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PASCAL BOILEAU

Published in N°278 - November 2018
Interview viewed 75 times

PASCAL BOILEAU

Pascal Boileau is the creator and organizer of the “Nice Shoulder Course” which is this year in its ninth edition. This course is the essential "rendez-vous" of shoulder specialists. We asked Pascal to give us an overview of the conference program and to share his vision of shoulder surgery.

The Nice Shoulder Course is an institution now, how do you feel about that?

Well, it has been 15 years since we started; we have come a long way since 2003. This year, similar to editions, we expect about 800 to 900 shoulder surgeons coming from more than 60 different countries. So, I guess you could say that it has become a kind of institution. Certainly, it is the biggest shoulder meeting in the world not organized by a scientific society, thanks to “my three fair ladies”: Agnes, Anne and Christina, who do a fantastic job! The concept must be appealing, since in recent years we have seen the emergence of many other similar “shoulder courses” in Paris, Berlin, Madrid, Moscow, among others.

Why did you start this course?

Initially, one of my goals was to travel less! I thought that if many colleagues attended my course, I would eventually be able to move less… But it didn’t work, as I am still traveling a lot - too much according to my wife and my assistant Agnès… More seriously, the other goal was academic: I wanted to share with friends and colleagues from all over the world cutting edge issues regarding shoulder pathology and surgery. This has worked!

What is the concept of the Nice Shoulder Course?

Basically, the concept of the Nice Shoulder Course is to mix science with practice. First, it is essentially a summary of the important shoulder literature published in the last two years. It is my privilege to invite surgeons who have published something that I feel important to present here in Nice. It is also an opportunity for us to present our own scientific works: almost all of my assistants, fellows, and residents are involved in scientific studies that they present during the course. Finally, the Nice Shoulder Course is the place where we present the results of a multicenter study focused on a specific “hot topic”. We also offer live surgeries and afternoon workshops with the “do it yourself!” concept. This allows the surgeons who come to the course to “get their hands dirty” rather than simply sitting listening to talks the entire time. We try to make this course as interactive as possible by presenting clinical cases and asking the participants to give their opinion and vote both on diagnosis and the treatment options. As you understood, the Nice Shoulder Course is “the place to be!”

What are the topics of the 2018 edition?

The course lasts for 3 days, and the structure remains the same. We always have a day on shoulder instability, AC-Joint separation, and new trends. The second day is on cuff and biceps pathology, muscle tendon tranfers, and proximal humerus fractures, while the third day is on a special topic, this year: “The Young Arthritic Shoulder"!... We have built a database including more than 1500 shoulder replacements performed in patients under the age of 60 years. This will allow us to report on the results according to the different etiologies: osteoarthritis, rheumatoid arthritis, necrosis, fracture sequelae, etc… the different types of shoulder arthroplasty and age stratification - that is shoulder replacements before 30, before 40, before 50 years, and to calculate survival rates. It is a lot of work and huge effort made by all involved. I must thank my assistant Mikaël Chelli, who is both a surgeon and a geek, and who designed EasyMedStat, the specific software that has allowed us to analyze the data.

Do you think that such multicenter studies are scientifically valuable?

Well, based on 30 years of experience, my answer is clearly: yes! But, this is only valuable and possible because we are a group of surgeons who are friends and share the same desire: to improve the results of our patients. We have known each other for many years and we share mutual trust. We are not afraid to share our clinical experience - with our successes, as well as our complications and failures. Some of us work in the public sytem, while others work in private practice, and we have great respect for each other.

Let’s talk about shoulder arthroplasty! Fifteen years ago, the big question with young arthritic shoulders was: should we resurface the glenoid or not?

I don’t want to reveal the results before the meeting, but the problem is still not solved at the moment! When facing a young patient with osteoarthritis, we are still debating between not putting any implant on the glenoid side, which means doing a hemiarthroplasty, but with the risk of persistent pain because of glenoid erosion, or doing a total shoulder arthroplasty by resurfacing the glenoid, at the risk of rapid implant loosening. On one hand, a hemi against a biconcave glenoid does not give good results, while on the other hand, about 50% of the glenoid implants in total’s are radiologically loose after 10 years, and we have found that glenoid loosening has a negative influence on the functional results. That’s why reverse is now being implanted in the presence of biconcave glenoids, even in younger patients. One problem, at the moment, is that a cemented polyethylene glenoid implant is the only option we have in total’s because of the failure of the metal-backed implants.

Did all “metal-backed” glenoids fail?

Not all, but 2/3 of them have been revised at 15 years follow-up. The accelerated wear of the poly seen with metal-backed implants leads to particle debris, granuloma, osteolysis, and, ultimately, implant loosening. The problem is that loose MB glenoids, by contrast to loose poly implants, are poorly tolerated and often need to be revised. That is the reason why we continue to use poly glenoid implants and cement, although we feel that this will not be the ultimate solution. We have to find something other than cement to fix the glenoid, and we probably have to find something other than polyethylene as a bearing surface. All shoulder arthroplasty registers are showing the rapid decline of MB glenoid survival. As you can see, there is still a lot to do in the shoulder!...

But why is it working so well in reverse arthroplasty?

MB glenoids work in RSA because the biomechanical environement is completely different than in anatomical total arthroplasty. In RSA, a metallic sphere is placed on the metallic baseplate. The forces are mainly compressive after 30 degrees of abduction, while in TSA the primary forces are shearing forces, which are detrimental for both the poly and the fixation of the implant. It is true that when we started to use the reverse prosthesis more than 20 years ago, everyone predicted that we would see a high rate of loosening of the glenoid implant. This did not happen, thanks to Paul Grammont who had the bright idea of lowering the humerus and using a large medialized sphere. Now, surgeons should not jump to conclusions and think that because it works in RSA, metallic glenoids work in TSA. The concept of a “universal MB glenoid” is not for tomorrow, unfortunatly!...

And what about the resurfacing of the humeral head?

I am happy that I didn’t jump on this train!... As I always say to residents and fellows, one of the difficulties of our job is to know which trains we should take, and which ones which should let pass. I did a few cases of humeral head resurfacing, and then stopped rapidly, as I realized that it was more difficult to restore the normal anatomy of the proximal humerus with a resurfacing than with a classical prosthesis. When you ream the humeral head (instead of cutting it), to implant a resurfacing head, you often end up with an implant that is too proud, which will overstuff the glenohumeral joint and irritate the cuff. I also found it technically more difficult to reattach the subscapularis with transosseous sutures when the humeral head was not osteotomized. In addition, when you want to resurface both the humeral head and the glenoid, you struggle at the time of glenoid exposure since the humeral head has not been cut and you take the risk of malpositionning the glenoid implant. Resurfacing of the humeral head has inferior results than a classical, stemmed humeral prosthesis as shown by our study, and it has been abandoned by most surgeons.

Knowing that there were no problems with the humeral stems, what do you think of the short stem trend?

It is true that on the humeral side, we had not encountered any problems with the current cemented or uncemented stemmed prostheses, and maybe we shouldn’t touch anything. However, this should be tempered by the fact that radiological problems like osteolysis, spot welding, etc… have been observed with stemmed reversed prostheses. So, I guess it's a normal evolution to shorten the humeral stem for both TSA and RSA in order to preserve as much bone as possible, to avoid stress shielding seen with uncemented stems, and to avoid cement as much as possible in young patients. Now, the real question is: should we move toward stemless humeral implants?... Although for the moment the concept of stemless shoulder prosthesis is still rejected by many surgeons, my opinion is that we should go in this direction. Teissier and the Tess group have shown that a stemless prosthesis could work for both anatomical and reverse implants; they have published their results, which are good, and this should be recognized and respected.

In a primary reverse prosthesis, do you still do the BIO-RSA?

Yes, more than ever! I started in 2006, and never quit. It’s an easy and fast procedure: the bone graft, harvested on the humeral side, is placed and fixed on the glenoid side, under the baseplate. At the beginning, I was using a symmetric disk of cancellous bone, but about seven years ago, I started harvesting an asymmetrical bone graft to lateralize, while also correcting the superior inclination of the glenoid. The nice thing is that something that I initially did intuitively, has now been proven to be scientifically sound. We have done a CT-scan study that showed that the inferior portion of the glenoid is superiorly oriented and this “RSA angle”, I mean “Reverse Shoulder Angle”, needs to be corrected in almost all cases. Preoperative planning with the Blueprint software developed with Gilles Walch and Jean Chaoui, shows in almost every case that the “angled BIO-RSA” is needed to correct the “RSA angle” which is about 20° in average. Correction of this “RSA angle” provides the best range of motion and avoids scapular notching.

Let’s get back to the first day of the meeting; have you stabilized the instability topic?

Stumbling question! Regarding anterior shoulder instability, there is a trend toward performing more and more Latarjet procedures. Why?... Because surgeons have become better at evaluating glenoid and humeral bone loss, and because it has become clear that the results of the Bankart procedure deteriorate with time. The novelty is the progressive spreading of the arthroscopic approach for the Latarjet procedure. I remember that 25 years ago, at the Paris ICSS shoulder meeting, some surgeons were reporting failures with arthroscopic Bankart while others reported good results with open Latarjet, and Daniel Goutallier, probably as a joke, said: “…if one day we are able to perform the Latarjet procedure under arthroscopy, then we will have no more problems with recurrent anterior shoulder instability!”. At that time, it sounded completely crazy, but today here we are!... Of course, performing arthroscopic Latarjet is challenging because you have to work partially inside the joint and partially outside the joint, but with proper training, most shoulder arthroscopists will be able to do it in the near future.

Is that so? Tell me how!

First of all, I think we should pay a tribute to Laurent Lafosse who opened the path of arthroscopic Latarjet, and has pushed us to the boundaries. Laurent has developed the arthroscopic Latarjet technique with screw fixation of the bone block and quickly started to spread it. I found it too difficult and hard to reproduce; I started to develop a “guided” arthroscopic Latarjet technique. My first idea was to drill the glenoid from posterior to anterior to be parallel to the glenoid surface and make it safe. I developed specific glenoid and coracoid guides, which allow matching between the glenoid and bone block drilling, ultimately providing automatic positioning of the bone block. I also designed specific spreaders to facilitate the passing of the bone block through the subscapularis muscle, again focusing on making it safe. I use the same instruments to perform the arthroscopic Bristow and the Eden-Hybbinnette procedures. Finally, I also looked for something other than screws for bone block fixation and designed specific suture-buttons.

Why use something else than screws for bone block fixation?

Actually, it’s a funny story which starts with a surgical complication!... One day, ten years ago now, in 2008, during a Latarjet procedure, I fractured the coracoid bone block and the remaining piece of bone was too small to be fixed with screws. I was pretty embarrassed and didn’t know what to do… That’s where I got the idea of using a suture-button to fix the small piece of coracoid to the anterior glenoid neck. I used a quadruple strand of sutures and tied the “Nice knot”; which is a sliding-locking knot. Since I was not sure of obtaining bone block healing, I carefully followed the patient with x-rays and CT-scan images. To my great satisfaction, I observed that the bone block perfectly healed to the scapula. I was very excited with this discovery!... Prior to that day, suture-button was used for soft tissues fixation but had never been used to obtain bone-to-bone healing. It was the first time that it was shown that a suture-button could be used to obtain bone healing. I think it’s what is called a “serendipitous discovery” - when you find a different application for something that already exists but is not sought for. It was a long shot, but for this patient, it was a chance to transform a failure into a success!

This has worked for one patient, but is it really possible to regularly obtain bone block healing with suture-button fixation?

Yes, I proved it and published it: suture-button is an efficient and safe alternative to screw fixation for Latarjet! Here is the story. Soon after this first patient, I started a prospective study and followed all patients that I operated with an arthroscopic Bristow-Latarjet procedure using suture-button fixation. CT-scans performed 6 months after surgery showed about 65 to 70% of bone healing. Although the results of this first study were encouraging, they made me realize that hand knot-tying was insufficient and that more compression on the bone block was needed to improve healing. This led me to design and develop a specific suture-tensioner that I added to my tool box. I also understood that the tensioner should not be used from an anterior portal (because of the obliquity), but from the posterior portal to be perfectly aligned with the suture-button; I also worked on the amount of tension needed, and ended up with 100 Newtons. The healing rate then increased to 80-85%. However, one problem still remained: when tensioning the suture, the suture could cut through the bone block and the anterior button flipped to the side. I solved this problem by designing a specific anterior peg-button. Since then, we have eliminated this possible sawing effect and have observed 95% bone block healing, which is equal, or even superior, to what is obtained with screw fixation.

But, is a suture-button really strong enough to allow early return to sport or work?

Believe it or not, from a mechanical standpoint a double-button is stronger than a screw for a simple reason: a suture-button is nothing else than a bolt! This means that it provides a double point of fixation for the bone block: from the front and from the back. Now, let me ask you a question: would you accept to climb into a plane whose pieces of metal, from the wings and the aircraft’s fuselage, are fixed with screws?... Probably not, if someone would explain to you that, with vibrations, the screws could loosen and that the pieces of metal could fall apart, leading to the plane crashing!... Everything in a plane is fixed with bolts!... That’s what suture-buttons are! The double-button is at least as strong as screws, and we use the same postop protocol and allow contact athletes (like rugby players, hand-ball players, hockey players, etc...) to go back to competition at 3 months.

Do you think it’s time for shoulder surgeons to start learning the arthroscopic Latarjet?

Yes, I do! All my assistants who left the Department in the past few years are able to do this procedure on their own and do it in private practice. It’s amazing to see how fast young surgeons learn to perform an arthroscopic Latarjet. They were born with shoulder arthroscopy and we should realize that some of them have almost never seen an open cuff repair or even an open Latarjet!... So, for them performing the Latarjet procedure under arthroscopy is sort of natural. Of course, a minimum of arthroscopic experience and skills are required before starting. It’s like skiing: you start with green slopes that is Bankart, then you go on red ones that is cuff repair, then black ones, Weaver-Dunn, and then you can go off-piste skiing: arthroscopic Latarjet! For the last three years, with the help of the Smith & Nephew company, we have started a teaching/training program in Nice for surgeons who want to learn this complex procedure. The surgeons come to see one or two cases with me in the OR on Thursday, so I can show them all the tips and tricks that I have developed through the years. The next day, they go to the anatomy lab and perform a case themselves on a specimen with the help of my operating nurse.

What else about your experience in surgery for instability?

We will present three important clinical studies during the Course, based on my experience with surgical revision of previous failed stabilization with recurrence of anterior instability. One is about failed arthroscopic Bankart revised with Latarjet, and another about failed Bristow/Latarjet with small glenoid defects revised with repeated soft tissue procedures, like Bankart and Hill-Sachs remplissage. The last one is on patients with failed Bristow/Latarjet and severe anterior glenoid bone loss that I revised with arthroscopic Eden-Hybbinette. I also use a suture-button to fix the iliac crest bone graft to the anterior neck of the scapula. The arthroscopic Eden-Hybbinette is much easier than the arthroscopic Latarjet because there is no need to pass through the subscap muscle and it’s a good start for those who are interested in learning how to perform a bone block procedure under arthroscopy.

And what about posterior instability?

Recurrent posterior instability is a very complex and difficult topic. Very often it is bilateral, and when patients come to see a surgeon, it’s because of uncontrolled and painful posterior subluxations. About 15 years ago, I made a classification, in which I differentiate three groups of patients with recurrent posterior instability: group 1, voluntary posterior instability, that should not be operated because it’s bilateral, painfree, and patients may have psychiatric problems; group 2, involuntary posterior instability which is unilateral, painful, often post-traumatic and is a good indication for surgery, and between these groups there is a third group which is voluntary posterior instability that became involuntary. Most surgeons refuse to take care of this third group of patients because of the initial voluntary component. In fact, there is a confusion between “voluntary” and “reproducible” posterior instability. Based on my experience, these young hyperlax patients are not crazy and have had a trauma that led to painful, involuntary recurrent posterior instability. Of course, the posterior instability is reproducible but it’s not voluntary anymore. Patients can show you how they can sublux their shoulder, but they are not doing it anymore because it’s painful and uncontrolled. I have operated on a number of patients like this with either soft tissue procedure or bone block procedure, or both. One of my fellows, Tristan Langlais, who is a pediatric orthopaedic surgeon, has studied the natural history from childhood to adulthood, and he has shown that, although these shoulders are more difficult to stabilize, it’s worth doing it and patients are very happy.

If surgery is indicated, how do you decide for a posterior bone block?

Tricky question! Evaluating posterior glenoid bone loss is much more difficult than anterior bone loss. What we have started to do is to look at bilateral 2D and 3D CT-scans with substraction of the humerus in order to compare the two glenoids and evaluate the possible posterior glenoid erosion.

How do you perform a posterior bone block?

I do it under arthroscopy and fix the bone block posteriorly with suture anchors. Once again, screws are not needed, and bone block healing is regularly obtained. The advange of arthroscopy is the possibility to do a posterior capsular shift in the same session. The disadvantage is that, because it’s done under arthroscopy, sometimes you may think that it should be done differently than in open surgery. That’s what I did early in my experience: I made the mistake of placing the bone block flush under arthroscopy and had recurrence of instability. As recommended by Gilles Walch many years ago, posterior bone blocks should be overhanging to provide optimal stability, by contrast to anterior bone block which should be placed flush to the joint line. Since part of the iliac crest bone resorbs, there is bone remodeling, and we have not observed any increased risk of osteoarthritis by doing this.

What about chronic acromio-clavicular dislocations? Is there any reason to operate on these patients?

What I learned from the patients I have operated on with chronic high grade AC dislocations is that about 50% of them have associated intraarticular pathology, such as labrum tears, partial cuff tear, or biceps pathology. This is what I have called the “iceberg theory”: the ugly deformity is what every body sees, but what doctors or surgeons often miss when a patient comes to see them, is the hidden underlying intraarticular pathology. Once again, the benefit of arthroscopy is that it allows reconstructing the AC join, as well as treating the intraarticular lesions at the same time. The all-arthroscopic modified Weaver-Dunn that is transfer of the CA ligament with the tip of the acromion inside a socket in the distal clavicle, works very well in our hands, and I don’t see any need to harvest a tendon in the knee or to pay for an allograft. It works even for previously failed AC stabilization, as we will report during the course.

And for acute high grade AC dislocations?

Based on my experience, reduction and fixation with a double-button alone is enough and there is no need to do any ligamentoplasty, but with two conditions: first, do it as soon as possible, ideally, in the first week after the trauma - after this delay, I recommend to do an associated ligamentoplasty; and second, over-reducing the AC separation, with the clavicle almost touching the coracoid process to increase the chance of healing of the trapezoid/conoid ligaments. Also, beware of pre-existing AC joint arthritis in older patients: in such cases, don’t forget to resect the distal clavicle, otherwhise you will create shoulder pain and patient will not like it at all!...

Is there anything new about the cuff pathology?

We still do tension-band (single-layer) cuff repair in about half of the cases, and in cases of tendon delamination, following Hiro Sugaya and the Japanese surgeons, we prefer to do a “double-layer” cuff repair: the deep layer is reattached first, closed to the articular margin, and the superficiel layer is brought more laterally. We have stopped doing “double-row” repair because we have seen some medial reruptures with necrosis at the muscle-tendon junction or retears of the deep layer, what Joe Iannotti has called “rupture in continuity” after cuff repair, which he will present during the course. Christian Gerber will present the results of an interesting experimental study in sheeps, comparing muscle atrophy and fatty infiltration after tenotomy, after section of the suprascapular nerve, and after combined tenotomy and neurectomy. Gilles Walch will talk about the importance of looking for fatty infiltration and how to look at it before deciding to repair the cuff tendons. As always in surgery, the indication is more important than the technique. Unfortunatly, we are repairing too many cuff tears.

The number of cuff repairs is increasing dramatically?

Yes, the industry is pushing us to implant as many suture-anchors as possible, and we, as surgeons, have a “big ego” and want to do fancy operations. We are overdoing it, and one of the reasons, I believe, is that the words that we use are not correct. Everybody, the radiologist, the patient, the surgeon, talks about “cuff tears”, while often we are facing patients with “cuff wears”. So, the question is: should we repair “cuff wears”?... I'm not sure. Tell me how a so-called “cuff tear” can suddenly become painful, when it has been there for years, as proven by the presence of fatty infiltration of the muscle on preop imaging studies?...

You mean that a hole is not supposed to be painful!

Exactly!... In degenerative cuff tears, shoulder pain is often related to biceps pathology, and not to the tear itself. With progressive upward migration of the humeral head, the biceps is either squeezed under the acromial arch (becoming delaminated and hypertrophic – an “hourglass biceps” or it has to escape anteriorly, becoming unstable and creating a subscapularis cleavage. When the shoulder is “functional”, with a perfect adaptation of the humeral head to the acromial arch, I think that we should not disturb this fragile muscle balance.

How can the surgeon unbalance a shoulder?

Even a “simple” acromioplasty can compromise the fragile muscle balance of a shoulder with a degenerative large or massive cuff tear. The risk of trying to repair “cuff wear” I mean “an old cuff tear”, is to transform a painful but well-balanced “functional” shoulder, into a “non-functional” one. This is the worst thing that can happen to a shoulder surgeon: I can tell you that a patient operated for shoulder pain who has a pseudoparalysis after the surgery will always remember the name of the surgeon and will hate him for the rest of his life! I really believe that we should select the cuffs to be repaired carefully. Of course, I oversimplify: you may have a patient with a chronic cuff wear who falls down and has an extension of the tear or wear. But, as Harrison L. MacLaughlin from New-York, one of the first surgeons to repair cuff tears in the fifties, wrote later in his carrier: “the more experience I have with cuff pathology, the less I repair degenerative cuff tears…”

So, what to do in case of massive irreparable cuff tears?

If the shoulder is painful but “functional” that is with conserved active forward elevation, the question the surgeon should ask himself is: “is the biceps still present?...” If the answer is YES, then an easy and efficient solution, proposed by Gilles Walch many years ago, is to perform an arthroscopic biceps tenotomy or tenodesis to relieve pain and restore a better shoulder function. The problem is that many surgeons decide during surgery if they are going to repair or not to repair a cuff tear, and that’s a mistake! I really believe that such a decision should NOT be taken during surgery, but in the office, based on clinical exam and preop imaging studies. If preop X-rays show a decreased acromiohumeral distance or glenohumeral narrowing with early OA, the cuff should not be repaired. There is no soft tissue operation that can lower a humeral head, which is superiorly migrated. The same is true if CT-scan or MRI show muscle fatty infiltration. We shouldn’t deal with fat tissue: we are orthopaedic surgeons, not plastic surgeons!

What do you think of the recent subacromial devices proposed for massive irreparable cuff tears?

I guess you are talking about the “two new kids on the block,” which are the “space balloon” and the superior capsular reconstruction.
The balloon is a spacer, placed between the humeral head and the acromial arch, which is supposed to bring some pain relief. It is filled with physiological serum, and it is supposed to disappear after three months.

The perfect crime!

Kind of!... No, more seriously, the “space balloon” could provide a solution for some rare patients with massive irreparable cuff tears who still have pain, despite a ruptured biceps. If they have a painful but “functional” shoulder, these patients are not good candidates for a reverse prosthesis. So, what should we do? At the moment, we don’t know if the balloon is better than nothing. Although the ballon has been on the market for about 10 years, we are still waiting for a prospective randomized study that could bring us an answer.

What is exactly the SCR, I mean the superior capsular reconstruction?

This procedure consists of covering the humeral head by using a facia lata graft, or a human dermis allograft, fixed on the greater tuberosity on one side and on the upper glenoid neck on the other side, and then to suture the remaining anterior and posterior cuff to the graft. The reason of the existence of this procedure is that Japanese surgeons didn’t have the ability to use the reverse prosthesis for 20 years. This is the time it took for the reverse prosthesis to be approved in Japan. Teruhisa Mihata, who developed this procedure, will present the biomechanical concept and the clinical results during the course. Markus Scheibel will look at it more critically, while George Athwal will try to define the place of the ballon and SCR in massive irreparable cuff tears.

So, it’s also a kind of spacer?

Yes, but a pretty expensive one! The allograft plus 6 or 8 anchors to fix it becomes as expensive as a reverse prosthesis! Personally, I have difficulty understanding how this operation works because the graft is attached medially to the glenoid neck and not to the remaining cuff. I can understand that it provides pain relief, if in the same time you cut the biceps. My question is, how can the ballon or the SCR restore shoulder function in case of true pseudoparalysis? In my experience, the only procedure that restores active forward elevation in case of shoulder pseudoparalysis is the reverse prosthesis.

Maybe the problem comes from the unclear definition of “shoulder pseudoparalysis”?

Exactly! As shoulder surgeons, we should agree on the definition of “shoulder pseudoparalysis”. At the moment, we don't have a clear definition. For me, in a pseudoparalyzed shoulder, not only active forward elevation is lost, but there is also anterosuperior escape of the humeral head in front of the acromion, which is very visible when you ask the patient to abduct the arm. This means that the vertical muscle balance of the shoulder is definitely lost and, according to my experience, there is no soft tissue procedure, neither the SCR or the balloon nor any tendon transfer, can solve this problem. Any interposition of soft tissue or artificial material will be squeezed and destroyed between the humeral head and the acromial arch. Even the Latissimus Dorsi transfer doesn’t work in pseudoparalyzed shoulders, as published by Christian Gerber. Again, the only solution for a true pseudoparalyzed shoulder is the reverse prosthesis. A pseudoparalyzed shoulder is different from what I call a “Painful Loss of Active Elevation”. If you have pain in your shoulder, you have difficulties to elevate the arm for sure, but it does not mean that your shoulder is unbalanced. If I remove the shoulder pain, by removing the intra-articular portion of the biceps, for instance, you will again be able to elevate the arm with less difficulty.

So, when do you propose a muscle transfer?

My main indication for Latissimus Dorsi transfer or L’Episcopo is ILER patients: Isolated Loss of External Rotation. These patients have a massive irreparable posterosuperior cuff tear involving the suprapinatus, the infraspinatus, and the teres minor; they have lost active external rotation, but retain anterior forward flexion. They are very hindered in all activities of daily living by a dropping arm. They have lost the horizontal muscle balance: 4 IR muscles vs zero ER muscles, while the vertical muscle balance is conserved. I harvest the LD under the pectoralis major through a small deltopectoral approach, and fix it, after tubulization, in a socket located at the teres minor insertion.

You also proposed this tendon transfer in association with a reverse arthroplasty …

Yes, for CLEER patients, Combined Loss of Elevation and External Rotation, whose shoulders have lost both the vertical and the horizontal muscle balance: these patients have both a pseudoparalized shoulder and a dropping arm. If you do a reverse prosthesis alone, they may be disappointed. It’s a lesson that I learned from one of my patients: a typical pretty elderly “niçoise” lady that I operated with a reverse prosthesis for cuff tear arthritis. When she came back for the six months’ follow-up visit, I asked her to elevate the arm forward, which she did. So, I said: I guess you’re happy?... And she said no, I am not, at all! You should have warned me before! Warn you from what? I said. Look Doc, how I do to comb my hair? Look how I do to bring a glass to my lips? I need to hold my forearm with my other hand, otherwhise it falls down! I'm bothered by this every single day of my life! I was stunned. At first, I did not understand what she meant. I finally understood when I looked at her preop CT-scan images and realized that she had no more external rotators at all. This patient made me realize the handicap caused by the absence of the infraspinatus and the teres minor. That's where I got the idea to combine the RSA with a tendon transfer for those patients. As always, if you listen carefully to your patients they show you the direction where to go!

What are the themes of the trauma session?

Acute proximal humerus fractures are a very difficult topic. We will present our experience with percutaneous IM nailing for the treatment of 2-part, surgical-neck fractures, which is very good; there is no need to open and plate these fractures anymore. For 3- and 4-part fractures, we do it open and do a superior transdeltoid approach with osteotomy of the tip of the acromion. This approach allows us to perfectly reduce and fix the greater tuberosity, which is the “key piece of the puzzle” with three muscle-tendons inserted on it. We use the same third-generation Aequalis IM nail, which is based on tuberosity fixation and not on humeral head fixation with locking screw technology. The problem in 3- and 4-part fractures is to neutralize the horizontal pulling forces of the anterior and posterior cuff muscles, not to fix the humeral head. It is a misconception and a misunderstanding of the physiopathology of these fractures to operate on them to fix the head. In fact, I haven’t used a plate for at least 15 years to fix a proximal humerus fracture. Who really cares about fixing the humeral head? There is no need! We know how to replace a necrosed humeral head, but we don’t know how to replace three retracted, scarred, fatty infiltrated muscles in the back of the shoulder, and we never will!... Locking plates did not solve any problems; they added a third one with glenoid destruction, in addition to humeral head necrosis and posterior migration of the GT. This is what I have called the “unappy triad after plating”. A device that burns bridges, like the proximal humerus locking plate, should be abandoned in my opinion. First, do no harm!

Let’s talk about reverse prothesis in trauma: don’t you think they are overindicated?

Yes, but the results are pretty good!... Of course, RSA should be limited to very displaced four-part fractures or dislocated fractures in elderly patients, over 70 years. What we have found is that it is important to reattach the tuberosities around the prosthesis to obtain optimal results. Why?... Because, once again, a reverse prosthesis without any ER muscles results in a bad shoulder, with no active external rotation and a dropping arm. And without solid tuberosities, there are more complications: more instability and more implant loosening; the prothesis being fixed only distally, there are more rotational loads proximally.

Since tuberosity repair is important, shouldn’t hemiarthroplasty be considered before rushing to reverse?

The problem is that the results of hemiarthroplasty in acute fractures are less predictable and reproducible than with reverse prosthesis. David Gallinet, Philippe Valenti, and the French Orthopaedic Society will present this during the course.

You recently moved to a new hospital in Nice…

Yes, it took more than ten years to build this new University hospital, called “Pasteur 2”, and for us to migrate to these new facilities. Now, we have all the subspecialities located at the same place: orthopaedics, traumatology, hand surgery, and plastic and reconstructive surgery have been grouped into what we have named UILS: University Institute for Locomotion and Sports. We have 100 beds plus the ambulatory unit, 10 operating rooms, and we have created specialized units for Hip & Knee, Shoulder & Elbow, Spine, Hand, Spine, etc… In addition to elective surgery, we do a lot of traumatology: we are the only level I traumatology center in Nice and are on call every day, 24/7. It’s a big “factory” and I’m lucky to have a group of friends and young surgeons around me who, every day, do an incredible job.

Is the new hospital more efficient than the previous small one?

No, when we came here, in the beginning, it was a real nightmare, and I was asking myself everyday if I was going to stay!... The new building itself is nice, the offices and operating rooms perfect, but what I had not anticipated is the new administrative organization and management implemented without any input from the physicians. In the old hospital where everything was working fine, I was in charge of my unit from the bottom to the top. When we arrived here in the new hospital, they had broken this vertical structure by cutting it horizontally with different directors and head nurses at all levels. I have no control anymore of what is going on in the wards and it’s disfunctional every day. We struggle and fight every day to make things work. But, as I said, all specialities are united, and despite the unreasonable administrative management, we have increased the number of patients treated.

Where you here during the awful terrorist attack in Nice?

Yes, I was here and it was a very sad and tragic episode for the city and this new hospital. But it was also the baptism of this new hospital. It was only one year after the opening and we faced very tragic hours with a lot of wounded and deceased. Everybody really did their job. All the residents, fellows, assistants, and even the medical students came spontaneously to the hospital that night to help. Doctors and nurses from private clinics came spontaneously to offer their services. I must say that everybody reacted very positively, from anesthesiologists to nurses and surgeons. We doctors held the reins… with the administration stepping aside recognizing that the situation was best managed by the physicians… Doctors did their job and took charge without asking anything for permission. It was a moment where we were all close, together, and it was the real launching of our new hospital.

Published in N°278 - November 2018