Nicolas Bronsard

Purpose Conserving the subscapularis tendon during reverse shoulder arthroplasty (RSA) has proven its impact on postoperative outcomes, particularly regarding stability and range of motion. A subscapularis preserving approach has been developed: the Anterior Muscle Sparing (AMS) approach that enables not to violate the subscapularis tendon. Our aim was to compare this approach with the conventional approach, which consists of reinserting the subscapularis at the end of the procedure, with a specific focus on intraoperative complications and postoperative position of the implants. Methods A retrospective consecutive study was performed of patients undergoing a primary RSA between January 2021 and December 2024 performed by the same surgeon. We included 32 patients receiving the standard approach (SA) and 24 patients receiving the AMS approach. Implant positioning was assessed through three different variables: the glenoid implant inclination relative to the floor of the supraspinatus fossa; the glenoid implant height described as the distance between the inferior border of the glenoid bone surface and the inferior part of the glenoid baseplate; and the humeral stem alignment relative to the intramedullary humeral shaft axis. Results There were no significant differences in terms of glenoid implant inclination (-4.71 ± 6.3° Vs -3.8 ± 7.17°; p = 0.68), glenoid implant height (0.608 ± 1.94 mm Vs 0.315 ± 0.896 mm ; p = 0.655), and PERFORM^® humeral stem alignment ( 1.34 ± 4.11° Vs 1.89° ± 4.63°; p = 0.715) between the two groups. The intraoperative complication rate was not significant different between the groups, with only two cases within the AMS approach group (p = 0.181). The mean operative times were not significantly different between the groups (94.06 min ± 18,71 Vs 81,73 min. ±16,58; p = 0,06). Since September 2023, when the senior author started performing RSAs with the described technique only one patient was converted from an AMS to a traditional approach during surgery due to an intraoperative complication. Conclusion When compared to the standard approach, the AMS showed no significant difference in terms of implant positioning, surgical operative times and intraoperative complication rate. An attempt to preserve the subscapularis tendon seems to be always justified, as this method is a safe and reliable alternative to the traditional approach. Level of evidence Level III, Retrospective Cohort Comparison Treatment study.

Extensive and complex abdominal wall defects, particularly those associated with intestinal or visceral organ damage, pose significant medical and surgical challenges. An ideal reconstruction must restore anatomy, function, sensation, and body image. Currently, no conventional reconstruction method fulfills all these criteria in such complex scenarios. However, vascularized composite allotransplantation (VCA) offers a unique solution, providing satisfactory anatomical and functional outcomes -- albeit at the cost of lifelong immunosuppression. Since the first reported human case in 2003, approximately 40 abdominal wall transplants have been performed worldwide, all in conjunction with intestinal or multivisceral transplantation. While various technical adaptations have been described, the procedure has proven to be both safe and effective for patients with complex abdominal wall defects. To date, no reinnervated abdominal wall allograft has been attempted in humans. However, reinnervation appears to be the next frontier, with the potential to enhance functional outcomes and reduce complications. This protocol outlines a standardized procedure for harvesting and preparing a vascularized abdominal wall composite allograft, designed to ensure optimal results and minimize tissue damage. The graft, vascularized via the deep inferior epigastric vessels, is harvested with generous margins to enable tension-free reconstruction. We also detail the specific steps required to collect an innervated specimen. At the end of the procedure, the two deep inferior epigastric arteries are cannulated, and the graft is perfused with preservation solution for transport. Ultimately, this protocol aims to standardize abdominal wall graft procurement. It is intended as a valuable resource for both translational research and clinical applications, particularly as interest in abdominal wall transplantation continues to grow.

Extensive and complex abdominal wall defects, particularly those associated with intestinal or visceral organ damage, pose significant medical and surgical challenges. An ideal reconstruction must restore anatomy, function, sensation, and body image. Currently, no conventional reconstruction method fulfills all these criteria in such complex scenarios. However, vascularized composite allotransplantation (VCA) offers a unique solution, providing satisfactory anatomical and functional outcomes -- albeit at the cost of lifelong immunosuppression. Since the first reported human case in 2003, approximately 40 abdominal wall transplants have been performed worldwide, all in conjunction with intestinal or multivisceral transplantation. While various technical adaptations have been described, the procedure has proven to be both safe and effective for patients with complex abdominal wall defects. To date, no reinnervated abdominal wall allograft has been attempted in humans. However, reinnervation appears to be the next frontier, with the potential to enhance functional outcomes and reduce complications. This protocol outlines a standardized procedure for harvesting and preparing a vascularized abdominal wall composite allograft, designed to ensure optimal results and minimize tissue damage. The graft, vascularized via the deep inferior epigastric vessels, is harvested with generous margins to enable tension-free reconstruction. We also detail the specific steps required to collect an innervated specimen. At the end of the procedure, the two deep inferior epigastric arteries are cannulated, and the graft is perfused with preservation solution for transport. Ultimately, this protocol aims to standardize abdominal wall graft procurement. It is intended as a valuable resource for both translational research and clinical applications, particularly as interest in abdominal wall transplantation continues to grow.

In vascularized composite allograft (VCA) for upper limb reconstruction, upper arm-level or transhumeral transplantations are performed less frequently than forearm and hand transplantations. Transplantation is technically more feasible at this proximal level, largely owing to the use of macrovascular anastomoses. Despite these challenges, the outlook for arm allotransplantation remains encouraging, and this protocol provides a standardized technique for harvesting a vascularized upper arm composite allograft, ensuring both optimal outcomes and minimal tissue trauma. In the case of upper arm transplant, the technique varies according to the level of transplantation: supracondylar, transhumeral at a proximal arm level, or through the shoulder with the donor humeral head. A circumferential skin incision at mid-arm, or depending on the level at the origin of the upper limb, is made. A skin flap, such as a deltoid flap, can be harvested from the donor for skin closure at proximal levels. Dissection of the cephalic vein and deeper the brachial or axillary artery and veins is required. Then, the surgeon must identify the nerves depending on the level (terminal branches of brachial plexus or anteromedial and anterolateral cords for proximal transplantation) and transect the biceps, brachialis, and triceps muscles. The coracobrachialis and the deltoid muscles may also be dissected depending on the amputation level. Finally, the surgeon must make a transhumeral osteotomy or, if needed, harvest the donor humeral head for shoulder reconstruction. In this case, a peroneus longus graft for the suspension ligamentoplasty can also be harvested. The goal of this protocol is to standardize the procedure of harvesting and preparing an upper arm allotransplant.