The complications of prostheses for fractures of the proximal humerus are understudied because the experience of each shoulder surgeon is limited and a standardised registration protocol is not yet available. A prospective study on complications in shoulder arthroplasty for fracture is, therefore, essential to explore variables that influence outcome. The purpose of this study is to report our experience with complications following arthroplasty for proximal humeral fractures.

In a multicenter study, four hundred and six patients treated with arthroplasty for proximal humeral fracture were prospectively followed during a nine year period; three hundred patients with a minimum of two years follow-up, at an average of forty-five months (range, 24–117), were available for review. Objective results were graded with the Constant score and range of motion. Subjective results were reported according to patient satisfaction.

At follow-up, the average Constant score was fifty-four points (range, 14–95) and active forward elevation was 103° (range, 10°–180°). Eighty-one percent of patients were satisfied or very satisfied. We observed a 59% rate of late (after three months) complications, including a high rate of tuberosity-related complications (72% malunion or nonunion). Initial tuberosity malposition was present in 35% of the patients. Secondary migration despite initial good positioning was observed in 24%.

Tuberosity complications were associated with poor final Constant score, poor range of motion and shoulder pain (p=0.001 for all items). A re-operation was performed in 5.3% of the cases. Patients who were mobilised according to the ‘early passive motion’ concept had double the incidence of secondary tuberosity migration, compared to those that were initially immobilised (14% versus 27%, p=0.004). Tuberosity complications are the most frequent late complication and they are associated with poor functional results. It is, therefore, incumbent upon the surgeon to maximise healing with adequate fixation of the tuberosities, followed by sufficient immobilization.

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

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

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

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

The objective of this study is to report the epidemiology and results of treatment of deep infection after a reverse shoulder arthroplasty.

This is a multicenter retrospective study involving 457 reverse prostheses performed between 1992 and 2002. Fifteen patients (3%) (mean age 71 ± 9 years) presented with a deep infection. Eight were primary arthroplasties and seven were revision procedures. There were five associated peri-operative fractures and three early postoperative complications requiring surgical treatment. Infection was treated by debridement (n=4), prosthetic resection (n=10) or two-stage revision (n=1).

The infection rate was 2% (8/363) for a primary reverse arthroplasty and 7% (7/94) for revisions. The infection was diagnosed at a mean of seventeen months (range, one to fifty-seven) post-operatively, corresponding to two acute, five sub-acute and eight chronic infections. The most common pathogen was P. acnes in six cases (40%). At a mean follow-up of thirty-four ± nineteen months, there were twelve remissions (80%) and three recurrent infections. The two acute infections (one debridement and one resection) and the eight chronic infections (seven resections and one two-stage revision) were in remission. Among the five sub-acute infections, the two resections were in remission, whereas the three debridements recurred. Overall, the ten resections were in remission with seven patients disappointed and three satisfied, a mean Constant score of thirty-one ± eight points and a mean active anterior elevation of 53 ± 15°. The two-stage exchange was in remission but remained disappointed with a Constant score of twenty-seven points and an active anterior elevation of 90°.

Infection compromises the functional results of the reverse prosthesis whatever the treatment performed. Acute infections appear to be satisfactorily treated by debridement or resection. Both resection and two-stage revision can successfully treat sub-acute and chronic infection; however, debridement alone is ineffective and not recommended. There is a high rate of infection when the reverse prosthesis is used in revision arthroplasty. Prevention, by looking for such infection before surgery and by performing a two-stage procedure is recommended in the case of any uncertainty.

Scapular notching is of concern in reverse shoulder arthroplasty and has been suggested as a cause of glenoid loosening. Our purpose was to analyze in a large series the characteristics and the consequences of the notch and then to enlighten the causes in order to seek some solutions to avoid it. 430 consecutive patients (457 shoulders) were treated by a reverse prosthesis for various etiologies between 1991 and 2003 and analyzed for this retrospective multicenter study. Adequate evaluation of the notch was available in 337 shoulders with a follow-up of 47 months (range, 24–120 months). The notch has been diagnosed in 62% cases at the last follow-up. Intermediate reviews show that the notch is already visible within the first postoperative year in 82% of these cases. Frequency and grade extension of the notch increase significantly with follow-up (p< 0.0001) but notch, when present, is not always evolutive. At this point of follow-up, scapular notch is not correlated with clinical outcome. There is a correlation with humeral radiolucent lines, particularly in metaphyseal zones (p=0.005) and with glenoid radiolucent lines around the fixation screws (p=0.006). Significant preoperative factors are: cuff tear arthropathy (p=0.0004), muscular fatty infiltration of infraspinatus (p=0.01), narrowing of acromio-humeral distance (p< 0.0001) and superior erosion of the glenoid (p=0.006). It was more frequent with superolateral approach than with deltopectoral approach (p< 0.0001) and with standard cup than with lateralized cup (p=0.02). We conclude that scapular notching is frequent, early and sometimes evolutive but not unavoidable. Preoperative superior glenoid erosion is significantly associated with a scapular notch, possibly due to the surgical tendency to position the baseplate with superior tilt and/or in high position which has been demonstrated to be an impingement factor. Preoperative radiographic planning and adapted glenoid preparation are of concern.

The purpose of this study is to catalogue humeral problems with reverse total shoulder arthroplasty and define their influence on outcome.

A multicenter retrospective review of 399 reverse humeral arthroplasties implanted between January 1994 and April 2003, yielded seventy-nine patients with humeral problems. We define a clinical humeral problem as an event that alters the expected rehab or postoperative course. Perioperative problems are fractures within the stem zone while postoperative problems involve fractures distal to the stem, prosthetic disassembly and subsidence. Radiologic problems include humeral loosening and radiolucencies of greater than 2 mm that have not had a clinical impact. All radiographs were available and reviewed by three orthopaedic surgeons. Objective results were rated according to the Constant score; active forward flexion and external rotation were recorded; and subjective outcome was noted.

We identified twenty-six intra-operative fractures and eleven postoperative fractures. There were four cases of disassembly, three cases of subsidence, and fifteen cases of radiographic loosening. At a mean follow-up of forty-seven months, average active elevation was 111.3 degrees, external rotation was 7.0 degrees, and absolute Constant score improved from 21.9 to 50.1 points. Seventy-one percent of the patients were satisfied or very satisfied. Intra-operative humeral fractures were associated with poor final Constant score (42.3), poor range of motion and increased shoulder pain (p=0.001 for all items). Constant score for those revision patients who experienced a fracture was lower by 9.6 points (p=0.0347) than those patients who underwent a reverse prosthesis for revision surgery without a fracture. Constant score for those patients with a postoperative fracture averaged 47.2 (range, 8–70). A re-operation was performed in seven of the cases (9%).

Intra-operative humeral fractures occur commonly when a reverse prosthesis is indicated for revision; humerotomy is not protective, however, and is not recommended for all humeral revisions. Fractures, either intraoperative or post-operative, result in lower Constant scores. Any patient who received an intervention for a humeral problem yielded a lower constant score. While postoperative Constant scores improved in all categories, they were lower than those patients who did not sustain a humeral complication.

The purpose of this study was to evaluate outcome following arthroscopic biceps tenotomy or tenodesis for massive irreparable rotator cuff tears associated with biceps lesions.

This is a retrospective study of sixty-eight consecutive patients (mean age 68 ± 6 years) with seventy-two irreparable rotator cuff tears treated with arthroscopic biceps tenotomy (thirty-nine cases) or tenodesis (thirty-three cases). All patients were evaluated clinically and radiographically at a mean follow-up of thirty-five months (range, 24–52).

Fifty-three patients (78%) were satisfied. Constant score improved from forty-six to sixty-seven points (p< 0.001). Presence of a healthy, intact teres minor on preoperative imaging correlated with increased postoperative external rotation (40 vs. 18°, p< 0.05) and higher Constant score (p< 0.05). Three patients with a pseudoparalyzed shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. By contrast, fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1 mm on average, and only one patient developed glenohumeral osteoarthritis. There was no difference between tenotomy and tenodesis (Constant Score sixty-one vs. seventy-three). A “Popeye” sign was clinically apparent in twenty-four tenotomy patients (61%), but none were bothered by it. Two patients required reoperation with a reverse prosthesis.

Arthroscopic biceps tenotomy and tenodesis effectively treats severe pain or dysfunction caused by an irreparable rotator cuff tear associated with biceps pathology. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated. Pseudoparalysis or severe cuff arthropathy are contraindications.

INTRODUCTION: Assessment of radiolucent lines (RLL) is the main component of the radiographic analysis of the glenoid component. The purpose of this study is to compare the radiographic results of two glenoid preparation techniques by analyzing periglenoid radiolucencies.

MATERIEL AND METHODS: The series consists of seventy-two shoulder arthroplasties with primary osteoarthritis. Shoulders were divided into two groups based on glenoid preparation technique:

Group 1: Thirty-seven shoulders operated on between 1991 and 1995 with flat back, polyethylene glenoid implants cemented after “curettage” of the keel slot.

Group 2: Thirty-five shoulders operated on between 1997 and 1999 with flat back, polyethylene glenoid implants cemented after cancellous bone compaction of the keel slot.

At least three of the following four fluoroscopically positioned, postoperative AP radiographs were analyzed: immediate postoperative, between the 3rd and 6th postoperative months, at one year postoperative and at two years postoperative. The immediate and the two year radiograph were required for study inclusion. The radiolucent line score (RLLS) was calculated using the technique of Molé, involving the summation of radiolucencies in each of six specified zones. The RLLS was compared between the two groups.

RESULTS: On the immediate postoperative radiographs the average of the total RLL score of the 9 analyzes was 2.39 in Group 1 and 1.67 in Group 2 (p=0.042). There was a statistically significant association between the glenoid preparation technique and the incidence of radiolucency around the keel as well (p=0.001). There was no significant difference in radiolucency behind the faceplate between the two groups (Group 1: 1.54 and Group 2: 1.41; p=0.394). On the 2-year postoperative radiographs the average RLL score of the 9 analyzes were 6.44 in the Group1 (4.05 under the tray, and 2.39 around the keel), and 4.19 in Group2 (p=0.0005) (2.86 under the tray, and 1.33 around the keel). The radiolucency around the keel and behind the faceplate (p=0.0005) was significantly more important (p=0.001) in the “curettage” glenoid preparation population. A significantly higher degree of progression of the total RLL score (p=0.002) and of the radiolucency behind the faceplate (p=0.001) was observed in the “curettage” glenoid preparation group.

DISCUSSION/CONCLUSION: Preparation of the glenoid component keel slot with cancellous bone compaction is radiographically superior to the “curettage” technique with regard to periglenoid radiolucen-cies. Although new techniques of glenoid preparation may help to decrease the rate of RLL, this study shows that even with better technique, the RLL are evolutive and may appear after few years in initially perfectly implanted glenoid.

Purpose of the study: The hypothesis of this study was that age over 50 years is not a contraindication for hamstring reconstruction of the anterior cruciate ligament (ACL).

Material and methods: Study period: September 1998 to September 2003. Type of study: prospective, consecutive series. The patient included in this study met the following criteria: age over 50 years at surgery; chronic anterior laxity, alone or associated with meniscal injury; one or more episodes of instability; absence of preoperative medial femorotibial osteoarthritis; no prior history of ligament surgery on the same knee. The same technique was used for all patients: four-strand single fiber arthroscopic hamstring ligamentoplasty using a blind femoral tunnel drilled via an anteromedial arthroscopic portal. All grafts were fixed with resorbable screws in the femur and tibia. The same rehabilitation protocol was used for all patients. IKDC scores were recorded. Plain x-rays were obtained (single leg stance ap and lateral views) as well as 30° patellar and passive Lachman (Telos).

Results: Eighteen patients were included, 12 women, mean age 59.5 years (range 51–66 years. Mean follow-up was 35 months (range 12–59 months). There were no cases of recurrent ACL tears, no loss of extension. Three patients complained of hpoesthesia involving the internal saphenous nerve and two patients presented postoperative knee pain. At last follow-up, the overall IKDC score was 7A, and 11B. All patients considered they had a normal or nearly normal knee. All were satisfied or very satisfied. None of the patients presented instability. The Lachman-Trillat test was hard stop in 13 cases and late hard stop in 5. The pivot test was negative in 16 knees and questionable in two. Mean residual differential laxity was 3.3 mm (range −1 mm to +7 mm) in passive Lachman. There was no evidence of osteoarthritic progression on the x-rays.

Discussion and conclusion: This series demonstrated that age over 50 years is not a contraindication for arthroscopic hamstring ACL grafting. This operation can be used to restore knee stability.

Purpose of the study: Completely arthroscopic repair of rotator cuff tears is widely considered as the standard treatment. We reviewed a multicentric retrospective series of patients.

Material and methods: This series of arthroscopic repairs of full-thickness tears of the supraspinatus and infraspinatus were assess with the Constant score together with arthroMRI or arthroscan at one year follow-up at least. Data were analyzed with SPSS10. The series included 576 patients who underwent surgery from January 2001 to June 2003. Mean age was 57.7 years, 52% males and 60% manual laborers. Mean preoperative Constant score was 46.4/100 (r13.4). The tear was limited to the supraspinatus in 69% of patients with extension to the upper third of the infraspinagus for 23.5% and to all tendons for 7.5%. The supraspinatus tear was distal in 41.7% of patients, intermediary for 44%, and retracted for 14.3%. Arthroscopic repair was performed in all cases, with locoregional anesthesia for 60.9%. Implants were resorbable for 33% and metallic for 62.1%. Acromioplasty was performed for 92.7% and capsulotomy for 14.9%.

Results: The mean subjective outcome was scored 8.89/10. The Constant score improved from 46.3±13.4 to 82.7±10.3 with 62% of patients being strictly pain free. The force score improved from 8.5±3.7 to 13.6±5.4. Outcome was excellent or very good for 94% of the shoulders at 18.5 mean follow-up. The rate of complications was 6.2% with 3.1% of patients presenting prolonged joint stiffness, 2.7% reflex dystrophy, 0.2% infection and 0.2% implant migration. The cuff was considered normal in 55.7% of the shoulders with an intratendon addition image for 19%, i.e. 74.7% non-torn cuffs. A point leakage was noted in 9.5% with pronounced leakage in 15.7%, i.e. 25.2% recurrent tears.

Discussion and conclusion: The functional outcome obtained after arthroscopic repair of rotator cuff tears is good. Arthroscopy has the advantage of a low rate of complications yet provides good clinical and anatomic results. Age is correlated with functional outcome and healing, but should not be considered as a contraindication.

Purpose of the study: The objective of this study was to identify clinical and anatomic factors which could affect the outcome of tendon healing after arthroscopic repair of rotator cuff tears.

Material and methods: This prospective cohort study included 122 patients who underwent arthroscopic treatment between May 1999 and September 2002. One hundred twelve patients (114 shoulders) were reviewed (93.4%). Mean age at surgery was 61 years. An arthroscan (78% of patients) or magnetic resonance imaging (MRI) were performed six months postoperatively. Mean follow-up was 24 months (range 13–46 months).

Results: Rotator cuff tears healed completely in 64% of the shoulders (n=73) and partially in 7% (n=8). No healing was observed in 29% (n=33). The Constant score was 49.8 preoperatively and 82.4 at last follow-up (p< 0.0001). Cuff healing improved clinical outcome with a Constant score of 85 points versus 77, particularly for force, 14.5 points versus 10 without healing. Four factors were statistically predictive of tendon healing: duration from symptom onset to operation (24 months for healed tears versus 37 months, p< 0.05); age at cuff repair (81% healed tears in patients aged less than 50 years versus 50% for patients aged over 65 years, p< 0.002); sagittal extension of the rotator interval or extension to the upper third of the infrascapularis (45% healed tears versus 79% without anterior extension, p< 0.0001); fatty degeneration (69% of healed tears for Goutallier grade 0 versus 38% for grade 1 and 2, p< 0.01).

Conclusion: This study demonstrated that four factors can predict tendon healing: time to treatment, age at surgery, anterior extension of the tear, fatty degeneration.

Purpose of the study: Arthroscopic reinsertion of SLAP lesions is the most commonly used approach. Tenodesis of the long biceps could be proposed as an alternative to reinsertion. The purpose of our study was to report the results of tenodesis and reinsertions for the treatment of type II SLAP lesions.

Material and methods: This was a consecutive monocentric comparative series analyzed retrospectively. Isolated type II SLAP lesions treated arthroscopically were retained for study: 25 cases treated from January 2000 to May 2004. Exclusion criteria were: associated instability, associated cuff tears, history of surgery. The long biceps tendon was reinserted on the glenoid tubercle using two threads mounted on resorbable anchors in ten patients (all men), mean age 27.5 years (range 19–57 years). Tenodesis of the long biceps in the gutter was performed in fifteen patients (six women and nine men), mean age 52.2 years (range 28–64 years). All patients were reviewed by an independent observer.

Results: In the reinsertion group, mean follow-up was 35 months (range 12–57 months). Three patients had revision tenodesis due to persistent pain and three others were disappointed because they were unable to resume their former sport. Four others were very satisfied. The mean Constant score improved from 65 to 83 points. Force was 16 kg in flexion and 5 kg in supination. In the tenodesis group, mean follow-up was 34 months (range 12–56 months). There were no revision procedures in this group. Subjectively, one patient was disappointed (atypical pain), two were satisfied and 12 very satisfied. The mean Constant score improved from 59 to 89 points. Force was 14.5 kg in flexion and 4.8 kg in supination.

Discussion: This series showed that results obtained with reinsertions can be disappointing: three revisions and three disappointed patients among ten procedures. In the tenodesis group, 14 of 15 patients were satisfied or very satisfied. Tenodesis of the long head of the biceps can be considered as an alternative to reinsertion for the treatment of type II SLAP lesions, particularly in older athletes.

Purpose of the study: The current approach for improving the performance of compact bone substitutes is to seed them with selected mesenchymatous stem cells amplified and differentiated to the osteoblastic line in vitro. We hypothesized that the preservation of all these elements in the bone marrow would be most effective for bone tissue formation.

Material and methods: Subcutaneous and intramuscular implantation in C57BL/6 mice. We developed a new approach for bone tissue engineering based on an extemporaneous incorporation of total bone marrow into an injectable bone substitute (IBS2). IBS2 is a new polymerizable hydrogel associated with beads of calcium phosphate (BCP) which can be used to implant total bone marrow. A subcutaneous and intramuscular implantation model in mice was tested to analyze the feasibility of this type of graft. Total bone marrow cells from C57BL/6 male mice were seeded in IBS (10 million cells per 100 microliters). This implant was injected subcutaneously (dorsal position) and intramuscularly (left hind foot) in C57BL/6 female mice. TRAP activity was measured under optical microscopy on paraffin embedded HES stained slices at 4 and 8 weeks.

Results and discussion: Incorporation of total bone marrow cells in injectable IBS2 produced implants which were rich in mesenchymatous cells, vessels, osteo-clasts, collagen fibers, and osteoid tissue. This demonstrated the great potential of this new approach. In addition, this method is simple and can be performed in the operative room without ex vivo culture. Comparison of this model of extemporaneous cell therapy with a graft of meschymatous cells amplified ex vivo is currently under way.

Purpose of the study: A statistical analysis of correlations between clinical outcome and anatomic results after arthroscopic repair of rotator cuff tears.

Material and methods: This multicentric series of rotator cuff tears was limited to the supraspinatus and infraspinatus. The statistical analysis searched for correlations between the clinical outcome (Constant score) and anatomic results (arthroscan and arthroMRI). The series included 576 patients, mean age 57.7 years, 52%μ males and 60% manual laborers. The tear was limited to the suprapsinatus in 69% of patients, with extension to the upper third of the infraspinatus in 23.5% and all tendons in 7.5%. The supraspinatus tear was distal in 41.7% of patients, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 59.7%, 1 in 27.1%, 2 in 10.8% and 3 in 2.4%.

Results: The Constant score (46.3 preoperatively and 82.7 postoperatively) was strongly correlated with successful repair. The correlation was found for force, motion, and activity, but not for pain. The clinical outcome was correlated with extension, retraction, cleavage, and degeneration of the preoperative injury. The anatomic result was statistically less favorable for older, more extended, retracted, and cleaved tears or tears associated with fatty degeneration. Age was correlated with the extent of the initial tear and also with less favorable clinical and anatomic results. Work accidents were correlated with less favorable clinical outcome.

Discussion: The large number of anatomic controls with contrast injection facilitated demonstration of several statistically significant correlations. This enabled disclosure in a single series of evidence confirming earlier reports in the literature: repair of cuff tears improves the overall functional outcome for massive tears; the anatomic result depends on the size of the initial tear; pre-operative fatty degeneration is an important prognostic criteria; cuff healing is age-dependent.

Conclusion: Study of anatamoclinical correlations helps guide therapeutic decision making and enables the establishment of reliable prognostic criteria after arthroscopic repair of rotator cuff tears.

Purpose of the study: Depending on the series, fractures of the anteroinferior glenoid labrum have been reported in 3% to 90% of patients with anterior shoulder instability. These fractures disrupt the physiological glenoid concavity and shorten the effective length of the glenoid arch. Indications for treatment depend on the size of the fragment and range from osteosynthesis to resection or suture. We hypothesized that these lesions could be treated arthroscopically (Bankart procedure with fragment suture). The purpose of this work was to analyze clinical and radiological outcome observed in nine patients with anterior instability associated with significant glenoid fracture.

Material and methods: This was a monocentric study of a continuous series of nine glenoid fractures associated with anteromedial dislocation in nine patients (three women and six men), mean age 35.5 years (range 17–75 years). Preoperatively, all of the fractures were considered to involve more than 25% of the glenoid surface. After detaching the capsulolabral lesion with the bony fragment and avivement of the anterior border, the Bankart procedure was performed with anchors and resorbable sutures. The shoulder was strapped for six weeks with passive rehabilitation (pendulum movements) initiated early.

Results: Mean follow-up was 27 months (range 12–48 months). There were no cases of recurrent instability. Seven patients were very satisfied and two were satisfied. Eight patients were able to resume their sports activities at the same level. Apprehension developed in all patients. At last follow-up, joint motion was normal for eight of the nine patients, the Duplay score was 100 for eight patients and 45 for one. All bony lesions healed in an anatomic position (six analyzed with plain x-rays and three with CT scan).

Discussion and conclusion: This short series demonstrates that glenoid fractures can be treated arthroscopically with concomitant treatment of the capsulolabroligament complex in order to reconstruct the glenoid arch, an essential element for restoring shoulder stability. It is thus necessary to identify bony lesions preoperatively to determine the most appropriate therapeutic approach. A long-term follow-up will be useful to assess the rate of recurrent instability and validate this therapeutic option.

There is no simple method available to identify patients who will develop recurrent instability after an arthroscopic Bankart procedure and who would be better served by an open operation.

We carried out a prospective case-control study of 131 consecutive unselected patients with recurrent anterior shoulder instability who underwent this procedure using suture anchors. At follow-up after a mean of 31.2 months (24 to 52) 19 (14.5%) had recurrent instability. The following risk factors were identified: patient age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an anteroposterior radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour.

These factors were integrated in a 10-point pre-operative instability severity index score and tested retrospectively on the same population. Patients with a score over 6 points had an unacceptable recurrence risk of 70% (p < 0.001). On this basis we believe that an arthroscopic Bankart repair is contraindicated in these patients, to whom we now suggest a Bristow-Latarjet procedure instead.

A systematic search of the literature published between January 1985 and February 2006 identified 62 studies which reported the results of arthroscopic procedures for chronic anterior shoulder instability or comparisons between arthroscopic and open surgery. These studies were classified by surgical technique and research methodology, and when appropriate, were included in a meta-analysis.

The failure rate of arthroscopic shoulder stabilisation using staples or transglenoid suture techniques appeared to be significantly higher than that of either open surgery or arthroscopic stabilisation using suture anchors or bio-absorbable tacks. Arthroscopic anterior stabilisation using the most effective techniques has a similar rate of failure to open stabilisation after two years.

This paper describes the current views on the pathology of lesions of the tendon of the long head of biceps and their management. Their diagnosis is described and their surgical management classified, with details of the techniques employed.

Introduction: The purpose of this study is to compare the radiographic results of two glenoid preparation techniques by analyzing periglenoid radiolucencies.

Material and methods: The series consists of 72 shoulder arthroplasties with primary osteoarthritis. Shoulders were divided into 2 groups based on glenoid preparation technique:

Group 1: 37 shoulders operated on between 1991 and 1995 with flat back, polyethylene glenoid implants cemented after curettage of the keel slot.

Group 2: 35 shoulders operated on between 1997 and 1999 with the same glenoid implants cemented after cancellous bone compaction of the keel slot.

At least 3 of the following 4 fluoroscopically positioned, postoperative AP radiographs were analyzed: immediate postoperative, between the 3rd and 6th months, at one year and at two years postoperative. The immediate and the two year radiograph were required for study inclusion. The radiolucent line score (RLLS) was calculated using the technique of Molé, involving the summation of radiolucencies in each of six specified zones. The RLLS was compared between the two groups.

Results: On the immediate postoperative radiographs the average of the total RLL score of the 9 analyzes was 2.39 in Group 1 and 1.67 in Group 2 (p=0.042). There was a statistically significant association between the glenoid preparation technique and the incidence of radiolucency around the keel as well (p=0.001). There was no significant difference in radiolucency behind the faceplate between the two groups (Group 1: 1.54 and Group 2: 1.41; p=0.394). On the 2-year postoperative radiographs the average RLL score of the 9 analyzes were 6.44 in the Group1 (4.05 under the tray, and 2.39 around the keel), and 4.19 in Group2 (p=0.0005) (2.86 under the tray, and 1.33 around the keel). The radiolucency around the keel and behind the faceplate (p=0.0005) was significantly more important (p=0.001) in the curettage glenoid preparation population. A significantly higher degree of progression of the total RLL score (p=0.002) and of the radiolucency behind the faceplate (p=0.001) was observed in the curettage glenoid preparation group.

Discussion/conclusion: Preparation of the glenoid component keel slot with cancellous bone compaction is radiographically superior to the curettage technique with regard to periglenoid radiolucencies.

Purpose: The purpose of this work was to evaluate the quality of cemented humeral stem fixation. We analysed the incidence and influence of humeral lucent lines and loosening after implantation of a shoulder prosthesis as a function of aetiology (fracture versus scapular osteoarthritis) and glenoid status (total versus partial humeral prosthesis).

Material and methods: This retrospective series included 1842 first-intention shoulder prostheses reviewed at mean five years (2–10). We selected patients whose initial diagnosis was fracture of the superior portion of the humerus (n=300) and centred osteoarthritis (n=767). All stems implanted for fracture were cemented. For osteoarthritis, there were 610 total prostheses and 157 simple humeral prostheses: 752 stems were cemented and 15 were implanted without cement. The Constant score and radiographic results (AP and lateral view at least) were noted.

Results: For cemented stems, the incidence of radiographic lucent lines and loosening was significantly higher in fractures (40% and 10% respectively) than in centred osteoarthritis (14% and 1%). Lucency and loosening did not influence functional outcome in patients with centred osteoarthritis but had a significantly negative effect on final outcome in fractures. For fractures, the incidence of lucent lines was correlated with migration of the tubercles. For osteoarthritis, there was no difference between total and partial prostheses in terms of loosening, but the functional outcome was significantly better with total prostheses.

Conclusion: Fixation of the humeral implant with cement remains the gold standard for shoulder prostheses implanted for centred osteoarthritis. However, cement fixation yields disappointing results for fractures: defective fixation of the humeral stem is correlated with migration of the tubercles. For osteoarthritis, there are not more lucent lines with a total prosthesis which provides the better functional results.