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• Despite rapid medical technology development, various challenges exist in three- and four-part proximal humeral fracture (PHF) management. This condition has led to a notably increased use of the reverse total shoulder arthroplasty (RTSA); however, open reduction and internal fixation (ORIF) is still the most widely performed procedure. Thus, these two modalities are crucial and require further discussion. We aim to compare the outcomes of three- or four-part PHF surgeries using ORIF and RTSA based on direct/head-to-head comparative studies.

• We conducted a systematic review and meta-analysis based on the Cochrane handbook and PRISMA guidelines. We searched MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Library) from inception to October 2020. Our protocol was registered at PROSPERO (registration number CRD42020214681). We assessed the individual study risk of bias using ROB 2 and ROBINS-I tools, then appraised our evidence using the GRADE approach.

• Six head-to-head comparative studies were included, comprising one RCT and five retrospective case-control studies. We found that RTSA significantly improved forward flexion but was comparable to ORIF in abduction (p = 0.03 and p = 0.47, respectively) and more inferior in external rotation (p < 0.0001). Moreover, RTSA improved the overall Constant-Murley score, but the difference was not significant (p = 0.22). Interestingly, RTSA increased complications (by 42%) but reduced the revision surgery rates (by 63%) compared to ORIF (p = 0.04 and p = 0.02, respectively).

• RTSA is recommended to treat patients aged 65 years or older with a three- or four-part PHF. Compared to ORIF, RTSA resulted in better forward flexion and Constant-Murley score, equal abduction, less external rotation, increased complications but fewer revision surgeries.

Cite this article: EFORT Open Rev 2021;6:941-955. DOI: 10.1302/2058-5241.6.210049

• Scapular dyskinesis can be present in healthy individuals as in patients with shoulder pathology.

• Altered patterns of scapular kinematics can cause or exacerbate rotator cuff tear pathology. However, more research is needed.

• Regardless of the cause or the consequence of rotator cuff tear, scapular dyskinesis impairs shoulder function, worsens the symptoms, and compromises the success of clinical intervention.

• The available literature suggests physical therapy as the first treatment for degenerative cuff tears, and scapular dyskinesis should be addressed if present. Non-responsive cases or traumatic tears may require surgery.

• Postsurgical physical therapy protocols after rotator cuff repair must consider scapular dyskinesia to improve the outcomes.

Cite this article: EFORT Open Rev 2021;6:932-940. DOI: 10.1302/2058-5241.6.210043

• The Kinematic Alignment (KA) technique for total knee arthroplasty (TKA) is an alternative surgical technique aiming to resurface knee articular surfaces.

• The restricted KA (rKA) technique for TKA applies boundaries to the KA technique in order to avoid reproducing extreme constitutional limb/knee anatomies.

• The vast majority of TKA cases are straightforward and can be performed with KA in a standard (unrestricted) fashion.

• There are some specific situations where performing KA TKA may be more challenging (complex KA TKA cases) and surgical technique adaptations should be included.

• To secure good clinical outcomes, complex KA TKA cases must be preoperatively recognized, and planned accordingly.

• The proposed classification system describes six specific issues that must be considered when aiming for a KA TKA implantation.

• Specific recommendations for each situation type should improve the reliability of the prosthetic implantation to the benefit of the patient.

• The proposed classification system could contribute to the adoption of a common language within our orthopaedic community that would ease inter-surgeon communication and could benefit the teaching of the KA technique. This proposed classification system is not exhaustive and will certainly be improved over time.

Cite this article: EFORT Open Rev 2021;6:881-891. DOI: 10.1302/2058-5241.6.210042

• Unicompartmental knee arthroplasty (UKA) has several advantages over total knee arthroplasty; however, in many reports, the risk of revision remains higher after UKA.

• Many reasons for failure of UKA exist.

• Successful treatment starts with accurate assessment of the symptomatic UKA as a specific mode of failure requires a specific solution.

• A structured and comprehensive evaluation aids assessment of the symptomatic UKA.

• This review provides an overview of the causes for a symptomatic medial UKA, its risk factors, diagnostic modalities that can be used, and briefly discusses treatment options.

Cite this article: EFORT Open Rev 2021;6:850-860. DOI: 10.1302/2058-5241.6.200105

• Surface bone sarcomas are rare malignant bone tumours. Osseous and cartilaginous surface bone sarcomas are the most common, with parosteal and periosteal osteosarcomas, periosteal chondrosarcomas and secondary peripheral chondrosarcomas being the most frequent.

• Their clinical symptoms are non-specific and include pain for several months, swelling and limited range of motion of the adjacent joints.

• Prompt diagnosis is important, as biological behaviour, imaging and histopathologic characteristics, treatment and prognosis differ considerably from their conventional intramedullary counterparts. Moreover, their imaging characteristics are not infrequently non-characteristic and may be misinterpreted as juxtacortical benign lesions leading to incorrect diagnosis and treatment, with life-threatening repercussions. Molecular studies and histopathological sampling are essential for accurate diagnosis.

• There are still numerous issues regarding the biology, pathophysiology and treatment options of these entities due to their rarity.

Cite this article: EFORT Open Rev 2021;6:905-917. DOI: 10.1302/2058-5241.6.210064

• Adjacent segment pathology (ASP) is a major cause of disability, and the recognition of the surgical risk factors associated with the development of this condition is essential for its prevention.

• Different surgical approaches, from decompression without fusion to non-instrumented and instrumented fusion, have distinct contributions to the development of ASP.

• Although motion-preservation procedures could reduce the prevalence of ASP, these are also associated with a higher percentage of complications.

• Several risk factors associated with previous surgery, namely the chosen surgical approach and anatomical dissection, the choice of interbody fusion, the increment and length of the fusion, and the restoration of sagittal alignment, may influence the development of ASP.

Cite this article: EFORT Open Rev 2021;6:966-972. DOI: 10.1302/2058-5241.6.210050

EFORT Open Rev 2021;6:823-824. DOI: 10.1302/2058-5241.6.212000

• Osteoarthritis (OA) is a global health issue with myriad pathophysiological factors and is one of the most common causes of chronic disability in adults due to pain and altered joint function.

• The end stage of OA develops from a destructive inflammatory cycle, driven by the pro-inflammatory cytokines interleukin-1β (IL-1β) and tumour necrosis factor alpha (TNFα).

• Owing to the less predictable results of total knee arthroplasty (TKA) in younger patients presenting with knee OA, there has been a surge in research evaluating less invasive biological treatment options, one of which is autologous protein solution (APS).

• APS is an autologous blood derivative obtained by using a proprietary device, made of APS separator, which isolates white blood cells (WBCs) and platelets in a small volume of plasma, and APS concentrator, which further concentrates platelets, WBCs and plasma proteins, resulting in a concentrated solution with high levels of growth factors including the anti-inflammatory mediators against IL-1β and TNFα.

• A single intraarticular injection of APS appears to be a promising solution for treatment of early-stage OA from current evidence, the majority of which comes from preclinical studies.

• More clinical studies are needed before APS can be widely accepted as a treatment modality for OA.

Cite this article: EFORT Open Rev 2021;6:716-726. DOI: 10.1302/2058-5241.6.200040

• This study was designed to identify the most frequent shoulder patient-reported outcome measures (PROMs) reported in high-quality literature.

• A systematic review was performed to identify shoulder PROMs, and their diffusion within the scientific literature was tested with a subsequent dedicated search in MEDLINE.

• 506 studies were included in the final data analysis, for a total number of 36,553 patients.

• The Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the American Shoulder, Elbow Surgeons Score (ASES) and the Shoulder Pain and Disability Index (SPADI) were the most frequently reported PROMs in the analysed publications, with disease-specific PROMs being used with increasing frequency.

• A core set of outcome measures for future studies on patients with shoulder pathologies, based on the international acceptance and diffusion of each PROM, is needed.

• A combination of the DASH score for shoulder outcome assessment with more specific PROMs, such as the ASES for rotator cuff pathology and osteoarthritis and the SPADI for shoulder stiffness and shoulder pain of unspecified origin, is proposed as a recommended set of PROMs.

Cite this article: EFORT Open Rev 2021;6:779-787. DOI: 10.1302/2058-5241.6.200109

• Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper limb, presenting with disturbance of ulnar nerve sensory and motor function.

• The ulnar nerve may be dynamically compressed during movement, statically compressed due to reduction in tunnel volume or compliance, and tension forces may cause ischaemia or render the nerve susceptible to subluxation, further causing local swelling, compression inflammation and fibrosis.

• Superiority of one surgical technique for the management of CuTS has not been demonstrated. Different techniques are selected for different clinical situations with simple decompression being the most common procedure due to its efficacy and low complication rate.

• Adjunctive distal nerve transfer for denervated muscles using an expendable motor nerve to restore the axon population in the distal nerve is in its infancy but may provide a solution for severe intrinsic weakness or paralysis.

Cite this article: EFORT Open Rev 2021;6:743-750. DOI: 10.1302/2058-5241.6.200129