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Gazi Huri Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey

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Mehmet Kaymakoglu Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey

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Nickolas Garbis Department of Orthopaedics and Traumatology, Loyola University, Chicago, USA

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  • 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.

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Filippo Familiari Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro, Italy

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Gazi Huri Department of Orthopaedic and Traumatology, Hacettepe University, Ankara, Turkey

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Roberto Simonetta Cure Ortopediche Traumatologiche Messina, Italy

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Edward G. McFarland Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA

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  • 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.

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Giovanni Di Giacomo Concordia Hospital for Special Surgery Rome, Italy

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Luigi Piscitelli Concordia Hospital for Special Surgery Rome, Italy

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Mattia Pugliese Università degli Studi di Roma La Sapienza, Dipartimento di Medicina Sperimentale, Trauma and Orthopaedics, Rome, Italy

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  • 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

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Alexandre Lädermann Division of Orthopaedics and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, Switzerland
Faculty of Medicine, University of Geneva, Switzerland

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Jérome Tirefort Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Switzerland

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Davide Zanchi Department of Psychiatry (UPK), University of Basel, Switzerland

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Sven Haller Faculty of Medicine, University of Geneva, Switzerland
Affidea Centre de Diagnostic Radiologique de Carouge CDRC, Geneva, Switzerland
Department of Surgical Sciences, Uppsala University, Sweden
Department of Neuroradiology, University Hospital Freiburg, Germany

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Caecilia Charbonnier Faculty of Medicine, University of Geneva, Switzerland
Medical Research Department, Artanim Foundation, Geneva, Switzerland

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Pierre Hoffmeyer Division of Orthopaedics and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, Switzerland

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Gregory Cunningham Division of Orthopaedics and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, Switzerland

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  • Shoulder apprehension is related to changes in functional cerebral networks induced by dislocations, peripheral neuromuscular lesions and persistent mechanical glenohumeral instability consisting of micro-motion.

  • All the damage to the osseous and soft-tissue stabilizers of the shoulder, as well as neurologic impairment persisting even after stabilization, must be properly identified in order to offer the best possible treatment to the patient.

  • There is growing evidence supporting the use of a global multimodal approach, involving, on the one hand, shoulder ‘reafferentation’, including proprioception, mirror therapy and even cognitive behavioural approaches, and, on the other hand, surgical stabilization techniques and traditional physical therapy in order to minimize persistent micro-motion, which may help brain healing. This combined management could improve return to sport and avoid dislocation arthropathy in the long term.

Cite this article: EFORT Open Rev 2018;3:550-557. DOI: 10.1302/2058-5241.3.180007

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John Edwin Kings College Hospital, London, UK

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Shahbaz Ahmed Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK

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Shobhit Verma Kings College Hospital, London, UK

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Graham Tytherleigh-Strong Cambridge University Hospitals, UK

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Karthik Karuppaiah Kings College Hospital, London, UK

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Joydeep Sinha Kings College Hospital, London, UK

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  • The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.

  • Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.

  • This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome.

  • The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.

Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078

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Evrim Sirin Marmara University Pendik Research and Teaching Hospital, Department of Orthopaedics and Traumatology, Turkey

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Nuri Aydin Istanbul University - Cerrahpasa. Cerrahpasa School of Medicine, Department of Orthopaedics and Traumatology, Turkey

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Osman Mert Topkar Marmara University Pendik Research and Teaching Hospital, Department of Orthopaedics and Traumatology, Turkey

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  • Acromioclavicular (AC) joint injury is a frequent diagnosis after an acute shoulder trauma – often found among athletes and people involved in contact sports.

  • This injury occurs five times more frequently in men than in women, with the highest incidence in the 20- to 30-year-old age group. Patients usually complain of pain and tenderness over the shoulder, particularly over the AC joint.

  • Depending on the degree of injury, the clavicle may become prominent on the injured site.

  • The original classification was described by Rockwood and Green according to the injured ligament complex and degree and direction of clavicular displacement.

  • Many surgical procedures have been described; among these are screws, plates, muscle transfer, ligamentoplasty procedures and ligament reconstruction using either autograft or allografts.

  • With the advancement of shoulder arthroscopy, surgeons are much more capable of performing mini-open or arthroscopically-assisted procedures, allowing patients an earlier return to their daily living activities. However, the results of conventional open techniques are still comparable.

  • The introduction of new arthroscopic equipment provides a great variety of surgical procedures, though every new technique has its own advantages and pitfalls. Currently there is no gold standard for the surgical treatment of any type of AC injury, though it should be remembered that whenever an arthroscopic technique is chosen, the surgeon’s expertise is likely to be the most significant factor affecting outcome.

Cite this article: EFORT Open Rev 2018;3:426-433. DOI: 10.1302/2058-5241.3.170027

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Paul Hoogervorst OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam

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Peter van Schie OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam

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Michel PJ van den Bekerom OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam

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  • Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.

  • Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.

  • However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

  • The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033

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Alexandre Lädermann Hopital de la Tour, Switzerland

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Philippe Collin Centre Hospitalier Prive Saint-Gregoire, France

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George S. Athwal St Joseph’s Health Care, Canada

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Markus Scheibel Charité – Universitätsmedizin Berlin, Germany

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Matthias A. Zumstein Inselspital, University of Bern, Switzerland

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Geoffroy Nourissat Groupe Maussins, France

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  • Various procedures exist for patients with irreparable posterosuperior rotator cuff tears (IRCT). At present, no single surgical option has demonstrated clinical superiority.

  • There is no panacea for treatment and patients must be aware, in cases of palliative or non-prosthetic options, of an alarming rate of structural failure (around 50%) in the short term.

  • The current review does not support the initial use of complex and expensive techniques in the management of posterosuperior IRCT.

  • Further prospective and comparative studies with large cohort populations and long-term follow-up are necessary to establish effectiveness of expensive or complicated procedures such as superior capsular reconstruction (SCR), subacromial spacers or biological augmentation as reliable and useful alternative treatments for IRCT.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180002

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Lars Adolfsson Department of Orthopaedics, University Hospital of Linköping, Sweden

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  • Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.

  • Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.

  • Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.

  • In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.

  • Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.

  • The following presentation reviews the recent literature on pathomechanisms and treatment alternatives.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062

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Duncan Avis Basingstoke & North Hampshire Hospital, UK

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Dominic Power Queen Elizabeth Hospital, UK

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  • Axillary nerve injury is a well-recognized complication of glenohumeral dislocation. It is often a low-grade injury which progresses to full recovery without intervention. There is, however, a small number of patients who have received a higher-grade injury and are less likely to achieve a functional recovery without surgical exploration and reconstruction.

  • Following a review of the literature and consideration of local practice in a regional peripheral nerve injury unit, an algorithm has been developed to help identification of those patients with more severe nerve injuries.

  • Early identification of patients with high-grade injuries allows rapid referral to peripheral nerve injury centres, allowing specialist observation or intervention at an early stage in their injury, thus aiming to maximize potential for recovery.

Cite this article: EFORT Open Rev 2018;3:70-77. DOI:10.1302/2058-5241.3.170003.

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