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After failed conservative management, operative intervention is typically indicated for patients with partial-thickness rotator cuff tears (PTRCTs) with persistent pain and disability symptoms.
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For PTRCTs involving < 50% of the tendon thickness, debridement with or without acromioplasty resulted in favourable outcomes in most studies.
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For PTRCTs involving > 50% of the tendon thickness, in situ repair has proven to significantly improve pain and functional outcomes for articular and bursal PTRCTs.
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The few available comparative studies in the literature showed similar functional and structural outcomes between in situ repair and repair after conversion to full-thickness tear for PTRCTs.
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Most non-overhead athletes return to sports at the same level as previous to the injury after in situ repair of PTRCTs. However, rates of return to preinjury level of competition for overhead athletes have been generally poor regardless of the utilized technique.
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During long-term follow-up, arthroscopic in situ repair of articular and bursal PTRCTs produced excellent functional outcomes in most patients, with a low rate of revision.
Cite this article: EFORT Open Rev 2020;5:138-144. DOI: 10.1302/2058-5241.5.190010
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Preoperative assessment of the glenoid in the setting of shoulder arthroplasty is critical to account for variations in glenoid morphology, wear, version, inclination, and glenohumeral subluxation.
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Three-dimensional computed tomography (3D CT) scan assessment of the morphology of glenoid erosion allows for a more accurate surgical decision-making process to correct deformity and restore the joint line.
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Newer technology has brought forth computer-assisted software for glenoid planning in shoulder arthroplasty and patient-specific instrumentation.
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There have been promising early findings, although further evaluation is needed to determine how this technology impacts implant survivorship, function, and patient-reported outcomes.
Cite this article: EFORT Open Rev 2020;5:126-137. DOI: 10.1302/2058-5241.5.190011
Upper Limb Unit, Department of Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands
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Department of Orthopedic Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Since the introduction of the radial head prosthesis (RHP) in 1941, many designs have been introduced. It is not clear whether prosthesis design parameters are related to early failure. The aim of this systematic review is to report on failure modes and to explore the association between implant design and early failure.
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A search was conducted to identify studies reporting on failed primary RHP. The results are clustered per type of RHP based on: material, fixation technique, modularity, and polarity. Chi-square tests are used to compare reasons for failure between the groups.
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Thirty-four articles are included involving 152 failed radial head arthroplasties (RHAs) in 152 patients. Eighteen different types of RHPs have been used.
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The most frequent reasons for revision surgery after RHA are (aseptic) loosening (30%), elbow stiffness (20%) and/or persisting pain (17%). Failure occurs after an average of 34 months (range, 0–348 months; median, 14 months).
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Press-fit prostheses fail at a higher ratio because of symptomatic loosening than intentionally loose-fit prostheses and prostheses that are fixed with an expandable stem (p < 0.01).
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Because of the many different types of RHP used to date and the limited numbers and evidence on early failure of RHA, the current data provide no evidence for a specific RHP design.
Cite this article: EFORT Open Rev 2019;4:659-667. DOI: 10.1302/2058-5241.4.180099
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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.
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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.
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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.
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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
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Department of Mechanical Engineering, Imperial College, London, UK
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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.
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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.
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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
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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.
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The two classically recognized approaches for shoulder arthroplasty are the deltopectoral and the transdeltoid approach.
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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.
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Inferior glenohumeral release is the key step that allows the humerus to be retracted back or downwards thereby exposing the glenoid face on.
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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
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Posterior dislocations are rare and diagnostically difficult injuries. Diagnosis is often delayed and this leads to a locked posteriorly dislocated humeral head.
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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.
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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
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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
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There is no consensus on outcomes of long versus short and uncoated versus coated uncemented stems in total shoulder arthroplasty (TSA).
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We reviewed the literature to compare revision rates and adverse radiographic observations at ⩾ 2 years of various uncemented humeral stem designs.
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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.
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The search returned 258 records, from which 20 articles (22 cohorts) met the inclusion criteria.
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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.
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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.
