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• Injuries to the rotator cuff (RC) are common and could alter shoulder kinematics leading to arthritis. Synthetic and biological scaffolds are increasingly being used to bridge gaps, augment RC repair and enhance healing potential. Our review evaluates the clinical applications, safety and outcome following the use of scaffolds in massive RC repair.

• A search was performed using EBSCO-Hosted Medline, CINAHL, Cochrane and PubMed using various combinations of the keywords ‘rotator cuff’, ‘scaffold’, ‘biological scaffold’, ‘massive rotator cuff tear’ ‘superior capsular reconstruction’ and ‘synthetic scaffold’ between 1966 and April 2018. The studies that were most relevant to the research question were selected. All articles relevant to the subject were retrieved, and their bibliographies hand searched.

• Synthetic, biosynthetic and biological scaffolds are increasingly being used for the repair/reconstruction of the rotator cuff. Allografts and synthetic grafts have revealed more promising biomechanical and early clinical results than xenografts. The retear rates and local inflammatory reactions were alarmingly high in earlier xenografts. However, this trend has reduced considerably with newer versions. Synthetic patches have shown lower retear rates and better functional outcome than xenografts and control groups.

• The use of scaffolds in the treatment of rotator cuff tear continues to progress. Analysis of the current literature supports the use of allografts and synthetic grafts in the repair of massive cuff tears in reducing the retear rate and to provide good functional outcome. Though earlier xenografts have been fraught with complications, results from newer ones are promising. Prospective randomized controlled trials from independent centres are needed before widespread use can be recommended.

Cite this article: EFORT Open Rev 2019;4:557-566. DOI: 10.1302/2058-5241.4.180040

• An os acromiale occurs when any of the primary ossification centres of the acromion fail to fuse with the basi-acromion. It is present in approximately 8% of individuals, and whilst the majority of these individuals are unaffected it can cause significant pain and disability. It can impact seemingly unrelated surgical intervention in the region such as subacromial decompression and reverse shoulder arthroplasty. A painful os acromiale can be both a diagnostic challenge, and difficult to manage. There remain a wide variety of surgical practices with variable outcomes achieved. We present an evidence-based discussion of the surgical techniques described to date in the literature, alongside a comprehensive review of the incidence and pathophysiology of os acromiale.

• This review was written after a comprehensive analysis of the literature to date relating to os acromiale. Particular focus was given to material examining surgical management techniques, and the condition’s incidence across different population groups.

• Open reduction and internal fixation using cannulated screws, or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale. There may be a biomechanical advantage of combining the two techniques. Preservation of large anterior deltoid attachment is necessary, with consideration being given to the local blood supply. There is likely no additional benefit from iliac crest vs local bone grafting. Research in this area remains of a low evidence level with small samples sizes. Appropriately powered clinical research of a higher-level evidence methodology is needed in order to differentiate further in the choice of surgical intervention.

Cite this article: EFORT Open Rev 2019;4:525-532. DOI: 10.1302/2058-5241.4.180100

• Glenoid exposure should offer frontal access to the glenoid to allow the ancillary tools to be used freely and thus facilitate the good positioning of the glenoid implant.

• The two classically recognized approaches for shoulder arthroplasty are the deltopectoral and the transdeltoid approach.

• The axillary nerve is the most important anatomical structure in the glenoid, passing down the anterior part of the subscapularis, the inferior pole of the joint and the deep face of the deltoid muscle.

• Inferior glenohumeral release is the key step that allows the humerus to be retracted back or downwards thereby exposing the glenoid face on.

• In difficult and stiff cases, once pectoralis major release, osteophyte resection and posterior capsulectomy have been performed, a compression fracture, produced by using a retractor to push against the upper extremity of the humerus, can provide the extra few millimetres of space required to use the ancillary tools without hindrance.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180057

• Posterior dislocations are rare and diagnostically difficult injuries. Diagnosis is often delayed and this leads to a locked posteriorly dislocated humeral head.

• Treatment options include conservative methods and surgical anatomic reconstruction options as well as non-anatomic surgical procedures such as subscapularis tendon transfer, hemiarthroplasty and total shoulder arthroplasty.

• Decision-making for treatment as well as prognosis depend on the extent of the articular defect size of the humeral head, duration of the dislocation and patient-specific conditions such as age and activity levels.

Cite this article: EFORT Open Rev 2019;4:194-200. DOI: 10.1302/2058-5241.4.180043

• Quantifying bone loss is important to decide the best treatment for patients with recurrent anterior glenohumeral instability. Currently, there is no standard method available to make a precise evaluation of the Hill–Sachs lesion and predict its engagement before the surgical procedure. This literature review was performed in order to identify existing published imaging methods quantifying humeral head bone loss in Hill–Sachs lesions.

• Searches were undertaken in Scopus and PubMed databases from January 2008 until February 2018. The search terms were “Hill-Sachs” and “measurement” for the initial search and “Hill–Sachs bone loss” for the second, to be present in the keywords, abstracts and title. All articles that presented a method for quantifying measurement of Hill–Sachs lesions were analysed.

• Several methods are currently available to evaluate Hill–Sachs lesions. The length, width and depth measurements on CT scans show strong inter and intra-observer correlation coefficients. Three-dimensional CT is helpful for evaluation of bony injuries; however, there were no significant differences between 3D CT and 3D MRI measurements. The on-track off-track method using MRI allows a simultaneous evaluation of the Hill–Sachs and glenoid bone loss and also predicts the engaging lesions with good accuracy.

Cite this article: EFORT Open Rev 2019;4:151-157. DOI: 10.1302/2058-5241.4.180031

• Manipulation under anaesthesia (MUA) for frozen shoulder (FS) leads to a considerable increase in range of motion and Oxford shoulder score, a significant reduction in pain and around 85% satisfaction.

• A clearly defined indication for MUA in FS patients cannot be extracted from this review or the available literature. The associating criteria before proceeding to MUA vary widely.

• All but one study in this review lacked a control group without intervention. Therefore, firm conclusions about the role of MUA in the treatment of FS cannot be drawn from the current literature.

• An overall complication rate of 0.4% was found and a re-intervention rate of 14%, although most of the included papers were not designed to monitor complications.

• The following criteria before proceeding to MUA are proposed: a patient unable to cope with a stiff and painful shoulder; clinical signs of a stage 2 idiopathic FS; lessening pain in relation to stage 1; external rotation < 50% compared to contralateral shoulder joint; a minimal duration of symptoms of three months; and failure to respond to an intra-articular corticosteroid infiltration.

Cite this article: EFORT Open Rev 2019;4:98-109. DOI: 10.1302/2058-5241.4.180044

• There is no consensus on outcomes of long versus short and uncoated versus coated uncemented stems in total shoulder arthroplasty (TSA).

• We reviewed the literature to compare revision rates and adverse radiographic observations at ⩾ 2 years of various uncemented humeral stem designs.

• We performed an electronic PubMed search for studies on uncemented primary TSA that reported one or more of the following observations at ⩾ 2 years for distinct stem designs: stem revision; subsidence; stress shielding; radiolucent lines; and humeral loosening.

• The search returned 258 records, from which 20 articles (22 cohorts) met the inclusion criteria.

• The most frequently reported designs were short uncoated stems (7/13 cohorts) at < 3 years and long uncoated stems (8/9 cohorts) at > 3 years.

• The incidences of revisions and adverse radiographic observations were lower for short coated designs, compared with short and long uncoated designs, but these findings should be confirmed by prospective studies with a longer follow-up.

Cite this article: EFORT Open Rev 2019;4:70-76. DOI: 10.1302/2058-5241.4.180046.

• The rotator cable and rotator interval are among the most recent topics of interest in current shoulder literature. Most of the research has been published in the last two decades and our understanding about the importance of these anatomical structures has improved with biomechanical studies, which changed the pre- and intra-operative approaches of shoulder surgeons to rotator cuff tears in symptomatic patients.

• The rotator cable is a thick fibrous bundle that carries the applied forces to the rotator cuff like a ‘suspension bridge’. Tears including this weight-bearing bridge result in more symptoms. On the other hand, the rotator interval is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the rotator cable.

• Advances in our knowledge about the rotator interval demonstrate that even basic anatomical structures often have greater importance than we may have understood. Misdiagnosis of these two important structures may lead to persistent symptoms.

• Furthermore, some distinct rotator cuff tear patterns can be associated with concomitant rotator interval injuries because of the anatomical proximity of these two anatomical regions. We summarize these two important structures from the aspect of anatomy, biomechanics, radiology and clinical importance in a review of the literature.

Cite this article: EFORT Open Rev 2019;4:56-62. DOI: 10.1302/2058-5241.4.170071.

• Knowledge of the pertinent anatomy, pathogenesis, clinical presentation and treatment of the spectrum of injuries involving the superior glenoid labrum and biceps origin is required in treating the patient with a superior labrum anterior and posterior (SLAP) tear.

• Despite the plethora of literature regarding SLAP lesions, their clinical diagnosis remains challenging for a number of reasons.

• First, the diagnostic value of many of the available physical examination tests is inconsistent and ambiguous.

• Second, SLAP lesions most commonly occur concomitantly with other shoulder injuries.

• Third, SLAP lesions have no specific associated pain pattern.

• Outcomes following surgical treatment of SLAP tears vary depending on the method of treatment, associated pathology and patient characteristics.

• Biceps tenodesis has been receiving increasing attention as a possible treatment for SLAP tears.

Cite this article: EFORT Open Rev 2019;4:25-32. DOI: 10.1302/2058-5241.4.180033.

• Shoulder stability depends on several factors, either anatomical or functional. Anatomical factors can be further subclassified under soft tissue (shoulder capsule, glenoid rim, glenohumeral ligaments etc) and bony structures (glenoid cavity and humeral head).

• Normal glenohumeral stability is maintained through factors mostly pertaining to the scapular side: glenoid version, depth and inclination, along with scapular dynamic positioning, can potentially cause decreased stability depending on the direction of said variables in the different planes. No significant factors in normal humeral anatomy seem to play a tangible role in affecting glenohumeral stability.

• When the glenohumeral joint suffers an episode of acute dislocation, either anterior (more frequent) or posterior, bony lesions often develop on both sides: a compression fracture of the humeral head (or Hill–Sachs lesion) and a bone loss of the glenoid rim. Interaction of such lesions can determine ‘re-engagement’ and recurrence.

• The concept of ‘glenoid track’ can help quantify an increased risk of recurrence: when the Hill–Sachs lesion engages the anterior glenoid rim, it is defined as ‘off-track’; if it does not, it is an ‘on-track’ lesion. The position of the Hill–Sachs lesion and the percentage of glenoid bone loss are critical factors in determining the likelihood of recurrent instability and in managing treatment.

• In terms of posterior glenohumeral instability, the ‘gamma angle concept’ can help ascertain which lesions are prone to recurrence based on the sum of specific angles and millimetres of posterior glenoid bone loss, in a similar fashion to what happens in anterior shoulder instability.

Cite this article: EFORT Open Rev 2018;3:632-640. DOI: 10.1302/2058-5241.3.180028