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Giovanni Di Giacomo, Luigi Piscitelli, and Mattia Pugliese

  • 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).

  • 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.

  • 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.

  • 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.

  • 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

Alexandre Lädermann, Jérome Tirefort, Davide Zanchi, Sven Haller, Caecilia Charbonnier, Pierre Hoffmeyer, and Gregory Cunningham

  • 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.

  • 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.

  • 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

John Edwin, Shahbaz Ahmed, Shobhit Verma, Graham Tytherleigh-Strong, Karthik Karuppaiah, and Joydeep Sinha

  • The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.

  • Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.

  • 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.

  • 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

Evrim Sirin, Nuri Aydin, and Osman Mert Topkar

  • Acromioclavicular (AC) joint injury is a frequent diagnosis after an acute shoulder trauma – often found among athletes and people involved in contact sports.

  • 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.

  • Depending on the degree of injury, the clavicle may become prominent on the injured site.

  • The original classification was described by Rockwood and Green according to the injured ligament complex and degree and direction of clavicular displacement.

  • Many surgical procedures have been described; among these are screws, plates, muscle transfer, ligamentoplasty procedures and ligament reconstruction using either autograft or allografts.

  • 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.

  • 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

Paul Hoogervorst, Peter van Schie, and Michel PJ van den Bekerom

  • 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.

  • 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.

  • However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

  • 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

Alexandre Lädermann, Philippe Collin, George S. Athwal, Markus Scheibel, Matthias A. Zumstein, and Geoffroy Nourissat

  • Various procedures exist for patients with irreparable posterosuperior rotator cuff tears (IRCT). At present, no single surgical option has demonstrated clinical superiority.

  • 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.

  • The current review does not support the initial use of complex and expensive techniques in the management of posterosuperior IRCT.

  • 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

Lars Adolfsson

  • 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.

  • Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.

  • Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.

  • In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.

  • 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.

  • 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

Duncan Avis and Dominic Power

  • 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.

  • 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.

  • 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.

Brett A. Lenart and Jonathan B. Ticker

  • Tears of the subscapularis tendon have been under-recognised until recently. Therefore, a high index of suspicion is essential for diagnosis.

  • A directed physical examination, including the lift-off, belly-press and increased passive external rotation can help identify tears of the subscapularis.

  • All planes on MR imaging should be carefully evaluated to identify tears of the subscapularis, retraction, atrophy and biceps pathology.

  • 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.

  • 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.

  • Biceps pathology, which is invariably present, should be addressed by tenotomy or tenodesis.

  • 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

Mohamed G. Morsy

  • 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.

  • 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).

  • 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.

  • 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).

  • 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