Reverse Total shoulder arthroplasty (RTSA) is an effective treatment and a surgical alternative approach to conventional total shoulder arthroplasty for patients with severe rotator cuff tears and glenoid erosion. To help optimize RTSA design, it is necessary to gain insight into the geometry of glenoid erosions and consider their unique morphology across the entire bone. One of the most powerful tools to systematically quantify and visualize the variation of bone geometry throughout a population is Statistical Shape Modeling (SSM); this method can assess the variation in the full shape of a bone, rather than of discrete anatomical features, which is very useful in identifying abnormalities, planning surgeries, and improving implant designs. Recently, many scapula SSMs have been presented in the literature; however, each has been created using normal and healthy bones. Therefore, creation of a scapula SSM derived exclusively from patients exhibiting complex glenoid bone erosions is critical and significantly challenging. In addition, several studies have quantified scapular bone properties in patients with complex glenoid erosion. However, because of their discrete nature these analyses cannot be used as the basis for Finite Element Modeling (FEM). Thus, a need exists to systematically quantify the variation of bone properties in a glenoid erosion patient population using a method that captures variation across the entire bone. This can be achieved using Statistical Intensity Modeling (SIM), which can then generate scapula FEMs with realistic bone properties for evaluation of orthopaedic implants. Using an SIM enables researchers to generate models with bone properties that represent a specific, known portion of the population variation, which makes the findings more generalizable. Accordingly, the main purpose of this research is to develop an SSM and SIM to mathematically quantifying the variation of bone geometries in a systematic manner for the complex geometry of scapulae with severe glenoid erosion and to determine the main modes of variation in bone property distribution, which could be used for future FEM studies, respectively. To draw meaningful statistical conclusions from the dataset, we need to compare and relate corresponding parts of the scapula. To achieve this correspondence, 3D triangulated mesh models of 61 scapulae were created from pre-operative CT scans from patients who were treated with RTSA and then a Non-Rigid (NR) registration method was used to morph one Atlas point cloud to the shapes of all other bones. However, the more complex the shape, the more difficult it is to maintain good correspondence. To overcome this challenge, we have adapted and optimized a NR-Iterative Closest Point (ICP) method and applied that on 61 eroded scapulae which results in each bone shape having identical mesh structure (i.e., same number and anatomical location of points). To assess the quality of our proposed algorithm, the resulting correspondence error was evaluated by comparing the positions of ground truth points and the corresponding point locations produced by the algorithm. The average correspondence error of all anatomical landmarks across the two observers was 2.74 mm with inter and intra-observer reliability of ±0.31 and ±0.06 mm. Moreover, the Root-Mean-Square (RMS) and Hausdorff errors of geometric registration between the original and the deformed models were calculated 0.25±0.04 mm and 0.76±0.14 mm, respectively. After registration, Principal Component Analysis (PCA) is applied to the deformed models as a group to describe independent modes of variation in the dataset. The robustness of the SSM is also evaluated using three standard metrics: compactness, generality, and specificity. Regarding compactness, the first 9 principal modes of variations accounted for 95% variability, while the model’s generality error and the calculated specificity over 10,000 instances were found to be 2.6 mm and 2.99 mm, respectively. The SIM results showed that the first mode of variation accounts for overall changes in intensity across the entire bone, while the second mode represented localized changes in the glenoid vault bone quality. The third mode showed changes in intensity at the posterior and inferior glenoid rim associated with posteroinferior glenoid rim erosion which suggests avoiding fixation in this region and preferentially placing screws in the anterosuperior region of the glenoid to improve implant fixation. / Graduate

Les prothèses totales d’épaule ont une survie limitée due essentiellement au descellement de l’implant scapulaire. Le but de ce travail de recherche est la contribution à la mise au point d’un nouvel implant scapulaire à fixation sans ciment.Une première partie a concerné la caractérisation de l’anisotropie et des hétérogénéités de l’os spongieux de la glène par une expérimentation en compression, cette partie a abouti à l’élaboration d’une loi de comportement de l’os spongieux de la glène. La seconde partie de ce travail s’est focalisée sur la modélisation par éléments finis des contraintes aux points d’ancrage de l’implant.Les résultats des tests de simulation montrent l’incapacité du spongieux à assurer un effet press-fit dans le plan transversal, car on observe le dépassement des contraintes maximales pour un déplacement minime. Ce résultat met en question les modes de fixation primaire utilisés ce jour dans les prothèses sans ciment. Nos résultats montrent que la modification de la direction de chargement serait susceptible d’améliorer la fixation primaire ce qui ouvre des perspectives nouvelles pour le dessin d’une prothèse sans ciment. / Total shoulder prostheses have a limited survival due mainly to the loosening of the glenoid implant. The purpose of this research is the contribution to the development of a new glenoid implant with cementless fixation.The first part concerned the characterization of the anisotropy and heterogeneity of cancellous bone of the glenoid by a compression experimental tests, this part has led to the drafting of a law of behavior of cancellous bone of the glenoid . The second part of this work has focused on finite element modeling of stress around the anchors of the glenoid implant.Simulation test results show the inability of the transversal plane of the glenoid to ensure effective press-fit fixation with stresses above strength properties of the cancellous bone with a minimal displacement. This calls into question the current modes of primary fixation of cementless implant. However, it appears that a change in the direction of loading would be beneficial for the primary fixation, which opens new perspectives for the design of a cementless prosthesis.

This dissertation aimed to develop a joint protection program for people with shoulder arthritis. The program was developed throughout a two-phase process. The first stage in developing the Shoulder Joint Protection Program for patients with different stages of arthritis focused on comprehending existing research and understanding the factors that influence shoulder joint protection. We considered the priorities and preferences of both patients and therapists, integrating different types of evidence like systematic reviews, narrative and scoping reviews, and analysis of shoulder movement. This evidence guided the creation of a preliminary joint protection program. The second stage assessed the content validity of this program, using cognitive interviews with patients and therapists. The findings from each phase were then presented in separate chapters, providing a complete view of the Shoulder Joint Protection Program (SJPP) for individuals with shoulder arthritis. The evidence presented in Chapters 2 and 3 suggests that no single optimal program has been defined for patients undergoing total shoulder joint replacement surgery, including both anatomical and reversed types. Further high-quality RCTs are needed to provide more conclusive results. To assess outcomes, various patient-reported outcomes have been developed and validated. However, our study, as presented in Chapter 4, reveals inconsistencies and a lack of clarity in the conceptual frameworks of the identified PROMs. Our scoping review in Chapter 5 offers comprehensive research on shoulder biomechanics during various activities, and spotlights potential injury prevention strategies. These identified strategies can guide the creation of training programs, coaching practices, and rehabilitation strategies aimed at minimizing the risk of shoulder injuries and bolstering overall shoulder health. Results from Chapter 6 suggest that participants have the capacity to modify their movement patterns to implement joint protection strategies, potentially beneficial in post-surgery rehabilitation and enhancing shoulder function. The application of motion analysis software tools, such as MediaPipe, has yielded reliable results, indicating their potential for future kinematic studies. The developed SJPP comprises two sections: general joint protection principles and specific protective strategies for daily activities. Both digital resources and a printed version were developed to increase the accessibility of the program. The study (Chapter 7) presents a substantial contribution to the resources for patients with shoulder arthritis. It was designed to enhance their quality of life and enable them to navigate everyday activities with greater ease and less discomfort. Further enhancements, such as the inclusion of content on sports and recreational activities, could make the program even more comprehensive and beneficial. Overall, the study underscores the importance of evidence-based, user-friendly resources for patients with shoulder arthritis and provides potential directions for future research and enhancements, such as including content on sports and recreational activities. The SJPP's ultimate goal is to enhance patients' quality of life, allowing them to perform everyday activities with less discomfort. / Thesis / Doctor of Rehabilitation (RhD) / This Ph.D. research project set out to create a program to help people with shoulder arthritis protect their joints. The development process was broken down into two main stages. In the first step, we looked at what we already know from research and figured out the main things that affect how well someone can protect their shoulder joint. We thought about what patients and therapists want and need. We looked at many different kinds of studies and even how people move their shoulders. All this helped us make a first version of our plan. In the second step, we checked how good our plan was. We did this by talking with patients and therapists. We wrote about everything we found out in different chapters. This gave us a full picture of our Shoulder Joint Protection Program (SJPP) for people with shoulder arthritis. Our final SJPP has two main parts: general rules to protect the joint and special tips for everyday activities. We made it available online and on paper so it's easy to get. Our study is a big help for patients with shoulder arthritis. It's meant to make their lives better and help them do everyday things with less pain. In the future, we might add more tips about sports and fun activities, which could make it even more helpful. In conclusion, our research shows how important it is to have easy-to-use, research-based tools for patients with shoulder arthritis. We've also given some ideas for future research. The main goal of the SJPP is to make patients' lives better, helping them do everyday things with less pain.

Shoulder arthroplasty surgery has shown remarkable progress during the last few decades. A number of factors affect postoperative range of motion, pain and prosthetic durability. Among these factors, the length of the lever arm and joint stability is the ones that can be altered by the selected prosthetic component. It is uncertain how much of the normal anatomy needs to be re-established. Stemless prostheses with total reliance on metaphyseal fixation were introduced in France in 2004 (TESS, Zimmer Biomet). The goals were to avoid stem-related complications. Stemless implants have other potential benefits, including the ability to restore shoulder anatomy. Study I: This is a prospective cohort study of 49 patients with one of two versions of the TESS prosthesis (anatomical or reverse) with clinical and radiological follow-up ranging from 9–24 months. The TESS prosthesis showed short-term results that were comparable with other shoulder prosthetic systems. Study II: This is a prospective comparative non-randomised study of 37 patients (40 shoulders) who underwent TESS reverse shoulder arthroplasty (RSA) with a follow-up ranging from 15–66 months. We found a significant improvement in functional outcome and reduction of pain in both stemmed and stemless groups. Glenoid overhang influenced the occurrence of scapular notching (SN). Study III: This is a radiological study showing that CT had a good reliability and reproducibility in estimating LHO. Study IV: This is a prospective radiological study of 69 patients (70 shoulders) with primary osteoarthritis (OA) who had undergone stemless total anatomical shoulder arthroplasty (TSA). This study showed that stemless anatomical TSA could be useful in restoring shoulder anatomy. Study V: This is a prospective study of 44 patients with OA who had undergone stemless anatomical TSA with a clinical and radiological follow up ranging from 12 – 50 months. Our study showed that LHO reconstruction close to the anatomy of a healthy contralateral shoulder improved shoulder function. Stemless anatomical TSA help to restore LHO. Increasing LHO may have a negative effect on shoulder function at three months but had no effect at 12 months. The main conclusions of this thesis are: 1. TSA (anatomic and reverse) using stemless humeral components is reliable if bone quality is adequate. The complication rate is comparable with other shoulder prosthetic systems. 2. Glenoid overhang decreased complications in RSA. 3. LHO measurement on AP radiographs is less reliable and underestimates the distance when compared with CT. 4. Stemless TSA could be of help in reconstructing shoulder anatomy. 5. Shoulder reconstruction close to the anatomy of a healthy contralateral shoulder improves shoulder function. / Axelprotes kirurgi har visat avsevärd utveckling under de senaste decennierna. Ett antal faktorer påverkar postoperativt rörelseomfång, smärta och proteshållbarhet. Bland dessa faktorer utgör längden av hävarmen och ledstabilitet de faktorer som kan ändras genom val av proteskomponent. Det är osäkert om den normala anatomin måste återupprättas. Oskaftad protes med eliminering av humerusstamm och tillit till metafysär fixering introducerades i Frankrike år 2004 (TESS, Zimmer Biomet). Målen var att undvika stam relaterade komplikationer. Oskaftat implantat har andra potentiella fördelar, inklusive möjligheten att återställa axelnsanatomi. Syftet med denna avhandling var: (1) Att undersök radiologisk stabilitet av oskaftade axelproteser. (2) Att studera effekten av protes placering vid omvänd axelartroplastik både radiologiska och kliniskt utfall. (3) Att studera tillförlitlighet av mätningen av den laterala humeral offset (LHO), avståndet mellan processus coracoideus till laterala kanten av tuberkulum majus, med användning av CT eller röntgen. (4) Att studera oskaftad axelprotes förmåga att återställa axelnsanatomi. (5) Att studera den kliniska betydelsen av LHO återställning i för det funktionella resultatet efter axelartroplastik. Studie I: Detta är en prospektiv kohortstudie av 49 patienter med en av de två versionerna av TESS (anatomisk eller omvänd) med klinisk och radiologisk uppföljning från 9-24 månader. TESS protes visade lovande resultat på kort sikt med komplikationer som var jämförbar med andra axelprotessystem. Studie II: Detta är en prospektiv jämförande icke-randomiserad studie av 37 patienter (40 skuldror) som opererades med TESS omvänd axelartroplastik med en uppföljning från 15-66 månader. Vi fann en signifikant förbättring av funktion och minskning av smärta i både skaftad och oskaftad grupper. Glenoid overhang bedöms påverka risken för scapular notching (SN). Studie III: Detta är en radiologisk studie som visade att CT hade god tillförlitlighet och reproducerbarhet att mäta LHO. Studie IV: Detta är en prospektiv radiologisk studie av 69 patienter (70 skuldror) med primär artros som hade genomgått oskaftad total anatomisk axelprotes. Denna studie visade att oskaftad axelprotes kan vara till hjälp att återställa axelnsanatomi. Studie V: Detta är en prospektiv studie av 44 patienter med unilateral primär artros som hade genomgått oskaftad total axelprotes med en klinisk och radiologisk uppföljning från 12 - 50 månader. Vår studie visade att LHO rekonstruktion till den friska axeln förbättrar axelfunktion. Oskaftat implantat kan vara av hjälp till att återställa LHO. Ökad LHO kan ha en negativ effekt på axelnsfunktion vid tre månader, men denna effekt påvisade ej vid 12 månader. De viktigaste slutsatserna i denna avhandling är: 1. Oskaftad total axel artroplastik (anatomisk och omvänd) är tillförlitlig om benkvalitén är god med komplikationer som var jämförbar med andra axelprotessystem. 2. Glenoid overhang minskar komplikationer vid omvänd axelartroplastik. 3. LHO mätningen på röntgen är mindre tillförlitlig och underskattar avståndet jämfört med CT. 4. Oskaftad axelprotes skulle kunna vara till hjälp för att rekonstruera axelnsanatomi. 5. Axel rekonstruktion inom anatomi till att efterlikna anatomi på den friska kontralaterala axeln förbättrar axelfunktion.