellum, this depends on the initial osteochondral damage and, with Essex-Lopresti syndromes, the implant's residual hyperpression. In these latter cases treatment requires combined surgery.

Results of cemented and press-fit bipolar radial head prosthesis in 35 elbows
L Kaas , N van Dijk, D Eygendaal (Amsterdam - NETHERLANDS, Breda - NETHERLANDS)
Purpose
Replacement of the comminuted fractured radial head is essential when the forearm or elbow is unstable as a result of concomitant injuries. The Judet prosthesis is a bipolar radial head prosthesis and is available in two types : cemented and press-fit. The goal of this study was to describe the results of the cemented and press-fit Judet prosthesis.
Material and Methods
35 patients with post traumatic disorders of the elbow with Judet radial head prosthesis were retrospectively reviewed : 19 patients had a cemented prosthesis and 16 patients had a press-fit.
Results
The mean follow-up period was 24.5 months. 22 patients scored excellent, 5 scored good and 5 fair on the Mayo Elbow Performance Index, with a mean of 92.7. The mean Elbow Function Assessment score was 92.9 (SD : 9.5, range : 65-100). The mean functional range of motion was 125.0° (range : 80°-140°). Complications (revision surgery, infection, symptomatic instability, overstuffing or persistent pain) occurred in 9 elbow (26%). Capitellar osteopenia was seen in 12 of 35 elbows (36%). Erosion of the capitellum was found in 1 elbow. Eleven of the 16 elbows (69%) with a press-fit implant showed osteolysis of the cortex, just distal to the collar of the implant. In the cemented implant group periprosthetic (balloon-shaped) lucencies in a variety of zones around the stem were found in 3 of 19 patients (16%).
Conclusion
The results of the Judet radial head prosthesis are good. Osteolysis of the proximal radius was found in the majority patients with a press-fit prosthesis, bit did not have any impact on the clinical outcome. The exact cause and clinical implications of this osteolysis have to be investigated.

Bilateral Simultaneous Total Elbow Arthroplasty in Inflammatory Arthritis
A Cil , S O'Driscoll, B Morrey, J Sanchez-Sotelo (Kansas City, Missouri - UNITED STATES, Rochester, Minnesota - UNITED STATES)
Purpose
Bilateral inflammatory arthritis is relatively common in the elbow joint, raising the consideration of simultaneous bilateral arthroplasty. The purpose of this study was to determine the outcome of simultaneous bilateral total elbow arthroplasty.
Material and Methods
Between 1991 and 2005, 14 rheumatoid patients underwent replacement of both elbows during the same episode of anesthesia (Group 1). They were matched by age, gender, ASA score, height, and weight with 14 rheumatoid patients who had undergone bilateral arthroplasty in two separate surgeries (Group 2). The outcome, complications, and hospital stay were compared between the two groups. Their mean follow up was 7.1 years in group 1 and 8 years in group 2.
Results
Bilateral simultaneous and bilateral staged total elbow arthroplasties resulted in similar outcomes in terms of range of motion (120° vs 115°), subjective satisfaction (23 vs 25 elbows), MEPS (86 vs 87 pts), and perioperative complications. The mean hospital stay was 5 days in Group 1 ; the mean combined hospital stay was 9.5 days in Group 2. At most recent follow-up, revision surgery had been performed in 6 elbows in Group 1 and 1 elbow in Group 2. This difference could be explained by the more common use of PMMA precoated ulnar components in Group 1 (18/28 -64%- vs 11/28 - 39%).
Conclusion
Simultaneous bilateral total elbow arthroplasty is a safe and effective procedure for patients with inflammatory arthritis. The relative abundance of precoated ulnar components implanted in Group 1 in our study lead to a higher revision rate.

Tilting angle of bipolar radial head prosthesis correlates with radiocapitellar instability
J Moon , S Kim, J Hong, H Kwon (Seoul - KOREA, REPUBLIC OF)
Purpose
The functional outcome after bipolar radial head replacement has shown to be satisfactory. Although the advantages of a bipolar radial head are obvious, tilting, none to its limit of bipolar head, is commonly seen in case of persistent subluxation of radial head. The purpose of this study was to assess relationship between tilting angle of bipolar radial head and radiocapitellar instability in patients with bipolar radial head prosthesis.
Material and Methods
Sixteen consecutive elbows in patients who underwent bipolar radial head arthroplasty for comminuted radial head fracture with instability were assessed radiologically. Tilting angle of bipolar radial head prosthesis and radiocapitellar joint instability was measured on latest follow up lateral radiograph. Spearman's correlation coefficient was used to measure the correlation between two variables.
Results
Mean tilting angle was 19.09° (5.04~33.32) and mean distance between the capitellum and the center of stem was 3.50 mm (0.71~7.01). Correlation coefficient (ρ) was 0.843 (p value = 0.01).
Conclusion
Tilting angle of bipolar radial head prosthesis was increased when the posterior subluxation of radial head prosthesis was increased. Tilting angle of bipolar radial head prosthesis can be used as an indicator implicating the instability of radial head prosthesis.

Short term results of Open Debridement and Lateral Resurfacing Elbow in the treatment of stiff osteoarthritic elbow: an Italian multicentric study
G Giannicola , R Angeloni, A Mantovani, A Greco, G Merolla, F Postacchini (Rome - ITALY, Firenze - ITALY, Legnago - ITALY, Cattolica - ITALY)

Purpose
Post mortem and clinical studies showed an early and elective involvement of the radio-humeral joint in primitive and secondary arthritis of the elbow. The lateral resurfacing elbow (LRE) was recently developed for the treatment of these conditions. Nevertheless few data are available in the literature about LRE results. A prospective Italian multicentric study has been realized with the purpose of analyzing LRE short term results in a suitable number of cases.
Material and Methods
Twenty patients were included in the study with an average age of 55. Eleven patients with primary osteoarthritis and nine with post-traumatic osteoarthritis underwent open debridement and LRE. Pre-operative and post-operative clinical evaluations were performed according to MEPS, m-ASES and Quick DASH score.
Results
The mean follow up was 22.6 months. At the last follow up the mean improvement of MEPS and m-ASES was 35 (p<0,005) and 34 (p<0,005) respectively ; the mean decrement of Quick DASH was 29 (p<0,005). The mean improvement of range of motion was 35° (p>0,005). With MEPI we observed excellent, good, fair and poor results in 12, 2, 3 and 3 patients, respectively. Five mild overstuffings and three malpositionings of the implant were observed. The implant survival rate was 100%.
Conclusion
This study has highlighted good short term results of LRE, with painless functional recovery of the elbow in over 80% of patients. Further studies with longer follow-up are mandatory.

The Value of Intraoperative Pathology for the Diagnosis of Infection in Total Elbow Arthroplasty
S Ahmadi , T Lawrence, B Morrey, J Sanchez-Sotelo (Rochester, Minnesota - UNITED STATES, Rochester - UNITED STATES)

Purpose
The perioperative diagnosis of infection in the setting of revision elbow arthroplasty may be difficult to establish. Intraoperative pathology for the identification of acute inflammatory changes has been reported of value in revision surgery after failed hip and knee arthroplasty. The purpose of this study was to evaluate the sensitivity, specificity, positive and negative predictive value of intraoperative pathology in the diagnosis of infection in revision elbow arthroplasty.
Material and Methods
Between 2000 and 2007, 296 consecutive revision elbow procedures were performed at our institution. Both intraoperative pathology and operative samples for cultures were obtained in 228 of these procedures, which form the basis of this study.
Results
Pathology was read as consistent with acute inflammation in 32 procedures (14%). Intraoperative cultures were positive in 39 procedures (17.1%). Intra-operative pathology was considered true positive (both pathology and cultures positive) in 20 surgeries (8.8%), true negative (both pathology and cultures negative) in 177 surgeries (77.6%), false positive (pathology positive but culture negative) in 12 surgeries (5.3%) and false negative (pathology negative but culture positive) in 19 surgeries (8.3%). The sensitivity and specificity of intraoperative pathology were 51.28 and 93.65 respectively. The positive and negative predictive values were 62.5 and 90.3 respectively.
Conclusion
In our study, intraoperative pathology had a high negative predictive value, but low sensitivity and positive predictive value. Absence of acute inflammation is useful in the exclusion of deep infection, but the presence of acute inflammation is not sensitive or predictive enough to be of value.

Treatment for Fractures of the Elbow Region in Elderly Patients - Open Reduction and Internal Fixation vs Total Elbow Arthroplasty
C Yoshioka , N Suenaga, N Oizumi, S Yamane (Sapporo - JAPAN)

Purpose
The purpose of the present study was to compare open reduction and internal fixation (ORIF) with total elbow arthroplasty (TEA) for fractures of the elbow region in elderly patients.
Material and Methods
Between 2003 and 2010, 16 patients over 65 years old with a fracture in the elbow region were treated with ORIF or semiconstrained TEA. There was a male and eight female with a mean age of 79.5 years in the ORIF group and a male and six female with a mean age of 76.3 years in the TEA group. There were two patients with a nonunion of the distal humerus and two patients who had a fresh fracture with a nonunion of a part of distal humerus in the TEA group. The mean follow-up period was 21.1 months in the ORIF group and 17.4 months in the TEA group.
Results
In the ORIF group, one patient required a hardware removal due to an infection. Her elbow healed after the additional surgery with an external fixation. In the ORIF group, one patient had slight pain and four patients had moderate pain. In the TEA group, two patients had slight motion pain and no patients had moderate pain. The average extension was -28.8 degrees in the ORIF group and -11.4 degrees in the TEA group. The average flexion was 116.3 degrees in the ORIF group and 132.9 degrees in the TEA group. The flexion angle was significantly different between the ORIF group and the TEA group (P<0.05). Mayo elbow performance scores were 77.8 in the ORIF group and 95 in the TEA group.
Discussion
TEA is considered to be a more useful treatment to acquire pain relief and improve elbow function in elderly patients with fractures of the elbow region compared to ORIF.

Motor Branch of the Brachialis: Anatomic localization and interest for selective motor branch block for central neurologic elbow management
F Genet , C Lautridou, A Schnitzler, P Denormandie, Y Allieu, B Parratte (Garches - FRANCE, Besançon - FRANCE)

Purpose
We aim to identify the coordinates of the brachialis motor nerve in relation to anatomical surface landmarks for the practice of selective motor nerve block, a useful technique to assess the role of brachialis muscle in central neurologic elbow management.
Material and Methods
Anatomic dissection of upper limbs of ten consecutive cadavers was performed.The musculocutaneous nerve was traced from the coracoid process to the interepicondylar line of the elbow. The branches arising from the musculocutaneous nerve and innervating the brachialis muscle were identified. Two measurements were taken from the epicondylar line : 1) to the coracoid process (mm), and 2) to the exit point of the brachialis motor branch (mm). The depth of the nerve was measured (mm).
Results
A total of 20 forearms from ten fresh French cadavers were used for the study (6 males, mean age 76.5 +/- 5.34 years (range 68 to 84) ). The brachialis nerve was found to exit from the musculocutaneous trunk at a mean distance from epicondylar line of 102 +/- 1.79 mm (range 7 to 13) and had a mean depth of 28.8 +/- 4.84 mm (range 20 to 38). Mean ratio was 65.9 +/-0.05% (range 58.1 to 75.0). In practice, this represents a landmark skin through a hand above epicondyle medial, just below the biceps brachii belly.
Conclusion
This localization of the brachialis motor nerve should help in the performance of nerve blocks to assess the role of each elbow flexor in the upper limb spastic flexion pattern or to assess of the other elbow flexors before neurotization of the brachialis motor branch.

09 - Shoulder Arthroplasty

Moderator :
P Habermeyer (Germany),
D Mole (France)

Results of Cemented Total Shoulder Replacement With a Minimum Follow-up of 10 Years
P Raiss , M Loew, F Zeifang (Heidelberg - GERMANY)
Purpose
The purpose of this study was to examine the clinical and radiological long-term data of patients treated with a 3rd generation cemented total shoulder replacement and a minimum follow-up of 10 years.
Material and Methods
60 arthroplasties with a cemented keeled glenoid component were analyzed clinically using the Constant score and with radiographs in two planes. Glenoid component loosening was analyzed according to Mole in the ap view and using a new method in the axillary view. All data were compared preoperatively and at a mean of 11 (10-15) years postoperatively.
Results
Mean Constant score improved from 26 (10-54) points preoperatively to 60 (17-86) points postoperatively (p<0.0001). Mean shoulder flexion increased from 80° (20-150°) to 125° (40-180°), mean abduction from 74° (20-130°) to 115° (30-180°) and external rotation from 9° (-20-40°) to 34° (-10-70°). No humeral components but 35% of glenoid components were found to be loose. Survivorship of the glenoid component using the Kaplan-Meier method was 100% after 13 years whereas survivorship with radiologic loosening as endpoint was only 42% after 13 years. Cranial migration of the humerus was found in 72% of cases indicating a possible rotator cuff failure.
Conclusion
Loosening of the glenoid component and rotator-cuff deficiency are major problems in total-shoulder replacement especially in the long-term. Future short- and mid-term analyzes of glenoid components loosening have a limited significance unless they are poor. It is crucial to evaluate glenoid loosening in the ap and axillary view.


Secondary Rotator Cuff Failure following Total Shoulder Arthroplasty in Primary Osteoarthritis
A Young , G Walch, G Pape, F Gohlke, L Favard (Sydney - AUSTRALIA, Lyon - FRANCE, Heidelberg - GERMANY, Bad Neustadt/Saale - GERMANY, Tours - FRANCE)

Purpose
We hypothesized that rates of secondary cuff failure would increase with long-term follow-up of total shoulder arthroplasty and result in less satisfactory outcomes. We assessed the prevalence of secondary cuff failure, and also clinical and radiological outcomes following shoulder arthroplasty in primary osteoarthritis.
Material and Methods
In 10 European centers, 704 total shoulder arthroplasties were performed for primary osteoarthritis. We analyzed 518 shoulders with complete radiographic and clinical follow-up greater than 5 years. Secondary rotator cuff failure was diagnosed radiographically with moderate or severe humeral superior subluxation. Survivorship analysis was performed with end point being secondary rotator cuff failure.
Results
At average 103.6 months (60 to 219), the rate of secondary rotator cuff failure was 17% and found to be significantly correlated with preoperative rotator cuff fatty infiltration ; implantation of the glenoid with superior tilt ; and duration of follow-up. Survivorship free of secondary cuff failure was 100% at 5 years, 84% at 10 years, and 43% at 15 years. Patients with secondary cuff failure had significantly worse clinical outcomes (Constant score, subjective assessment and range of motion) and radiographic results (radiolucent line score, glenoid component migration).
Discussion
Secondary rotator cuff failure occurs in a considerable number of patients in the long-term after TSA performed for primary osteoarthritis. Preoperative fatty infiltration of the cuff muscles and implantation of the glenoid with superior tilt were found to be prognostic factors. Furthermore, secondary rotator cuff failure was associated with worse clinical and radiological outcomes

Demographic data, clinical outcome and short-term survival: 2139 shoulder replacements reported to the Danish Shoulder Arthroplasty Registry
J Rasmussen , J Jakobsen, S Brorson, B Olsen (Copenhagen - DENMARK, Aalborg - DENMARK)

Purpose
We present the Danish Shoulder Arthroplasty Registry (DSR) and report demographic data, short-term outcome and implant survival.
Material and Methods
The DSR was established in 2004. All Danish hospitals performing arthroplasty surgery are reporting. Data are collected electronically by the operating surgeon providing demographic and operative data. Follow-up results are collected 10-14 months post-operatively using Western Ontario Osteoarthritis of the Shoulder index (WOOS). We use descriptive statistics for presentation and the Kaplan-Meier statistics for survival data.
Results
2139 primary shoulder arthroplasties were reported between January 2006 and December 2008. There were 70.3% women. Mean age was 69.4 (SD 12.4). 53.8% patients were diagnosed with a proximal humeral fracture ; 29.8% with osteoarthritis ; 4.3% with arthritis ; 6.5% with rotator cuff arthropathy ; and 3.3% with caput necrosis. Median WOOS for all diagnoses was 59.1, interquartile range 36.9-81.6. WOOS for patients with arthritis, osteoarthritis, fractures, rotator cuff arthropathy and caput necrosis was 59.3 ; 68.1 ; 54.3 ; 65.6 ; and 49.4 respectively. 107 (5.0%) primary arthroplasties had been revised by the end of June 2010. The most frequent indications of revision were dislocation (n = 26) and glenoid attrition (n = 18). The cumulative revision rate was lowest for patients diagnosed with a proximal humeral fracture or caput necrosis and highest for patients diagnosed with rheumatoid arthritis.
Conclusion
We have presented the funding, data collection and organization of the DSR. As data increases, DSR will become a valuable tool for obtaining knowledge on risk factors, functional outcome and implant survival.

Clinical Outcomes of Hemiarthroplasty vs Biologic Resurfacing in Patients Under the Age of 50
EC Lin , D Harwood, GP Nicholson, BJ Cole, NN Verma, AA Romeo (Chicago, Il - UNITED STATES, Chicago,Il - UNITED STATES)

Purpose
The purpose of this study is to compare clinical outcomes of hemiarthroplasty (HA) with biologic resurfacing (BR), in patients under the age of 50.
Material and Methods
A retrospective review of all patients under the age of 50, who had undergone a primary HA or BR was completed. Follow-up examinations included range of motion, strength testing and the SANE, VAS, SST, ASES, and Constant score. Failure criteria were defined as a revision or an ASES score under 50.
Results
24 consecutive HA patients were identified ; 17 (71%), with a mean age of 34.0 ± 10.4 years (range, 16.8 to 49.6 years) were available for follow-up at a mean of 3.1 ± 1.7 years (range, 1.0 to 6.0 years). 22 consecutive BR patients were identified ; 20 (91%), with a mean age of 37.7 ± 8.9 years (range, 19.0 to 53.7 years) were available for follow-up at a mean of 3.6 ± 1.2 years (range, 2.0 to 5.9 years). Compared to the BR patients, the HA patients had significantly better VAS (2.1 ± 2.6 vs 4.8 ± 2.2) and SANE (75.0 ± 23.2 vs 54.5 ± 21.8) scores (p<.05). In the HA population, 3 patients had undergone a revision procedure (2 TSA, 1 RTSA) at a mean of 3.9 ± 2.0 years (range, 1.8 to 5.6 years) from surgery, and 3 others had ASES scores under 50. In the BR population, 6 patients had undergone a revision procedure (4 TSA, 1 RTSA, 1 graft removal) at a mean of 2.0 ± 1.8 years (range, .23 to 4.5 years) from surgery, and 6 others had ASES scores under 50. Post-operative range of motion and the following scores were not significantly different for HA compared with BR : SST 7.2 ± 3.9, 6.9 ± 3.6 ; ASES 65.5 ± 21.7, 59.5 ± 22.1 ; Constant 59.2 ± 19.7, 53.0 ± 18.1.
Conclusion
The results of this study suggests that in patients under the age of 50, hemiarthroplasty provides significantly greater pain relief and function, with fewer failures than biologic resurfacing, at a mean follow-up of greater than 3 years.

Reimplantation of a New Cemented All-Polyethylene Glenoid does not Solve the Problem of Glenoid Loosening
N Bonnevialle , B Melis, L Neyton, D Molé, G Walch, P Boileau (Toulouse - FRANCE, Nice - FRANCE, Lyon - FRANCE, Nancy - FRANCE)

Purpose
to evaluate the results of reimplantation of a new all-polyethylene cemented glenoid in patients with asymptomatic failed anatomical total shoulder arthroplasty (TSA) due to aseptic glenoid loosening or wear.
Material and Methods
Retrospectivecohort study of 42 patients (42 TSA) with asymptomaticfailed glenoid implant : 19 aseptic glenoid loosening and 23 PE wear or dissociation from a MB implant. The revision surgery consisted of removal of the loosened or worn implants and reimplantation of a new all-polyethylene (PE) cemented glenoid implant. Additional bone graft was needed in 10 cases. All patients were reviewed clinically and radiologically with a mean of 74 months (24-138). Glenoid cementing was evaluated on radiographs using the glenoid score of Molé.
Results
Complications associated with glenoid loosening or wear were frequently found : rotator cuff tear (2 cases), subscapularis tears or insufficiency (17 cases), prosthetic instability (8 cases). At a mean follow up of six years, 7 patients (17%) had already required a new reoperation due to recurrent glenoid loosening : 3 were converted to HA, 3 to RSA and one to Resection Arthroplasty. The overall rate of glenoid loosening was 67% (patients re-revised + patients with a Molé score ≥ 12). Among the 10 glenoid bone grafts performed, 6 presented complete osteolysis and 4 a partial one. At last follow-up, the mean Constant score was 57 points (+16 points) and Active Anterior Elevation averaged 125 ° (+19 °).
Conclusion
Aseptic glenoid loosening or wear in TSA is often associated with underestimated subscapularis tear or insufficiency. As a result, reimplantation of a new cemented PE glenoid does not solve the problem of glenoid loosening or wear : at a mean of 6 years, 50% of patients showed signs of radiographic glenoid loosening and 17% had to be reoperated again for glenoid loosening.

Reimplantation of a New Cemented All-Polyethylene Glenoid does not Solve the Problem of Glenoid Loosening
N Bonnevialle , B Melis, L Neyton, D Molé, G Walch, P Boileau (Toulouse - FRANCE, Nice - FRANCE, Lyon - FRANCE, Nancy - FRANCE)

Purpose
to evaluate the results of reimplantation of a new all-polyethylene cemented glenoid in patients with asymptomatic failed anatomical total shoulder arthroplasty (TSA) due to aseptic glenoid loosening or wear.
Material and Methods
Retrospectivecohort study of 42 patients (42 TSA) with asymptomaticfailed glenoid implant : 19 aseptic glenoid loosening and 23 PE wear or dissociation from a MB implant. The revision surgery consisted of removal of the loosened or worn implants and reimplantation of a new all-polyethylene (PE) cemented glenoid implant. Additional bone graft was needed in 10 cases. All patients were reviewed clinically and radiologically with a mean of 74 months (24-138). Glenoid cementing was evaluated on radiographs using the glenoid score of Molé.
Results
Complications associated with glenoid loosening or wear were frequently found : rotator cuff tear (2 cases), subscapularis tears or insufficiency (17 cases), prosthetic instability (8 cases). At a mean follow up of six years, 7 patients (17%) had already required a new reoperation due to recurrent glenoid loosening : 3 were converted to HA, 3 to RSA and one to Resection Arthroplasty. The overall rate of glenoid loosening was 67% (patients re-revised + patients with a Molé score ≥ 12). Among the 10 glenoid bone grafts performed, 6 presented complete osteolysis and 4 a partial one. At last follow-up, the mean Constant score was 57 points (+16 points) and Active Anterior Elevation averaged 125 ° (+19 °).
Conclusion
Aseptic glenoid loosening or wear in TSA is often associated with underestimated subscapularis tear or insufficiency. As a result, reimplantation of a new cemented PE glenoid does not solve the problem of glenoid loosening or wear : at a mean of 6 years, 50% of patients showed signs of radiographic glenoid loosening and 17% had to be reoperated again for glenoid loosening.

Clinical meaning of unexpected intraoperative positive cultures in shoulder arthroplasty revision
AM Foruria , T Fox, JW Sperling, RH Cofield (Madrid - SPAIN, Boston - UNITED STATES, Rochester Mn - UNITED STATES)

Purpose
Our aim was to analyze the clinical meaning of unexpected intraoperative positive cultures (UIPC) in the setting of shoulder arthroplasty revision for causes different than infection.
Material and Methods
Between 1990 and 2006, 107 consecutive patients with UIPC, with no previous diagnosis of infection and fulfilling inclusion criteria were identified. Thirty-five patients had 2 or more previous surgeries. Forty-four partial, 62 total and one reverse arthroplasties with different preoperative diagnosis were revised. Chief complaint included pain in 82 patients. Thirty-five patients had loose components. Diagnosis of instability and glenoid osteoarthritis accounted for 29 cases each. Intraoperative pathology was negative for acute inflammation in 97 cases. Two or more cultures were obtained in 81 patients.
Results
Seventy-six patients had one positive culture. Most prevalent bacteria were propionibacterium (68 cases) and staphiloccoccus epidermidis (21 cases). Fifty-three patients were treated with antibiotics and 52 were not, other than the perioperative prophylaxis. Nineteen patients remained on chronic antibiotic suppression. 90 patients had more than one year of follow up (median 5.2 years). Thirteen patients had a postoperative arthroplasty infection diagnosed by culture a mean of 2.5 years after the revision. In 9 of these the infection was produced by the same microorganism (propionibacterium). Of these 9, 3 had been treated with antibiotics after revision and 4 had not. Five were surgically re-revised~
Conclusion
Subsequent to revision surgery, 12% of shoulders with a UIPC developed clinical and microbiological infection. Postoperative antibiotic treatment had seemingly little effect in preventing this from occurring.

Reimplantation of a New Cemented All-Polyethylene Glenoid does not Solve the Problem of Glenoid Loosening
N Bonnevialle , B Melis, L Neyton, D Molé, G Walch, P Boileau (Toulouse - FRANCE, Nice - FRANCE, Lyon - FRANCE, Nancy - FRANCE)

Purpose
to evaluate the results of reimplantation of a new all-polyethylene cemented glenoid in patients with asymptomatic failed anatomical total shoulder arthroplasty (TSA) due to aseptic glenoid loosening or wear.
Material and Methods
Retrospectivecohort study of 42 patients (42 TSA) with asymptomaticfailed glenoid implant : 19 aseptic glenoid loosening and 23 PE wear or dissociation from a MB implant. The revision surgery consisted of removal of the loosened or worn implants and reimplantation of a new all-polyethylene (PE) cemented glenoid implant. Additional bone graft was needed in 10 cases. All patients were reviewed clinically and radiologically with a mean of 74 months (24-138). Glenoid cementing was evaluated on radiographs using the glenoid score of Molé.
Results
Complications associated with glenoid loosening or wear were frequently found : rotator cuff tear (2 cases), subscapularis tears or insufficiency (17 cases), prosthetic instability (8 cases). At a mean follow up of six years, 7 patients (17%) had already required a new reoperation due to recurrent glenoid loosening : 3 were converted to HA, 3 to RSA and one to Resection Arthroplasty. The overall rate of glenoid loosening was 67% (patients re-revised + patients with a Molé score ≥ 12). Among the 10 glenoid bone grafts performed, 6 presented complete osteolysis and 4 a partial one. At last follow-up, the mean Constant score was 57 points (+16 points) and Active Anterior Elevation averaged 125 ° (+19 °).
Conclusion
Aseptic glenoid loosening or wear in TSA is often associated with underestimated subscapularis tear or insufficiency. As a result, reimplantation of a new cemented PE glenoid does not solve the problem of glenoid loosening or wear : at a mean of 6 years, 50% of patients showed signs of radiographic glenoid loosening and 17% had to be reoperated again for glenoid loosening.

Clinical meaning of unexpected intraoperative positive cultures in shoulder arthroplasty revision
AM Foruria , T Fox, JW Sperling, RH Cofield (Madrid - SPAIN, Boston - UNITED STATES, Rochester Mn - UNITED STATES)

Purpose
Our aim was to analyze the clinical meaning of unexpected intraoperative positive cultures (UIPC) in the setting of shoulder arthroplasty revision for causes different than infection.
Material and Methods
Between 1990 and 2006, 107 consecutive patients with UIPC, with no previous diagnosis of infection and fulfilling inclusion criteria were identified. Thirty-five patients had 2 or more previous surgeries. Forty-four partial, 62 total and one reverse arthroplasties with different preoperative diagnosis were revised. Chief complaint included pain in 82 patients. Thirty-five patients had loose components. Diagnosis of instability and glenoid osteoarthritis accounted for 29 cases each. Intraoperative pathology was negative for acute inflammation in 97 cases. Two or more cultures were obtained in 81 patients.
Results
Seventy-six patients had one positive culture. Most prevalent bacteria were propionibacterium (68 cases) and staphiloccoccus epidermidis (21 cases). Fifty-three patients were treated with antibiotics and 52 were not, other than the perioperative prophylaxis. Nineteen patients remained on chronic antibiotic suppression. 90 patients had more than one year of follow up (median 5.2 years). Thirteen patients had a postoperative arthroplasty infection diagnosed by culture a mean of 2.5 years after the revision. In 9 of these the infection was produced by the same microorganism (propionibacterium). Of these 9, 3 had been treated with antibiotics after revision and 4 had not. Five were surgically re-revised~
Conclusion
Subsequent to revision surgery, 12% of shoulders with a UIPC developed clinical and microbiological infection. Postoperative antibiotic treatment had seemingly little effect in preventing this from occurring.

Lesser Tuberosity Osteotomy vs. Subscapularis Tenotomy in Shoulder Arthroplasty: A Multicenter RCT
P Lapner , E Sabri, K Rakhra, K Bell, G Athwal (Ottawa - CANADA, London - CANADA)

Purpose
Controversy exists regarding the optimal technique of subscapularis management during shoulder arthroplasty. The purpose of this multicentre randomized double-blind study was to compare the functional outcomes and healing rates of lesser tuberosity osteotomy (LTO) to subscapularis tenotomy (ST).
Material and Methods
Patients undergoing shoulder arthroplasty were randomized to receive either a LTO or ST. The primary outcome was to compare subscapularis strength, as measured by an electronic hand-held dynamometer at 12 months. Secondary outcomes included range of motion, WOOS, Constant and ASES scores. A sample size calculation determined that 80 patients provided 80% power with a 50% effect size to detect a significant difference between groups.
Results
Baseline demographic data did not differ between groups including age (p = 0.69), sex (p = 0.77), affected side (p = 0.59) and arthroplasty type (hemiarthroplasty or total, p = 0.77). Strength comparison between groups revealed no statistical differences at any time interval (p = 0.744, baseline, p = 0.449, 3 month, p = 0.203, 6 months, 12 months, p = 0.45). Statistically significant improvements occurred in both groups from baseline to 12 month time points in all clinical outcome scores (p<0.0001).
Discussion
No statistically significant differences in primary or secondary outcomes were identified between the LTO and ST. This trial does not demonstrate any clear advantage of one subscapularis mobilization technique over the other.

10 - Elbow

Moderator :
G Herzberg (France),
P Mansat (France)

Natural History of Unreduced Gartland type II Supracondylar Fractures of the Humerus: Functional and Radiological Evaluation in the Teenager
M Valencia , L Moraleda, G Gonzalez, R Barco (Madrid - SPAIN)
Purpose
The purpose of this study is to evaluate, in the teenager, the clinical and radiological outcomes of type 2 supracondylar fractures occurred during childhood and treated conservatively without any attempt of reduction.
Material and Methods
26 patients who sustained a type II supracondylar fracture of the humerus and were treated conservatively were reviewed at an average follow-up of 8 years. The average age at the time of fracture was 6 years and mean age at the latest follow-up was 14 years. Clinical outcomes were evaluated with the Mayo Elbow Performance Score and the Quick-DASH questionnaire. Radiographic assessment included : Baumann's angle, carrying angle and lateral humero-capitelar angle.
Results
Clinically, there were significant differences between the injured and uninjured elbow regarding flexion (140.4 Vs 145 degrees, p<0.001), extension (12 Vs 6.7 degrees, p<0.001), and the clinical carrying angle (9.8 Vs 13 degrees, p = 0.009) Radiographically, there were significant differences in the carrying angle (5.6 Vs 9 degrees, p = 0.013) and lateral humero-capitellar angle (30 Vs 43 degrees, p = 0.002). Posterolateral instability was not detected in any case. The average Quick-DASH score was 4.7 and the mean MEPS was 96.
Conclusion
Teenagers who sustained a type II supracondylar fracture of the humerus treated conservatively during childhood showed a mild cubitus varus deformity and a mild increase in the extension of the elbow. However, functional results were excellent in the majority of patients.

The first 100 elbow arthroscopies of one single surgeon: Analysis of complications
D Marti , B Jost (Zurich - SWITZERLAND)

Purpose
Elbow arthroscopy is performed not so frequently and regarded as technically challenging. In the literature the complications rates after elbow arthroscopy is reported to be rather high in up to 11% of the patients. The purpose of this study was to retrospectively analyze the frequency and type of complication of the first 100 consecutive elbow arthroscopies performed by a single surgeon.
Material and Methods
From September 2004 to April 2009, 100 consecutive elbow arthroscopies were preformed in a standardized fashion in lateral decubitus position with standard portals. The charts were retrospectively reviewed and the number and type of complications were noted and analyzed.
Results
The average age of the 100 patients (65 men, 35 women) at time of the operation was 41 years. Indications for arthroscopy were : stiffness (n = 35), (posttraumatic) osteoarthritis (n = 29), loose bodies (n = 27), tennis elbow (n = 23) and others (n = 20). There were no severe and permanent complications, but 5 patients (5%) with 6 minor complications. Two patients had a hematoma, one patient a transient sensory ulnar neuropathy, one patient a CRPS and one patient had a wound healing problem combined with a sensomotor lesion of the median nerve which completely recovered within one year. There was no infection. Four of the five patients with complications were treated for osteoarthritis. Complications were not associated with the learning curve.
Conclusion
With the common knowledge and experience of today even technically demanding procedures like elbow arthroscopies can be performed from the beginning relatively safely with a low risk for complications. Although in our series the complication rate of 5% is not negligible severe complications were not encountered and the overall of complication rate is lower than reported in the literature.

The first 100 elbow arthroscopies of one single surgeon: Analysis of complications
D Marti , B Jost (Zurich - SWITZERLAND

Purpose
Elbow arthroscopy is performed not so frequently and regarded as technically challenging. In the literature the complications rates after elbow arthroscopy is reported to be rather high in up to 11% of the patients. The purpose of this study was to retrospectively analyze the frequency and type of complication of the first 100 consecutive elbow arthroscopies performed by a single surgeon.
Material and Methods
From September 2004 to April 2009, 100 consecutive elbow arthroscopies were preformed in a standardized fashion in lateral decubitus position with standard portals. The charts were retrospectively reviewed and the number and type of complications were noted and analyzed.
Results
The average age of the 100 patients (65 men, 35 women) at time of the operation was 41 years. Indications for arthroscopy were : stiffness (n = 35), (posttraumatic) osteoarthritis (n = 29), loose bodies (n = 27), tennis elbow (n = 23) and others (n = 20). There were no severe and permanent complications, but 5 patients (5%) with 6 minor complications. Two patients had a hematoma, one patient a transient sensory ulnar neuropathy, one patient a CRPS and one patient had a wound healing problem combined with a sensomotor lesion of the median nerve which completely recovered within one year. There was no infection. Four of the five patients with complications were treated for osteoarthritis. Complications were not associated with the learning curve.
Conclusion
With the common knowledge and experience of today even technically demanding procedures like elbow arthroscopies can be performed from the beginning relatively safely with a low risk for complications. Although in our series the complication rate of 5% is not negligible severe complications were not encountered and the overall of complication rate is lower than reported in the literature.

Demographic and Anthropometric Factors Affecting the Elbow Range of Motion in Healthy Adults
F Canet , J Chapleau, Y Petit, GY Laflamme, D Rouleau (Montréal - CANADA
)
Purpose
In order to use elbow's range of motion (ROM) routinely as a diagnostic index, it is important to provide information on the influence of demographic and anthropometric data on ROM measured on x-rays. The aim of this study is to assess the impact of age, gender, laterality, body mass index (BMI), joint laxity, sport, and upper limb dimensions on the elbow ROM in flexion/extension.
Material and Methods
51 adults were recruited for this study. Lateral x-rays were taken of each elbow at maximal flexion and at maximal extension. Demographic data were self-reported. Hyperlaxicity was defined as a score. Gender and laterality impact were assessed by Student T test. The influence of age, Body Mass Index (BMI) and forearm and mid-brachial circumferences on flexion, extension and ROM was evaluated with Pearson correlation coefficient.
Results
The sample of 102 elbows has a mean maximal flexion of 151°±5°, a mean maximal extension of 12°±7° and a mean ROM of 139°±8°. Gender had a statistically significant influence on flexion (p<0.001) and on ROM (p = 0.010). Laterality has a significant impact on extension (p = 0.021) and on ROM (p = 0.025). A significant decrease of flexion (p = 0.018), extension (p = 0.006) and ROM (p<0.001) was observed in older subjects. While sport and physical activity had no significant impact on the range of motion, the hyperlaxity score was slightly correlate with maximal extension only (p = 0.060). Finally, lower flexion (r = -0.58, p<0.001) and ROM (r = -0.43 ; p<0.001) were shown on adults with a high BMI or high forearm and mid-brachial circumferences.
Conclusion
The factors that could justify a diminished elbow range of motion in healthy adults are male gender, advanced age, dominant side, high body mass index and high forearm or arm circumferences. This information is important in research contexts where demographic or anthropometric factors on mislead the evaluation of elbow's range of motion.

Outcome after osteosynthesis of the distal humerus fracture with a Y-shaped reconstruction (Lambda) plate
N Mercier , R Rouchy, D Saragaglia (Grenoble - FRANCE)

Purpose
The aim of this study was to evaluate the functional results and record the complications after treating distal humerus fractures with open reduction and internal fixation using Y-shaped reconstruction plate.
Material and Methods
From 1992 to 2008, 115 patients (116 distal humeral fractures) were treated operatively by open reduction and internal fixation using the above-mentioned Lambda plate. However, 41 patients were lost to follow-up (most of them were foreigners), that's why 74 patients (75 fractures) were available for this prospective study. There were 44 women and 30 men. The mean age at the time of surgery was 46.56 years ± 23.33 (range, 16-95). Twenty two (29%) patients were 65 years old or over. According to the AO classification there were 25 distal diaphyseal fractures (33%), 12 A fractures (12%), 6 B fractures (8%) and 35 C fractures (47%). A trans-olecranon approach with extra-articular osteotomy was realized in 26 cases and a trans-tricipital approach (older patients) in 49 cases.
Results
There was no case of infection. There was no case of non-union of the olecranon osteotomy. We encountered 2 patients with a non-union fracture (lateral condyle and diaphyseal). A revision surgery was suggested for the first case and was realised for the second case.We noticed, at the time of the revision, 2 ulnar dysesthesia and 1 radial dysesthesia (a pre-operative radial nerve palsy existed). Patients were followed from 24 to 227 months, with an average follow-up of 114.81 months (SD, 63.57). The mean flexion was 132.95°±12.98 (range, 90-150). The mean extension was -12.28°±13.71 (range, -45-0). A primary stable osteosynthesis which allows early physiotherapy was gained in 40 fractures, in 25 cases additional immobilisation was carried out (15 to 42 days).
Conclusion
This study reveal that the use of Y-shaped reconstruction plate provides stable fixation of distal humeral fractures, even in patients with osteoporosis.A stable osteosynthesis allowing early physiotherapy is achieved in the majority of patients. This plate is effective in achieving bony union with low implant failure and acceptable functional outcomes.

Three-dimensional analysis of acute plastic bowing of ulna in radial head dislocation and radial shaft fracture with computed simulation system
E Kim , H Moritomo, T Murase, JI Miyake, T Kataoka, K Sugamoto (Seoul - KOREA, REPUBLIC OF, Osaka - JAPAN)

Purpose
Little study has been published on acute plastic bowing of the ulna and its pathogenesis. The purpose of this study was to investigate three-dimensional plastic bowing deformity of the ulna in order to elucidate mechanism of injury and proper treatment.
Material and Methods
Ten acute plastic bowing deformities of ulnas of children with four chronic radial head dislocations (Monteggia equivalent) and six malunited radial shaft fractures were analyzed their rotational deformity in axial plane, bending deformity in saggital and coronal plane in Euler angle space using three-dimensional computed tomography and a markerless registration technique. All of cases were conducted corrective osteotomy with custom made surgical template by rapid prototyping technique and computerize simulation.
Results
Deformed Ulnas with radial head dislocation had 17.2°± 20.2° external rotation in axial plane, 7.1°± 3.2° extension in saggital plane, and 5.3°± 7.2° valgus in coronal plane. Otherwise, those with a radial shaft fracture had 13.9°± 12.4° internal rotation, 0.6°± 3.3° extension, and 5.3°± 7.2° valgus compared with their mirror images of ulnas of opposite side.
Discussion
Major deformities of plastic bowing of the ulnas were rotation rather than bending. External rotational stress on ulna was suspected to cause radial head dislocation, and internal rotational stress made radial shaft fracture during outstretched falling down injury. So, correction of rotational deformity of the ulna must be considered in the treatment strategy of chronic radial head dislocation and malunited radial fracture.

Three-dimensional analysis of acute plastic bowing of ulna in radial head dislocation and radial shaft fracture with computed simulation system
E Kim , H Moritomo, T Murase, JI Miyake, T Kataoka, K Sugamoto (Seoul - KOREA, REPUBLIC OF, Osaka - JAPAN)

Purpose
Little study has been published on acute plastic bowing of the ulna and its pathogenesis. The purpose of this study was to investigate three-dimensional plastic bowing deformity of the ulna in order to elucidate mechanism of injury and proper treatment.
Material and Methods
Ten acute plastic bowing deformities of ulnas of children with four chronic radial head dislocations (Monteggia equivalent) and six malunited radial shaft fractures were analyzed their rotational deformity in axial plane, bending deformity in saggital and coronal plane in Euler angle space using three-dimensional computed tomography and a markerless registration technique. All of cases were conducted corrective osteotomy with custom made surgical template by rapid prototyping technique and computerize simulation.
Results
Deformed Ulnas with radial head dislocation had 17.2°± 20.2° external rotation in axial plane, 7.1°± 3.2° extension in saggital plane, and 5.3°± 7.2° valgus in coronal plane. Otherwise, those with a radial shaft fracture had 13.9°± 12.4° internal rotation, 0.6°± 3.3° extension, and 5.3°± 7.2° valgus compared with their mirror images of ulnas of opposite side.
Discussion
Major deformities of plastic bowing of the ulnas were rotation rather than bending. External rotational stress on ulna was suspected to cause radial head dislocation, and internal rotational stress made radial shaft fracture during outstretched falling down injury. So, correction of rotational deformity of the ulna must be considered in the treatment strategy of chronic radial head dislocation and malunited radial fracture.
Resorbable Herbert screws in capitellum fractures fixation


R Rotini , E Guerra, A Marinelli, G Bettelli, M Cavaciocchi (Bologna - ITALY)
Purpose
The use of resorbable materials is one of the main recent applications of bioengineering in orthopaedics. The Authors report their experience in osteosynthesis of capitellum fractures by resorbable Herbert screws.
Material and Methods
In the period 2005-2010, at the Shoulder and Elbow Surgery Unit of the Rizzoli Institute, 10 cases of capitellum fracture have been treated. There were 3 men and 7 women, mean age 46,4 yrs (range 15-65 yrs). According to McKee, fractures have been divided in : type 1 - 3 cases ; type 2 - 1 case ; type 4 (limited to capitellum) - 1 case ; type 4 (shear fractures) - 5 cases. Type 3 fractures (highly comminuted) had been excluded. ORIF has been performed by Herbert resorbable screws and pins (poly-L-lactic acid, RSB Implant, Hit Medica, San Marino, Italy). Follow up is 31,7 months (range 12-65). An MRI evaluation has been performed to check the process of resorption of the biomaterial and any articular reaction at least at one year after surgery.In every case a stable intra-operative fixation has been achieved, allowing to begin the rehabilitation the day after surgery (early CPM). In two cases a screw broke during positioning, because of a non perfect congruency between the tapped hole and insertion axis.
Results
The fractures healed in all cases with amean MEPS score of 98 (85-ma100). No chondrolysis or foreign body reactions have been observed at follow up.
Conclusion
the Authors tested the safety and the effectiveness of capitellum fractures osteosynthesis by resorbable screws. The main advantage in the use of PMMA is to achieve an anatomical fixation passing through the articular cartilage to reach subchondral bone ; the in-out technique is better in order to fix the small fractured fragments with a compression force ; further surgery to remove the hardware has not to be expected. On the other hand the surgical technique has to be extremely precise beacuse of the fragility of the resorbable implants.

ICL 4 : Muscle tendon transfers


Moderator : P Boileau (France)

Biomechanics of tendon transfer for irreparable rotator cuff tears
G Herzberg (Lyon - FRANCE)

Latissimus dorsi transfer for irreparable rotator cuff tears: Modified surgical technique
M Tauber (Salzburg - AUSTRIA)

Latissimus dorsi transfer for irreparable rotator cuff tears: Arthroscopic approach
J Kany (Toulouse - FRANCE)

Latissimus dorsi transfer for irreparable rotator cuff tears: Indications and long-term results
C Gerber (Zurich - SWITZERLAND)

Pectoralis major transfer for subscapularis deficiency: Under the conjoint tendon. Technique, indications and results
H Resch (Salzburg - AUSTRIA)

Pectoralis major transfer for subscapularis deficiency: Over the conjoint tendon
B Jost (Zurich - SWITZERLAND)

Tendon transfer combined with RSA: RSA combined with latissimus dorsi
C Gerber (Zurich - SWITZERLAND)

Tendon transfer combined with RSA: RSA combined with latissimus dorsi and teres major (modified l'Episcopo)
P Boileau (Nice - FRANCE)

Pectoralis inverse transfer for deltoid insufficiency
M Tauber (Munich - GERMANY)

 

CL 5: Open and arthroscopic approacches to the elbow: tips and tricks

Moderator :
S Antuña (Spain)

The flow of open elbow approaches - Anatomy revisited
S Antuña (Madrid - SPAIN)

Tips and tricks in open surgery: "Triceps on", ulnar nerve, coronoid.

R van Riet (Antwerp - BELGIUM)

How to make elbow arthroscopy safe and easy: the set up
R Barco (Madrid - SPAIN)

Elbow arthroscopy for complex procedures: avoiding pitfalls.
M Mansat (Toulouse - FRANCE)

CL 6: Biceps pathology: current approach

Moderator : N Pouliart (Belgium)

Anatomy and biomechanics of the long tendon of the biceps from insertion to pulley
F Gohlke (Wuerzburg - GERMANY)

Spectrum of pathology
N Pouliart (Brussels - BELGIUM)

Biomechanical aspects of biceps tenodesis and repair: from SLAP to pulley lesion

S Alexander (London - UNITED KINGDOM)

To tenodese or to repair? From SLAP to pulley lesion: clinical aspects
N Bonnevialle (Toulouse - FRANCE)

AWARD SESSION

Moderators : Alessandro Castagna - P. Boileau

2011 Best poster prize

2011 Best paper prize

2011 Didier Patte Prize

Travel report of the 2010 European fellows travelling in the US

Philip KASTEN, Dennis LIEM (Germany)

Travel report of the 2011 Intra European travelling fellows
Davide BLONNA ( Italy), Stefan GREINER (Germany)

Introduction of the ASES fellows
George ATHWAL (London, Canada), Jay KEENER (St Louis, MO, USA)

Introduction of the Australian fellow
Kenneth CUTBUSH (Brisbane, Australia)

Introduction of the NZ fellow
Adam DALGLEISH (Auckland, NZ)

Attitude and expectations for the surgical treatment of rotator cuff tears not responding to conservative management. Survey among European shoulder surgeons
Nicole POULIART (Brussels, Belgium)

11 - Shoulder Instability
Moderator : E Calvo (Spain), M Zumstein (Switzerland)

Arthroscopic Bristow-Latarjet Procedure: A Computed Tomography Analysis of Bone Block Positioning and Healing
CE Thélu , X Ohl, N Mercier, J Old, P Boileau (Nice - FRANCE, Grenoble - FRANCE, Winnipeg - CANADA)

Purpose
Improper surgical placement of the coracoid bone block and screw failures are common complications which have been reported in up to 50% of patients operated with the Bristow-Latarjet procedure. Purpose : to evaluate the positioning and healing of the coracoid bone graft after arthroscopic Bristow-Latarjet procedure.
Material and Methods
We prospectively followed a series of 82 consecutive patients treated with an all-arthroscopic technique Bristow-Latarjet procedure. The coracoid bone block was fixed in the standing position with a cannulated screw. In our technique, the position of the transferred coracoid bone block and screw was " aimer dependent ", depending on a specific guide. Patients had an early postoperative CT-scan (<3 months) to evaluate the bone block and screw positioning, and a late one (>6 months) to evaluate the bone block healing. The images were analyzed by 2 observers different from the operating surgeon.
Results
The reproducibility study showed good reliability of the method of measurements. The bone block was subequatorial in 94% (77/82) of the cases. The bone block was flush to the glenoid surface in 90% (74/82), too lateral (>3 mm) in 6% (5/82) and too medial (>3 mm) in 4% (3/82). The mean inclination angle between the screw and the glenoid surface was 20.7°±8.0. At an average of 18 months posteroperatively (range, 6-32), we observed eighteen (22%) grafts which did not heal and/or migrated from their original position. Conclusion
Consistent placement of the transferred coracoid bone graft is regularly obtained with the arthroscopic technique, but bone block healing must be improved.

The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair – A retrospective case series of 49 consecutive patients
SL Schmid , M Farshad, S Catanzaro, C Gerber (Zurich - SWITZERLAND)

Purpose
Recurrence of anterior shoulder instability after operative repair is a rare but disabling condition for which treatment options are insufficiently studied. Coracoid transfer according to Latarjet is a highly successful treatment option for recurrent anterior shoulder instability. It was the purpose of this study to verify the hypothesis that this procedure is also effective after recurrence of instability after previous operative repair.
Material and Methods
Forty-nine consecutive patients with either one (n = 32), two (n = 12) or at least three (n = 5) previous stabilizations other than the Latarjet procedure and recurrence of anterior instability associated with a lesion of the anterior glenoid rim were revised with a coracoid transfer according to Latarjet. Clinical outcome was assessed at a mean follow-up of 38 (23-63) months with standard clinical parameters including subjective shoulder value (SSV), scoring according to Constant and Murley (CS) and testing of stability. Standardized antero-posterior and axillary lateral radiographs before and after the Latarjet revision were used to assess osteoarthritis.
Results
All 49 patients could be reviewed. No shoulder redislocated, subluxations recurred in two patients and five further patients reported a slight, unspecified uncertainty. No revision surgery was carried out or planned. Forty-three shoulders (88%) were subjectively excellent or good, 3 fair, 3 poor. Dissatisfaction was associated with persistent pain. Preoperative pain was the key predictor of postoperative pain : Patients with postoperative pain had a more than 20 fold chance to have preoperative pain than those without postoperative pain. The mean SSV increased from 53% to 78% (p<0.001) and the CS remained high (from 80% to 85% ; p = 0.061). Optimal graft placement was obtained in 30 cases and was related with better clinical outcome and lesser progression of osteoarthritis than suboptimal graft placement.
Conclusion
Coracoid transfer according to Latarjet can effectively restore anterior shoulder stability if previous operation(s) have failed to do so. If such recurrence is associated with chronic pain, this is likely to persist and to compromise subjective outcome.

Arthroscopic anatomical glenoid reconstruction using an autologous tricortical iliac crest bone grafting technique for anteroinferior shoulder instability
M Scheibel , N Kraus, K Hug, G Diederichs (Berlin - GERMANY)

Purpose
The aim of this study was to evaluate clinical and radiological results of patients treated with an arthroscopic anatomical autologous iliac crest bone grafting technique for bony-mediated anteroinferior shoulder instability.
Material and Methods
Fifteen shoulders of fourteen consecutive patients (1 f/ 13 m, Ø age 30.9 yrs) with large anterior glenoid rim defects were treated arthroscopically using an iliac crest bone grafting technique together with capsulolabral reconstruction. The follow-up consisted of four shoulder scores (Constant Score (CS), Rowe Score (RS), Western Ontario Shoulder Instability Index (WOSI), Subjective Shoulder Value (SSV) ) as well as bilateral true a/p, axillary and Bernageau views to evaluate the glenoid rim and signs for instability arthropathy. In addition 3D-CT was used pre-, postoperatively, after 6 months and after 12 months to assess the reconstruction and graft remodelling.
Results
After a mean follow-up of 18.9 months the patients achieved on average 85 points in the CS, 88 points in the RS, 77% in the WOSI and 84% in the SSV. No redislocations have been observed. Radiographically, the anterior sclerosis zone was recreated in all patients. Osteoarthritis (grade I) was present in four cases preoperatively. Two additional patients had grade I osteoarthritis at the final follow-up. After one year all grafts were osteointegrated. The CT-based glenoid index improved from preoperatively 0.78 to 1.12 postoperatively and 1.02 after one year. Regarding CT scans a partial graft resorption could be seen from postoperatively to the one year follow-up showing a remodelling of the glenoid to an anatomic situation (pear-shape glenoid) (Wolff's law).
Conclusion
The arthroscopic glenoid reconstruction using an autologous tricortical iliac crest bone grafting technique yields good to excellent early clinical results and allows an anatomic reconstruction of the glenoid concavity.

Subscapularis muscle function following arthroscopic and open anterior instability repair
C Bartl , G Salzmann, S Eichhorn, F Gebhard, A Imhoff (Ulm - GERMANY, Freiburg - GERMANY, Munich - GERMANY)

Purpose
Subscapularis muscle function was evaluated following different techniques of arthroscopic and open anterior instability repair to compare the rates of postoperative subscapularis muscle insufficiency.
Material and Methods
Subscapularis (SSC) function was evaluated with the specific clinical tests and the strength testing was performed with a force measurement plate (FMP) in the belly-press test and the lift off test position and compared to the normal contralateral shoulder (CLS). Group 1 (G1) consisted of 18 patients treated with an arthroscopic primary instability repair via an anteroinferior SSC-penetrating approach. In group 2 there were 16 patients treated with an anteroinferior arthroscopic revision repair in the same technique. Group 3 consisted of 16 patients that were treated with an instability repair via an anterosuperior approach without penetration of the subscapularis. In group 4, 18 patients underwent anterior instability repair via an inverted L-shaped SSC-tenotomy.
Results
Postoperatively there was a significant gain in the clinical scores for all 4 groups. In G1 and G3 there was no positive postoperative SSC-test. In G2 there was a positive test in one patient (6%) and in G4 there were positive SSC-tests in four patients (22%). In the belly-press test position strength values for the operated shoulder were 89,1 N (CLS 94,1 N) in G 1 ; 86,7 N (CLS 91,1 N) in G 2 ; 92,4 N (CLS 97,8 N) in G 3 and for the operated shoulder 72,3 N (CLS 91,4 N) in G4. In the lift-off test position strength for the operated shoulder was 69,1 N (CLS 73,5 N) in G 1 ; 66,3 N (CLS 71,3 N) in G 2 ; 70,4 N (CLS 75,8 N) in G 3 and 53,3 N (CLS 70,4 N) in G 4. In the open repair group (G4) there were significant lower SSC strength values for the operated shoulder in both test positions compared to the other repair techniques (G1, G2, G3). Only in G 4 there was a significant SSC strength deficit compared to the contralateral side.
Conclusion
Significant postoperative subscapularis muscle insufficiency was only detected in the open instability repair group. Arthroscopic instability repair via the anterosuperior approach and as well arthroscopic primary and revision procedures with a subscapularis penetrating anteroinferior approach did not lead to subscapularis insufficiency.

Effect of hyperlaxity on rotator cuff balance in first league handball players
JM Glasson , P Zanetti, U Akgun (Nice - FRANCE, Istanbul - TURKEY)

Purpose
Hyperlaxity has been considered to be an adventageous feature in throwing athletes. However, in certain circumstances, this may lead to microtraumatic instability. Our hypothesis is ; Hyperlaxity in throwing athletes can impair the rotator cuff balance in favour of internal rotators.
Material and Methods
15 (10male - 5female) first division Handball players (mean age : 22 years [17-29] ) were included in this study. None of the players have a previous shoulder injury or discomfort. Evaluation criterias were Xray controlled glenohumeral integrity, hyperlaxity scores and Isokinetic tests of rotator cuff muscles of both shoulders. Regarding to hyperlaxity scores 2 groups were formed as Gr I (Normal shoulders, n : 16) and Gr II (Hyperlax shoulders, n : 14) Each shoulder was assessed in a RE2 adapted position with 2 different angular speed (60°/sec. And 120-180°/sec). Isokinetic test parameters were eccentric/concentric internal/external rotator muscle torques, muscle response times and endurance. A one-way analysis of variance (ANOVA) was used for statistical analysis. Any differences were considered significant at p < 0.05.
Results
Concentric torques of internal and external rotators of Gr II shoulders was significantly lower than Gr I shoulders. (p<0.05) Endurance of external rotators in concentric tests of Gr II shoulders was significantly lower than Gr I shoulders. (p<0.05) Muscle response times in concentric tests showed no significant difference between 2 groups. (p>0.05) Eccentric torques of internal rotators showed no significant difference between 2 groups. (p>0.05) Eccentric torques of external rotators of Gr II shoulders was significantly lower than Gr I shoulders. (p<0.05) Endurance of external rotators in eccentric tests of Gr II shoulders was significantly lower than Gr I shoulders. (p<0.05) Muscle response times in eccentric tests was delayed significantly in Gr II shoulders. (p<0.05).
Conclusion
Our results showed that hyperlaxity has a negative effect on rotator cuff muscle balance in throwing athletes. External rotators were effected more than internal rotators aspecially in eccentric tests. Physical training programs of throwing athletes should include concentric and eccentric strengthening of external rotators in the shoulder which may prevent a possible microtraumatic instabilty.

Folding-unfolding of the anterior shoulder capsule as an indicator of glenohumeral ligament tension: analysis of stable, unstable and frozen shoulders
N Pouliart , F Handelberg (Brussels - BELGIUM)

Purpose
Judging adequate tension of the glenohumeral ligaments can be difficult as no definite measurements exist. The MGHLand ABIGHL are arthroscopically visible as folds in the anterior shoulder capsule. In a cadaveric study, these folds became more prominent in ADIR whereas they were smoothed out upon ABER. The present study was set up to determine whether this folding-unfolding mechanism (FUM) is useful as an indicator of capsular tension.
Material and Methods
The indication for surgery and EUA were correlated with observation of the FUM and capsuloligamentous lesions in 485 consecutive shoulder arthroscopies in lateral decubitus with 30° of abduction in the scapular plane. 115 shoulders underwent arthroscopy for instability, 51 for a frozen shoulder, and 161 for rotator cuff tears - 10 involving the subscapularis tendon - and 158 for various other pathologies.
Results
Stable shoulders : The ABIGHL and the MGHL were each marked by a fold in N (eutral) R (otation) that became more prominent in I (nternal) R (otation). When progressing to full ER both folds were smoothed out to form a sheet-like capsule. Frozen shoulders : The anterior capsule was smooth without visible folds in any degree of rotation. Unstable shoulders : In 77 shoulders with at least anteroinferior instability, the MGHL and ABIGHL still formed folds in IR. However, the folds were not as prominent when the capsule was detached from the labrum. Full ER, increased up to 90° in some patients, did not result in smoothing of the folds, not even with increased abduction. In 37 shoulders with isolated anterosuperior instability, the FUM of the ABIGHL was as in stable shoulders. The FUM of the MGHL was deficient is these cases. In addition, the rotator cuff interval did not narrow with ER. After capsular shift, the FUM reappeared with an ER that was reduced to 45°.
Conclusion
Smoothing of the anteroinferior capsule at a maximum of 45°ER and 45°AB is useful to judge normal tension in the MGHL and IGHL. When the FUM does not occur within this range, these ligaments are probably insufficient.

Is out still in? Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence (a randomized controlled trial)
S Liavaag (Arendal - NORWAY)
Purpose
Our aim was to compare the recurrence rate in patients with primary traumatic dislocation treated with immobilization in external or internal rotation after two years follow-up.
Material and Methods
One hundred and eighty-eight patients with a primary anterior traumatic dislocation of the shoulder were randomly assigned to treatment with immobilization in either internal rotation (ninety-five patients) or external rotation (ninety-three patients) for three weeks. The primary outcome measure was a recurrent dislocation within twenty four months follow-up.
Results
The follow-up rate after a minimum period of two years was 93/95 (97.9 %) in the internal rotation group and 91/93 (97.9%) in the external rotation group. The compliance rate was 45/95 (47.4 %) in the internal group and 63/93 (67.7 %) in the external rotation group. The intention to treat analyses showed that the recurrence rate was 28/91 (30.8 %) in the external rotation group and 23/93 (24.7 %) in the internal rotation group (p = 0.36).
Conclusion
We conclude that immobilization in external rotation does not reduce the rate of recurrence for patients with first-time traumatic anterior shoulder dislocation.

Long-Term Results After Arthroscopic Shoulder Stabilization Using Suture Anchors; A 8-10 Year Follow Up Study
J van Der Linde (Amsterdam - NETHERLANDS ANTILLES)

Purpose
To evaluate the long-term follow up after arthroscopic stabilization using suture anchors with emphasis on both re-dislocations and subjective shoulder function.
Material and Methods
We included 67 consecutive patients with 70 affected shoulders. After 8-10 years patients were asked to report the presence and course of their re-dislocations. Subjective shoulder function was addressed using the OIS, the WOSI and the SST. Patients rated their health status using the SF-36.
Results
Sixty-five patients with 68 affected shoulders (97%) were evaluated for follow-up, 35% reported a re-dislocation. We found a relationship between the number of suture anchors and recurrent instability, with 2 having a higher recurrence rate than 3 or more (p = 0.06). Also the presence of a Hill Sachs defect, slightly increased the risk of a re-dislocation (p = 0.07). Median shoulder function scores were 16 out of 12-60, 22 out of 0-210 and 12 out of 0-12 for the OIS, WOSI and SST respectively.
Conclusion
With a follow-up of 97%, about one-third of the stabilized shoulders experienced at least one re-dislocation after 8-10 years.
The presence of a Hill Sachs defect and the use of less then three suture anchors might increase the chance of a re-dislocation. Patients without a re-dislocation have a significantly better shoulder function compared to patients with a re-dislocation.

The Instability Severity Index Score (ISIS): Multicenter Study on Validation and Reliability
D Rouleau , A Djahangiri, S Pelet, V Godbout, J Ramsay, F Balg (Montréal - CANADA, Lausanne - SWITZERLAND, Québec - CANADA, Montreal - CANADA, Sherbrooke - CANADA)

Purpose
ISIS has been developed to predict success of arthroscopic Bankart repair. The inter-observer reliability of the score is not known. The objective of the present study is to evaluate the reliability of ISIS in a multi-centric study (4 North-American centers, 1 European center).
Material and Methods
A prospective group of patients suffering from shoulder instability and waiting for stabilization surgery were recruited. Two independent evaluators were asked to score patient instability severity with ISIS. The patient also fielded functional scores (WOSI, Walch-Duplay, Quick-DASH). Data on age, sex, type of instability, number of dislocations and type of surgery were collected. The test-retest method and Intra-class correlation coefficient (ICC) was used. A correlation greater than 0.75 is considered good, over 0.85 very good, and over 0.9 excellent.
Results
53 patients with shoulder instability were included, 43 of which are males with a mean age of 27. The majority are anterior traumatic instability cases (N = 51, 96%) ISIS is very reliable with an ICC of 0,864 (CI 95% 0,764-0.921). The ISIS score is not related to the pre-operative functional score, sex or number of dislocations.
Conclusion
Our results show that the ISIS score is reliable when used in a multicentre study in anterior traumatic instability populations. In the pre-operative period, the score is not related to patient perceived functional state or to the number of previous dislocations.

The influence of the bony bankart lesion on the clinical outcome of arthroscopically stabilized shoulders
C Jaspars , A Voordijk, J Willems (Amsterdam - NETHERLANDS)

Purpose
The objective of the present study is to evaluate the clinical outcome after an arthroscopic stabilization procedure of recurrent instability of the shoulder, comparing the clinical outcome with the size of the preoperative glenoid defect.
Material and Methods
The study contains the clinical and radiologic evaluation of carefully selected patients. Patients with an insufficient MRI-arthro, a large Hill Sachs lesion or poor quality of soft tissues (capsule, IGHL) were excluded to minimize the influence of these factors on the clinical outcome. Data were collected by analysis of questionnaires (WOSI, NSST) and a clinical examination (ROWE, Constant score). We used the en face sagittal oblique view of the preoperative MRI-arthro in combination with Osiris® software to calculate the percentage of bone loss of the glenoid circle.
Results
53 patients were included. The mean follow-up was 41 mnths (range 24-45). The mean size of the glenoid defect was 8,27% (range 0%-27,3%) of the circle. The postoperative ROWE score (mean 86) was higher as the preoperative ROWE score (p<0,05). 3 shoulders redislocated. We could not find a significant correlation between the size of the glenoid defect and the questionnaires, clinical outcome, as well as redislocation rate.
Discussion
The used concept of the inferior part of the glenoid being a circle can be used in assessing the glenoid bone loss in patients with shoulder instability. An advantage of the Osiris software in measuring the defect is its' simplicity and reproducibility. Although the glenoid bone loss is generally accepted as being an important if not prominent factor in the success of an arthroscopic soft tissue procedure, we could not find a relation between the size of defect and the redislocation rate as well as clinical and subjective outcome in a well selected group of patients. Possibly this ongoing study will supply more data with a longer follow-up or a greater group size.

12 - TIPS and tricks

Moderator : G Porcellini (Italy), C Torrens (Spain)

Ultrasound and Clinical evaluation of soft tissue versus hardware biceps tenodesis: Is hardware tenodesis worth the cost?
H Elkousy , D O'Connor, A Rodriguez-Santiago, D Doherty, G Gartsman, TB Edwards (Houston - UNITED STATES)

Purpose
Biceps pathology is addressed often by tenodesis or tenotomy. Several techniques have been described for tenodesis. The outcomes have been good for both tenodesis and tenotomy but the time and resources spent for tenodesis have been increasing with more complicated and more rigid fixation methods. The purpose of this study was to assess the failure rate of soft tissue versus hardware fixation of biceps tenodeses by ultrasound to determine if the expense of a hardware tenodesis technique is warranted.
Material and Methods
Seventy-two patients that had undergone an arthroscopic biceps tenodesis over a three year period were evaluated using postoperative ultrasonography and clinical examination. The tenodesis technique employed was either a soft tissue technique employing sutures or an interference screw technique employing hardware based on surgeon preference.
Results
Patient age averaged 57.9 years with ultrasound and clinical exam done at an average of 9.3 months postoperatively. Thirty-one patients had a hardware technique and 41 had a soft tissue technique. 67.7% of biceps tenodeses done with hardware were intact compared to 75.6% for the soft tissue technique by ultrasound (p = .46). By clinical evaluation, 80.7% of hardware techniques and 78.0% of soft tissue techniques were intact. Average material cost to the hospital for the hardware technique was $514.32 USD compared to $32.05 USD for the soft tissue technique.
Discussion
Biceps tenodesis success as determined by clinical deformity and ultrasound was not improved when using hardware as compared to soft tissue techniques. Soft tissue techniques are equally efficacious and more cost effective than hardware techniques.

There A 'De Quervain's Syndrome' of the Biceps Tendon? A Histological Analysis of the Extraarticular Biceps Synovium and Comparison with MRI, Arthroscopy and Physical Exam
J Streit , J Wanner, C Lenarz, M Rodgers, P Murthy, R Gobezie (Cleveland, Oh - UNITED STATES)

Purpose
The etiology of pain within the bicipital groove is sometimes unclear, and arthroscopic examination may not always reveal intra-articular biceps pathology. Biceps tenosynovitis has been likened to De Quervain's tenosynovitis at the wrist, but no data exists regarding the histopathologic changes in the extra-articular biceps tendon and tenosynovium found in patients without apparent intra-articular biceps pathology. We have performed a prospective study to examine these histopathologic changes in patients with pain localized to the bicipital groove.
Material and Methods
Extra-articular biceps tendon and tenosynovium were sent for histopathologic examination from thirty-eight patients undergoing biceps tenodesis and arthroscopic evaluation of the glenohumeral joint. The findings of our pathologist were then analyzed in conjunction with physical examination findings, MRI findings, arthroscopic findings, and ultimate need for surgical intervention in the glenohumeral joint at arthroscopy. The predictive value of physical examination and radiologic findings for evidence of biceps pathology was also assessed.
Results
The histopathologic findings of tendon and tenosynovium taken from our 38 patients (mean age 43.6 years ; 65.8% male) revealed the following : In the synovium, there was apparent fibrous connective tissue in 26.3%, evidence of chronic inflammation and hyperplasia in 23.7%, proliferative synovium in 7.9%, and no evidence of acute inflammation in any specimen. In the substance of the biceps tendon, degenerative change was noted in 76.3%, while no specimen showed evidence of acute inflammation and 7.9% of specimens were noted to have no evidence of any damage. Synovial hyperplasia was found to be weakly correlated with an arthroscopically-confirmed rotator cuff tear (r2 = 0.23), but otherwise no clinical, MRI, or arthroscopic findings were found to be associated with histopathologic findings. Evidence of a SLAP tear by arthroscopy was significantly associated with positive Speed and O'Brien tests, as well as tenderness in the groove, while intra-articular tearing of the biceps tendon was not significantly associated with any of these tests. There was no significant association between MRI findings and either physical examination or arthroscopic evidence of biceps tearing or SLAP tear.
Conclusion
Bicipital groove pain was usually associated with degenerative biceps tendon substance and variable findings of chronic disease within the tenosynovium similar to those associated with De Quervain's tenosynovitis. No evidence of acute inflammation was found in any specimen. Physical examination findings indicative of biceps pathology did not reliably predict findings at arthroscopy, except in the case of a SLAP tear.

Arthroscopic repair of subscapularis tear. Clinical and ultrasound evaluation
E Fandridis , G Delle Rose, N Gerostathopoulos, A Orgiani, A Plagou, A Castagna (Athens - GREECE, Milan - ITALY)

Purpose
To evaluate the structural integrity of subscapularis (SSC) tendon after arthroscopic repair by using ultrasound (US), and correlate US findings with postoperative clinical tests.
Material and Methods
We retrospectively studied 37 patients with SSC tears, operated arthroscopically in two centres. The mean age was 56.5 years (31-74), the male/female ratio was 22/15 and the right/left arm ratio was 29/8. Traumatic injury was referred in 22 patients, and four patients had an isolated SSC tear. Tears were classified according to Romeo and Fox. Preoperative MRI was performed in all patients. SSC tears were repaired by suture-anchors in 33 patients. Tenodesis or tenotomy of LHB was performed in all cases, except in two cases where the long head of the biceps was ruptured. Internal rotation lag (IRL) sign, lift-off test, Napoleon sign and bear-hug test were performed pre- and postoperatively. Postoperative US evaluation was performed in all cases.
Results
The mean follow up was 24 months (12-49). US evaluation revealed 29 intact (Group I) and 8 non-intact (Group II) SSC tendons. Correlation of clinical and US findings resulted in the following subgroups : Group Ia : 19 patients with sonographically intact SSC and all negative clinical tests for re-tear. Group Ib : 8 patients with intact SSC and some positive tests for re-tear, Group Ic : 2 patients with intact SSC and all positive tests fro re-tear, Group IIa : 4 patients with non-intact SSC and all positive tests for re-tear, and Group IIb : 4 patients with non-intact SSC and some positive tests. In the majority of patients in groups Ib, Ic and IIb, SSC preoperative MRI revealed SSC fatty infiltration.
Conclusion
US was highly consistent with clinical postoperative evaluation in 62% of patients. The discrepancy in the remaining cases may be explained by the preoperative SSC fatty infiltration and/or by the tenodesis effect of the repaired SSC.

The clinical results for the repair of massive rotator cuff tear using polyglycolic acid sheet- new artificial material -
Y Mochizuki (Hiroshima - JAPAN)

Purpose
We reported that poly-glycolic acid sheet (PGA) was effective experimentally for the regeneration of the insertion and the proper portion of the rotator cuff tendon.We reported the clinical results of the massive rotator cuff repair using the PGA sheet.
Material and Methods
Out of 336 cases, patch graft was performed on 55 cases. Twenty seven cases had patch graft using the tensor fascia lata performed (PG group) and 28 cases had patch graft using the PGA sheet performed (PGA group). 34 cases were male, 21cases were female. The average age was 63.5 years old. We evaluated the clinical results using JOA score. The MRI findings were evaluated by using Spielmann criteria. The clinical results were analyzed statistically.
Results
The average JOA score improved from 54.9 points to 91.7 points postoperatively in the PG group and from 52.6 points to 90.7 points postoperatively in the PGA group with statistically significant difference in each group. Eight cases (30.8 %) demonstrated the type 3 signal intensity on MRI findings in the PG group by Spielmann criteria, and four cases (15.4 %) in the PGA group with statistically significant difference.In blood examination, the values of CRP were almost normalized with time by 3 weeks after surgery. There were no remarkable complications such as hydroarthrosis and destruction of bone tissues. The re-tear ratio was 30.8% in the PG group comparing with 15.4 % in the PGA group. There was statistically significant difference.
Conclusion
The clinical use of the PGA sheet for the repair of massive rotator cuff tear was preferable and safe. This study suggested the PGA sheet which was new artiicial material would be useful for the regeneration of rotator cuff in the cases of massive rotator cuff tear from the points of MRI findings.


3 - New technics


Moderator : A Cartucho (Portugal), L Neyton (France)

The High Failure of Rate of Biologic Resurfacing of the Glenoid in Young Patients with Glenohumeral Arthritis
EJ Strauss , K Mcgill, GP Nicholson, BJ Cole, NN Verma, AA Romeo (Chicago, Il - UNITED STATES, Chicago,Il - UNITED STATES)
Purpose
Biological resurfacing of the glenoid with lateral meniscus allograft or human acellular dermal tissue matrix for treatment of glenohumeral arthritis in young patients has an unacceptably high failure rate at intermediate-term follow up. The purpose of this study is to compare the clinical outcomes of biological interposition arthroplasty of the glenohumeral joint using either a lateral meniscus allograft (LMA) or a human acellular dermal tissue matrix (HADTM).
Material and Methods
45 patients with a mean age of 42.2 years were treated with biologic resurfacing of the glenoid were followed for an average of 2.8 years. Among the 41 patients (91.1%) available for follow up evaluation LMA resurfacing was used in 31 cases and HADTM interposition was used in 10 cases.
Results
The overall clinical failure rate was 51.2% (21 of 41 patients). Failure was defined as actual or recommended conversion to TSA, revision surgery for graft removal, patient reported disabling pain/loss of function and/or post-operative ASES score of < 50. The LMA cohort had a failure rate of 45.2% with a mean time to failure of 3.4 years. Those treated with a HADTM had a failure rate of 70.0% with a mean time to failure of 2.2 years. Nine patients (22%) failed treatment within 2 years of the procedure.
Conclusion
Biologic resurfacing of the glenoid with LMA or HADTM results in a high rate of clinical failure at intermediate follow-up. Our results suggest that biologic resurfacing of the glenoid may not have a role in the management of glenohumeral arthritis in the young active patient.

Five year results of a cementless glenoid component in patients with primary osteoarthritis. A prospective study
S Lichtenberg , B Scheiderer, P Magosch, P Habermeyer (Heidelberg - GERMANY)

Purpose
Early results of cementless glenoid components showed good radiological results.The aim of the study is to evaluate the midterm results and to analyze the complications.
Material and Methods
Sixty-five patients suffering from primary osteoarthritis were treated in a mean age of 66 years by the implantation of a TSA using a single type of cementless glenoid component. Six percent had a type A1 glenoid according to Walch, 16% had a type A2 glenoid, 56% had a type B1 glenoid and 22% had a type B2 glenoid. Fifty-three patients were clinical and radiological (standardized x-ray in 3 planes) followed-up after a mean of 64 months. The functional results were documented using the age- and gender related Constant score (CS). The assessment of 3 zones of the glenoid component for radio lucent lines was performed using the true-ap and the axillary view.
Results
Functional a significant improvement (P<0.0001) of the CS from 49% pre-op to 89.8% post-op was observed. The active ROM improved significantly (p<0.0001) for flexion (118° pre-op, 146° post-op), for abduction (87° pre-op, 133° post-op) and external rotation (21° pre-op, 44° post-op). Radiologically 3 (5.7%) patients showed RLL in 1 zone < = 1 mm. Another patient showed a RLL < = 2 mm in 1 zone. A glenoid component loosening occurred in 5 cases (9.4%) after a mean of 66.4 months. Four patients showed an B1 glenoid type and 1 patient had a A2 glenoid type pre-op. Three patients (5.7%) had a PE-wear. The revision rate was 11.3% (6 pat.) after a mean of 68 months.
Conclusion
Cementless glenoid components showed a lower rate of RLL, but a higher rate of loosening compared to the results of cemented glenoid components. Glenoidlossening predominantly occurred in patients with preoperative eccentric glenoid morphology.

CUFF REINFORCEMENT WITH BIOLOGICAL OR SYNTHETIC MATERIAL, WHAT IS THE DIFFERENCE?
J Leuzinger , C Sternberg, D Tomala (Pfäffikon - SWITZERLAND)

Purpose
Since certain years there were published different studies showing the results of augmentation with patches in rotator cuff repair. The results in in vitro studies and in animal models were encouraging regarding biological as well as synthetic patches.
The aim of these study was to show the influence of augmentation in cuff repair in patients with a biological deficit and a possible differences between biological material and a synthetic implants.
Material and Methods
As per 1st January 2008 we started a prospectiv study. In this study 55 Patients were included. After arthroscopic reconstruction of the cuff, we arthroscopically reinforced the repair with a patch. Medial it was fixated with single stitches, lateral with ancors. On the one hand side we implanted the Graft Jacket (Wright Medical ©) on the other hand side we used the Artelon Tissue Reinforcement (Artimplant ©). The Graft Jacket is made by human skin matrix and is not cross linked. The Artelon Patch is a synthetic polyurethan mash.
Inclusion criteria : Patients with massiv rotator cuff tear, patients with revision surgery after primarily failed rotator cuff repair and patients older than 65 years
Exclusion criteria : Osteoarthritis and fatty infiltration more than degrees II by Gouttalier
All patients underwent a preoperative Arthro MRI and also an Arthro MRI in the 4 months follow-up. The evaluation of the patients has been made by constant score results. In all cases it was possible to reinforce the cuff arthroscopically.
Results
We haven't seen any local complications like infections or graft rejection. In just one case, with Graft Jacket and also in one case with Artelon Patch there were signs of a foreign body reaction.
The rerupture rate has been overall less than 20%, in the patients with Artelon. The difference in the rerupture rate between patients with Artelon patch and Graft Jacket was not significant.
Conclusion
- The arthroscopic augmentation of the rotator cuff is technical possible
- In contrast to the results shown in literature we were able to reduce the rerupture rate to less than 20% even in patients with a biological deficit
- There was no difference between biological or synthetic reinforcemen

Fine ct scan analysis of SMR Metal Back Glenoid in reverse shoulder prosthesys using an eccentric glenosphere
C de Biase , R Ferreri, A Bellelli, G Di Giorgio (Rome - ITALY, Cassino - ITALY)

Purpose
The aim of this study is to establisced the medium term bone osteointegration of glonoid metal back in reverse shoulder prosthesis using a 36 eccentric glenosphere with a minimum of 24 months follow-up.
Material and Methods
We selected 20 patients with a minimum follow up of 24 months and with a 36 eccentric glenosphere. We made a ct scan and a xray study of the glenoid in 16 patients. We divided the baseplate in six zones and an additional around the peg. And we valuated the presence of bone ingrowth around the peg, the presence of lucency, osteolysis or loosening in the 7 zones. The imagies were reviewed from both one expert muscoloskeletal radiologist and one senior orthopedic surgeon.
Results
In our series we observe no mobilization of the implants ; in all the implants we had a bone integration of the peg and of the baseplate of metal back ; in 6 cases we had a lucency less than 1 mm and in 2 more than 1 mm in different zones of the metal back. We didn't have, as previously reported, any scapular notcghing in this series.
Discussion
The ct scan analysis is a reliable method to evaluate the bone ingrowth around the metal back despite the artifacts due to the glenosphere. Some lucency may due to the incomplete seating of the metalback rather than for osteolysis.
The micromotion generate by the eccentric glenosphere and trasmitted to the metalback, in our series, didn't influence the osteointegration of the implant

The Swedish Shoulder Arthroplasty Register, 1 and 5 year follow up by WOOS
B Salomonsson , A Nordquist, H Rahme (Stockholm - SWEDEN, Malmo - SWEDEN, Uppsala - SWEDEN)

Purpose
To analyse the answers from the patients that returned the 5-year follow-up by WOOS score from the Swedish Shoulder Arthroplasty Register during 2004 to
2010. We wanted to analys the results by diagnoses concerning the different concepts of arthroplasty (Hemi or Total), and different diagnoses.
Material and Methods
The Swedish Shoulder Arthroplasty register now contains more than 7300 primary procedures. More than 1700 patients has answered by returning complete self evauating WOOS score to the Shoulder registry 5 years after the surgery. The surgery was
performed 1999-2005 and the follow-up alanysed was performed during 2004-2010. For surgery performed 2004-2010 the follow-up is analysed at 1 year follow up.
All patients were evaluated by the WOOS score sent by mail.
Results
The WOOS score resluts from more than 1500 primary procedures
of the main diagnostic groups is presented for Total Shoulder Arthroplasty (TSA) do better than the Hemi Shoulder Arthroplasty (HSA).
For reumatoid arthritis at 1 year follow up, HSA had WOOS 70% compared to TSA had WOOS 80%.
For osteoartrosis at 1 year follow up, HSA had WOOS 77% compared to TSA had WOOS 86%.
For 5 year follow up we have results for diagnoses and different concepts.
Conclusion
In our 1-year follow-up we find that it is better to offer
a TSA than a HSA to the patient with Reumatoid arthritis or Osteoarthritis regarding the outcome at the follow-up by WOOS score.
The same is eveident in the 5 year follow up that will be presented.

An Innovative method of shoulder strength assessment
P Collin , B Barnaji (Saint Grégoire - FRANCE, Bengalore - INDIA)

Purpose
Strength testing is an important aspect of shoulder examination, itis essential for diagnosing sports related conditions, assessment of progress and outcome of surgical repairs, fitness to return to work/sports. Strength assessment to date still has so many limitations as there is no single standard instrument for measuring and various devices mentioned in the past had many problems in terms of reliability, accuracy and cost.
purpose of the study was to compare the values of our method with existing method and to assess if this method of strength testing is better and as reliable as isometric dynamometer.
Material and Methods
80 shoulders, 60 normal (group 1) and 20 pathologic (group 2) tested in standard testing position of 90*elevation in the scapular plane with elbow extended forearm pronated and resistance given just proximal to the wrist. 3 different instruments used for strength testing, the spring balance, portable dynamometer & weighing machine. Each shoulder is tested 3 times with each device & mean value is noted for all 3 devices and subjected to statistical analysis.
Results
In both groups there was statistically significant difference between spring balance and dynamometer with P value0.0218 (group1) & 0.0172 (group2) but not between weighing machine and dynamometer (P value0.5713 group 1 & 0.5582 group2).
We have also measured the difference between mean values of DM&WM and SB &DM, the confidence interval and students T test are statistically significant in both the groups.
Conclusion
Our innovative method is as accurate as the dynamometer, weighing machine is readily available in all setups.


Rehabilitation after arthroscopic cuff repair

Moderator : JP Liotard (France)

Opening of the symposium
G Walch (Lyon - FRANCE)

Rehabilitation protocols and postoperative course
T Marc, J Willems (Montpellier - FRANCE, Amsterdam - NETHERLANDS)

Preoperative education
K Chaory (Rennes - FRANCE)
Rennes' Team

Range of motion recovery: muscle's relaxation and humeral head centering
S Gain (Rennes - FRANCE)
Rennes' Team

Muscle's reactivation
S Gain (Rennes - FRANCE)
Rennes' Team

Discussion

Surgical or conservative treatment
L d'Asnières de Veigy (Nice - FRANCE)
Nice's Team

Delayed rehabilitation: the healing time
P Duplan (Nice - FRANCE)
Nice's Team

Ambulatory rehabilitation after one month: tips and tricks to succeed
P Oddoux, L Païdassi (Nice - FRANCE)
Nice's Team

Discussion

Preoperative range of motion assessment and full range of motion recovery
F Borel (Lyon - FRANCE)
Lyon's Team

Immediate postoperative rehabilitation with hydrotherapy in rehabilitation centre
A Cyvoct (Hauteville-Lompnes - FRANCE)
Lyon's Team

Postoperative controls and personal stretching
JP Liotard (Lyon - FRANCE)
Lyon's Team

Discussion

An American experience
A Ladermann (Geneva - SWITZERLAND)
Geneva's Team

Discussion

Coffee Break

Results of the multicentric studies during the first 6 postoperative months
DF Gazielly, A Cools (Geneva - SWITZERLAND, Ghent - BELGIUM)

Results - Rennes' Team
P Collin (Saint Grégoire - FRANCE)

Results - Nice's Team
P Duplan (Nice - FRANCE)

Results - Lyon's Team
JP Liotard (Lyon - FRANCE)

General open discussion

Rehabilitation and preoperative stiffness, immediate or differed/delayed rehabilitation? In or out patient rehabilitation? Personal stretching for recovering the mobility or active rehabilitation with tools? Length of rehabilitation and length out of work? Problems and complications associated with the rehabilitation.

Rehabilitation 1

Moderator : DF Gazielly (Switzerland), J Nowak (Sweden)

Massive irreparable rotator cuff tears: What can we do in rehabilitation
O Patiño (Buenos Aires - ARGENTINA)

Purpose
The purpose of this prospective, randomized, blinded, trial study is to compare two shoulder rehabilitation protocols in patients with massive irreparable rotator cuff tear. One group was treated using anterior deltoid muscle rehabilitation and strengthening program, and the other using conventional exercises with elastic bands.
Material and Methods
Forty seven selected voluntary patients with diagnosis of massive irreparable rotator cuff tear were included in this study. Group 1 (n = 24) was instructed in exercises of anterior deltoid muscle ; group 2 (n = 23) was instructed in conventional exercises using elastic bands. Both groups were supervised by physical therapists three times a week during three months. The Constant score and visual analogue scale of patient satisfaction were recorded before and after the treatment. The final follow up was performed by a blinded observed.
Results
The mean age was 76.9 years (range 68-88). The follow up was 24 months (range 6-28). The Constant score improved from mean 37 points (ST± 11) to mean 50 points (ST±11). VAS satisfaction improved from mean 3.6 (ST±1.3) to 5.3 (ST±1.5) (P>0.05, T test). Analysis between group differences showed better results in Constant score and VAS satisfaction in group 1 than in group 2. The Constant score difference between pre and post treatment in group 1 was mean 17 (ST±10) whereas in group 2 was mean 7 (ST±4) (P>0.005 T-test). VAS satisfaction difference pre and post treatment was 2.6 (ST±1.6) in group 1 and mean 0.8 (ST±0.1) (P>0.05, T test) in group 2.
Conclusion
This study showed better outcomes using anterior deltoid muscle reabilitation and strengthening program than conventional exercises with elastic bands in patients with massive irreparable rotator cuff tear.

Early Versus Delayed Rehabilitation For Reverse Shoulder Arthroplasty In Cuff Tear Arthropathy
T Peterson , C Wood-Wentz, J Sperling, S Steinmann, R Cofield, J Sanchez-Sotelo (Rochester, Minnesota - UNITED STATES, Rochester Mn - UNITED STATES)

Purpose
Currently, there is limited information regarding the best rehabilitation protocol for patients undergoing reverse shoulder arthroplasty. The purpose of this study was to compare the outcomes of early versus delayed range of motion programs in patients who underwent a primary reverse total shoulder arthroplasty for cuff tear arthropathy (CTA).
Material and Methods
101 consecutive reverse arthroplasties performed for CTA were assigned to four different therapy programs based on surgeon's preference regarding initiation of range of motion : immediate, at 2 weeks, at 6 weeks, or based on patient comfort. Pain, range of motion, and complications were recorded retrospectively at a median follow-up of 2.2 years. Groups were compared using linear regression and Cox proportional hazards models.
Results
At most recent follow-up, pain was graded as no or mild in 84%, mean elevation was 132 degrees, and mean external rotation was 42 degrees. Complications included acromion stress fractures (6), glenoid loosening (4), dislocation (2), transient brachial plexopathy (2), polyethylene dissociation (1), and deep infection (1). With the numbers available, there were no differences in any of the outcome measures or complications amongst the different therapy groups.
Conclusion
The timing of initiation of motion seems to have little effect on the final outcome or complications after reverse shoulder arthroplasty for CTA.

The truth about frozen shoulder associations
W White , CD Smith, TD Bunker (Exeter - UNITED KINGDOM)

Purpose
The aim of this study was to compare statistically the incidence of comorbidities in a group of frozen shoulder patients and an age and sex matched control group and to compare the incidence of frozen shoulder in siblings of patients in both groups. Frozen shoulder is said to be associated with medical co-morbidities such as diabetes, thyroid disease, high cholesterol and heart disease. However some of these associations have been made in patients with a clinical diagnosis of frozen shoulder without comparison to an age and sex matched control group.
Material and Methods
101 patients were identified to have clinical and arthroscopically proven frozen shoulder and no other intra-articular pathology. A further 101 patients were recruited from a fracture clinic as an age and sex matched control group. Each patient was given a questionnaire to document comorbidities and frozen shoulder in siblings.
Results
The only co-morbidity found to be an independent risk factor for frozen shoulder was diabetes (p = 0.002). No link was found between frozen shoulder and high cholesterol (p = 0.86), heart disease (p = 0.81) and thyroid disease (p = 0.23). Having a sibling with frozen shoulder was found to be an independent risk factors for frozen shoulder (risk ratio 3.3, p<0.02).
Conclusion
This is the first large study to use a precise diagnosis and a well matched control group to demonstrate the associations of frozen shoulder. It confirms the link of frozen shoulder with diabetes and strengthens the argument for a genetic link. It disproves the association of heart disease, thyroid disease and high cholesterol with frozen shoulder.

Treatment of Stiff Shoulder – A Prospective, Multicenter, Comparative study of the six commonly used techniques utilized – 235 case follow up
P Gleyze , P Clavert, PH Flurin, T Joudet, B Toussaint, L Hubert (Colmar - FRANCE, Strasbourg - FRANCE, Bordeaux - FRANCE, Libourne - FRANCE, Annecy - FRANCE, Angers - FRANCE)

Purpose
The authors wanted to evaluate and compare the therapeutic power of different techniques used for the treatment of stiff shoulder and to propose a standard therapeutic algothrym.
Material and Methods
A comparative multicentric prospective study (passive FF reduced of more than 30°) has been realized :
T1 : Conventional rehabilitation with respect of pain limit, T2 : Self exclusive rehabilitation over pain control, T3 : Self rehabilitation controled by a physiotherapist, T4 : T1 + Loco-regional anesthesia block, T5 : T1 + Capsular distention, T6 : Endoscopic capsulotomy
The therapeutic power of each technique was evaluated every week during a 6-weeks period, and then at 3-months, 6-months and a final review with evaluation of the subjective and objective criteria i.e. Constant score, goniometric measurements.
Results
Total 235 cases (T1 : 58 cases, T2 : 59 cases, T3 : 31 cases, T4 : 11 cases, T5 : 31 cases, T6 : 45 cases) had patient follow up during 18-months (3-21).
Conventional rehabilitation ; (T1) improved the pain and passive motion. Overall the pain techniques (T2 & T3) give a quicker improvement of both day and night pain (S6-p<0,05) during the first 6 weeks. Loco-regional anesthesia (T4) and distention (T5) can accelerate the improvement. A capsulotomy cannot give faster pain relief but can improve passive motion at between 3 and 6-months (p<0,05).
If we consider T1 as the gold standard, the relief of the pain barrier improves the final result by 12%, loco-regional anesthetic block or distention of 3 to 6% and capsulotomy 15% this means 3% more than with self-rehabilitation.
Conclusion
The authors propose, for all symptomatic stages no matter what stage of the evolution :
- 1 to 3-months : self-rehabilitation cominated with conventionnal rehab
- 3 to 6-months : in case of failure of treatment, loco-regional anesthetic block or distention can sometimes be considered.
- 6-months : in case of failure, an endoscopic capsulotomy can be considered.

Systematic review of postoperative therapy protocols used in studies assessing arthroscopic rotator cuff repair: has there been a trend towards accelerated rehabilitation?
T Donaldson , L Funk, P Wright (Wigan - UNITED KINGDOM)

Purpose
Whilst there have been many developments in the arthroscopic techniques employed to treat tears of the rotator cuff, little has been done to determine whether postoperative rehabilitation has undergone a similar evolution.
Material and Methods
A literature search was performed using the Pubmed bibliographic database for studies of arthroscopic rotator cuff repair between 1996 and 2011. Studies were divided into two groups ; those published between 1996 and 2008 and between 2009 and 2011. Details of the rehabilitation protocol were recorded including duration and type of sling, initiation of passive range of movement, initiation of active range of movement and initiation of strengthening exercises.
Results
55 papers were included. The studies included varied widely in all aspects of the therapy programme used. Those studies published during the later time period there was a trend towards a longer period of immobilisation in a sling and the delay of strengthening exercises until the twelfth postoperative period or beyond. The initiation of passive and active range of movement exercises was similar in both groups.
Conclusion
Despite ongoing improvements in surgical technique to provide increasingly secure fixation of the rotator cuff there has not been a trend towards earlier mobilisation in the rehabilitation protocols published in the orthopaedic literature.

Standard or decelerated rehabilitation after arthroscopic rotator cuff repair: a randomized, prospective study
G van Den Bogaert , S Defoort, A Cools, E Witvrouw, O Verborgt (Herentals - BELGIUM, Brugge - BELGIUM, Gent - BELGIUM)

Purpose
To compare the effect on functional and structural outcome of standard and decelerated rehabilitation programs after arthroscopic rotator cuff repair.
Material and Methods
40 patients with full-thickness rotator cuff tears were randomly assigned to a standard or decelerated rehabilitation protocol after arthroscopic repair. Standard protocol included immediate physiotherapy with passive mobilisations, while the decelerated group did not get formal therapy the first 6 weeks. All patients were clinically assessed pre-operatively and post-operatively at 6 weeks, 3 months and 1 year using Constant score, VAS and SST. At 1 year postoperatively, the integrity of the repair was assessed with ultrasound examination.
Results
Clinically, there was no significant difference between standard and decelerated rehabilitation groups at 6 weeks, 3 months or 1 year post-operatively in terms of Constant score, SST and VAS score. Only pain (p = 0,10) and VAS score (p = 0,05) tended to be better at 6 weeks after decelerated rehabilitation compared to standard rehabilitation. On ultrasound examination there was no difference in structural integrity between the 2 groups.
Discussion
Concerns for recalcitrant stiffness and poorer functional outcomes have led to some to favor early postoperative therapy. We found that early restriction of motion did not lead to poorer functional outcome at 6 weeks, 3 months or 1 year postoperatively or difference in structural integrity on ultrasound after 1 year.

Early activation or a more protective physiotherapy protocol after ASD – a prospective randomized pilot-study with a two-year follow-up
I Hultenheim Klintberg , AC Gunnarsson, U Svantesson, J Karlsson (Gothenburg - SWEDEN)

Purpose
To evaluate if patients after ASD who were treated according to a comprehensive well-defined protocol with a more progressive approach became pain free and attained higher shoulder function at an earlier stage compared to those who treated according to a more general approach.
Material and Methods
Thirty-two patients (13 women), mean age 46 (SD7, range 31-56) years with primary shoulder impingement, selected for ASD were included. The Traditional group (n = 19) started with active assisted range of motion exercises on the day of surgery, dynamic exercises for the rotator-cuff after six weeks and strengthening exercises after eight weeks. The Progressive group (n = 13) started active assisted range of motion and specific dynamic exercises for the rotator-cuff on the day of surgery. Strengthening exercises started after six weeks. A clinical evaluation was made pre-operatively, six weeks, three, six, 12 and 24 months after surgery. Pain, patient satisfaction, range of motion and muscular strength were evaluated. Constant score and Functional Index of the Shoulder were also used.
Results
Both groups showed significant improvements in pain during activity and at rest, in range of motion in extension and abduction, in strength of external rotation and in function. Progressive group versus Traditional group at the 3 months showed VAS in pain at rest 0/10 mm. The majority of patients were pain-free from 6 months. At the 2 year follow up the groups attained, 160/150º in active flexion, 180/170º in active abd-uction and 90/75º in external rotation. Using Constant Score the groups attained 87/67 points and 7 of 8 respectively 13 of 18 reported satisfaction with shoulder-function.
Conclusion
After ASD, a comprehensive, well-defined and controlled physiotherapy protocol was associated with slightly faster recovery of shoulder function. No adverse effects were noted, the protocol may therefore safely be used after ASD.

Rehabilitation 2

Moderator : O Gagey (France), HV Johannsen (Denmark)

Early activation or a more protective physiotherapy protocol after ASD – a prospective randomized pilot-study with a two-year follow-up
I Hultenheim Klintberg , AC Gunnarsson, U Svantesson, J Karlsson (Gothenburg - SWEDEN)

Purpose
To evaluate if patients after ASD who were treated according to a comprehensive well-defined protocol with a more progressive approach became pain free and attained higher shoulder function at an earlier stage compared to those who treated according to a more general approach.
Material and Methods
Thirty-two patients (13 women), mean age 46 (SD7, range 31-56) years with primary shoulder impingement, selected for ASD were included. The Traditional group (n = 19) started with active assisted range of motion exercises on the day of surgery, dynamic exercises for the rotator-cuff after six weeks and strengthening exercises after eight weeks. The Progressive group (n = 13) started active assisted range of motion and specific dynamic exercises for the rotator-cuff on the day of surgery. Strengthening exercises started after six weeks. A clinical evaluation was made pre-operatively, six weeks, three, six, 12 and 24 months after surgery. Pain, patient satisfaction, range of motion and muscular strength were evaluated. Constant score and Functional Index of the Shoulder were also used.
Results
Both groups showed significant improvements in pain during activity and at rest, in range of motion in extension and abduction, in strength of external rotation and in function. Progressive group versus Traditional group at the 3 months showed VAS in pain at rest 0/10 mm. The majority of patients were pain-free from 6 months. At the 2 year follow up the groups attained, 160/150º in active flexion, 180/170º in active abd-uction and 90/75º in external rotation. Using Constant Score the groups attained 87/67 points and 7 of 8 respectively 13 of 18 reported satisfaction with shoulder-function.
Conclusion
After ASD, a comprehensive, well-defined and controlled physiotherapy protocol was associated with slightly faster recovery of shoulder function. No adverse effects were noted, the protocol may therefore safely be used after ASD.

The Effect of Core Stabilization Exercises in the Rehabilitation of Patients with Subacromial Impingement Syndrome
N Canbulat , A Seyahi, SM Eren, A Ucak, E Berker, M Demirhan (Istanbul - TURKEY)

Purpose
The aim of this study was to investigate whether core stabilization exercises can improve shoulder function and reduce symptoms in patients with subacromial impingement syndrome (SIS). We have hypothetized that the addition of core stabilization exercises to the standard rehabilitation would give better clinical results when compared to the standard rehabilitation alone.
Material and Methods
Thirty-six patients (mean age 53.3 (29-75) were randomly assigned to a core exercise group (I), and a standard protocol group (II) of 18 patients each. Both groups received a standard rehabilitation program involving TENS, ultrasound therapy, and ROM and strengthening exercises. Additionally, the core exercise group were assigned to a core stabilization exercise program. All the shoulders were rated using DASH, Constant and ASES scores before the treatment and at the 6 week and 6 month follow-up. Wilcoxon and Mann-Whitney U tests were used in statistical analysis.
Results
The groups were homogenous for their mean age (p = 0.35) and pretreatment scores (p = 0.10 ; p = 0.35 ; p = 0.48, for DASH, Constant and ASES, respectively). All functional scores in both groups improved significantly at the 6 week follow-up (p = 0.0001 ; p = 0.0001 ; p = 0.001 (Group I's) and p = 0.02 ; p = 0.01 ; p = 0.08 (Group II's) DASH, Constant and ASES, respectively) and 6 month follow-up (p = 0.0001 ; p = 0.0001 ; p = 0.0001 (Group I's) and p = 0.0001 ; p = 0.0001 ; p = 0.001 (Group II's) DASH, Constant and ASES, respectively). The Constant and ASES scores were significantly better in Core exercise group (I) at 6 week (p = 0.008 and 0.039) and 6 month (p = 0.02 and 0.001) follow-up.
Conclusion
The inclusion of core stabilization exercises in standard comprehensive physiotherapy applied in the rehabilitation of patients with subacromial impingement syndrome significantly improves treatment effectiveness.

Supraspinatus Strain Measurements: What happens after Tears and Repairs?
DT Lie , A Yew, JM Sheng, SM Chou (Singapore - SINGAPORE)

Purpose
To simultaneously measure the bursal and articular strains of the supraspinatus in an intact glenohumeral joint and demonstrate the effect of tears and repairs on strain pattern.
Material and Methods
Nine fresh-frozen shoulders were tested on a purpose-built rig. With 10 kg loaded at the rotator cuff muscles, DVRTs were used to measure the strains of the supraspinatus at the bursal (anterior and posterior) and articular (anterior) sides simultaneously at varying elevation angles of the scapular plane. Partial thickness tears were made at the anterior bursal-side of the supraspinatus and enlarged to full-thickness tear. Single-row repair using simple stitches and horizontal stitches and double-row repair were performed on the tear.
Results
Strains of the anterior and posterior bursal surfaces decreased to -3.3% and -5.4% while the articular surface increased to +16.3% at 60o elevation, showing the divergent strain pattern between layers of the intact supraspinatus tendon. A 2-mm partial tear at the bursal side caused 2% strain increment at the articular side, and 5% on the bursal surface. This reflects the strain across the tear gap. Following a full-thickness tear the strain further increased to 4% for the articular side, consistent with the observation of gap increase while the bursal surfaces did not show any marked strain increases. After single row repairs there was a 6.7% strain increment at the articular side, whilst strain on the bursal surface reduced to as much as 0.8% of the intact. Articular surface strains were restored to 0.5% of the intact only with dual-row repairs.
Conclusion
The varying strain patterns between articular-bursal and anterior-posterior surfaces implied occurrence of shearing which may cause intratendinous tears. Tears caused increased strain on the supraspinatus. Single-row repairs restored strain on the bursal surface only. Strain across the tendon is best restored with dual-row repairs.

Ultrasound-Guided Suprascapular Nerve Block for Patients with Persistent Shoulder Pain
J Sultan , J Wilson, E Goodyear, U Narendran, B Roy (Manchester - UNITED KINGDOM, Warrington - UNITED KINGDOM)

Purpose
Anatomical studies have shown that more than 70% of pain sensation around the shoulder is transmitted via the suprascapular nerve. Suprascapular nerve block (SSNB) has been previously used in rheumatology clinics as a method of controlling chronic shoulder pain. This study aims to assess the efficacy of ultrasound-guided SSNB for pain control in a group of Orthopaedic patients with persistent shoulder pain and reduced function.
Material and Methods
Nineteen patients were prospectively recruited and constituted two main groups ; the primary frozen shoulders group and the persistent postoperative stiffness group. SSNBs were performed by two experienced anaesthetists as a day-case procedure. Using a high-resolution ultrasound scanner, 10 mL to 15 mL of 0.5% Bupivacaine were infiltrated around the nerve in the suprascapular notch. Numerical analogue pain scores (NAPS), from 0 to 10, were collected prior to the block and 20 minutes, 2-3 days, 2 weeks and 8 weeks post-block. In addition, Oxford Shoulder Scores (OSS) were collected pre-block and at 8 weeks post-block.
Results
The mean pre-block NAPS was 8.2 ± 1.8 and, at all subsequent points, the average pain score was significantly improved (p < 0.0001). The mean OSS improved significantly at 8 weeks post-block, from 17.3 ± 7.0 pre-block to 28.4 ± 11.3 (p = 0.0005). The response in the persistent postoperative pain and stiffness group was better than the primary frozen shoulders group, although this was not statistically significant. No complications were recorded for any of the patients.
Conclusion
We conclude that ultrasound-guided SSNB is a simple technique that can be successfully employed to achieve rapid relief of symptoms in patients with persistent shoulder pain and reduced function. This can be used as a temporizing measure whilst other interventions, such as physiotherapy or surgery, are contemplated.

Evaluation of upper-limb EMG activity and kinematics during reaching : a comparison between subject with SCI and able bodied subjects
J Jacquier-Bret , N Rezzoug, H Tournebise, P Gorce, Y Allieu (Toulon - FRANCE, Hyères - FRANCE, Montpellier - FRANCE)
Purpose
The present work investigated the kinematics and muscular activity of subjects suffering from a spinal cord injury (SCI) at the level C6/C7 during a reach-to-grasp task.
Material and Methods
Eight able-bodied subjects and five individuals with a SCI (three C6 ASIA-A, one C6 ASIA-D and one C7 ASIA-A, none had undergone surgery for tendon transfer), all right-handed, were instructed to grasp ten times a light cubic object placed in front of them at distance of 40 cm. Each repetition was followed by a recovery period of 1 minute. During the motion, the muscular activation was recorded from surface electromyography. Six upper limb muscles were considered : pectoralis major (PM), anterior deltoid (AD), posterior deltoid (PD), biceps brachii (BB), triceps brachii (TB), and extensor carpi radialis (ECR). For the subjects with SCI, the electrodes placed on the TB were used to verify that no voluntary contraction occurred. For each considered muscle, a maximal voluntary isometric contractions test was conducted. Simultaneously, the kinematics (orientation and position of each segment) of the upper limb was recorded with for electromagnetic sensors placed on the shoulder, the arm, the forearm and the back of the hand.
Results
Firstly, AD and PM presented a greater level of relative activation level for individuals with SCI in comparison to the control group. Secondly, greater ranges of motion were found for the clavicle angles (protraction and elevation) in patients with tetraplegia whereas lower amplitudes were observed for the axial rotation of the humerus and for the elbow flexion in this group.
Conclusion
The results suggest that the quadriplegic subjects can execute grasping movement successfully by an increase of the relative activity of the shoulder muscles and a modification of the upper limb kinematics at the shoulder and elbow joints. This latter result support the hypothesis proposed by several authors that subjects with SCI can perform elbow extension by exploiting interaction torques generated by the shoulder muscles.

Correlation of shoulder external rotation strength with Constant Score and quality of life perception
J Miquel , G Vilà, F Santana, C Torrens (Barcelona - SPAIN)

Purpose
The objective of the study is to evaluate the correlation between the capacity to perform external rotation and quality of life perception (QLP) and if this correlation is affected by external rotation strength.
Material and Methods
Prospective study including 78 patients with a mean age of 59.96. There were 51 females and 27 males. 36 consulting because glenohumeral arthritis, 24 cuff disorders, 9 fractures and 9 instabilities. All patients completed SF-36 quality of life questionnaire and Constant Score. External rotation strength with the arm at the side (ER1) and with the arm at 90º of anterior elevation (ER2) was recorded with a digital strength tester.
Results
Ability to perform external rotation correlates with QLP (0,549 PF_norm, 0,418 RP_norm, 0,415 PHY comp), independently of total Constant Score. Increasing external rotation improves QLP.Strenght of external rotation correlates less than the ability to perform external rotation with QLP. Eventhough ER2 have a stronger correlation than ER1 (ER2 values on SF-36 : 0,467 PF_norm, 0,240 RP_norm, 0,381 PHY comp, while values for ER1 are : 0,326 PF_norm, 0,213 RP_norm, 0,326 PHY comp).
Discussion
There is a clear correlation external rotation and the QLP, and this correlation is independent of the total Constant Socre.The strenght of external rotation correlates less with QLP than the ability of external rotation. Strength at 90º of anterior elevation presents higher correlation than strenght with the arm at the side.
Muscular transpositions could improve QLP by restoring external rotation ability independent of the strength obtained.

Are problems in functioning reported in ICF Checklist by patients with shoulder pain represented in patient reported outcome measures?
Y Roe , S Ostensjo, E Bautz-Holter, H Soberg (Oslo - NORWAY)

Purpose
The purpose was to identify the most common problems in functioning among individuals with shoulder pain, according to the ICF components body functions (b) and activities and participation (d), and to investigate whether these problems are represented in the content of three commonly used shoulder questionnaires.
Material and Methods
A cross-sectional study and a content linking procedure. Outpatients at a hospital were interviewed using an ICF Checklist. Presence of functional problems was registered. The frequency of cases with a problem was estimated for each category. The content of DASH, SPADI and ASES were trough a formal procedure linked to ICF categories. The linked content from the questionnaires were finally compared to the most frequently identified categories from the ICF Checklist interviews.
Results
165 participants, 54% women with a mean age of 46.5 years (SD = 12.5) were included. The five most frequently identified problems in the ICF body function component were : b280 Pain (98,8%), b710 Mobility of joint (90,9%), b134 Sleep (78,8%), b740 Muscle endurance functions (73,9%) and b130 Energy and drive functions (70,3%) The five most frequent in the activities and participation component were : d430 Lifting and carrying objects (84,8%), d850 Remunerative employment (78,8%), d920 Recreation and leisure (76,4%), d410 Changing basic body position (75,2%) and d510 Washing oneself (69,1%). None of the ICF categories b740, b130 and the d410 were present in the linked content from DASH, SPADI or ASES.
Conclusion
The results of this study show that some of the most frequent functional problems reported by individuals with shoulder pain are not covered by the content of three commonly used shoulder questionnaires.

CL 7: Injuries to both ends of the clavicle: SCJ and ACJ

Moderator : S Gumina (Italy)

Introduction
S Gumina (Rome - ITALY)

Visualization of arthroscopic portals. Safe and dangerous zones?

N Pouliart (Brussels - BELGIUM)

Management of the lateral and medial end clavicle fractures
H Resch (Salzburg - AUSTRIA)

Traumatic sternoclavicular dislocation: when and how I treat it
O Levy (Reading - UNITED KINGDOM)

Acute and chronic type III-VI AC joint dislocations: stabilization techniques
M Zumstein (Nice - FRANCE)

ICL 8 New perspectives in arthroscopy of the shoulder

Introduction
TC Ludvigsen

Visualization of arthroscopic portals. Safe and dangerous zones.
P Golano

Biceps tenodesis. A novel technique with focus on site and tension

E Calvo (Madrid - SPAIN)

Arthroscopic bone block procedures
E Taverna (Mendrisio - SWITZERLAND)

Treatment of irreparable massive tears. The subacromial balloon.
V Senekovic (Ljubljana - SLOVENIA)

ICL 9 Proximal ulnar fractures and osteotomies


Moderator : BS Olsen (Denmark)

Introduction
BS Olsen (Copenhagen - DENMARK)

Olecranon fractures, cerclage or plate fixation?
R van Riet (Antwerp - BELGIUM)

Coronoid process fractures. Treatment options
BS Olsen (Copenhagen - DENMARK)

Elbow joint surgery. Oleacranon osteotomy or triceps reflectiing/splitting techniques.
D Stanley (Sheffield - UNITED KINGDOM)

Ulnar osteotomy in the treatment of chronic traumatic radial head dislocation in children
JO Soejbjerg (Aarhus - DENMARK)