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• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• Decision-making for the treatment of pseudoparalytic shoulders is complex and a high level of experience in shoulder surgery and outcome evaluation is required.

• Management and results depend on clinical findings, tear and tissue quality, patient and surgeon criteria. Clinical findings determine the exact definition and direction of pseudoparesis and pseudoparalysis.

• Tear pattern and tissue quality determine if the rotator cuff is repairable or irreparable. Age and general health are important patient factors.

• Non-operative treatment is the first option for patients with a higher risk profile for reconstruction or arthroplasty, but delineation of its value requires better evidence.

• Tendon transfers are used for irreparable loss of the horizontal force couple balance (rotation). Options include latissimus dorsi, pectoralis minor and major for loss of active internal rotation, and latissimus dorsi ± teres major and lower trapezius for loss of active external rotation (AER).

• Partial cuff repair with or without superior capsular reconstruction using allograft or biceps tendon is an option for loss of active forward elevation.

• Treatment for the combined loss of elevation and external rotation patients is still not clear. Options include lateralised reverse shoulder arthroplasty (RSA) alone or combined RSA with a tendon transfer.

• RSA with loss of AER can be revised by adding a tendon transfer.

• The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.

• The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.

• Zumstein et al defined a ‘complication’ following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient’s final outcome.

• High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.

• Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture.

Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039

• Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%.

• A ‘problem’ is defined as an intraoperative or postoperative event that is not likely to affect the patient’s final outcome, such as intraoperative cement extravasation and radiographic changes. A ‘complication’ is defined as an intraoperative or postoperative event that is likely to affect the patient’s final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement.

• Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature.

• High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications.

• The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient’s final outcome, and their prevalence has dramatically decreased.

• With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications.

Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040