Alexandre Lädermann’s research while affiliated with University of Geneva and other places

Background and purpose Literature showed that single Tightrope fixation in acromioclavicular joint (ACJ) dislocation cases does not secure horizontal joint stability. A positive clinical cross-body adduction test is a usual outcome finding. We hypothesized that some cases might have some degree of horizontal stability, which might be confirmed with ultrasound examination. Methods This clinical study was performed on 27 patients who underwent single Tightrope application in acute ACJ dislocation. Patients were divided into group A which had an arthroscopic technique, and group B which had an open technique augmented with trans-ACJ fixation using two k-wires for 6 weeks. A clinical examination of the operated shoulders was done, and the results were compared with the sound shoulder examination in the same patient at the last 24 months postoperative follow-up visit. Besides, the results of the cross-body adduction test were correlated with ultrasound findings at the same visit. Records, operative details, and postoperative radiography were reviewed to assess if any factors would diminish the dynamic horizontal stability of the ACJ. Body mass index (BMI) was calculated per case. Results Group A had 17 patients (three patients had grade III dislocations, and 14 patients had grade V dislocations). Group B had 10 patients (four patients had grade III dislocations, and six patients had grade V dislocations). The clinical cross-body adduction test gave gross positive results in 14 patients out of group A patients while it gave gross positive results in six patients out of group B patients. Group A patients with negative results were 3, while group B patients with negative results were 4. By ultrasound, differences in horizontal translation of the clavicle within the ACJ in resting and cross-arm positions were more obvious in all operated shoulders than in all sound shoulders. Conclusion The less the Rockwood grading, the more potential to secure more horizontal stability. An open approach also gives more horizontal stability. With increased BMI, horizontal instability is usually masked. So, some factors may diminish, or mask clinical dynamic horizontal instability, which can be confirmed or rolled out with ultrasound usage.

Purpose: We hypothesized that not all cases of single Tightrope fixation in acromioclavicular joint dislocation cases should give positive clinical cross body adduction test and might have some certain degree of horizontal stability which might be confirmed with ultrasound examination. Materials and Methods: This clinical study was performed on twenty-seven patients who retrospectively underwent single Tightrope application in acute acromioclavicular joint dislocation. Patients were divided into group A which had an arthroscopic technique and group B that had an open technique augmented with trans-acromioclavicular joint fixation using two k-wires for six weeks in all group B cases. Clinical examination of operated shoulders was done, and results were compared to sound shoulder examination in the same patient at the last 24 months post-operative follow-up visit besides, results of the cross-body adduction test were correlated with ultrasound findings at the same visit. Records, operative details, and post-operative X-rays were reviewed to assess if any factors would diminish the dynamic horizontal stability of the acromioclavicular joint. Body mass index (BMI(was calculated per each case. Results: Group A had seventeen cases, three had grade III and fourteen had grade V dislocations. Group B had ten cases, four had grade III, and six had grade V. Clinical cross-body adduction test gave gross positive results in fourteen patients in group A and six patients in group B. Group A patients with negative results were three while Group B patients with negative results were four. For ultrasound findings, differences in horizontal translation of the clavicle within the acromioclavicular joint in resting and cross-arm positions were more obvious in all operated shoulders than all sound shoulders. Conclusion: The less the Rockwood grading, the more potential to secure more horizontal stability. An open approach also gives more horizontal stability. With increased BMI, horizontal instability is usually masked. So, some factors may diminish, or mask clinical dynamic horizontal instability which can be confirmed or rolled out with ultrasound usage.

Background The bone morphology of the greater tuberosity and lateral acromion plays a central role in subacromial impingement syndrome. The critical shoulder angle (CSA) and greater tuberosity angle (GTA) are two-dimensional measurement parameters that have been validated to evaluate it radiologically. These markers are, however, static and don’t consider the dynamic effect of glenohumeral motion. Objectives This study aimed to better understand the biomechanics in subacromial impingement with a dynamic simulation based on a validated 3D biomechanical model coupling joint kinematics and 3D reconstructed computed tomography. Study design & methods Sixty-one patients were included in this study: a case group of 44 patients with degenerative rotator cuff tears involving only the supraspinatus, and a control group of 17 without a rotator cuff tear. Patients with previous surgeries, traumatic cuff tears, and cuff tear arthropathy were excluded. CSA, GTA, and impingement-free range of motion (IF-ROM) of the glenohumeral joint in scaption were calculated. Correlation tests were used to determine the relationship between ROM and CSA, GTA, and combined CSA and GTA values. Results CSA and GTA were significantly higher in the rotator cuff tear group (p = 0.001 and < 0.001), while IF-ROM was significantly higher in the control group (p = 0.001). There was no overall correlation between CSA and GTA (R = 0.02, p = 0.8). Individual correlation between both angles with IF-ROM was negatively weak for CSA (R = -0.4, p < 0.001) and negatively moderate for GTA and IF-ROM (R = -0.5, p < 0.001). However, combining both angles resulted in a negatively high correlation with IF-ROM (R = -0.7, p < 0.001). Conclusion Subacromial space narrowing during scaption is highly correlated to the cumulative values of GTA and CSA. These findings suggest that the combined bony morphology of the lateral acromion and greater tuberosity plays an important role in subacromial impingement. Level of evidence III

Background: Recently, a stemless reverse shoulder arthroplasty (RSA) design was developed in order to preserve bone stock. Clinical and radiological studies of such design with larger cohorts with over 100 patients are not frequent. The purpose of this study was to present clinical and radiological results of a newly developed stemless RSA. The hypothesis was that this design would provide similar clinical and radiological results compared to other stemless and stemmed implants. Methods: Between September 2015 and December 2019, all patients who had a primary EASYTECH® stemless RSA were considered eligible for inclusion in this prospective multi-center study. Minimum follow-up was two years. Clinical outcomes consisted of Constant score, adjusted Constant score, QuickDASH, subjective shoulder value (SSV) and the American Shoulder and Elbow Surgeons Shoulder Score (ASES). Radiographic parameters included radiolucency, loosening, scapular notching and specific geometrical parameters. Results: Stemless RSA was implanted in 115 patients (61 women and 54 men) at 6 different clinical centers. The average age at the time of surgery was 68.7 years. The average preoperative Constant score was 32.5 and it showed significant improvement at the latest follow-up at 61.8 (p < .001). SSV also demonstrated significant improvement postoperatively (27.0 pts to 77.5 pts, p< .001). Scapular notching was observed in 28 patients (24.3%), humeral loosening in 5 patients (4.3%) and glenoid loosening in 4 patients (3.5%). Our total complication rate was 17.4%. Eight patients (4 women and 4 men) underwent an implant revision. Conclusion: Clinical outcomes of this stemless RSA seem to be comparable to other humeral designs, however complication and revision rates are higher than rates compared to historical controls. Surgeons should proceed with caution when using this implant until longer term follow-up data is available.

Background: There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations. Methods: An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3 cm and >3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher's exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman's correlation tests. Results: In total, 499 surgeons with a median of 15 years of experience (IQR = 9-25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p < 0.0001), Latarjet (53% vs. 12%, p < 0.001), ARCR < 3 cm (80% vs. 42%, p < 0.001) and >3 cm (84% vs. 61%, p < 0.001), aTSA (50% vs. 21%, p < 0.001) and rTSA with subscapularis repair (61% vs. 22%, p < 0.001) and without subscapularis repair (57% vs. 17%, p < 0.001), and isolated BT (18% vs. 7%, p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p < 0.001), Latarjet (78% vs. 44%, p < 0.001), ARCR < 3 cm (50% vs. 17%, p < 0.001) and >3 cm (34% vs. 13%, p < 0.001), and aTSA (69% vs. 41%, p < 0.001) and rTSA with subscapularis repair (70% vs. 35%, p < 0.001) and without subscapularis repair (73% vs. 39%, p < 0.001). Increasing years of experience demonstrated a negative correlation with the duration of sling use after Bankart repair (r = -0.20, p < 0.001), Latarjet (r = -0.25, p < 0.001), ARCR < 3 cm (r = -0.14, p = 0.014) and >3 cm (r = -0.20, p < 0.002), and aTSA (r = -0.37, p < 0.001), and rTSA with subscapularis repair (r = -0.10, p = 0.049) and without subscapularis repair (r = -0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p < 0.001), Latarjet (4.6 vs. 3.6 weeks, p < 0.001), ARCR < 3 cm (5.2 vs. 4.5 weeks p < 0.001) and >3 cm (5.9 vs. 5.1 weeks, p < 0.001), aTSA (4.9 vs. 4.3 weeks, p < 0.001), rTSR without subscapularis repair (4.0 vs. 3.6 weeks, p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated. Conclusions: There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery. Level of evidence: Level IV.

Background: This study aims to report the rate of biceps-related complications after LHB tenotomy, investigating related risk factors and their influence on the outcome. The hypothesis is that these complications have a limited clinical influence. Methods: A single-center prospective observational study was performed between 2015 and 2017 on consecutive patients who underwent RCR associated with LHB tenotomy. Patients were clinically and radiologically evaluated preoperatively, at six months and one year, and screened for postoperative popeye deformity, cramps, and bicipital discomfort. Each complication was analyzed for the following risk factors: age, sex, body mass index (BMI), dominant arm, manual work, tear patterns, and tendon healing. Finally, the clinical outcome was compared between patients with and without complications. Results: 207 patients were analyzed. Cramps, popeye deformity, and discomfort, were respectively, present in 16 (7.7%), 38 (18.4%) and 52 (25.1%) cases at six months and 17 (8.2%), 18 (8.7%) and 24 (11.6%) cases at one year. Cramps were associated with lower age (p = 0.0005), higher BMI (p = 0.0251), single tendon tear (p = 0.0168), manual work (p = 0.0086) at six months and manual work (p = 0.0345) at one year. Popeye deformity was associated with male sex at six months (p < 0.0001). Discomfort was associated with lower age (p = 0.0065), manual work (p = 0.0099), popeye deformity (p = 0.0240) at six months and manual work (p = 0.0200), single tendon tear (p = 0.0370), popeye deformity (p = 0.0033) at one year. Patients without complications showed a significant higher Constant score, pain and subjective shoulder value (SSV) (75.3 vs. 70.4, p = 0.00252; 0.9 vs. 1.9, p < 0.00001; 80.2 vs. 76.4; p = 0.00124) at six months and pain and SSV (0.6 vs. 2.0; p = 0.00044; 91.1 vs. 77.8; p ≤ 0.00001) at one year. Conclusions: Younger age, male sex, higher BMI, manual work, and single tendon tears are risk factors associated with the development of biceps-related symptoms during the first year after tenotomy in association with rotator cuff repair. Nevertheless, the clinical influence of these symptoms on shoulder outcomes is limited.

Background: There is a current lack of knowledge regarding optimal rehabilitation and duration of sling immobilization after an open Latarjet procedure. A shift towards immediate self-rehabilitation protocols in shoulder surgery is observed to avoid postoperative stiffness and fasten return to sport. Avoiding sling immobilization could further simplify rehabilitation and provide an even faster return to activities of daily living and enhance patient satisfaction. Methods: This study is a single-center, randomized control trial. Sixty-eight patients will be instructed with the same standardized immediate post-operative self-rehabilitation protocol. Patients will be allocated 1:1 between a sling immobilization group for the first three postoperative weeks and no sling group without postoperative immobilization. The primary endpoint will be functional outcome at 6 months postoperative evaluated by the disease-specific Rowe score. Secondary endpoints will include baseline, 3-, 6-, and 12-month single assessment numeric evaluation (SANE) of instability score, visual analog pain scale (VAS), and range of motion measurement. At the 6-month time point, graft bony union and position will be assessed by computed tomography. Motion capture technology will evaluate the baseline and 6-month postoperative range of motion. Finally, time to return to work and sport, along with patient satisfaction, will also be recorded. Discussion: This study will allow further insights into the optimal rehabilitation protocol after open Latarjet surgery and enhance patient care by helping identify rehabilitation and coracoid graft-related factors influencing functional outcomes, bony union, range of motion, and patient satisfaction. Trial registration: The protocol was approved by the ethical committee board (CCER 2019-02469) in April 2020 and by ClinicalTrials.gov (Identifier: NCT04479397) in July 2020.

Background: Since Mihata's 2012 proposal to arthroscopically reconstruct the superior capsule of patients with massive irreparable cuff tears, many studies have reported the clinical results of this technique using different types of grafts (fascia lata autograft, dermal allograft, porcine dermal xenograft or long head of biceps autograft). Purpose: The objective of this meta-analysis was to report the clinical and radiological results of these superior capsule reconstructions. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) recommendations were used to conduct this systematic review. A bibliographic search was performed of the electronic databases MEDLINE, Scopus, Embase and the Cochrane Library. The quality of the studies was assessed according to the MINORS criterion (Methodological Index for Nonrandomized Studies). The inclusion criteria were studies in English evaluating superior capsular reconstruction. Results: No level I or II studies met the inclusion criteria. Eighteen studies were selected from the 97 identified, including 637 shoulders (64% male) with a mean age of 62 years [95% CI: 60.3-63.5]. At the mean follow-up of 24.3 months (12-60), the range of motion was significantly increased from 82.6° [60.0-105.2] to 141.9° [109.9-173.8] in abduction, from 113.1° [98.3-127.9] to 153.3° [147.4-159.2] in elevation, from 35.5° [30.9-40.2] 43.4° [35.4-51.3] in external rotation and from 7.2 [5.4-9] to 9.9 [8.9-10.9] in internal rotation. Functional scores were significantly improved from 5.4 [4.8-5.9] to 1.3 [0.9-1.7] points for VAS, from 42.5 [15.7-69.3] to 59.3 [30.1-88.6] points for Constant, from 39.0% [38.1- 39.8] to 79.8% [76.4-83.3] for the SSV, and from 48.2 [45.2-51.1] to 81.2 [77.2-85.1] points for the ASES. The healing rate was 76.1% [64.4-84.9]. The complication rate was 5.6% [1.8-16.3] and the reverse shoulder arthroplasty revision rate was 7.1% [3.8-12.8]. Conclusion: Superior capsule reconstructions allow satisfactory clinical and radiological results to be obtained at 2 years of follow-up. Due to the small number of high quality comparative studies available, its true place in the therapeutic arsenal cannot be fully confirmed. However, it seems that the best indication for this technique is isolated irreparable rupture of the supraspinatus, in cases of medical treatment failure. Level of evidence: III; Meta-analysis of heterogeneous studies.

The suitable treatment for recurrent anterior shoulder instability with subcritical glenoid bone loss remains controversial. Although the Latarjet procedure is one of the most successful surgery for shoulder instability, it has been associated with potential complications in my patients with limited bone loss and poor soft-tissue conditions, which motivated me to further investigate Bankart augmentation techniques. A myriad of them have been devised and proposed for this specific group of patients; however, there are no sufficient clinical data reported in the literature to support one of them particularly or clarify in which situation they should be used. Further comparative and prospective studies are therefore needed to build an evidence-based decision tree to help us treating our patients and better match their expectations. That said, current literature and my experience have resulted in a shift in my treatment paradigm undertaken 3 years ago to augmented Bankart in case of subcritical glenoid bone loss.