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Mark F Siemensma, Anna E van der Windt, Eline M van Es, Joost W Colaris, and Denise Eygendaal

  • The elbow is prone to stiffness due to its unique anatomy and profound capsular reaction to inflammation. The resulting movement impairment may significantly interfere with a patient’s activities of daily living.

  • Trauma (including surgery for trauma), posttraumatic arthritis, and heterotopic ossification (HO) are the most common causes of elbow stiffness.

  • In stiffness caused by soft tissue contractures, initial conservative treatment with physiotherapy (PT) and splinting is advised. In cases in which osseous deformities limit range of motion (e.g. malunion, osseous impingement, or HO), early surgical intervention is recommended.

  • Open and arthroscopic arthrolysis are the primary surgical options. Arthroscopic arthrolysis has a lower complication and revision rate but has narrower indications.

  • Early active mobilization using PT after surgery is recommended in postoperative rehabilitation and may be complemented by splinting or continuous passive motion therapy. Most results are gained within the first few months but can continue to improve until 12 months.

  • This paper reviews the current literature and provides state-of-the-art guidance on the management regarding prevention, evaluation, and treatment of elbow stiffness.

Rui Claro and Hélder Fonte

  • The treatment of rotator cuff tears (RCTs) has evolved. Nonsurgical treatment is adequate for many patients; however, for those for whom surgical treatment is indicated, rotator cuff repair provides reliable pain relief and good functional results. However, massive and irreparable RCTs are a significant challenge for both patients and surgeons.

  • Superior capsular reconstruction (SCR) has become increasingly popular in recent years. It works by passively restoring the superior restriction of the humeral head, thus restoring the pair of forces and improving the kinematics of the glenohumeral joint. Early clinical results using fascia lata (FL) autograft were promising in terms of pain relief and function.

  • The procedure has evolved, and some authors have suggested that FL autografts could be replaced by other methods. However, surgical techniques for SCR are highly variable, and patient indications remain undefined. There are concerns that the available scientific evidence does not support the popularity of the procedure.

  • This review aimed to critically evaluate the biomechanics, indications, procedural considerations, and clinical outcomes associated with the SCR procedure.

Claudio Rosso, Mark E Morrey, Michael O Schär, Kushtrim Grezda, and

  • Platelet-rich plasma (PRP) is a revolutionary treatment that harnesses the regenerative power of the body's own platelets to promote healing and tissue regeneration.

  • While PRP therapy has emerged as a promising option for augmenting biologic healing in the shoulder, the complexity of shoulder disorders makes it difficult to draw definitive conclusions about the efficacy of PRP across different conditions and stages of disease.

  • Our comprehensive review of twenty-four studies highlights the current state of PRP therapy in shoulder pathologies, revealing a wide variety of number of patients, control groups and results. Despite these challenges, the regenerative potential of PRP therapy is moderate in some conditions, with numerous studies demonstrating the positive effects.

  • In conclusion, the authors of this study recommend the use of PRP therapy for adhesive capsulitis and rotator cuff repair of medium to large tears. However, they do not recommend the use of PRP for subacromial impingement or rotator cuff tears. It is up to the clinician's discretion to decide whether PRP therapy is appropriate for individual cases. However, there is still insufficient evidence to support the inclusion of PRP therapy in treatment protocols for other shoulder disorders. Therefore, further research is needed to fully explore the potential of PRP therapy in the treatment of various shoulder conditions.

A Prkić, N P Vermeulen, B W Kooistra, B The, M P J van den Bekerom, and D Eygendaal

  • Purpose: Total elbow arthroplasty (TEA) is rarely performed compared to other arthroplasties. For many surgical procedures, literature shows better outcomes when they are performed by experienced surgeons and in so-called ‘high-volume’ hospitals. We systematically reviewed the literature on the relationship between surgical volume and outcomes following TEA.

  • Methods: A literature search was performed using the MEDLINE, EMBASE and CINAHL databases. The literature was systematically reviewed for original studies comparing TEA outcomes among hospitals or surgeons with different annual or career volumes. For each study, data were collected on study design, indications for TEA, number of included patients, implant types, cut-off values for volume, number and types of complications, revision rate and functional outcome measures. The methodological quality of the included studies was assessed using the Newcastle–Ottawa Scale.

  • Results: Two studies, which included a combined 2301 TEAs, found that higher surgeon volumes were associated with lower revision rates. The examined complication rates did not differ between high- and low-volume surgeons. In one study, low-hospital volume is associated with an increased risk of revision compared to high-volume hospitals, but for other complication types, no difference was found.

  • Conclusions: Based on the results, the evidence suggests that high-volume centers have a lower revision rate in the long term. No minimum amount of procedures per year can be advised, as the included studies have different cut-off values between groups. As higher surgeon- and center-volume, (therefore presumably experience) appear to yield better outcomes, centralization of total elbow arthroplasty should be encouraged.

Anna Wawrzyniak and Przemysław Lubiatowski


  • The purpose of this study was to collect and evaluate clinical and radiological evidence on shoulder neuroarthropathy (NA) in syringomyelia (SM) that may support the management and treatment of patients with this condition.

Materials and methods

  • This systematic review is based on the analysis of reports available in PubMed, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials using the following keywords: syringomyelia, neuroarthropathy, Charcot joint and shoulder degeneration. Thirty-nine publications were found presenting case reports or case series meeting our criteria. Pooled data included a group of 65 patients and 71 shoulders with NA secondary to SM.


  • The most commonly reported symptoms were range of motion (ROM) limitation, weakness, swelling, pain and dissociated sensory loss. NA is usually monolateral and concerns only the shoulder. The average active shoulder ROM was flexion −59.2° (s.d. 37.9), internal rotation −29.8° (s.d. 22.6) and external rotation −21.1° (s.d. 23.6). Most of the patients (75%) presented with complete or nearly complete proximal humerus degeneration, while the degree of glenoid preservation varied. Fifty-two neuroarthropathic shoulders were treated conservatively with physiotherapy, anti-inflammatory medication and splinting. Eighteen patients were treated by surgical intervention.


  • Shoulder NA due to SM is a devastating and progressive condition, and its course is often unpredictable. Patients with unexplained shoulder degeneration should be evaluated for SM, especially if there are additional neurological symptoms. Conservative treatment usually reduces shoulder pain without improving ROM. For select patients, shoulder arthroplasty may be a better option for restoring function.

Emilio Calvo, María Valencia, Antonio Maria Foruria, and Juan Aguilar Gonzalez

  • Latarjet modifies the anatomy of the shoulder, and subsequent revision surgery is challenging.

  • It is mandatory to determine the cause of recurrence in order to select the best treatment option. A CT scan is needed to measure glenoid track and evaluate coracoid graft status: position, degree of consolidation, and osteolysis.

  • Conservative management can be advocated in selected patients in whom the instability level does not interfere with the activities they wish to perform. Surgical treatment is based on the glenoid track measurement and coracoid graft suitability.

  • The coracoid graft is considered suitable if it preserves the conjoint tendon insertion, does not show osteolysis, and is large enough to reconstruct the glenoid surface. Adding a remplissage is recommended for those cases with a coracoid graft insufficient to convert large off-track Hill–Sachs lesions into on-track.

  • If the coracoid graft is suitable to reconstruct bone defects in terms of size and viability but is poorly positioned or avulsed, graft repositioning can be a valid option.

  • In patients with unsuitable coracoid bone graft, free bone graft is the revision technique of choice. The size of the graft should be large enough to restore the glenoid surface and to convert any off-track Hill–Sachs lesion into on-track.

  • There is a small group of patients in whom bone defects were properly addressed but Latarjet failed due to hyperlaxity or poor soft tissue quality. Extraarticular capsular reinforcement is suggested in this population.

Koray Şahin, Alper Şükrü Kendirci, Muhammed Oğuzhan Albayrak, Gökhan Sayer, and Ali Erşen

  • Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume.

  • Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis.

  • Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation.

  • In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered.

  • Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients.

  • In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

Abdul-ilah Hachem, Andres Molina-Creixell, Xavier Rius, Karla Rodriguez-Bascones, Francisco Javier Cabo Cabo, Jose Luis Agulló, and Miguel Angel Ruiz-Iban

  • Recurrent posterior glenohumeral instability is an entity that demands a high clinical suspicion and a detailed study for a correct approach and treatment. Its classification must consider its biomechanics, whether it is due to functional muscular imbalance or to structural changes, volition, and intentionality.

  • Due to its varied clinical presentations and different structural alterations, ranging from capsule-labral lesions and bone defects to glenoid dysplasia and retroversion, the different treatment alternatives available have historically had a high incidence of failure.

  • A detailed radiographic assessment, with both CT and MRI, with a precise assessment of glenoid and humeral bone defects and of glenoid morphology, is mandatory.

  • Physiotherapy focused on periscapular muscle reeducation and external rotator strengthening is always the first line of treatment. When conservative treatment fails, surgical treatment must be guided by the structural lesions present, ranging from soft tissue repair to posterior bone block techniques to restore or increase the articular surface.

  • Bone block procedures are indicated in cases of recurrent posterior instability after the failure of conservative treatment or soft tissue techniques, as well as symptomatic demonstrable nonintentional instability, presence of a posterior glenoid defect >10%, increased glenoid retroversion between 10 and 25°, and posterior rim dysplasia. Bone block fixation techniques that avoid screws and metal allow for satisfactory initial clinical results in a safe and reproducible way.

  • An algorithm for the approach and treatment of recurrent posterior glenohumeral instability is presented, as well as the author’s preferred surgical technique for arthroscopic posterior bone block.

Antonio Cartucho

  • Massive rotator cuff tears (MRCTs) present a particular challenge due to high rates of retear that can range from 18 to 94%, failure of healing after repair, and potential for irreparability.

  • Management of MRCTs must take into consideration the patient's characteristics, clinical examamination and expectation, number and quality of muscle tendons units involved.

  • Conservative treatment, arthroscopic long head of the biceps tenotomy, cuff debridement, partial repair, and superior capsule reconstruction are viable solutions to treat selected patients.

  • The goal of tendon transfers is to achieve stable kinematic by restoring rotational strength and force coupling of the shoulder joint.

  • The ideal candidate is a young, motivated patient with small degenerative changes of the glenohumeral joint, a massive irreparable cuff tear, significant atrophy, fatty infiltration, and functional deficit.

  • Patients with posterosuperior massive tears have impaired shoulder function with external rotation weakness and eventually lag sign If the teres minor is affected.

  • Latissimus dorsi transfer is the most used with results lasting for long follow-up and lower Trapezius transfer is becoming a surgical option. For anterosuperior tears, there is still controversial if pectoralis major is the best option when compared to latissimus dorsi although this last has a similar vector force with the supraspinatus tendon.

  • Complications associated with tendon transfers include neurovascular injury, infection, and rupture of the transferred tendon.

Stefan Bauer, Taro Okamoto, Stephanie M Babic, Jonathon C Coward, Charline M P L Coron, and William G Blakeney

  • Variable definitions of pseudoparalysis have been used in the literature.

  • Recent systematic reviews and biomechanical studies call for a grading of loss of force couple balance and the use of the terms ‘pseudoparesis’ and ‘pseudoparalysis’.

  • Pain should be excluded as the cause of loss of active function.

  • Key players for loss of force couple balance seem to be the lower subscapularis as an anterior inferior checkrein and the teres minor as a posterior inferior fulcrum.

  • Loss of three out of five muscle–tendon units counting upper and lower subscapularis separately is predictive of pseudoparalysis.

  • Shoulder equator concept: loss of all three posterior, or all three superior, or all three anterior muscle–tendon units is predictive of pseudoparalysis (loss of fulcrum for deltoid force).

  • Every effort should be made to prevent propagation of rotator cuff tears into the subscapularis and posterior rotator cuff (infraspinatus and teres minor) to maintain force couple balance (value of partial cuff repair).

  • Clinical assessment of active forward elevation, active external rotation, and active internal rotation is important to define and grade the severity of loss of force couple balance.

  • Additional features such as patient age, traumatic aetiology, chronicity, fatty infiltration, and stage of cuff tear arthropathy are useful for a specific diagnosis with implications for treatment.