Purpose: The best strategy to adopt for the long head of the biceps during total shoulder arthroplasty for centred primary joint degeneration remains a controversial issue. We analysed the influence of long head of the biceps (LHB) tenodesis on outcome.

Material and methods: From retrospective multicentric series of 766 shoulder prostheses implanted for centred primary degeneration of the shoulder joint, we selected 625 shoulders with sufficient data concerning the LHB. We defined two groups: 131 shoulders with LHB tenodesis and 494 shoulders with a preserved LHB. We analysed clinical outcome with the Constant score and subjective outcome at two years. We identified four groups: 70 humeral prostheses without tenodesis, 10 humeral prostheses with tenodesis, 424 total shoulder arthroplastues without tenodesis, and 121 total shoulder arthroplasties with tenodesis.

Results: The Constant score was significantly better in the tenodesis group (74.7) than in the group without tenodesis (70.8). This significant difference was also found for the weighted score and likewise for active anterior elevation and active external rotation in position 1. There was no difference concerning postoperative fatty degeneration. By subgroups, the analysis showed significant improvement in the Constant score for humeral prostheses with tenodesis and total shoulder arthroplasty with tenodesis over the same implants without tenodesis. This same significant difference was observed for the 364 patients who had a minimum follow-up of 36 months: tenodesis improved the Constant score, the weighted Constant score, active anterior elevation, and active external rotation.

Discussion: The causal role of the LHB in shoulder pain is now well documented in the literature. Several authors have advocated tenotomy or tenodesis of the LHB during surgical treatment of rotator cuff tears. The same is not true for shoulder arthroplasty for the treatment of primary degeneration. Dines and Hersch reported their experience with ten patients with a painful total shoulder arthroplasty who were improved with arthroscopic tenotomy or tenodesis.

Conclusion: Our large series confirms that tenodesis of the LHB is preferable during implantation of a humeral prosthesis or a total shoulder prosthesis for the treatment of centred primary joint degeneration with good results that persist over time.

Purpose: The indication for humeral or total shoulder prosthesis in patients with avascular osteonecrosis of the shoulder depends on the radiographic stage of the necrosis. The purpose of this study was to analyse the prognostic radiographic features enabling proper identification of the indications for humeral or total prostheses.

Material and methods: This retrospective multicentric study included 53 shoulders operated on for prosthetic repair of avascular osteonecrosis. There were 20 men and 29 women, mean age 57 years. A humeral prosthesis was used in 34 cases and a total prosthesis in 19. Clinical assessment was based on the Constant score and the radiographic analysis used the Arlet and Ficat classification. Staging was II (n=4), III (n=16), IV (n=21) and V (n=12). Independently of the radiographic stage of necrosis, three characteristic groups were defined. Group 1 (19 shoulders) included necrosis without bony collapse of the humeral head. Group 2 (20 shoulders) included necrosis with bony collapse of the humeral head with preservation of the anatomic relations with the glenoid cavity. Group 3 (14 shoulders) included necrosis with bony collapse and impaction of the humeral head in the glenoid with medialisation of the humerus.

Results: Preoperatively, presence of bony collapse was associated with decreased pain and motion score. Major joint stiffness was noted in group 3 (8). The humeral prosthesis gave similar results for groups 1 and 2 (Constant score 73 and 75.3). Less satisfactory results was the rule in group 3 (Constant score 51.6). There was a postoperative erosion of the glenoid cavity in 83% of the shoulders in group 3 versus 12.5% in group 1 and 17% in group 2. The total prosthesis optimised results despite persistence of a difference between groups 2 and 3 (Constant score 83 and 64 respectively).

Discussion: Destabilisation of the glenohumeral joint by impaction of the humeral head against the glenoid cavity has an effect on the clinical result of the prosthetic surgery. Preservation of the anatomic relations of the articulation (groups 1 and 2) appears to be necessary for good results. Impaction medialisation of the humerus has a negative effect on the clinical result of humeral prostheses with a risk of glenoid erosion.

Conclusion: Independently of radiographic stage of necrosis, the presence of humeral impaction with medi-alisation should be considered individually as it has a negative effect on the clinical outcome of these prostheses, particularly humeral prostheses.

We studied 54 patients operated on for combined supraspinatus and infraspinatus rotator-cuff tears. The presence or absence of the dropping and hornblower’s clinical signs of impaired external rotation were correlated with Goutallier stage-3 or stage-4 fatty degeneration of infraspinatus and teres minor. These grades of fatty degeneration have previously been correlated with a poorer outcome from reconstructive surgery.

We found that hornblower’s sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor and the dropping sign 100% sensitivity and 100% specificity for similar degeneration of infraspinatus.

In seven patients, teres minor showed hypertrophy. This muscle can give useful function for the activities of daily living in patients with rotator-cuff tears in whom it is intact.

We have studied the three-dimensional geometry of the proximal humerus on human cadaver specimens using a digitised measuring device linked to a computer. Our findings demonstrated the variable shape of the proximal humerus as well as its variable dimensions. The articular surface, which is part of a sphere varies individually in its orientation as regards inclination and retroversion, and it has variable medial and posterior offsets.

These variations cannot be accommodated by the designs of most contemporary humeral components. Although good clinical results can be achieved with current modular and non-modular components their relatively fixed geometry prevents truly anatomical restoration in many cases.

To try to restore the original three-dimensional geometry of the proximal humerus, we have developed a new type of humeral component which is modular and adaptable to the individual anatomy. Such adaptability allows correct positioning of the prosthetic head in relation to an individual anatomical neck, after removal of the marginal osteophytes. The design of this third-generation prosthesis respects the four geometrical variations which have been demonstrated in the present study. These are inclination, retroversion, medial offset and posterior offset.

We report the technique and results of percutaneous cerclage used in treating 186 torsional fractures of the tibia, most of which were due to skiing accidents in young patients. It is recommended only for this type of fracture and has the advantages of simplicity, a low rate of complications and a relatively brief period in hospital.