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Damage to the medial collateral ligament of the elbow from an instability episode usually heals with non-operative treatment. In some cases, residual instability may occur, leading to functional impairment.
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Non-operative management can be successful when bracing, taping and therapy are used to stabilise the elbow.
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A recent report detailing the efficacy of platelet-rich plasma in effectively treating ulnar collateral ligament (UCL) injuries in throwers has shown promise. However, there remain specific groups that should be considered for repair or reconstruction. These may include throwing athletes, wrestlers and some individuals involved in highly active physical activity which demands stability of the elbow.
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The results of surgical repair and reconstruction allowing a return to sports are quite good, ranging from 84% to 94%. Complications are generally low and mostly centred on ulnar nerve injuries.
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This report represents a review of the literature concerning valgus instability over the past five years, supplemented by selective older articles where relevant.
Cite this article: EFORT Open Rev 2017;2:1-6. DOI:10.1302/2058-5241.2.160037.
Department of Orthopedics, AZ Monica, Deurne, Belgium
Department of Orthopedics, AZ Monica, Deurne, and University Hospital Antwerp, Edegem, Belgium
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Department of Orthopedics, AZ Monica, Deurne, Belgium
Department of Orthopedics, AZ Monica, Deurne, and University Hospital Antwerp, Edegem, Belgium
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Department of Orthopedics, AZ Monica, Deurne, Belgium
Department of Orthopedics, AZ Monica, Deurne, and University Hospital Antwerp, Edegem, Belgium
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Chronic posterolateral rotatory instability (PLRI) is the most common form of chronic elbow instability.
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PLRI usually occurs from a fall on the outstretched hand. On impact, the radial head and ulna rotate externally coupled with valgus displacement of the forearm. This leads to posterior displacement of the radial head relative to the capitellum, thus causing disruption of some or all of the lateral-sided stabilisers.
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PLRI is mainly a clinical diagnosis with a history of instability, clicking and lateral-sided pain, with a positive clinical examination including the pivot-shift test, push-up, chair and tabletop test.
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MRI can often help guide diagnosis but more commonly assists in surgical planning.
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Surgery is indicated in patients with persistent, symptomatic instability of the elbow causing pain or functional deficit. There are several surgical techniques to treat PLRI, often leading to good to excellent results.
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An open or arthroscopic technique has been successfully used in patients with symptomatic PLRI following one or more episodes of dislocation or subluxation. At the pre-operative examination under general anaesthesia, all of our patients had a positive pivot-shift test but not a frank dislocation. We prefer to perform a lateral collateral ligament (LCL) reconstruction with an allograft tendon.
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The outcomes after repair are good to excellent in the majority of patients. Results of acute repair are generally better compared with reconstruction. This is due to the fact that predictive factors for a poor outcome include the number of previous surgeries and the prevalence of degenerative changes at the elbow.
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Recurrent instability is not uncommon following repair or reconstruction and has been reported in up to 25% of patients after medium- to longer-term follow-up.
Cite this article: EFORT Open Rev 2016;1:461-468. DOI: 10.1302/2058-5241.160033
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Rotator cuff lesions (RCL) have considerable variability in location, tear pattern, functional impairment, and repairability.
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Historical classifications for differentiating these lesions have been based upon factors such as the size and shape of the tear, and the degree of atrophy and fatty infiltration. Additional recent descriptions include bipolar rotator cuff insufficiency, ‘Fosbury flop tears’, and musculotendinous lesions.
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Recommended treatment is based on the location of the lesion, patient factors and associated pathology, and often includes personal experience and data from case series. Development of a more comprehensive classification which integrates historical and newer descriptions of RCLs may help to guide treatment further.
Cite this article: Lädermann A, Burkhart SS, Hoffmeyer P, et al. Classification of full thickness rotator cuff lesions: a review. EFORT Open Rev 2016;1:420-430. DOI: 10.1302/2058-5241.1.160005.
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Lateral epicondylitis, also known as ‘tennis elbow’, is a very common condition affecting mainly middle-aged patients.
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The pathogenesis remains unknown but there appears to be a combination of local tendon pathology, alteration in pain perception and motor impairment.
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The diagnosis is usually clinical but some patients may benefit from additional imaging for a specific differential diagnosis.
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The disease has a self-limiting course of between 12 and 18 months, but in some patients, symptoms can be persistent and refractory to treatment.
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Most patients are well-managed with non-operative treatment and activity modification. Many surgical techniques have been proposed for patients with refractory symptoms.
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New non-operative treatment alternatives with promising results have been developed in recent years.
Cite this article: Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391-397. DOI: 10.1302/2058-5241.1.000049.
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Distal biceps tendon (DBT) conditions comprise a spectrum of disorders including bicipitoradial bursitis, partial tears, acute and chronic complete tears.
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In low-demand patients with complete DBT tears, non-operative treatment may be entertained provided the patient understands the potential for residual weakness, particularly in forearm supination.
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Most acute tears are best treated by primary repair using either single-incision or double-incision techniques with good clinical outcomes.
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Single-incision techniques may carry a higher risk of nerve-related complications, whereas double-incision techniques have historically been considered to carry a higher risk of heterotopic ossification, particularly if the ulna is exposed.
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Various fixation techniques, including bone tunnels, cortical buttons, suture anchors, interference screws or a combination seem to provide different fixation strength but similar clinical outcomes.
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Some chronic tears may be repaired primarily, provided tendon tissue can be identified; alternatively, autograft or allograft reconstruction can be considered, and good outcomes have been reported with both techniques.
Cite this article: Alentorn-Geli E, Assenmacher AT, Sanchez-Sotelo J. Distal biceps tendon injuries: a clinically relevant current concepts review. EFORT Open Rev 2016;1:316-324. DOI: 10.1302/2058-5241.1.000053.
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Distal triceps ruptures are rare injuries due to the special anatomical features of the muscle and tendon–bone junction.
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This injury typically occurs at the tendon–bone junction due to an eccentric contraction of the muscle.
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The treatment is controversial, especially in partial ruptures; surgical repair is indicated for complete ruptures of the distal triceps tendon.
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Several repair techniques have been described for acute complete ruptures.
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Chronic ruptures often require reconstruction rather than direct repair.
Cite this article: Demirhan M, Ersen A. Distal triceps ruptures. EFORT Open Rev 2016;1:255-259. DOI: 10.1302/2058-5241.1.000038.
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There are three main patterns of complex elbow instability: posterolateral (terrible triad), varus posteromedial (anteromedial coronoid fracture with lateral collateral ligament complex disruption), and trans-olecranon fracture dislocations.
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Radial head fractures, in the setting of complex elbow instability, often require internal fixation or arthroplasty; the outcome of radial head replacement is dictated by adequate selection of the head diameter, correct restoration of radial length, and proper alignment and tracking.
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Small coronoid fractures can be ignored. Larger coronoid fractures, especially those involving the anteromedial facet, require fixation or graft reconstruction, particularly in the presence of incongruity.
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The lateral collateral ligament complex should be repaired whenever disrupted. Medial collateral ligament disruptions seem to heal reliably without surgical repair provided all other involved structures are addressed.
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The most common mistakes in the management of trans-olecranon fracture dislocations are suboptimal fixation, lack of fixation of coronoid fragments, and lack of restoration of the natural dorsal angulation of the ulna.
Cite this article: Sanchez-Sotelo J, Morrey M. Complex elbow instability. EFORT Open Rev 2016;1:183-190.
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Shoulder arthroplasty is a demanding procedure with a known complication rate. Most complications are associated with the glenoid component, a fact that has stimulated investigation into that specific component of the implant. Avoiding glenoid component malposition is very important and is a key reason for recent developments in pre-operative planning and instrumentation to minimise risk.
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Patient-specific instrumentation (PSI) was developed as an alternative to navigation systems, originally for total knee arthroplasty, and is a valid option for shoulder replacements today. It offers increased accuracy in the placement of the glenoid component, which improves the likelihood of an optimal outcome.
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A description of the method of pre-operative planning and surgical technique is presented, based on the author’s experience and a review of the current literature.
Cite this article: Gomes N. Patient-specific instrumentation for total shoulder arthroplasty. EFORT Open Rev 2016;1:177-182. DOI: 10.1302/2058-5241.1.000033.
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The reported rate of complications of reverse shoulder arthroplasty (RSA) seems to be higher than the complication rate of anatomical total shoulder arthroplasty.
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The reported overall complication rate of primary RSA is approximately 15%; when RSA is used in the revision setting, the complication rate may approach 40%.
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The most common complications of RSA include instability, infection, notching, loosening, nerve injury, acromial and scapular spine fractures, intra-operative fractures and component disengagement.
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Careful attention to implant design and surgical technique, including implantation of components in the correct version and height, selection of the best glenosphere-humeral bearing match, avoidance of impingement, and adequate management of the soft tissues will hopefully translate in a decreasing number of complications in the future.
Cite this article: Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev 2016;1:72-80. DOI: 10.1302/2058-5241.1.160003.
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Shoulder dysfunction in the setting of irreparable rotator cuff tears (RCTs) can be treated successfully with different types of tendon transfer:
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Latissimus dorsi transfer for irreparable posterosuperior RCTs works best for young, active patients with an intact subscapularis, no pseudoparalysis or previous surgery, and a functioning teres minor.
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A more anatomical transfer for irreparable posterosuperior RCTs is a lower trapezius transfer, and early results are promising.
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Isolated irreparable tears of the subscapularis can be successfully managed with pectoralis major tendon transfer with a concentric humeral head. However, restricted external rotation (ER) may occur, depending on technique.
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Pectoralis minor transfer can successfully address combination irreparable tears of the upper border subscapularis and the supraspinatus without significant loss of ER.
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Rotator cuff arthropathy with ER lag benefits most from a reverse total shoulder arthroplasty and a combination latissimus dorsi and teres major transfer (LDTMT) regardless of patient age.
Cite this article: Axe JM. Tendon transfers for irreparable rotator cuff tears: An update. EFORT Open Rev 2016;1:18-24. doi: 10.1302/2058-5241.1.000003
