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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.
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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.
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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.
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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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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.
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Despite the plethora of literature regarding SLAP lesions, their clinical diagnosis remains challenging for a number of reasons.
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First, the diagnostic value of many of the available physical examination tests is inconsistent and ambiguous.
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Second, SLAP lesions most commonly occur concomitantly with other shoulder injuries.
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Third, SLAP lesions have no specific associated pain pattern.
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Outcomes following surgical treatment of SLAP tears vary depending on the method of treatment, associated pathology and patient characteristics.
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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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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).
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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.
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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.
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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.
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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
Faculty of Medicine, University of Geneva, Switzerland
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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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Medical Research Department, Artanim Foundation, 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.
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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.
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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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The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.
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Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.
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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.
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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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Acromioclavicular (AC) joint injury is a frequent diagnosis after an acute shoulder trauma – often found among athletes and people involved in contact sports.
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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.
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Depending on the degree of injury, the clavicle may become prominent on the injured site.
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The original classification was described by Rockwood and Green according to the injured ligament complex and degree and direction of clavicular displacement.
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Many surgical procedures have been described; among these are screws, plates, muscle transfer, ligamentoplasty procedures and ligament reconstruction using either autograft or allografts.
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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.
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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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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.
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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.
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However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.
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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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Various procedures exist for patients with irreparable posterosuperior rotator cuff tears (IRCT). At present, no single surgical option has demonstrated clinical superiority.
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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.
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The current review does not support the initial use of complex and expensive techniques in the management of posterosuperior IRCT.
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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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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.
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Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.
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Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.
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In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.
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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.
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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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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.
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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.
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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.
