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Tears of the subscapularis tendon have been under-recognised until recently. Therefore, a high index of suspicion is essential for diagnosis.
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A directed physical examination, including the lift-off, belly-press and increased passive external rotation can help identify tears of the subscapularis.
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All planes on MR imaging should be carefully evaluated to identify tears of the subscapularis, retraction, atrophy and biceps pathology.
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Due to the tendency of the tendon to retract medially, acute and traumatic full-thickness tears should be repaired. Chronic tears without significant degeneration should be considered for repair if no contraindication exists.
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Arthroscopic repair can be performed using a 30-degree arthroscope and a laterally-based single row repair; one anchor for full thickness tears ⩽ 50% of tendon length and two anchors for those ⩾ 50% of tendon length.
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Biceps pathology, which is invariably present, should be addressed by tenotomy or tenodesis.
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Timing of post-operative rehabilitation is dictated by the size of the repair and the security of the repair construct. The stages of rehabilitation typically involve a period of immobilisation followed by range of movement exercises, with a delay in active internal rotation (IR) and strengthening in IR.
Cite this article: EFORT Open Rev 2017;2:484–495. DOI: 10.1302/2058-5241.2.170015
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Posterolateral humeral head defects can be large and engage on the anterior glenoid, and they usually contribute to anterior shoulder instability in 40% to 90% of cases.
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The purpose of this study is to evaluate the results of the largest series of patients who underwent arthroscopic remplissage with Bankart repair for recurrent anterior shoulder instability due to associated Bankart lesions, with large and engaging (> 25% involvement) humeral Hill-Sachs defects (HSDs).
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A total of 51 patients underwent arthroscopic Bankart repair with remplissage technique for the treatment of recurrent anterior glenohumeral instability with large and medial HSDs. Pre-operative imaging in all patients identified a Bankart lesion with an associated HSD that involved > 25% of the humeral head. The Rowe score was used to assess the patients clinically.
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A total of 46 patients were male. The mean age of the patients was 28.7 years (18 to 43). The mean follow-up period was 31 months (20 to 39). At the final follow-up, three patients reported recurrence of instability (two dislocations and one subluxation). The mean Rowe score improved to 95.4 points (function, 45.5 of 50; stability, 26.4 of 30; motion, 8 of 10; pain, 8 of 10).
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The arthroscopic remplissage technique with Bankart repair gave satisfactory results and is still considered to be an effective, safe and reliable procedure for treatment of glenohumeral instability in cases with large and medial HSDs.
Cite this article: EFORT Open Rev 2017;2:478–483. DOI: 10.1302/2058-5241.2.160070
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Neurectomy is one of the treatments available to the surgeon treating patients with spasticity of the upper limb.
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Its popularity has increased in recent years.
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Accurate knowledge of the anatomical variations of the terminal branches to the muscles is required in order to achieve a successful outcome.
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Although the anatomy has been thoroughly studied, there are still controversies regarding the percentage of the nerve to be resected for a successful result, and also regarding the terminology that has been used in the literature to describe the procedure.
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The literature for neurectomies for the upper limb is reviewed and an agreement regarding terminology is proposed.
Cite this article: EFORT Open Rev 2017;2:469-473. DOI: 10.1302/2058-5241.2.160074
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Frozen shoulder causes significant functional disability and pain in a population group constituted by patients who are often middle-aged and working.
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Frozen shoulder remains poorly understood. The available literature is limited and often prone to bias.
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A rapid, non-surgical and cost-effective treatment that reduces pain and restores function is an attractive option.
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Hydrodilatation is a potential first-line treatment of frozen shoulder in secondary care.
Cite this article: EFORT Open Rev 2017;2:462–468. DOI: 10.1302/2058-5241.2.160061
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Medial elbow pain is uncommon when compared with lateral elbow pain.
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Medial epicondylitis is an uncommon diagnosis and can be confused with other sources of pain.
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Overhead throwers and workers lifting heavy objects are at increased risk of medial elbow pain.
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Differential diagnosis includes ulnar nerve disorders, cervical radiculopathy, injured ulnar collateral ligament, altered distal triceps anatomy or joint disorders.
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Children with medial elbow pain have to be assessed for ‘Little League elbow’ and fractures of the medial epicondyle following a traumatic event.
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This paper is primarily focused on the differential diagnosis of medial elbow pain with basic recommendations on treatment strategies.
Cite this article: EFORT Open Rev 2017;2:362-371. DOI: 10.1302/2058-5241.2.160006
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Shoulder stability depends on the position of the arm as well as activities of the muscles around the shoulder. The capsulo-ligamentous structures are the main stabilisers with the arm at the end-range of movement, whereas negative intra-articular pressure and concavity-compression effect are the main stabilisers with the arm in the mid-range of movement.
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There are two types of glenoid bone loss: fragment type and erosion type. A bone loss of the humeral head, known as a Hill-Sachs lesion (HSL), is a compression fracture of the humeral head caused by the anterior rim of the glenoid when the humeral head is dislocated anteriorly in front of the glenoid. Four out of five patients with anterior instability have both Hill-Sachs and glenoid bone lesions, which is called a ‘bipolar lesion’.
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With the arm moving along the posterior end-range of movement, or with the arm in various degrees of abduction, maximum external rotation and maximum horizontal extension, the glenoid moves along the posterior articular margin of the humeral head. This contact zone of the glenoid with the humeral head is called the ‘glenoid track’.
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A HSL, which stays on the glenoid track (on-track lesion), cannot engage with the glenoid and cannot cause dislocation. On the other hand, a HSL, which is out of the glenoid track (off-track lesion), has a risk of engagement and dislocation. Clinical validation studies show that the ‘on-track/off-track’ concept is able to predict reliably the risk of a HSL being engaged with the glenoid. For off-track lesions, either remplissage or Latarjet procedure is indicated, depending upon the glenoid defect size and the risk of recurrence.
Cite this article: EFORT Open Rev 2017;2:343-351.
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The shape of the acromion differs between patients with degenerative rotator cuff tears and individuals without rotator cuff pathology.
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It can be assessed in the sagittal plane (acromion type, acromion slope) and in the coronal plane (lateral acromion angle, acromion index, critical shoulder angle).
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The inter-observer reliability is better for the measurements in the coronal plane.
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A large lateral extension (high acromion index or high critical shoulder angle) and a lateral down-sloping of the acromion (low lateral acromion angle) are associated with full-thickness supraspinatus tears.
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The significance of glenoid inclination for rotator cuff disease is less clear.
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The postulated patho-mechanism is the compression of the supraspinatus tendon between the humeral head and the acromion. Bursal side tears might be caused by friction and abrasion of the tendon. Articular side tears could be due to impairment of the gliding mechanism between tendon fibrils leading to local stress concentration. Further research is needed to understand the exact pathomechanism of tendon degeneration and tear.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160076. Originally published online at www.efortopenreviews.org
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Periprosthetic shoulder infection (PSI) is rare but potentially devastating. The rate of PSI is increased in cases of revision procedures, reverse shoulder implants and co-morbidities. One specific type of PSI is the occurrence of low-grade infections caused by non-suppurative bacteria such as Propionibacterium acnes or Staphylococcus epidemermidis.
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Success of treatment depends on micro-organism identification, appropriate surgical procedures and antibiotic administration efficiency. Post-operative early PSI can be treated with simple debridement, while chronic PSI requires a one- or two-stage revision procedure. Indication for one-time exchange is based on pre-operative identification of a causative agent. Resection arthroplasty remains an option for low-demand patients or recalcitrant infection.
Cite this article: EFORT Open Rev 2017;2:104-109. DOI: 10.1302/2058-5241.2.160023
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Distal humeral replacement and the total elbow are two commonly-used arthroplasties
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Each prosthesis has evolving indications and surgical techniques
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Recent changes in device design and implantation methods are due to biomechanical and clinical outcome-based research
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New prostheses and methods provide: better elbow kinematics, more durable bearings and longer-lasting joint replacement potential
Cite this article: EFORT Open Rev 2017;2:83-88. DOI: 10.1302/2058-5241.2.160064
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Shoulder joint dislocation is the most common joint dislocation seen in the emergency department.
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Traumatic dislocation may cause damage to the soft-tissues surrounding the shoulder joint and sometimes to the bone. The treatment, which aims at restoration of a fully functioning, pain-free and stable shoulder, includes either conservative or surgical management preceded by closed reduction of the acute dislocation.
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Conservative management usually requires a period of rest, generally involving immobilisation of the arm in a sling, even though it is still debated whether to immobilise the shoulder in internal or external rotation.
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Operative management, with no significant differences in term of re-dislocation rates between open and arthroscopic repair, incorporates soft-tissue reconstructions and/or bony procedures and is recommended in young male adults engaged in highly demanding physical activities.
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At our institution, non-operative management is favoured particularly for patients with multi-directional instability or soft-tissue laxity. Conservative measures are often preferred in older patients or younger patients that are not actively engaged in overhead activities. Immediate surgery on all first-time dislocations may subject many patients to surgery who would not have had any future subluxation.
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For these reasons, initially we will always try physical therapy and activity modification for the vast majority of our patients.
Cite this article: EFORT Open Rev 2017;2:35-40.DOI: 10.1302/2058-5241.2.160018.
