• 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

• 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

• Based on the literature, 294 shoulder arthrodeses after brachial plexus injury in adults were assessed, mostly male; the mean age of the patients was 33 years, and the mean follow-up time was 5.5 years. The most common cause of injury was a traffic accident, especially on a motorcycle.

• Arthrodesis position ranged from 15 to 40 degrees of flexion, 15 to 60 degrees of abduction, and 0 to 50 degrees of internal rotation with the predominance of position by the 30-30-30 rule. Plates, screws, and external fixation were used for stabilization. The complication rate was at the level of 28%, the most common complication being delayed union or nonunion.

• Active movements of flexion and abduction averaged 61 and 56 degrees, respectively, while reaching the hand to the mouth, front pocket, and buttock was feasible for 69%, 71%, and 38%, respectively, after surgery. Shoulder pain was present in 77% of patients, and 28% experienced no relevant pain reduction after surgery. The subjective satisfaction rate was 82% based on significant improvement and satisfaction reported by patients after arthrodesis.

• Arthrodesis of the shoulder, in adult patients after brachial plexus palsy, can reduce shoulder pain, increase stability, and result in a range of motion that increases the possibility of carrying out everyday activities. This affects the high level of subjective patient satisfaction after surgery.

Cite this article: EFORT Open Rev 2021;6:797-807. DOI: 10.1302/2058-5241.6.200114

• The main goal of this study was to determine the rate of return to sport (RTS) after shoulder arthroplasty.

• A systematic review of the literature was performed using the PRISMA guidelines. All clinical studies written in English, French or German, with a level of evidence of 1 to 4, and evaluating return to sport after shoulder arthroplasty, were included.

• A total of 23 studies were included with 2199 patients who underwent hemiarthroplasty (HA), anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RSA). Mean age was 68 years (range 18 to 92.6), sex ratio (male:female) was 1:1.5. The surgery was performed on the non-dominant/dominant shoulder in 1:1.8 cases. The mean follow-up was 4.2 years. The rate of RTS was 75.5% with a mean time of 7 months. It was 77.4% for TSA, 75% for RSA and 71.2% for HA (P = non-significant).

• RTS after shoulder arthroplasty is high, regardless the type of arthroplasty, with a trend for a higher rate after TSA. Patients who were able to maintain a sport activity preoperatively had a greater chance of RTS after arthroplasty. Failure to RTS seems to be mostly linked to the severity of the underlying condition and length of preoperative disability.

Cite this article: EFORT Open Rev 2021;6:771-778. DOI: 10.1302/2058-5241.6.200147

• Fractures of the scapular spine are relatively rare and can occur without (1) or with (2) association to a reverse shoulder arthroplasty (RSA). To date there are only limited data on the topic. The aim of this scoping review was to identify all available literature and report current treatment concepts.

• A scoping review was conducted by searching PubMed for relevant studies between 2000 and October 2020. All studies were included which gave detailed descriptions of the treatment strategy.

• A total of 21 studies with 81 patients were included for the analysis. The mean age over all patients was 62 years (range: 24 to 89 years) and 77% of the patients were female. In 19.8% of cases, the fracture occurred after a traumatic fall from standing height. Eighty-six per cent of the patients had an RSA-associated scapular spine fracture (2). These patients were older compared to group (1) (47 ± 19.6 vs. 76 ± 5.6 years, p = 0.0001) and the majority were female (85%). The majority from group (1) underwent operative treatment with plate fixation. Most patients regained full function and range of motion. RSA-associated fractures (2) were mainly treated non-operatively, with moderate clinical outcome. A high rate of nonunions was reported.

• Scapular spine fractures without RSA are mainly treated operatively with good clinical results. In association with RSA, scapular spine fractures are mainly treated non-operatively and lead to inferior clinical and radiological results. This scenario seems to be problematic and further research is required to sharpen treatment concepts in this group.

Cite this article: EFORT Open Rev 2021;6:788-796. DOI: 10.1302/2058-5241.6.200153

• A consensus is beginning to emerge about the indications for fixation of fractures involving the glenoid fossa of the scapula. The same cannot be firmly said for extra-articular fractures of the blade or the processes of the scapula, with a good deal of reliance on expert opinion from high-volume centres. There are no randomized controlled studies and the systematic reviews that do exist can only pool the data from available case series, making meaningful meta-analysis of limited value. Interest in scapula fractures has increased of late due to the specific association of fractures of the scapular spine and acromion with reverse shoulder arthroplasty.

• This review summarizes the available evidence that can assist decision making when faced with a patient with a scapula fracture. Which patients should at least be considered for open reduction and internal fixation, either in the centre where they present or after referral to a more specialist centre? These patients are those with a fracture sufficiently displaced that it interferes with the mechanical function of the shoulder girdle and the aim of fixation is to reduce pain and disability.

• Since the majority of scapula fractures heal quickly with non-surgical treatment and do not cause significant disability, decision making can be difficult, and it is perhaps the case that it is easier to err on the side of caution.

• However, it seems that there are fracture types, such as significantly displaced double disruptions of the superior suspensory complex, widely displaced lateral column fractures and fractures producing angular deformity of the glenoid process, that benefit from early reduction and stabilization with the expectation of a good outcome for the patient.

Cite this article: EFORT Open Rev 2021;6:518-525. DOI: 10.1302/2058-5241.6.210010

• The congruent-arc Latarjet (CAL) allows reconstruction of a greater percentage of glenoid bone deficit because the inferior surface of the coracoid is wider than the lateral edge of the coracoid used with the traditional Latarjet (TL).

• Biomechanical studies have shown higher initial fixation strength between the graft and the glenoid with the TL.

• In the TL, the undersurface of the coracoid, which is wider than the medial edge used with the CAL, remains in contact with the anterior edge of the glenoid, increasing the contact surface between both bones and thus facilitating bone consolidation.

• The shorter bone distance around the screw with the CAL is potentially less tolerant of screw-positioning error compared to the TL. Moreover, the wall of the screw tunnel is potentially more likely to fracture with the CAL due to the minimal space between the screw and the graft wall.

• CAL may be very difficult to perform in patients with very small coracoids such as small women or skeletally immature patients.

• Radius of curvature of the inferior face of the coracoid graft (used with the CAL) is similar to that of the native glenoid. This may potentially decrease contact pressure across the glenohumeral joint, avoiding degenerative changes in the long term.

Cite this article: EFORT Open Rev 2021;6:280-287. DOI: 10.1302/2058-5241.6.200074

• Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures.

• After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement.

• Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems.

• The incidence of complications such as dislocation, notching and acromial fractures has also evolved.

• Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled.

• Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures.

Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085

• Humeral shaft fractures are relatively common, representing approximately 1% to 5% of all fractures.

• Conservative management is the treatment of choice for most humeral shaft fractures and offers functional results and union rates that are not inferior to surgical management.

• Age and oblique fractures of the proximal third are risk factors for nonunion. Surgical indication threshold should be lower in patients older than 55 years presenting with this type of fracture.

• Functional outcomes and union rates after plating and intramedullary nailing are comparable, but the likelihood of shoulder complications is higher with intramedullary nailing.

• There is no advantage to early exploration of the radial nerve even in secondary radial nerve palsy.

Cite this article: EFORT Open Rev 2021;6:24-34. DOI: 10.1302/2058-5241.6.200033

• Stemless shoulder arthroplasty relies solely on cementless metaphyseal fixation and is designed to avoid stem-related problem such as intraoperative fractures, loosening, stress shielding or stress-risers for periprosthetic fractures.

• Many designs are currently on the market, although only six anatomic and two reverse arthroplasty designs have results published with a minimum of two-year follow-up.

• Compared to stemmed designs, clinical outcome is equally good using stemless designs in the short and medium-term follow-up, which is also the case for overall complication and revision rates.

• Intraoperative fracture rate is lower in stemless compared to stemmed designs, most likely due to the absence of intramedullary preparation and of the implantation of a stem.

• Radiologic abnormalities around the humeral implant are less frequent compared to stemmed implants, possibly related to the closer resemblance to native anatomy.

• Between stemless implants, several significant differences were found in terms of clinical outcome, complication and revision rates, although the level of evidence is low with high study heterogeneity; therefore, firm conclusions could not be drawn.

• There is a need for well-designed long-term randomized trials with sufficient power in order to assess the superiority of stemless over conventional arthroplasty, and of one design over another.

Cite this article: EFORT Open Rev 2021;6:35-49. DOI: 10.1302/2058-5241.6.200067