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• A synovial plica (fold) is normal anatomic finding, and occurs in 86–100% of cases; however, symptomatic plica is much less common (7.2–8.7% of all elbow arthroscopies).

• Synovial plica syndrome is a painful elbow condition related to symptomatic synovial plica.

• Synovial plica syndrome is diagnosed by clinical examination (lateral elbow pain) commonly accompanied by local tenderness, pain at terminal extension and/or painful snapping.

• Synovial plica syndrome may be mimicked by other elbow conditions, commonly tennis elbow, loose bodies, and degenerative arthritis.

• Magnetic resonance imaging or ultrasound scan may support diagnosis in correlation with clinical findings, but symptomatic plica may also be diagnosed as unexpected during elbow arthroscopy.

• The arthroscopic resection is effective and safe if conservative treatment fails.

Cite this article: EFORT Open Rev 2020;5:549-557. DOI: 10.1302/2058-5241.5.200027

• The stability of the glenohumeral joint depends on soft tissue stabilizers, bone morphology and dynamic stabilizers such as the rotator cuff and long head of the biceps tendon. Shoulder stabilization techniques include anatomic procedures such as repair of the labrum or restoration of bone loss, but also non-anatomic options such as remplissage or tendon transfers.

• Rotator cuff repair should restore the cuff anatomy, reattach the rotator cable and respect the coracoacromial arch whenever possible. Tendon transfer, superior capsular reconstruction or balloon implantation have been proposed for irreparable lesions.

• Shoulder rehabilitation should focus on restoring balanced glenohumeral and scapular force couples in order to avoid an upward migration of the humeral head and secondary cuff impingement. The primary goal of cuff repair is to be as anatomic as possible and to create a biomechanically favourable environment for tendon healing.

Cite this article: EFORT Open Rev 2020;5:508-518. DOI: 10.1302/2058-5241.5.200006

• Operative treatment with tension band wiring or plate is the gold standard of care for displaced olecranon fractures.

• In elderly patients, multiple comorbidities combine with increased intraoperative risks, and postoperative complications may yield poor results.

• There are small series in the literature that show promising results with non-operative treatment.

• Non-operative treatment may provide reasonable function and satisfaction in the elderly population and could be considered as a treatment option in this group, especially for those with comorbidities, to avoid postoperative complications and the need for re-operation.

Cite this article: EFORT Open Rev 2020;5:391-397. DOI: 10.1302/2058-5241.5.190041

• Primary radial head arthroplasty (RHA) produces good or excellent results in approximately 85% of patients. However, complications are not uncommon and have been described in up to 23% of cases.

• The number of RHA is increasing, and consequently the absolute number of complications is expected to rise as well. The decision on whether to revise or remove the prosthesis seems more likely to depend on the preference of the surgeon or the hospital, rather than on objectifying problems with the prosthesis.

• The current article presents an algorithm for the work-up and treatment of most complications that can occur following RHA.

• Five subgroups of problems were identified: osteoarthritis, stiffness, instability, infection and implant-related issues.

• In short, the preferred treatment depends mainly on the chondral condition and stability of the elbow joint.

Cite this article: EFORT Open Rev 2020;5:398-407. DOI: 10.1302/2058-5241.5.190055

• Despite recent improvements in surgical implants and techniques, distal humerus nonunion does occur between 8% and 25% of the time.

• Careful identification and improvement of any modifiable risk factors such as smoking, metabolic disorders, immunosuppressant medications, poor nutritional status and infection is mandatory.

• A recent computed tomography scan is paramount to determine the nonunion pattern, assess residual bone stock, identify previously placed hardware, and determine whether there is evidence of osteoarthritis or malunion of the articular surface.

• Internal fixation is the treatment of choice in the majority of patients presenting with reasonable bone stock and preserved articular cartilage; total elbow arthroplasty is an appealing alternative for elbows with severe destruction of the articular cartilage or severe bone loss at the articular segment, especially in older, female patients. Internal fixation requires not only achieving a stable fixation, but also releasing associated elbow contractures and the liberal use of bone graft or substitutes.

• Although reported union rates after internal fixation of distal humerus nonunions are excellent (over 95%), the complication rate remains very high, and unsatisfactory results do occur.

Cite this article: EFORT Open Rev 2020;5:289-298. DOI: 10.1302/2058-5241.5.190050

• Frozen shoulder, a common and debilitating shoulder complaint, has been the subject of uncertainty within the scientific literature and clinical practice.

• We performed an electronic PubMed search on all (1559) articles mentioning ‘frozen shoulder’ or ‘adhesive capsulitis’ to understand and qualify the range of naming, classification and natural history of the disease. We identified and reviewed six key thought leadership papers published in the past 10 years and all (24) systematic reviews published on frozen shoulder or adhesive capsulitis in the past five years.

• This revealed that, while key thought leaders such as the ISAKOS Upper Extremity Council are unequivocal that ‘adhesive capsulitis’ is an inappropriate term, the long-term and short-term trends showed the literature (63% of systematic reviews assessed) preferred ‘adhesive capsulitis’.

• The literature was divided as to whether or not to classify the complaint as primary only (9 of 24) or primary and secondary (9 of 24); six did not touch on classification.

• Furthermore, despite a systematic review in 2016 showing no evidence to support a three-phase self-limiting progression of frozen shoulder, 11 of 12 (92%) systematic reviews that mentioned phasing described a three-phase progression. Eight (33%) described it as ‘self-limiting’, three (13%) described it as self-limiting in ‘nearly all’ or ‘most’ cases, and six (25%) stated that it was not self-limiting; seven (29%) did not touch on disease resolution.

• We call for a data and patient-oriented approach to the classification and description of the natural history of the disease, and recommend authors and clinicians (1) use the term ‘frozen shoulder’ over ‘adhesive capsulitis’, (2) use an updated definition of the disease which recognizes the often severe pain suffered, and (3) avoid the confusing and potentially harmful repetition of the natural history of the disease as a three-phase, self-limiting condition.

Cite this article: EFORT Open Rev 2020;5:273-279.DOI: 10.1302/2058-5241.5.190032

• National registries provide useful information in understanding outcomes of surgeries that have late sequelae, especially for rare operations such as total elbow arthroplasty (TEA).

• A systematic search was performed and data were compiled from the registries to compare total elbow arthroplasty outcomes and evaluate trends. We included six registries from Australia, the Netherlands, New Zealand, Norway, the United Kingdom and Sweden.

• Inflammatory arthritis was the most common indication for total elbow arthroplasty, followed by acute fracture and osteoarthritis. When comparing 2000–2009 to 2010–2017 data, total elbow arthroplasty for inflammatory arthritis decreased and total elbow arthroplasty for fracture and osteoarthritis increased. There was an increase in the number of revision TEAs over this time period.

• The range of indications for total elbow arthroplasty is broadening; total elbow arthroplasty for acute trauma and osteoarthritis is becoming increasingly more common. However, inflammatory arthritis remains the most common indication in recent years. This change is accompanied by an increase in the incidence of revision surgery.

Cite this article: EFORT Open Rev 2020;5:215-220. DOI: 10.1302/2058-5241.5.190036

• After failed conservative management, operative intervention is typically indicated for patients with partial-thickness rotator cuff tears (PTRCTs) with persistent pain and disability symptoms.

• For PTRCTs involving < 50% of the tendon thickness, debridement with or without acromioplasty resulted in favourable outcomes in most studies.

• For PTRCTs involving > 50% of the tendon thickness, in situ repair has proven to significantly improve pain and functional outcomes for articular and bursal PTRCTs.

• The few available comparative studies in the literature showed similar functional and structural outcomes between in situ repair and repair after conversion to full-thickness tear for PTRCTs.

• Most non-overhead athletes return to sports at the same level as previous to the injury after in situ repair of PTRCTs. However, rates of return to preinjury level of competition for overhead athletes have been generally poor regardless of the utilized technique.

• During long-term follow-up, arthroscopic in situ repair of articular and bursal PTRCTs produced excellent functional outcomes in most patients, with a low rate of revision.

Cite this article: EFORT Open Rev 2020;5:138-144. DOI: 10.1302/2058-5241.5.190010

• Preoperative assessment of the glenoid in the setting of shoulder arthroplasty is critical to account for variations in glenoid morphology, wear, version, inclination, and glenohumeral subluxation.

• Three-dimensional computed tomography (3D CT) scan assessment of the morphology of glenoid erosion allows for a more accurate surgical decision-making process to correct deformity and restore the joint line.

• Newer technology has brought forth computer-assisted software for glenoid planning in shoulder arthroplasty and patient-specific instrumentation.

• There have been promising early findings, although further evaluation is needed to determine how this technology impacts implant survivorship, function, and patient-reported outcomes.

Cite this article: EFORT Open Rev 2020;5:126-137. DOI: 10.1302/2058-5241.5.190011

• Since the introduction of the radial head prosthesis (RHP) in 1941, many designs have been introduced. It is not clear whether prosthesis design parameters are related to early failure. The aim of this systematic review is to report on failure modes and to explore the association between implant design and early failure.

• A search was conducted to identify studies reporting on failed primary RHP. The results are clustered per type of RHP based on: material, fixation technique, modularity, and polarity. Chi-square tests are used to compare reasons for failure between the groups.

• Thirty-four articles are included involving 152 failed radial head arthroplasties (RHAs) in 152 patients. Eighteen different types of RHPs have been used.

• The most frequent reasons for revision surgery after RHA are (aseptic) loosening (30%), elbow stiffness (20%) and/or persisting pain (17%). Failure occurs after an average of 34 months (range, 0–348 months; median, 14 months).

• Press-fit prostheses fail at a higher ratio because of symptomatic loosening than intentionally loose-fit prostheses and prostheses that are fixed with an expandable stem (p < 0.01).

• Because of the many different types of RHP used to date and the limited numbers and evidence on early failure of RHA, the current data provide no evidence for a specific RHP design.

Cite this article: EFORT Open Rev 2019;4:659-667. DOI: 10.1302/2058-5241.4.180099